Impact of a Standardized EMS Handoff Tool on Inpatient Medical Record Documentation at a Level I Trauma Center

Maddry, Joseph K.; Araña, Allyson A.; Clemons, Melissa A; Medellín, Kimberly L; Shults, Nicole M; Perez, Crystal A; Savell, Shelia C; Gutierrez, Xandria E; Reeves, Lauren K; Mora, Alejandra G.; Bebarta, Vikhyat S.

doi:10.1080/10903127.2020.1824050

Cited by 12 publications

(3 citation statements)

References 22 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…While addressing SDoH in all medical records, terminology should be consistent to avoid miscommunication. 8 Systematic and prescribed formatting for verbal hand-offs from EMS to ED personnel have improved efficacy and information transmission, 11 , 16 , 18 , 35 and the National Emergency Medical Services Information System (NEMSIS) 36 has standardized and improved the collection of EMS data. The creation of a specific data collection tool can increase and improve information acquisition and neutral reporting of patients’ SDoH.…”

Section: Discussionmentioning

confidence: 99%

“…Nevertheless, information exchange through verbal hand-offs from EMS professionals to ED nursing staff and subsequent reporting to additional hospital personnel often results in lost information and miscommunication. [11][12][13][14][15][16][17][18][19] Electronic health record documentation by EMS is a reliable channel through which information about a patient's SDoH can be shared with all healthcare personnel associated with the patient's hospitalization. 20 There is a paucity of SDoH information in EMS records for pediatric patients, 21 but the presence, appraisal, and connections of SDoH information in EMS records for adult patients is unknown.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Social Determinants of Health in EMS Records: A Mixed-methods Analysis Using Natural Language Processing and Qualitative Content Analysis

Burnett¹,

Stemerman²,

Innes³

et al. 2023

WestJEM

View full text Add to dashboard Cite

Introduction Social determinants of health (SDoH) are known to impact the health and well-being of patients. However, information regarding them is not always collected in healthcare interactions, and healthcare professionals are not always well-trained or equipped to address them. Emergency medical services (EMS) professionals are uniquely positioned to observe and attend to SDoH because of their presence in patients’ environments; however, the transmission of that information may be lost during transitions of care. Documentation of SDoH in EMS records may be helpful in identifying and addressing patients’ insecurities and improving their health outcomes. Our objective in this study was to determine the presence of SDoH information in adult EMS records and understand how such information is referenced, appraised, and linked to other determinants by EMS personnel. Methods Using EMS records for adult patients in the 2019 ESO Data Collaborative public-use research dataset using a natural language processing (NLP) algorithm, we identified free-text narratives containing documentation of at least one SDoH from categories associated with food, housing, employment, insurance, financial, and social support insecurities. From the NLP corpus, we randomly selected 100 records from each of the SDoH categories for qualitative content analysis using grounded theory. Results Of the 5,665,229 records analyzed by the NLP algorithm, 175,378 (3.1%) were identified as containing at least one reference to SDoH. References to those SDoH were centered around the social topics of accessibility, mental health, physical health, and substance use. There were infrequent explicit references to other SDoH in the EMS records, but some relationships between categories could be inferred from contexts. Appraisals of patients’ employment, food, and housing insecurities were mostly negative. Narratives including social support and financial insecurities were less negatively appraised, while those regarding insurance insecurities were mostly neutral and related to EMS operations and procedures. Conclusion The social determinants of health are infrequently documented in EMS records. When they are included, they are infrequently explicitly linked to other SDoH categories and are often negatively appraised by EMS professionals. Given their unique position to observe and share patients’ SDoH information, EMS professionals should be trained to understand, document, and address SDoH in their practice.

show abstract

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Social Determinants of Health in EMS Records: A Mixed-methods Analysis Using Natural Language Processing and Qualitative Content Analysis

Burnett¹,

Stemerman²,

Innes³

et al. 2023

WestJEM

View full text Add to dashboard Cite

show abstract

“…An der Klinik der Autoren hat sich, vergleichbar dem AMPLE-Schema (Allergie, Medikation, "past medical history", letzte Mahlzeit, Event [Akutereignis]) der Anamnese, ein Schema mit dem Akronym "MIST" zur Übergabe durchgesetzt (Erklärung: Tab. 2; [12,13]). lung dieser Erstbeurteilung etabliert [14,15,16].…”

Section: Schockraumaktivierungunclassified

Trauma care in the emergency room phase

Halvachizadeh,

Berk,

Kaiser

et al. 2023

Notfall Rettungsmed

View full text Add to dashboard Cite

ZusammenfassungDie Schockraumphase gilt als Schnittstelle zwischen der prähospitalen und der klinischen Phase der Polytraumaversorgung. Eine strukturierte und fokussierte Identifikation und Behandlung von lebensbedrohlichen Verletzungen erfolgen zu Beginn dieser Phase. Anschließend gilt es, die Verletzungen des/der Polytraumapatient:in adäquat zu diagnostizieren und die physiologische Stabilität zu definieren. Dies beinhaltet, neben der strukturierten Evaluation des Verletzungsmusters, ein repetitives Assessment des pathophysiologischen Status. Besondere Berücksichtigung finden v. a. Ausmaß von Blutungen und Weichteilverletzungen sowie Koagulopathien und Körpertemperatur. Basierend auf der Verletzungsverteilung und dem physiologischen Status der Polytraumapatient:in sollte interdisziplinär eine adäquate Behandlungsstrategie initiiert werden. Teamtrainings, Vor- und Nachbesprechungen sowie ein regelmäßiger Austausch im Schockraumteam während der Behandlung helfen, die Behandlungsqualität zu steigern.

show abstract