Aus dem Universitäts-Notfallzentrum des Universitätsklinikums Freiburg im Breisgau Handover Improvement within the Emergency Care Setting: Implementation and Training of New Mnemonics in a German Emergency Department INAUGURAL-DISSERTATION zur Erlangung des Medizinischen Doktorgrades der Medizinischen Fakultät der Albert-Ludwigs-Universität Freiburg im Breisgau Vorgelegt 2018 von Nora Vanessa Lennartz geboren in Stuttgart
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Aus dem Universitäts-Notfallzentrum
des Universitätsklinikums
Freiburg im Breisgau
Handover Improvement within the Emergency Care
Setting: Implementation and Training of New
Mnemonics in a German Emergency Department
INAUGURAL-DISSERTATION
zur
Erlangung des Medizinischen Doktorgrades
der Medizinischen Fakultät
der Albert-Ludwigs-Universität
Freiburg im Breisgau
Vorgelegt 2018
von Nora Vanessa Lennartz
geboren in Stuttgart
Dekan: Prof. Dr. Norbert Südkamp
1. Gutachter: Prof. Dr. med. Hans-Jörg Busch
2. Gutachter: PD Dr. Dirk Maier
Jahr der Promotion: 2020
I
Table of Contents
I. List of abbreviations ....................................................................................................... II
II. List of tables ...................................................................................................................III
III. List of figures ................................................................................................................. IV
IV. Abstract .......................................................................................................................... V
V. Deutsche Zusammenfassung ........................................................................................ VI
1. Introduction and Background .......................................................................................... 1
increased patient morbidity and mortality” (Marmor and Li 2017, p. 297). Many studies
identified that, especially in emergency departments, much information is lost during handover
(Ye et al. 2007; Manser and Foster 2011, p. 184; Meisel et al. 2015; Yong et al. 2008; Blum
and Tremper 2009). This information loss is of crucial significance in an emergency
department, where patients are at high risk and often timely intervention is central to a patients’
successful treatment. On top of that, overcrowding, noisy surroundings, patient relocation and
unexpected events are common in emergency departments. This poses a further threat to
patient safety. If information is lost it can not only have direct effects on the treatment of the
patient but also on various other aspects: increased lengths of stay, treatment delays,
confusion regarding care, medication errors, avoidable readmission and increased costs
(Sujan et al. 2014). This shows, how important standardization of the handover process is for
patient safety.
Since little research has been published about this, concerning German emergency
departments, evidence-based best practices cannot be developed.
2 Following items were listed as the 9 intervention points for advancing patient safety, by the WHO: 1. Look-Alike,
Sound-Alike Medication Names, 2. Patient Identification, 3. Communication During Patient Hand-Overs, 4. Performance of Correct Procedure at Correct Body Site, 5. Control of Concentrated Electrolyte Solutions, 6. Assuring Medication Accuracy at Transitions in Care, 7. Avoiding Catheter and Tubing Mis-Connections, 8. Single Use of Injection Devices, 9. Improved Hand Hygiene to Prevent Health Care-Associated Infection WHO 2007a
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2. Study design and methods
This study analyses whether the handover restructuring process and training thereof lead to
an increase in patient and staff satisfaction and a subjective stress reduction in the staff. The
following section contains additional details about the theory behind this intervention and the
hypothesis of the causal contiguities. Furthermore, a rough summary of the initial situation of
the University emergency department of Freiburg (UNZ) is presented. The section will end with
the description of the Methods used for the survey and the conducted interventions.
2.1. Study design
We performed a single centre survey in the ED of the University Medical Centre of Freiburg –
Germany, where approximately 50.000 patients are treated annually. The study was
conducted throughout the years of 2015 until 2017. The focus was set on emergency patients
of internal medicine. All doctors and nurses took part in the restructuring process and survey.
We set two focus points of intervention and questioning. The first was the transition from pre-
clinical to clinical treatment. In practice this means handover from EMS to ED ward. The
second was the handovers given to the responsible senior physician during morning rounds in
the ED ward. The study consisted out of two main strands: Intervention and observational
research. The intervention was an implementation of standard mnemonics and predefined
handover procedures. The goal was to smoothen the handover process, improve
communication, lower staff stress levels, improve patient and staff satisfaction and on the long
run, enhance patient security. Two different mnemonics were implemented: the ID-S₂A₂MPLE
for the interface of the emergency medical services to emergency department, and the ID-
PHONE for ward rounds and anamnesis of the patient. The observational research was meant
to assess whether these goals were accomplished. The patients were chosen by chance and
capability to take part in a questionnaire. The goal to reach all staff, present during the time
period of data collection was only partly successful, due to time pressure or unwillingness to
answer the questionnaire. Since there was only a limited amount of data which could be
collected, some of the parameters were not obtained: Improvements in communication skills
and patient security could not be analysed. In theory, an enhancement of the factors should
be observed, but since we could not obtain any data, this can only be presumed.
The main goal of this work was, to structure handover processes in the emergency department.
It was recognized, by leading personnel that there is room for improvement in this area and
that interventions were sensible. To evaluate whether the interventions also fulfilled their
intended purpose, they were accompanied by this study, to obtain the necessary data.
Questionnaire data was collected before and after the restructuring process, to compare pre-
15
and post-intervention ratings of the handover process. Ambulance, ED-staff and patients were
questioned with different questionnaires, and the collected data analysed. The need for training
and collectively deciding on the best structure of handover was recognized in this process. A
training for ED-staff was held for this purpose, before the implementation of new handover
mnemonics and structures. Here, the importance of non-technical skills was underlined, and
the results of the questionnaires discussed. In a joint effort, the ID-PHONE mnemonic was
specified and tasks for each person taking part in the handover process (attending resident,
nursing staff and chief resident) defined. This mnemonic, which is specified below in the
following section, was intended for handovers during ward rounds in which the respective chief
resident is informed about the patient by the attending resident and attending nursing staff.
Furthermore, it should be used as a guide for taking over patients from the emergency medical
service and noting important patient information. In this way, all relevant information is already
collected in a structured manner and can easily be passed on in this manner.
For the emergency medical services another mnemonic was designed. The ID-S₂A₂MPLE. It
was adapted from the already existing SAMPLER mnemonic and specified for this setting (Lars
Schmitz-Eggen 2018). There was no training conducted for this mnemonic, but information
sent out to all EMSs, attending to patients who are delivered to the University Hospital of
Freiburg. Here a pre- and post-intervention survey was also conducted, to see whether
satisfaction rating rose through standardization.
2.2. Methods
In the first part of this section, the two different mnemonics which were implemented are
presented, followed by the different questionnaires used to obtain our data. In the last part, the
conducted training will be briefly described.
2.2.1. Mnemonics: ID-PHONE and ID-S2A2MPLE
The protocol acronym represents the systematic approach to the patient´s history and the
handover to the following shift of physicians and nurses. Always beginning with the
identification of the patient (ID) the sequence of handover runs along the PHONE-path. The
acute complaint or problem is then stated (P) including the mode of entry into the hospital (e.g.
