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首页> 外文期刊>Prehospital emergency care >Information loss in emergency medical services handover of trauma patients.
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Information loss in emergency medical services handover of trauma patients.

机译：创伤患者紧急医疗服务移交中的信息丢失。

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INTRODUCTION: Little is known about how effectively information is transferred from emergency medical services (EMS) personnel to clinicians in the emergency department receiving the patient. Information about prehospital events and findings can help ensure expedient and appropriate care. The trauma literature describes 16 prehospital data points that affect outcome and therefore should be included in the EMS report when applicable. OBJECTIVE: To determine the degree to which information presented in the EMS trauma patient handover is degraded. METHODS: At a level I trauma center, patients meeting criteria for the highest level of trauma team activation ("full trauma") were enrolled. As part of routine performance improvement, the physician leadership of the trauma program watched all available video-recorded full trauma responses, checking off whether the data points appropriate to the case were verbally "transmitted" by the EMS provider. Two EMS physicians then each independently reviewed the trauma team's chart notes for 50% of the sample (and a randomly selected 15% of the charts to assess agreement) and checked off whether the same elements were documented ("received") by the trauma team. The focus was on data elements that were "transmitted" but not "received." RESULTS: In 96 patient handovers, a total of 473 elements were transmitted, of which 329 were received (69.6%). On the average chart, 72.9% of the transmitted items were received (95% confidence interval 69.0%-76.8%). The most commonly transmitted data elements were mechanism of injury (94 times), anatomic location of injury (81), and age (67). Prehospital hypotension was received in only 10 of the 28 times it was transmitted; prehospital Glasgow Coma Scale [GCS] score 10 of 22 times; and pulse rate 13 of 49 times. CONCLUSIONS: Even in the controlled setting of a single-patient handover with direct verbal contact between EMS providers and in-hospital clinicians, only 72.9% of the key prehospital data points that were transmitted by the EMS personnel were documented by the receiving hospital staff. Elements such as prehospital hypotension, GCS score, and other prehospital vital signs were often not recorded. Methods of "transmitting" and "receiving" data in trauma as well as all other patients need further scrutiny.
机译：简介：关于如何有效地将信息从紧急医疗服务（EMS）人员传输到接收患者的急诊科临床医生知之甚少。有关院前事件和发现的信息可以帮助确保适当且适当的护理。创伤文献描述了影响结果的16个院前数据点，因此在适用时应包括在EMS报告中。目的：确定EMS创伤患者移交中呈现的信息降级的程度。方法：在一级创伤中心，招募符合最高创伤团队激活水平（“完全创伤”）标准的患者。作为例行绩效改善的一部分，创伤计划的医生领导会观看所有可用的视频记录的完整创伤反应，并检查EMS提供者是否通过语言“传输”了适合该病例的数据点。然后，两名EMS医师各自独立地检查了创伤小组50％样本的图表笔记（以及随机选择的15％图表以评估一致性），并检查了创伤小组是否记录了相同的要素（“收到”） 。重点是“已发送”但未“接收”的数据元素。结果：在96例患者移交中，总共传输了473个元素，其中接收了329个元素（占69.6％）。在平均图表上，收到了72.9％的已传输项目（95％的置信区间69.0％-76.8％）。最常传送的数据元素是损伤的机理（94次），损伤的解剖位置（81）和年龄（67）。院前低血压仅在传播的28次中有10次被接受。院前格拉斯哥昏迷量表[GCS]评分10的22倍;脉率13为49倍结论：即使在EMS提供者和医院内临床医生之间直接口头接触的单人移交的受控环境中，由EMS人员发送的院前关键数据点中只有72.9％由接收医院的工作人员记录。通常没有记录诸如院前低血压，GCS评分和其他院前生命体征等内容。在创伤以及所有其他患者中“传输”和“接收”数据的方法需要进一步检查。

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