UC Irvine

Western Journal of Emergency Medicine: Integrating Emergency

Care with Population Health

Title
Emergency Physician Awareness of Prehospital Procedures and Medications

Permalink
https://escholarship.org/uc/item/5q45n08c

Journal
Western Journal of Emergency Medicine: Integrating Emergency Care with Population
Health, 15(4)

ISSN
1936-900X

Authors
Waldron, Rachel
Sixsmith, Diane

Publication Date
2014

DOI
10.5811/westjem.2014.2.18651

Copyright Information
Copyright 2014 by the author(s).This work is made available under the terms of a Creative
Commons Attribution-NonCommercial License, available at
https://creativecommons.org/licenses/by-nc/4.0/

Peer reviewed

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University of California
 Original Research

Emergency Physician Awareness of

Prehospital Procedures and Medications
Rachel Waldron, MD New York Hospital Queens, Department of Emergency Medicine, Flushing, New York
Diane M. Sixsmith, MD, MPH

Supervising Section Editor: Christopher Kahn, MD, MPH

Submission history: Submitted June 25, 2013; Revision received February 13, 2014; Accepted February 21, 2014.
Electronically published May 21, 2014
Full text available through open access at http://escholarship.org/uc/uciem_westjem
DOI: 10.5811/westjem.2014.2.18651

Introduction: Maintaining patient safety during transition from prehospital to emergency department
(ED) care depends on effective handoff communication between providers. We sought to determine
emergency physicians’ (EP) knowledge of the care provided by paramedics in terms of both
procedures and medications, and whether the use of a verbal report improved physician accuracy.

Methods: We conducted a 2-phase observational survey of a convenience sample of EPs in an

urban, academic ED. In this large ED paramedics have no direct contact with physicians for non-
critical patients, giving their report instead to the triage nurse. In Phase 1, paramedics gave verbal
report to the triage nurse only. In Phase 2, a research assistant (RA) stationed in triage listened to
this report and then repeated it back verbatim to the EPs caring for the patient. The RA then queried
the EPs 90 minutes later regarding their patients’ prehospital procedures and medications. We
compared the accuracy of these 2 reporting methods.

Results: There were 163 surveys completed in Phase 1 and 116 in Phase 2. The oral report had
no effect on EP awareness that the patient had been brought in by ambulance (86% in Phase 1
and 85% in Phase 2.) The oral report did improve EP awareness of prehospital procedures, from
16% in Phase 1 to 45% in Phase 2, OR=4.28 (2.5-7.5). EPs were able to correctly identify all oral
medications in 18% of Phase 1 cases and 47% of Phase 2 cases, and all IV medications in 42% of
Phase 1 cases and 50% of Phase 2 cases. The verbal report led to a mild improvement in physician
awareness of oral medications given, OR=4.0 (1.09-14.5), and no improvement in physician
awareness of IV medications given, OR=1.33 (0.15-11.35). Using a composite score of procedures
plus oral plus IV medications, physicians had all three categories correct in 15% of Phase 1 and 39%
of Phase 2 cases (p<0.0001).

Conclusion: EPs in our ED were unaware of many prehospital procedures and medications
regardless of the method used to provide this information. The addition of a verbal hand-off report
resulted in a modest improvement in overall accuracy. [West J Emerg Med. 2014;15(4):504–510.]

INTRODUCTION United States. The 33 states that maintain EMS procedure

Paramedics are responsible for bringing a significant formularies list a total of 31 different procedures. The 25
number of patients into the emergency department (ED) states that maintain EMS medication formularies list 29
and provide many different procedures and medications different categories of medications.1
in the prehospital phase of care. The 2011 National Patient safety should be a high priority during the critical
Emergency Medical Services (EMS) Assessment estimates transition from paramedic to emergency physician (EP). It
that there are 203,807 paramedics currently working in the is important for the EPs assuming care to be aware of what

Western Journal of Emergency Medicine 504 Volume XV, NO. 4 : July 2014
Waldron and Sixsmith Emergency Physician Awareness