EMS, admission by general practitioner or self-admittances). Then the past medical history (H)
including allergies and medication is discussed before the objective (O) vital signs and
laboratory findings and examination results are presented. This is followed by the next steps
(N) to be taken, and the possible discharge or admission to another hospital ward (E, German:
“Entlassung”- discharge). This mnemonic was meant to be used during morning ward rounds
16
where the attending physician and attending nurse handed over information about the patient
to the senior physician on duty.
In addition to the mnemonics, a specific procedure for handover was also enacted. Here, each
position got their own tasks and information that they were to pass on and ask for. Additionally,
the roadmap for communicating this information in a structured and understandable manner
to the patient was established. The handover was to take place outside of the patient’s room
for a variety of reasons. The first intention was to keep a personal relationship to the patient
and concentrate fully on her or his needs, when being in contact. Secondly, the staff can
discuss the illness and situation of the patient more freely, using medical technical terms, with
the patient not being present. This enables the treating staff to ask more questions and discuss
how to go about the treatment without any danger of confusing the patient. The information
discussed during handover between the staff, can be very upsetting for a patient and have
negative effects on her or his clinical status. It was agreed by the senior physicians that it is
important to focus completely on the patient when communicating with them. The respective
information should be focused on what is important for the patient to know and should be
transferred in an understandable manner.
The table below illustrates the specific information to be handed over and tasks each
profession has during rounds. The consultant will then be the main person talking to and
discussing further steps with the patient. In addition to these tasks, an extra employee will be
responsible to organize relocations and transfer of the patients to other wards. They give
information about where vacant beds are available and where patients could be relocated to.
The physicians then also define demands, as to where to the patients should be best relocated.
Needless to say, these patients have already been treated in the ED and are now stable
enough for a relocation to another hospital ward.
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Table 2: ID-PHONE Protocol for medical rounds during handover
MEDICAL ROUNDS PROTOCOL
Resident Nursing Personnel Consultant
Communication with the patient
ID IDENTIFICATION
Name, Age Name Name Introduction
P ACUTE PROBLEM
main symptom, working diagnosis, measures
taken
domestic situation, compliance,
communication / mobility, isolation,
surveillance
main diagnosis, what should be treated
topic, main diagnosis, consequence
H PAST MEDICAL HISTORY
allergies, known illnesses,
general practitioner or medical specialist
treating patient
allergies, situation at home,
living will, caretaker Questions?
explain, motivate, repeat, mirror, sum
everything up
O OBJECTIVE DATA
A-B-C-D-E, lab values,
imaging / dynamics
A-B-C-D-E, vital signs,
diagnostic findings Questions?
what was reached / tested? what is still
missing?
N NEXT STEPS
treatment plan, missing tests,
tasks for nursing personnel or secretary
Tasks for doctors or secretary
notes about treatment plan and tasks
what is going to happen next? explain
invasive treatment, new / different
medication
E DISCHARGE/ NEXT STEPS
suggestions, goals, reasons for delay
suggestions, goals, reasons for delay
summary and final decision, taking ethics
into account
when / where / how, Information for
relatives, debriefing outside of
patient room
Separate columns and rows are used for each profession and according task.
For the handover between EMS and ED ward, it was taken into account that the ABCDE
scheme is an established part of primary care. To enable its further usage, the ABCDE scheme
was integrated completely into the ID-S2A2MPLE-protocol. This new protocol was intended
mainly for the use of the ED staff themselves, but it was also expected of the ambulance staff
to do their handover according to the protocol. Posters hung in the handover area with the
specific protocol scheme portrayed made this achievable. It contained the following information
structure:
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Table 3: ID-S2A2MPLE mnemonic
Mnemonic Meaning of mnemonic Further explanation
ID Identification of patient,
Time and date of admission,
Team
By team, the EMS team which transferred the patient is meant
S₂ Situation In which the patient was found
Symptoms
A₂ ABCDE Standard mnemonic by which the patient’s parameters are obtained in the field
Allergies
M Medication Standard medication of patient, as well as already applied by EMS
P Patient History
L Last meal
E Exploration Information about family doctor, social anamnesis, relatives, home address, living will, etc.
In the end, this scheme was used as a shared understanding aid for EMS- and ED-staff, whilst
the admission was noted done on the ID-PHONE mnemonic. Since most of the work and
information transfer within the ED was structured through the ID-PHONE, it turned out to be
more complicated and time consuming using two different forms of written mnemonics. Since
the ID-S2A2MPLE-mnemonic is hung out on posters in the handover area, ambulance staff can
use it as an aid for structuring their handover.
2.2.2. Survey Questionnaires
The surveys consisted of questionnaires divided into two sections. The first section asked for
a rating of the importance of given items. In the second section, the personal satisfaction with
the respective items was prompted for. The main focus was put on the satisfaction ratings and
their respective change after the implementation of standardized handover protocols.
Importance ratings were obtained for different reasons: It was of interest whether these also
changed through a new protocol and, most importantly, through staff training in communication
and through better communication also stress reduction. Avoiding an integration of satisfaction
ratings of participants, who did not care about certain items, was also achieved through this.
19
This resulted in a more robust, statistical analysis. All questionnaires were handed out to the
ED staff, patients and EMS staff and collected after the completion. Forms which were not
filled out completely were only used if more than half of the questions were answered.
2.2.3. Questionnaires for emergency medical services
The first phase of surveying the EMS took place at the beginning of 2015. In this first phase,
the satisfaction with the already existing ABCDE scheme was evaluated.
One goal of the survey was to evaluate where, according to EMS and ED staff, shortcomings
in the handover process existed. The main goal of survey was to examine the impact the
implementation of the new handover had on its process. Information was sent out to the
different EMS operating in the Freiburg region. These were the German Red Cross (DRK), the
Malteser, the Johanniter and the German Air rescue (DRF). They were informed that the
survey would take place in the ED of the University Hospital of Freiburg and asked to hand this
information on to their fellow colleagues. The questionnaires were given out to the EMS, upon
arrival in the ED ward, together with the admission files for the respective patient. This was
done by the central admission desk of the ED. They were told that the questionnaires were to
be filled out directly after the handover by one of the EMS staff members and returned to the
admission desk. To understand where and how handovers take place, the following flow chart
depicts the proceedings of an emergency case in the UNZ of Freiburg:
20
Figure 1: Workflow from preclinical assessment of the patient to his or her discharge from the emergency department of the University Hospital of Freiburg
21
In the first two weeks of the survey, a person responsible for the survey was present at the
admission desk for several hours per day and helped explain the purpose of the survey, as
well as answer questions regarding the questionnaire. For the most part, these were filled out
thoroughly and diligently. Those which were only filled out by 50% or less were excluded out
of the analysis. The questions which could be answered on an ordinal scale were analysed
statistically, while all other answers (e.g. team allegiance, type of admission, references to time
and date, etc.) as well as written comments, were analysed qualitatively. The questionnaire
(which can be found in German language in the Appendix), comprised following items:
1. General information about date, check-in/-out time, EMS-organisation (DRK, DRF,
Malteser, Johanniter) as well as respective team member (emergency doctor,
4=very important/very satisfied. When calculating the means of the single items, an
approximate of the overall importance or satisfaction in the respective survey group can be
given. This can be done through locating the mean on a continuum of the rating scale.
