Assessing clinical handover between paramedics and the trauma team.

INTRODUCTION: The aim of effective clinical handover is seamless transfer of information between care providers. Handover between paramedics and the trauma team provides challenges in ensuring that information loss does not occur. Handover is often time-pressured and paramedics' clinical notes are often delayed in reaching the trauma team. Documentation by trauma team members must be accurate. This study evaluated information loss and discordance as patients were transferred from the scene of an incident to the Trauma Centre.
METHODS: Twenty-five trauma patients presenting by ambulance to a tertiary Emergency and Trauma Centre were randomly selected. Audiotaped (pre-hospital) and videotaped (in-hospital) handover was compared with written documentation.
RESULTS: In the pre-hospital setting 171/228 (75%) of data items handed over by paramedics to the trauma team were documented and in the in-hospital handover 335/498 (67%) of information was documented. Information least likely to be documented by trauma team members (1) in the pre-hospital setting related to treatment provided and (2) in the in-hospital setting related to signs and symptoms. While 79% of information was subsequently documented by paramedics, 9% (n=59) of information was not documented either by trauma team members or paramedics and constitutes information loss. Information handed over was not congruent with documentation on seven occasions. Discrepancies included a patient's allergy status and sites of injury (n=2). Demographic details were most likely to be documented but not handed over by paramedics.
CONCLUSION: By documenting where deficits in handover occur we can identify points of vulnerability and strategies to capture this information. (c) 2009 Elsevier Ltd. All rights reserved.