treatments and medications were provided to their patients prior

to ED arrival. This study was inspired by a change made in ED
triage process at our increasingly busy urban teaching hospital.
Previously, the paramedics would bring the patient into the ED
after triage and have the opportunity to speak to the EP who
would assume care of the patient. However, due to unacceptably
long ambulance turnaround times, EMS was instructed to
leave the patient with the triage nurse and provide details of
their prehospital treatments and procedures there. This practice
eliminated any face-to-face contact with the physician.
Patients brought by ambulance are more likely to be
acutely ill or at risk and have more complicated medical
histories than patients who walk in.2,3 Emergency patients
in general are more likely to have information gaps that
lead to increased length of stay in the ED.4 In cases in which
paramedics provide significant prehospital interventions and
medications under standing orders, the failure to transmit
accurate information about what was done prior to ED arrival
increases the potential for error.
Increasing attention is being paid to transitions in patient
care, and in particular, to handovers from one provider to
another. Research has shown that these transitions are areas in
which loss of information or poor communication can affect
patient safety, lead to medical errors, and cause patient harm.5,6
Much of the research in this area involves transfers within a
Figure 1. Survey used in study. Reverse side listed all possible
specialty or after a procedure, e.g., resident to resident at shift prehospital medications and procedures.
change, or from the operating room to the recovery room.7,8
In an effort to reduce errors and improve patient safety, the
Joint Commission made a standardized approach to handoffs a ambulances participating in the 911 system are staffed with 2
national patient safety goal.9 paramedics; generally the private ALS ambulances have one
Relatively little research exists on the handoff of patients paramedic and one emergency medical technician (EMT).
from the outside to the inside, i.e., from the prehospital care Ambulance patients are triaged and then brought back to see a
provider to the ED. One such study on trauma patients showed physician immediately; they are not sent to the waiting room.
that only 72.9% of the information verbally transmitted by the Patients were seen by a resident physician (usually emergency
prehospital providers was received by the ED staff. Significant medicine) or physician’s assistant with attending physician
data such as prehospital hypotension and prehospital Glasgow supervision, or by an attending physician alone.
Coma scale were received less than half the time.10 We included cases in our study when an RA was available.
We sought to determine what effect the change in our They were limited to patients treated by paramedics, since basic
triage process had on physician awareness of prehospital level EMTs perform few interventions. We excluded critical
procedures and medications. We then attempted to replicate cases brought directly to our trauma room,because in these
a face-to-face encounter between the paramedic and the EP, cases the physician usually met the paramedic upon arrival
using research assistants (RA), to see if this would improve to the ED. The RA identified these patients at triage and then
physician awareness of prehospital interventions. surveyed the EP (resident or attending) caring for them (Figure
1). The survey was done about 90 minutes after patient arrival,
METHODS to give the physician the opportunity to see the patient and
We conducted a 2-phase observational survey of a review the nursing triage note and the written prehospital care
convenience sample of EPs at an urban teaching hospital with report (PCR). The PCR is generally available and attached to
an annual census of 120,000 patients per year at the time of the chart within 15 minutes of patient arrival. The 2 physicians
the study. The ED is a Level 1 Trauma Center and a STEMI/ involved in the study were excluded from participating in it.
Stroke Center, and has an emergency medicine residency Using a written survey, the RA asked the physician
program. Thirty-five percent of ED patients are brought in whether the patient had arrived by ambulance (100% had --
by ambulances that are staffed by a mix of agencies -- the this was to test physician awareness of this fact), which of 3
Fire Department of New York, voluntary hospitals, and prehospital procedures were done (oxygen, intravenous [IV],
private ambulance services. All advanced life support (ALS) blood draw), whether or not any medications were given, and

Volume XV, NO. 4 : July 2014 505 Western Journal of Emergency Medicine
Emergency Physician Awareness Waldron and Sixsmith

assuming care of the patient, much as a paramedic would. The

RA would then give the “report” on the patient’s prehospital
care to the treating physician. The report given by the RA
repeated the paramedic’s presentation as close to verbatim as
possible, using the notes taken at triage. The goal was for the
RA to replicate the paramedic’s standard practice of giving an
oral report directly to the physician, since our large, busy ED
was unable to accommodate this practice. About 90 minutes
later, the physician was surveyed by the same RA to determine
awareness of prehospital interventions.
Only 2 RAs, both premedical students, were used for Phase
2 due to the complexity of the task. Procedures and medical
terms were reviewed with them prior to the start of Phase 2. If
the physician had left due to shift change, the survey was not
performed. There was a 1-year gap between the end of Phase