Since Data was collected before and after the intervention, a comparison will be drawn. “Pre-
intervention” will be abbreviated by “pre” and “post-intervention” by “post”. Furthermore, the
satisfaction ratings were analysed twice: Once including all data collected, and once correcting
for the importance ratings. The latter included only cases in which respondents rated the
respective item as either rather or very important, which corresponds to either a 3 or 4 on the
ordinal scale. This is labelled by: “For all cases, if importance>2”. Whenever an important
difference in the satisfaction ratings can be found, because of varying importance ratings, the
numbers, corrected for importance are used in the analysis.
3.1. Emergency medical service
The staff of the EMS were altogether quite satisfied with the handover process in the ED of the
University Hospital of Freiburg (UNZ). In the survey ahead of the implementation of the new
protocol, they were most satisfied with the collegial atmosphere (mean: 3.68, SD:0.546, N=80)
and least satisfied with the standardized handover (mean:3.17, SD:0.703, N=64). They also
voted a standardized protocol as least important (mean:2.89, SD:0.786, N=82). Even when
3 Fulfilled conditions, in order to be able to use the Mann-Whitney U-test are the following: All the observations from both groups were independent of each other, the responses are coded on an ordinal scale from 1 to 4, under the null hypothesis H0, the distributions of both populations are equal and under the alternative hypothesis H1 distributions are not equal.
27
correcting for the importance rating of standardized protocols, EMS staff were least satisfied
with them before the new protocol implementation (mean:3.26, SD:0.693, N=43). The things
rated most important by the EMS staff were that the data they handed over was complete
(mean:3.62, SD:0.584, N=79) and that the team receiving the handover was complete
(mean:3.63, SD:0.601, N=81). A team is complete when the nurse looking after the patient
post-admission and the attending physicians are present. In a stressful and overrun ED, it can
easily happen that one of these persons are not present at handover. In the UNZ, this rarely
happens though, which can also be seen in the high satisfaction ratings of the EMS staff and
the percentage of times a nurse and doctor were present at handover (pre-intervention (pre):
overall estimated time spent in the UNZ stayed the same though, at 13 mins. All these numbers
are only estimated and can therefore not be relied upon.
Overall, a trend towards less satisfaction for all items, except for waiting time until handover
and completeness of handed-over data, is observed when not correcting for importance
ratings. If only respondents who rated the respective items as rather or very important are
included, a trend towards more satisfaction can be seen for waiting time until handover,
feasibility of patient registration in advance at the admission desk, completeness of handed-
over data and the overall satisfaction with todays handover. None of these trends are
statistically significant.
29
Figure 2: Mean importance rated by Paramedics from the Ambulance Services, pre-and post-intervention
Mean importance rated by Paramedics from the Ambulance Services, pre-and post-implementation of the standardized protocols (pre=2015; post=2017). The scale is ranging from 1= “not important”, 2= ”less important”, 3= ”quite important” to 4= ”very important”. Error bars represent the standard deviation of the mean. N(pre)= 86, N(post)= 87. Statistically significant differences are marked: *=p<0.05.
30
Figure 3: Mean satisfaction rated by Paramedics from the Ambulance Services, pre-and post-intervention, corrected for importance
Mean satisfaction rated by Paramedics from the Ambulance Services, pre-and post-implementation of the standardized protocols (pre=2015; post=2017), corrected for importance: If importance was rated quite or very important, it had a value of >2. Only satisfaction ratings of respondents, rating the respective items as important were included. The scale is ranging from 1= “not satisfied”, 2= “less satisfied”, 3= “quite satisfied” to 4= “very satisfied”. Error bars represent the standard deviation of the mean. N(pre)= 86, N(post)= 87. Statistically significant differences are marked: *=p<0.05.
31
The staff of the UNZ were less satisfied than the emergency medical service (EMS) with the
completeness of the team (mean:3.30, SD:0.912, N=27) and the collegial atmosphere
(mean:3.57, SD:0.573, N=28), before the intervention. They rated the quality of the respective
handovers with a mean of 3.32 (SD 0.772, N=28), which means they were rather satisfied with
the quality. According to the ED-staff, before the intervention, a physician was present during
the entire handover 89% of the time. Only half of the time the EMS protocols were used during
the following treatment in the ED, and in 15% a seamless treatment was not possible due to
missing data. According to the answers of the questionnaire, no incidents occurred where a
patient experienced an adverse event because of missing data.4 No data post-intervention was
obtained.
Figure 4: Importance and satisfaction ratings of handover from EMS to ED, rated by ED-staff
Mean importance and satisfaction rated by staff from the emergency department, pre-implementation of the standardized protocols (t=04/2015). The scale is ranging from 1= “not important/satisfied”, 2= “less important/satisfied”, 3= “quite important/satisfied” to 4= “very important/satisfied”. Error bars represent the standard deviation of the mean. N=26.
The following table displays the different ambulance operators which deliver patients to the
ED.
4 Adverse events can be defined as unwanted incidents, caused by healthcare management, which resulted in a prolonged hospitalization, new disability or death. Rafter et al. 2015
32
Table 4: Number of Ambulance Operators, who filled out the questionnaire during both survey periods. A disclosure was only given in half of the questionnaires.
Ambulance Service Organisation Number of questionnaires answered (this allows an approximate of times, they delivered patients to the UNZ during the survey phase)
DRK (Deutsches Rotes Kreuz) 55
Malteser 23
Johanniter 2
DRF (Deutsche Luftrettung) 12
3.2. Patient and ED-staff
Since patients and ED-staff received a similar questionnaire, some of the responses can be
easily compared. The part of the questionnaire, which was identical for both groups, was
analysed in direct comparison. Question items which were not identical, were analysed
independently.
In general, patients were already quite (45.6%) or very (48.9%) satisfied with the work of the
ED-staff before the intervention. This means that altogether 95% of the patients were satisfied.
The intervention that followed was a communication training and explanation of the new inter-
shift handover procedure for ED-staff, which also pays special attention to the communication
with the patient. Thereafter, the overall patient satisfaction rose to 97.5%. Considering that the
satisfaction ratings were already very high, this was rather surprising. 59% were very satisfied
and 38.5% quite satisfied with their stay and treatment by the end of 2016.
The least satisfied patients were those, who had been in the emergency ward for 4-6 hours.
This accounts especially for information about the waiting time, where 33% were not satisfied,
and information about the estimated length of stay, where 40% were not satisfied. Also,
information about the next steps becomes increasingly important with time spent in the ED, as
patients become increasingly less satisfied with this information. This is observed before as
well as after the intervention. As shown in Figure 5, information about the next steps given
from ED staff was one of the most important items for patients (pre: mean: 3.76, SD: 0.455,
N=88; post: mean: 3.9, SD: 0.307, N=39; p=0.096). Most important was the expertise of the
followed by the comprehensibility of the explanations (pre: mean: 3.90, SD: 0.300, N= 91; post:
mean: 3.88, SD:0.335, N=40; p=0.657). These three parameters remained the most important
33
ones for patients throughout. As expected, most importance ratings of the questioned
parameters did not change significantly (see Figure 5). We did not expect a change of the
importance ranking of patients due to an intervention within the ED, since they did not take
part in the changing process and the patient collectives were completely independent from
each other. Surprisingly one item changed significantly (p=0.032): The importance rating of
being given the opportunity for questions rose from 3.63 (SD: 0.532, N= 87) to 3.84 (SD: 0.37,
N=38). This needs to be controlled for, in the analysis of the satisfaction ratings.
34
Figure 5: Mean importance rated by patients and emergency department staff pre-and post-intervention
Mean importance rated by patients and emergency department staff pre-and post-implementation of the standardized protocols (pre=2015; post=2016/2017). The scale is ranging from 1= “not important”, 2= “less important”, 3= “quite important” to 4= “very important”. Error bars represent the standard deviation of the mean. The range of the number of respondents (N) results from the fact that not all the items were answered by all of the respondents. Statistically significant differences are marked: *=p<0.05.
35
We expected to observe an influence of the intervention on the satisfaction ratings of patients.
A trend towards more satisfaction was observed in all questioned parameters, although without
achieving any statistical significance. The satisfaction with the two most important items
(professional competence of the doctor and that explanations are understandable) was quite
high, both before and after the intervention: 94% were very or quite satisfied with the
comprehensibility of the explanations given by the staff before the intervention in 2015 (N=84)
and 97.8% afterwards in 2016 (N= 39; p=0.612). The ratings for professional doctoral
competence were quite similar, 97.3% (N=87) before and 97.1% (N=38) after the intervention
stated to be satisfied with this (p=0.583). In both time slots these were one of the three
parameters they were most satisfied with. This means that the items most important for
patients were also rated most satisfying. This cannot be said for information about the next
steps. It was rated as the third most important item, but satisfaction ratings were moderate,
compared to the other items.
Figure 6: Comparison of satisfaction ratings of the three most important items rated by patients
Pre- (N= 58-80) and post- (N=32-40) implementation of the ID-Phone Protocol (pre=2015; post=2017). Numbers are noted in rounded percentages. No statistical significance was found, differences in percentages can be seen as trends. The range of the number of respondents (N) results from the fact that not all the items were answered by all of the respondents.
36
Before the communication training, the ED staff thought the importance of understandable
explanations to be significantly lower than rated by patients (ED-staff: mean:3.63, SD:0.5,
N=24; patients: mean:3.9, SD:0.3, N=91; p=0.001). This was not observed for the second
survey round, here ED staff rated understandable explanations more important than before
Table 5: Importance ratings, comparing ED staff and patients, pre- and post-intervention Table is illustrating the mean, Standard Deviation (SD) and Number (N) of the respondents of the questionnaire. Pre-intervention (t=1): 04/2015. Post-intervention (t=2): 2016/2017.
Importance Ratings
Pre-intervention (t=1) Post-intervention (t=2)
Patients ED- staff
Patients ED-staff
Mean (SD)
N Mean (SD)
N Mean (SD)
N Mean (SD)
N
Waiting time until first contact
3.58 (0.56)
90 3.71 (0.46)
24 3.45 (0.60)
40 3.53 (0.64)
15
Information given about waiting time
3.29 (0.72)
80 3.67 (0.48)
24 3.18 (0.80)
38 3.8 (0.41)
15
Explanations are understandable
3.9 (0.3)
91 3.63 (0.5)
24 3.88 (0.34)
40 3.73 (0.46)
15
Opportunity for questions given
3.63 (0.53)
87 3.42 (0.65)
24 3.84 (0.37)
38 3.73 (0.46)
15
Integration of patient's reference person
3.42 (0.81)
79 3.13 (0.76)
23 3.39 (0.75)
33 3.14 (0.77)
14
Explanations about the next steps
3.76 (0.46)
88 3.42 (0.65)
24 3.9 (0.31)
39 3.57 (0.51)
14
Information about expected length of stay
3.43 (0.69)
88 3.46 (0.72)
24 3.5 (0.83)
38 3.38 (0.65)
13
Professional competence of doctor
3.93 (0.26)
87 3.48 (0.59)
23 3.93 (0.27)
38 3.21 (0.8)
14
Understandable explanations of given medication
3.6 (0.57)
78 2.54 (0.88)
24 3.74 (0.51)
35 2.86 (1.03)
14
Doctor greets patient personally
3.31 (0.76)
90 3.5 (0.59)
24 3.18 (0.8)
38 3.53 (0.83)
15
Relaxed atmosphere during rounds
3.47 (0.61)
88 3 (0.59)
24 3.55 (0.65)
38 3.27 (0.59)
15
Patient has the possibilty to report about his/her illness
3.38 (0.73)
91 3.42 (0.65)
24 3.53 (0.69)
38 3.47 (0.64)
15
Staff is being responsive to patient's fears
3.37 (0.77)
90 3.21 (0.72)
24 3.47 (0.74)
36 3.73 (0.46)
15
Enough time for patients to talk
3.7 (0.49)
90 3.5 (0.66)
24 3.74 (0.45)
38 3.8 (0.41)
15
37
As seen in Table 5, Explanations about medication was rated least important by doctors as
well as by nurses at both surveying times (mean:2.66, SD:0.94; N=38 pre-and post-
intervention combined), whereas patients did find this very important (mean:3.65, SD:0.55,
N=113 pre-and post-intervention combined). It was one of the three parameters they were
least satisfied with: 15.2% said they were either less or unsatisfied. Figure 7 shows that less
than half of the patients were very satisfied. This changed after the intervention: 62.5% rated
the explanations about medication very satisfying in 2016 and only 9.4% were either less or
unsatisfied (p=0.117). Though the staff of the UNZ thought information about waiting time to
be significantly more important than the patients did (p=0.020), it was the parameter patients
were least satisfied with (pre: mean:3.29, SD:0.72, N=80; post: mean:3.18, SD:0.8, N=38;
p=0.736). The staff members did however, correctly rate information about waiting time as one
of the parameters they perceived patients to be least satisfied with. Additionally, Information
about duration of stay in the ED was rated dissatisfying by patients (pre: mean:3.43, SD:0.69,
N=88; post: mean:3.5, SD:0.83, N=38, p=0.526) (see below in Figure 8).
Figure 7: Comparison of satisfaction ratings of the three items rated by patients as most unsatisfying
Pre- (N= 58-80) and post- (N=32-40) implementation of the ID-Phone Protocol (pre=2015; post=2017). Numbers are noted in rounded percentages. No statistical significance can be, differences in percentages can be seen as trends. The range of the number of respondents (N) results from the fact that not all the items were answered by all of the respondents.