Table 1. Demographics of patients in study of physician

awareness of prehospital interventions.
Phase 1 Phase 2 p-value
Figure 2. Awareness by surveyed providers for 3 broad catego- Total number 163 116
ries: procedures, specific oral medications, and specific intrave- Age mean (+/-SD) 71 (18) 68 (20) 0.1
nous medications. Male (%) 88 (54%) 50 (43%) 0.07
Chief complaint (%)
the specific names of the oral and intravenous medications Abdominal pain 7 (4.3%) 8 (6.9%) 0.34
given. The physicians were not aware that a study was being Altered mental status 21 (12.9%) 5 (4.3%) 0.02
undertaken. The survey was labeled as an ED throughput 0.61
Chest pain 32 (19.6%) 20 (17.2%) 0.31
survey, with 7 other random questions, such as chest x-ray
Dizzy/weak 9 (5.5%) 10 (8.6%) 0.34
result and time to contact an admitting resident, interspersed 0.48
with the study questions. This was done to prevent a change Dyspnea 29 (17.8%) 26 (22.4%)
0.73
in physician behavior if they could easily determine the true Fever 5 (3%) 2 (1.7%) 0.39
purpose of the study. We knew in advance that many of the GI Bleed 2 (1.2%) 2 (1.7%) 0.48
procedures listed, such as cardioversion, would never be 0.88
Musculoskeletal pain 4 (2.5%) 5 (4.3%)
0.90
checked off since critical patients were excluded; this was Nausea/vomiting 5 (3%) 2 (1.7%) 0.67
a further effort to blind the physicians to the purpose of the 0.86
Other 27 (16.6%) 20 (17.3%)
study. In addition, the surveys were done no more than once
Seizure 2 (1.2%) 3 (2.6%)
per week to avoid the physicians becoming overly familiar
with the survey. All questions included the answer “don’t know Syncope 15 (9.2%) 9 (7.8%)
yet” to avoid blanks and guessing on the part of the physician. Trauma 5 (3%) 4 (3.5%)
Although we did not anticipate initially that physician assistants Provider completing
would participate in the study, some did, and in these cases the survey
RA wrote “PA” on the survey to identify them. Attending physician 96 (59%) 53 (46%) 0.03
In Phase 1, with our usual triage process, the paramedics Resident physician 34 (21%) 50 (43%) <0.0001
gave their verbal report to the triage nurse and had no contact
Physician assistant 7 (4%) 7 (6%) 0.51
with the physician. The triage nurse did not give a verbal report
of EMS treatment to the physician. The physicians could obtain Not recorded 26 (16%) 6 (5%) 0.005
information about prehospital care from the triage nurses’ notes Number of PCR’s
contained within the electronic medical record and from the showing actual
treatment was given
paramedics’ written PCR. We did not record whether or not the
physician used either of these sources of information. Procedures 152 (93%) 102 (88%) 0.002
In Phase 2, an RA stationed at triage listened to the Oral medications 27 (17%) 21 (18%) 0.9
paramedic present to the triage nurse and took notes. The RA Intravenous 21 (13%) 4 (3%) 0.07
then transported the patient back to the assigned bed in the ED medications
and found the physician (resident or attending) who would be PCR, prehospital care report; GI, gastrointestinal

Western Journal of Emergency Medicine 506 Volume XV, NO. 4 : July 2014
Waldron and Sixsmith Emergency Physician Awareness