38
In these items a trend towards more satisfaction can be seen. This can also be said for all
other questioned items and the general satisfaction of the patients with their treatment. The
general high levels of satisfaction are particularly interesting, because the ED-staff themselves
perceived patients to be significantly less satisfied than what was found through the survey. In
every single item ED-staff rated patients to be less satisfied, than they actually were. This trend
was consistent for both surveying times, with the lone exception being the question about the
professional competence of the doctor. The professional competence of the physician was
rated with a mean of 3.66 (SD:0.53, N=74) pre-intervention and with a mean of 3.71 (SD:0.52,
N=35) post-intervention (p=0.583). This shows patients to be very satisfied with the
competence of their attending doctor. This was also the item, the ED-staff were most satisfied
A statistical difference between the patient’s and ED-staff satisfaction ratings was observed
only before the intervention (p=0.000). After the intervention, no statistical difference in the
satisfaction rating with the professional competence of the attending doctor can be found
(p=0.116). In all other items, the ED-staff is significantly less satisfied with their work and the
treatment of the patients, than the patients themselves are (p<0.05). This is true for both
timepoints, before and after the intervention.
The parameter patients were most satisfied with was the personal greeting by the doctor in
charge (pre: mean:3.69, SD:0.54, N=80; post: mean:3.84, SD:0.37, N=38; p=0.145). This was
followed by the professional competence of the doctor (numbers mentioned above) in charge
and the understandability of the given explanations (pre: mean:2.6, SD:0.6, N=84; post:
mean:3.67, SD:0.53; N=39; p=0.612). This chronological order of most satisfying items stayed
the same for both points in time. For more information see below Figure 8. Before the
intervention, ED-staff was also most satisfied with the personal greeting by the doctor in charge
(mean:3.14, SD:0.71, N=22), followed by professional competence of the doctor (numbers
mentioned above) and that the patient has the possibility to talk about his/her illness (mean:2.8,
SD:0.616, N=20). After the intervention this changed to a small degree: the professional
competence of the doctor becomes the most satisfying item (numbers above) followed by the
personal greeting (mean:3.23, SD:0.725, N=13) and that explanations are understandable
(mean:2.77, SD:0.832, N=13).
A very interesting phenomenon is that the satisfaction of the staff with a relaxed atmosphere
during rounds decreased significantly (pre: mean:2.45, SD:0.67, N=22; post: mean:1.85,
SD:0.56, N=13; p=0.022). This was the only item that showed a significant change after the
intervention for the satisfaction ratings and the one they were least satisfied with in the second
questionnaire round. Furthermore, patients did not become less but rather more satisfied with
this (pre: mean:3.46, SD:0.693, N=80; post: mean:3.62, SD:0.633, N=39; p=0.205).
39
In general, the staff of the UNZ perceive patients to be less satisfied with their work than they
are. Before the training and new communication guidelines, only 9.5% thought that patients
were very satisfied in all 14 Items and 49.3% thought they were quite satisfied before the
intervention. This means that about 40% of the staff believed patients not to be satisfied with
the work of the ED. In 2016, this did not change much, 12% believed patients to be very
satisfied while 44.8% thought they were quite satisfied.
40
Figure 8: Mean satisfaction rated by patients and emergency department staff pre-and post-intervention
Mean satisfaction rated by patients and emergency department staff pre-and post-implementation of the standardized protocols and staff training (pre=2015; post=2016/2017). The scale is ranging from 1= “not satisfied”, 2= “less satisfied”, 3= “quite satisfied” to 4= “very satisfied”. Error bars represent the standard deviation of the mean. The range of the number of respondents (N) results from the fact that not all the items were answered by all of the respondents. Statistical significant differences are marked: *=p<0.05.
41
3.3. Stress coping and communication mechanisms
Although more than half of the staff stated that they were somewhat familiar with
communication and stress reduction techniques before the training, 40% did not know or use
techniques to cope with stress (see Table 6: Perception and use of stress management
and communication techniques by ED-staff). After the training, 80% of the staff felt confident
in stress reduction techniques. This leaves only 20% which did not know or use these
techniques confidently. Also, techniques for communication were better known to the staff after
the training.
According to the staff, ward rounds became better structured and the structure known to all.
The percentage of staff who completely agreed with this rose from 12.5% before the new
handover, to 26.7% afterwards. Furthermore, the nursing staff received a better-defined role
during handovers, which enabled them to bring in important information about the patient (see
Table 6: Perception and use of stress management and communication techniques by
ED-staff). Less respondents thought that handover or discharge of patients followed a known,
written documentation. Also, less staff knew which information patients need for a successful
discharge and treatment at home (92% knew what was needed beforehand, 73.3%
afterwards).
23 of 25 respondents believed that the information transferred during rounds was very much
dependent of which doctor was doing the rounds. This did not change after the training and
handover protocol introduction, however. Also, all of the post-intervention questioned
personnel believed that the transfer of information is strongly dependent on the person,
handing over.
Structured, written protocols were used in 30% of the time before the implementation of the
new protocol. Three months after the training, written protocols were used in 43% of the time.
Fortunately, after the intervention 73.3% of the staff felt that patients have the possibility to talk
about their experience of their disease, compared to 60.8% beforehand. This could potentially
be a result of an increased focus on, and improved communication with the patient. In 80% of
the cases, the patient and her or his well-being, was the centre of attention during ward rounds.
17.5% more cases than in 2015. It should be noted that all these results should be
acknowledged as general trends, as none showed a statistical significance (p>0.05).
42
Table 6: Perception and use of stress management and communication techniques by ED-staff
Share of ED staff, who rated the listed items according as to how often they applied for in their personal reality. Share is given in percentages of the total numbers. Separated by the surveying times: T=1: 04/2017, T=2: 10/2016. Respondent numbers being N(t=1)= 26 and N(t=2)= 15.
Perception and use of stress management and communication techniques by ED-staff
True True most of the time
True less often Not true
I know and use communicative techniques, which help to communicate effectively with the patient
T=1 20% 60% 20% 0%
T=2 26.7% 60% 13.3% 0%
I know and use communicative techniques, which help to communicate effectively with my team and supervisor
T=1 16% 56% 24% 4%
T=2
26.7% 53.3% 20% 0%
I know and use deliberatively techniques, which help me to cope with stress
T=1 20% 40% 36% 4%
T=2 35.7% 35.7% 28.6% 0%
The procedure and involvement of patients during the ward rounds is strongly dependent on the round-leading physician
T=1 58.3% 33.3% 8.3% 0%
T=2 80% 20% 0% 0%
Ward rounds are clearly structured. This structure is known to all people involved and everyone has a defined responsibility
T=1 12.5% 50% 20.8% 16.7%
T=2
26.7% 46.7% 13.3% 13.3%
During ward rounds, the patient is the centre of attention and her or his well-being is elevated through communication
T=1 12.5% 50% 25% 12.5%
T=2 6.7% 73.3% 13.3% 6.7%
The nursing staff have a set, clearly defined role at every ward round and bring in important information about the patient
T=1 8.3% 37.5% 37.5% 16.7%
T=2
13.3% 60% 13.3% 13.3%
The patient is given the opportunity to report about her or his personal experience of the illness
T=1 13% 47.8% 21.7% 17.4%
T=2 20% 53.3% 13.3% 13.3%
43
The handover follows a known, written documented procedure
T=1 4% 28% 44% 24%
T=2 0% 46.7% 20% 33.3%
During the handover of patients, the transfer of information is strongly dependent on the person, handing over
T=1 52% 32% 12% 4%
T=2 66.7% 33.3% 0% 0%
The discharge of patients follows a known, written documentation
T=1 20% 44% 28% 8%
T=2 13.3% 26.7% 40% 20%
I know, which information patients need for a successful discharge to their home and make sure that these are transferred
T=1 32% 60% 0% 8%
T=2 33.3% 40% 20% 6.7%
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4. Discussion
The literature highlights the importance of structured handovers for patient safety, shared
understanding, stress reduction and greater staff- as well as patient satisfaction. Our results
show a more diverse picture. They show that patient satisfaction is generally elevated through
standardized handover protocols and procedures. This general trend cannot be seen in staff
satisfaction. Training is of major importance to successfully implement a new handover
scheme, which is accepted by the staff. Furthermore, a substantial misjudgement on the part
of the ED-staff was found, concerning what they believed patients to be of importance. We
collected information about the importance and satisfaction of staff and patients. This allows
us to take up subjective opinions and feelings of the affected individuals. We were not able to
collect objective data on patient safety or the like. This section discusses the implications of
these results, shortcomings of this survey and indications for further research. Since we
performed two interventions, at two different check-points, with two different mnemonics, the
results of these are also discussed separately.
4.1. New Mnemonics for different operators: ID-S2A2MPLE
The introduction of the ID-S₂A₂MPLE Mnemonic for the handover checkpoint of the ambulance
service, did not show any effect on the satisfaction ratings with the handover process. On the
contrary, there was rather a trend towards less satisfaction post-intervention. This is a puzzling
result we did not expect, especially concerning communication and collegial atmosphere. Here
the satisfaction reduced significantly. This might be because of the different backgrounds and
working places (Meisel et al. 2015). Ambulance staff and hospital staff have a different
education and working field, as well as different workflows. How to deal with communication
problems with people who come from a different provider and have different fields of operation
was not part of the training the ED-staff received. However, it is a very crucial point of
communication failure and should be addressed for both sides. Here, it would be especially
important to have regular communication trainings for both, ambulance and ED-staff. Training
only one side, would not be sufficient to enable a firm understanding and efficient
communication on both sides. The survey only included questioning the EMS, but since the
staff come from different providers and do not belong to the university hospital, no training for
these was done. Only a short introduction of the new ID-S₂A₂MPLE Mnemonic was sent to the
different ambulance providers. The respective provider was asked to inform its employees, but
this off course could not be secured from our side. On the other hand, the ED-staff did receive
communication and stress coping training. This was done during the implementation process
of the ID-PHONE, where a definite trend towards more satisfaction of the patients can be made
out. The results underline the already existing studies that new mnemonics and
45
handovers only contribute to a better handover, if they are accompanied by training
(Owen et al. 2009; Manias et al. 2016). This might explain, why satisfaction ratings show no
rise, but rather a fall or stagnation by the ambulance staff.
We do not know what schooling the ambulance staff receive and can therefore interpret their
returned survey sheets only as to whether the communication training accompanying the ID-
PHONE implementation also enhanced communication between the different professions and,
as to whether the new mnemonic bettered the handover.
What can be said, is that EMS staff perceived structure in handovers to be more important
after the implementation of the new handover. They were not more satisfied with it but
recognized that it was important to have a structure, set responsibilities and specifications of
this process. Off course, the EMS already have a protocol, by which they operate. This is also
used for handover. Since it is quite detailed, the idea was to simplify this protocol and create a
shared mnemonic, by which ED and ambulance staff go. This should lead to creating a
common ground of understanding and demands. What we observed was the ID-S₂A₂MPLE
Mnemonic not actually being used as such for the handover though. The reality showed that
for ED-staff, the ID-S₂A₂MPLE mnemonic was used as a guideline and ground of shared
understanding. The ID-PHONE was used by the ED-staff for noting down the handover
information. The EMS staff have their own protocol given by their operator. They leave this
protocol with the data of the patient, at the hospital. This is the reason, they rather go by their
protocol than by the new mnemonic. Nevertheless, a poster with the ID-S₂A₂MPLE Mnemonic
is displayed at the area of handover, for staff to orientate themselves. In practice, ED-staff use
the ID-PHONE Mnemonic to note down the patient’s data and EMS-staff orientate themselves
with the help of ID-S₂A₂MPLE. Whenever there is confusion in structure or questions about
missing information, the ID-S₂A₂MPLE poster can be used for a common operating ground.
We did not set a timer, to allocate the waiting and handover time of the EMS staff but asked
for an estimate by the latter. The EMS staff estimated both time periods to have risen after the
intervention, by 30 seconds to one minute. Interestingly they estimated the total amount of time
spent in the ED the same in both time slots, at 15 minutes. These numbers cannot be used
statistically in the analysis, since they cannot be objectified. It is nevertheless interesting, to
see that there is a feeling of more time needed for handing over the patient. This reflects the
controversy in the literature. If a more structured handover is introduced, it should, in theory,
reduce handover time. In practice, most studies have shown that it increases handover time,
because of it being more detailed (Keebler et al. 2016, p. 1196), (Lendemans 2012, p. 301).
Our results show a similar trend. To make assumptions or statements about these time issues,
an objective time measurement would be necessary.
46
Furthermore, we only questioned ED-staff about their satisfaction with the handover and
included information before the new mnemonic was introduced. It would have been interesting
to see, whether ED-staff satisfaction changed or also stayed the same. Also, how often they
used the protocol of the ambulance after the intervention.
Before the intervention only half of the time, the protocol of the EMS was used after handover,
for further treatment. The question, which poses itself here is, why this is not done more often,
and whether this could bring a stronger improvement, than changing the already trained
handover structure of the EMS. Since the services do not only deliver to one hospital, but many
different ones, it should pose quite a challenge to adapt to different handover structures at
each hospital. It would make more sense, to train the ambulance staff regularly on how to
structure a handover properly and what data is of importance for the further treatment. At the
same time, hospital staff should be trained on communicating with staff from other
backgrounds and to structure their own uptake of information and questions. Simulation
trainings and feedback thereafter on a regular basis, would be of need. Since this can only be
done in a joint effort, with enough finances, the importance of this needs to be recognized by
all operators involved, and regular training be set as a top priority for patient safety. The results
show that only implementing a new structure, does not bring about the desired effect.
4.2. Training and new handover: ID-PHONE
This can be underpinned by the second section of the survey, namely the implementation of
the ID-PHONE Mnemonic, for handovers within the department and the concomitant training.
Here, the new handover scheme was communicated to all people involved, it was
accompanied by a training of the multipliers thereof, and specified on sheets, used in the
treatment of patients. It was also adjusted to the needs of the specific department after a trial
period. All leading physicians agreed to the new structure and made sure, it was applied during
handover and ward rounds. This may be the reason, why unlike the EMS staff, patients as well
as ED-staff to a certain extent were more satisfied with the handling of the patients’ treatment
in the second survey round. Another important finding was that patients were already very
satisfied with the work of the ED before the intervention. The staff on the other hand did
not believe their work to be satisfying for the patient. They were not able to estimate their
patients’ satisfaction with their treatment, or what was important for them, correctly. As shown
in the results, they do not know, what is really important for the patient. Information about
medication is rated as least important for patients, which is a complete misjudgement. This
information is indeed important for patients and rated as one of the things, they were least
satisfied with. Apparently, staff believe patients to have other worries, during their stay,
supposedly more pressing. The results show though that patients would like to generally be
47
better informed. This probably gives them a feeling of having somewhat control, in a situation
where they actually are out of control for the most part. This can also be seen in the low
satisfaction ratings on information about waiting time and information about the time duration
of their stay in the ED. It is noticeable that patients were least satisfied with the information
they got. The actual treatment they received was, for the most part, very satisfying in their
opinion. Communicating with the patient, letting them know, what is happening and when, is a
crucial point, which should be set high on the importance scale of the ED.
The least satisfied are those, who have been in the ED for 4-6 hours. Often, these are the
patients, which have passed the acute phase of their diagnostic and treatment successfully
and would now like to leave the ward, or at least receive some more information, e.g. about
the next steps. The problem of relocating patients to other wards within the hospital, is already
being tackled by the department. It put a substantial amount of extra stress on the staff, having
to organize beds for the admitted patients, since more than often, no other ward had enough
beds, to take up new patients. For this purpose, the department engaged an extra workforce,
who is exclusively responsible for the discharge and relocation of outgoing patients. Verbal
feedback allowed to draw the conclusion that this already reduces the stress of the staff
substantially and allows a better workflow.
The problem of keeping patients in the ED too long, is a worldwide phenomenon. In the UK, it
was tried to tackle this, by setting a rule, by which every patient arriving at an emergency ward
must be treated and discharged within 4 hours (Jones and Schimanski 2010). This is quite a
high set goal and can cause more stress, than lower it. Which is the reason, the target was set
for only 95% of the emergency cases in the meantime, and a discussion about the benefit for
patient security is still ongoing (Hughes 2010), (Campbell) But it shows the importance for fast
treatment and discharge, also having in mind the patient’s safety and satisfaction.
A very rewarding result is the great satisfaction with the professional competence of the
doctor, on both sides. Apparently, the patients as well as the staff believe their work to be
professional and satisfying. In the second survey round, no statistically significant difference
existed between the satisfaction ratings of staff and patients on this topic. What could have
been a trigger for this boost in satisfaction, making it the item the staff was most satisfied with,
is the presentation of the results of the first round of the survey. A poster was displayed in the
ED, showing that patients were already very satisfied with the work of the ED and that the staff
falsely estimated them not to be. This might have given them more confidence in their work.
Noticeable here, is the comparable low satisfaction with themselves on the non-professional,
interpersonal level. It seems that they are not confident with themselves on the non-technical,
communication-level but much more confident on the technical, medical knowledge-based
level. This is no great surprise, since knowledge of medical facts and interventions, is the basis
48
of today’s education. Non-technical skills, that is cognitive and social skills, on the other hand
are neglected in the medical education and training, especially in the German setting, but there
is also literature on this neglect being apparent in North America (Manser et al. 2010; Gordon
et al. 2017; Gordon et al. 2012, p. 1043; Raduma-Tomàs et al. 2011). Here, not only
appropriate communication, but also stress reduction techniques play a major role (Ríos-
Risquez and García-Izquierdo 2016; Ratanawongsa et al. 2012). This is a field, where regular
training and more focus, already in the basic medical education, is necessary.
The study showed that already one training session for communication and stress
management has a positive impact. Ward rounds and handovers are better structured, the
nursing staff has a better-defined role, more people use written, structured protocols and the
patients feel to have more possibility to talk about their experience of illness. Also, the staff
indicates that there was an advancement in their own techniques to deal with stress and to
communicate effectively. This could be a result of the training and thereafter better structure
of the processes in the ED. Here more surveys would need to be done, before and after
training, and more staff should take part in this. Furthermore, the training itself should be
analysed and best practices drawn from it. Through this, recommendations for further trainings
can be compiled and the direct impact of the training, independently from other restructuring
processes, analysed.
4.3. Downfalls and recommendations for further research
The aim of this study was to examine what impact a better structure in handovers and training
in non-technical skills have on the satisfaction of patients and staff. Satisfaction is off course a
very important parameter, for measuring the success of this intervention. In theory though,
such an intervention should primarily have a positive influence on patient safety. We were not
able to gather information about this aspect, although it was the overall goal we wanted to
achieve with this intervention. A further theory, of other studies is that less stress of the staff
also leads to better treatment and therefore less adverse events. Since a great amount of data
would have been necessary, to allocate data about the outcome of the patient’s treatment and
the reason for this, we were not able to include this aspect into our survey. This leaves us not
being able to verify the theory that better structured handovers and NTS training lead to less
adverse events and therefore greater patient safety. Additionally, the subjectivity of the
answers and specific setting of the surveyed ED, hinders the study to be objectively
comparable. Therefore, we can make conclusions and recommendations for the Freiburger
University setting of the emergency department, but not compare it to other settings or surveys.
Another pitfall of this study is the size of the questioned collective. We had quite some
difficulty, acquiring enough emergency personnel, in order to make statements about the
49
statistical significance of the results. This was due to different reasons: on the one hand,
there is only a limited number of employees, which could be questioned. On the other hand,
the high working load as well as stressful and time critical treatment of the patients, leaves
staff with only little spare time on their hands. The main reasons for not filling out the
questionnaire, were not having enough time for doing so, staff forgetting about filling them
out, or that they were annoyed by this task and refused to fill out the sheets. Here, less
question items would have probably raised the compliance. We face similar difficulties with
the EMS, although they had somewhat more time to fill out the sheets. Here, we took out
several question items after a trial run, which were not of such great importance for the
analysis of the intervention. This elevated the compliance.
For future research, a bigger case number would be of great importance. This would allow for
more statements on the findings, which can be statistically underpinned. Since this is a case
study on the specific setting of the University Hospital of Freiburg, a generalization cannot be
done. The structure and training were adapted to the demands of the department and can
therefore not generally be used in other emergency department settings. But
recommendations for other houses can be posed, with the annotation, to adapt this to their
respective setting and evaluate its success and applied changes. In order to really implement
a certain handover scheme in the minds of the different ambulance operator staff, it would be
sensible, to implement the same handover scheme in all hospitals, these operators deliver
patients to. In our case, these would be the hospitals of Freiburg and its surroundings. This,
on the other hand, probably cannot be done, without a strong combined effort of all of these
hospitals. For now, only recommendations, collected through this study, can be transferred to
other institutions, with the call for more similar studies on this topic. Another limiting factor of
this study is the fluctuation of the ED-staff. To control for rating fluctuations because of personal
reasons, it would make sense to question the same person before and after the intervention.
Especially when having such a small case number, as found for the ED-staff. This was not
possible, due to a part of the physicians only rotating into the ED for a limited amount of time.
To make statements on the influence this kind of intervention has on patient safety, other data
needs to be collected. The study would need to be conceptualized on a larger scale, collecting
patient data on their treatment and outcome. Here, a detailed analysis of the reasons for
adverse events would need to be made before and after the intervention. In addition to that, it
would be of great interest to analyse the influence NTS training has on staff stress levels and
patient safety. It would make sense to do this training concomitantly, but this makes it hard to
distinguish the respective influence. Separate training sessions, independently from
restructuring processes, could help filter out the lone effect NTS training has. In general, more
50
studies on these kinds of interventions in Germany would be necessary, in order to compare
findings and formulate best practices.
What has not been discussed in this paper at all but is of great importance for the treatment of
patients in the future, is the growing digitalization. In the Freiburger UNZ the patient sheet, filed
out by ambulance staff, is in the process of being digitalized. This means that all information
will be available in the digital form and therefore easier to access. The digitalization has in
general far reaching consequences for treatment and information collection and transfer. This
is quite a big topic, which opens a whole new field of discussion and would need separate
studies. It is however, an important topic for handover structures and will have a crucial
influence on handover practices.
51
5. Conclusion
This survey was conducted to examine the influence standardization of handover structure has
on the satisfaction of patients and staff in an emergency department (ED), as well as in the
emergency medical service (EMS). New handover mnemonics were introduced.
Concomitantly surveys depicting what is of importance for patients and staff and how satisfied
they are with the current workflow, were carried out. The new handovers implemented were
the ID-PHONE mnemonic for handovers between shifts in the emergency department, and the
ID-S2A2MPLE mnemonic for handovers between EMS and ED. Furthermore, the benefits
additional training on communication, stress management and structuring information has on
satisfaction, was considered. The overall question in mind was, whether standardizations of
handovers bring about an actual benefit to the workflow, as well as care and treatment of the
patients. The study was conducted as a case study in the emergency department of the
University hospital of Freiburg, Germany.
Our findings show that first and foremost, patients were already very satisfied with the work of
the physicians and nurses of the emergency department. The staff on the other hand estimated
their work less satisfying. Especially on items concerning non-technical skills, like
communication, information-transfer, stress-management and the like, they were significantly
less satisfied with their work, than the patients were, except for their professional performance.
Items, the patients rated least satisfying all concerned aspects of information transfer.
Information about medication, waiting time and the time of their stay in the ED were the three
items they were least satisfied with. Although satisfaction ratings of patients were already quite
high, an overall trend towards more satisfaction in the second survey round was observed.
The same can be said for the ED-staff satisfaction ratings. The ambulance staff on the other
hand, showed no change in their satisfaction. Although a statistically significant rise of the
importance rating of standardized protocols and handover time was observed. Whether or not,
this intervention has an influence on the quality of care and treatment and can raise patient
safety, has yet to be shown.
The two different trends in satisfaction ratings between EMS and ED staff, underpin the theory
that new handover protocols are most beneficial, if accompanied by a communication training.
This training was conducted during the survey period, but only for ED-staff. The results also
lead to the conclusion that non-technical skills are an important but often neglected factor,
contributing to the quality of care. More training in this field could reduce stress and raise the
satisfaction of the staff. This was not verified statistically, since there was no direct comparable
control group with a similar setting and working background, which did not receive any training.
Studies conducted on this topic in the US, support this assumption though (Dawson et al. 2013;
Owen et al. 2009).
52
This survey feeds into the literature on the importance of standardized handovers. This field of
research has grown significantly in the anglophone countries, but not yet established itself in
German emergency medicine research. Since this is only a case study, it is of great
importance, to have further case studies of this kind for comparison in the German emergency
care setting. Additionally, a study analysing the influence these interventions have on patient
safety would bring about a great contribution to the literature. This study can be used as a
basis and support for further research on handovers in the German emergency medicine
sector.
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VI. Publication bibliography
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Anagnostopoulos, Fotios; Liolios, Evangelos; Persefonis, George; Slater, Julie; Kafetsios, Kostas; Niakas, Dimitris (2012): Physician burnout and patient satisfaction with consultation in primary health care settings. Evidence of relationships from a one-with-many design. In Journal of clinical psychology in medical settings 19 (4), pp. 401–410. DOI: 10.1007/s10880-011-9278-8.
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VII. Appendix
Figure 9: Ambulance service questionnaire
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Figure 10: Patient questionnaire
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Figure 11: German version of the ED-staff questionnaire concerning stress management techniques and patient treatment
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Table 7: English translation of the ED-staff questionnaire concerning stress management techniques and patient treatment
1. Communication and stress
1.1. I know and use communicative techniques, which help to communicate effectively with the patient
1.2. I know and use communicative techniques, which help to communicate effectively with my team and supervisor
1.3. I know and use deliberatively techniques, which help me to cope with stress
1.4. The communication with colleagues is a substantial factor of stress for me
1.5. The communication with patients and/or their relatives is a substantial factor of stress for me
1.6. The communication with fellow residents/ superiors is a substantial factor of stress for me
2. Ward rounds
2.1. The procedure and involvement of patients during the ward rounds is strongly dependent on the attending round-leading physician
2.2. Ward rounds are clearly structured. This structure is known to all people involved and everyone has a defined responsibility
2.3. During ward rounds, the patient is the centre of attention and her or his well-being is elevated through physician-patient communication
2.4. The nursing staff have a set, clearly defined role at every ward round and bring in important information about the patient
2.5. The patient is given the opportunity to report about her or his personal experience of the illness
3. Patient handover
3.1. The handover follows a known, written documented procedure
3.2. During the handover of patients, the transfer of information is strongly dependent on the physician/nurse handing over
4. Discharge of patients
4.1. The discharge of patients follows a known, written documentation
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4.2. I know, which information patients need for a successful discharge to their home and make sure that these are transferred
5. General
5.1. Our organisation and communication are directed towards the support of patient satisfaction and their well-being
5.2. My work is directed towards satisfying the patient in the best possible way
5.3. My work is directed towards satisfying my colleagues in the best possible way
5.4. My work is directed towards satisfying my superior in the best possible way
5.5. My work is directed towards satisfying myself in the best possible way
6. Specification of team data: profession, time span already employed, like/dislike working in the UNZ
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Figure 12: Questionnaire for ED-team concerning handover from emergency medical service to ED
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Figure 13: Freiburger ID-S2A2MPLE scheme
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Figure 14: Freiburger ID-PHONE scheme
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Figure 15: Freiburger ID-PHONE-handover scheme, with the specific tasks each position needs to fulfill
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VIII. Conflict of interest
The authors of this paper certify that they have no affiliations with or involvement in any
organization or entity with any financial interest (such as honoraria; educational grants;
participation in speakers’ bureaus; membership, employment, consultancies, stock ownership,
or other equity interest; and expert testimony or patent-licensing arrangements), or non-
financial interest (such as personal or professional relationships, affiliations, knowledge or
beliefs) in the subject matter or materials discussed in this manuscript.