Table 2. Proportion of correct responses by surveyed providers in We obtained local institutional review committee
each phase. approval for all phases of the study, and the requirement for
written informed consent was waived.
Phase 1 Phase 2 p-value Odds ratio
(n=163) (n=116) (confidence RESULTS
interval)
Over a 3-year period we collected 163 cases in Phase 1
Mode of arrival 140 (86%) 99 (85%) 0.89 1.04 and 116 cases in Phase 2. Phase 1 and 2 patients were well
(%) (.53- 2.05)
matched for age and gender. The 2 groups overall had similar
chief complaints (p=0.544), but when analyzed by specific chief
Correctly name 26 (16%) 52 (45%) <0.0001 4.28
procedures (2.45-7.46)
complaint we noted there were significantly more patients with
altered mental status in Phase 1 (p=0.02) Resident physicians
Correctly 125 (77%) 96 (83%) 0.21 1.45 responded to a higher percentage of surveys in Phase 2 than in
report if any (.79-2.66)
Phase 1 (p<0.0001) The 2 groups received a similar percentage
medications
were given of medications (p=0.9 oral, p=0.07 IV) but had more procedures
performed in Phase 1 (p=0.002) (Table 1).
The report from RA to physician had mixed results
1 and the start of Phase 2. Despite the gap, the attending group in physician awareness of prehospital interventions, as
of providers and the physician assistant group of providers summarized in Table 2. For the first question, whether the
remained essentially the same, although the resident group report improved physician awareness that the patient was
changed as residents graduated and new ones started. brought in by ambulance, no improvement was evident. In
The PCR was copied and attached to the survey. At a later Phase 1, the physicians correctly identified the mode of arrival
date, one experienced EP (R.W.) extracted data from every as being by ambulance in 86% of cases, and in Phase 2 in 85%
Phase 1 and Phase 2 PCR. Data extracted included actual of cases OR=1.04 (0.53-2.05). In the remainder of the cases,
procedures performed: oxygen (O2), IV placement, and blood the physicians either did not know or thought the patient had
draws. The EP also recorded which oral, nebulized, IV and been brought in by private car. The report did seem to improve
intramuscular (IM) medications were administered. The PCRs physician awareness of procedures performed. The physicians
were generally legible, and procedures and medications are were able to identify all procedures performed in 16% of the
listed on a flowchart, so data collection was straightforward. Phase 1 cases and 45% of the Phase 2 cases OR=4.28 (2.5-7.5).
To simplify the analysis, and due to small numbers in each One of the most important questions we sought to
category, oral and nebulized medications were grouped answer was how aware EPs are of the specific prehospital
together, as were IV and IM medications. The oral medications medications administered, and if the RA verbal hand-off report
included albuterol, aspirin, oral glucose and nitroglycerin. The improved this knowledge. A variety of oral and IV medications
IV medications included adenosine, dextrose, furosemide, were given and are listed in Table 3. When we analyzed all cases,
glucagon, magnesium, morphine, naloxone, and thiamine. including cases for which no medications were given, we found
We analyzed data by using a direct comparison of the survey that the report did not improve overall awareness of whether or
questions versus the data extracted from the PCR. The survey not a medication in any form (oral or IV) was given by EMS. The
questions were either a correct match with a value of “1” or an physicians were able to answer this question correctly in 77% of
incorrect match with a value of “0.” To achieve a correct match Phase 1 and 83% of Phase 2 cases, OR=1.5 (0.8-2.6). This high
in the category, the physician needed to be able to relate all that percentage of correct answers was mainly due to the fact that no
was done - all procedures or all medications. A correct match was medications were given most of the time, so a guess of “none”
also obtained if the physician answered “none” and no procedures was often correct. The report did not improve awareness for any
had been done, or “none” and no medications had been given. individual medications, with no significant p-values (Table 3).
An incorrect match was obtained if the physician answered, When we excluded the correct “none” answers and
“don’t know.”. We calculated the total score of the 3 categories analyzed only cases in which a medication was given by EMS,
(procedures plus oral medications plus IV medications) by physician awareness of the specific medications was low
summing the correct matches of the individual categories. (Table 4). The report modestly improved physician accuracy in
We performed data analysis using SAS 9.2 for Windows. naming all oral medications given, from 18% in Phase 1 to 47%
To test for differences between normally distributed in Phase 2, OR=4.0 (1.09-14.5). The report had no effect on
continuous variables, we used the student’s t-test. For non- physician accuracy for naming all IV medications given, with
normally distributed continuous variables, the Wilcoxon rank a rate of 42% in Phase 1 and 50% in Phase 2, OR=1.33 (0.15-
sum test was used. For categorical variables, we used the Chi- 11.35), thus with a confidence interval including one.
Square test or the Fisher’s Exact test for cell counts less than To analyze overall effectiveness of the report, we used a
five. We calculated odds ratios and 95% confidence intervals composite score that included procedures, specific names of
for all 2 by 2 tables. all oral medications, and specific names of all IV medications.

Volume XV, NO. 4 : July 2014 507 Western Journal of Emergency Medicine
Emergency Physician Awareness Waldron and Sixsmith

Table 3. Summary of medication awareness by surveyed providers.

Phase 1 provider correct Phase 2 provider correct p-value
n (%) n (%)
Oral medications
None 105/136 (77%) 82/95 (86%) 0.08
Albuterol 2/6 (33%) 2/4 (50%) 1.0
Aspirin 2/8 (25%) 5/6 (83%) 0.10
Nitroglycerin 0/1 (0%) 0/1 (0%) --
Oral glucose 0/0 1/1 (100%) --
Aspirin + nitroglycerin 1/12 (8%) 2/9 (22%) 0.55
Intravenous medications
None 103/142 (72%) 81/112 (72%) 0.97
Adenosine 2/3 (67%) 0/0 --
Dextrose 1/2 (50%) 1/2 (50%) 1.0
Furosemide 2/3 (67%) 0/0 --
Glucagon 2/3 (67%) 0/0 --
Magnesium 0/1 (0%) 0/0 --
Morphine 0/0 1/2 (50%) --
Naloxone 0/1 (0%) 0/0 --
D50 + thiamine 3/6 (50%) 0/0 --
D50 + thiamine + glucagon 0/1 (0%) 0/0 --
D50 + thiamine + naloxone 0/1 (0%) 0/0 --

Table 4. Providers’ complete awareness of all oral and study was improved by a verbal hand-off report, but there
intravenous medications given. was significant information loss in both phases of the study.
Phase 1 Phase 2 p-value Odds ratio Similar results to our study were found in an investigation
provider provider (confidence of hand-offs between paramedics and the trauma team.
correct correct interval) In that study, information least likely to be documented
n (%) n (%)
by trauma team members was treatment provided in the
prehospital setting. Overall there was loss of 9% of available
Provider 5/27 10/21 0.03 4.0
information.11
correctly (18%) (47%) (1.09-14.5)
This is consistent with previous reports which show
identified all oral
that even when using standardized approaches to hand-off,
medications
there is information loss.12 The implications of this data
loss, particularly as it regards medication administration, are
Provider 9/21 2/4 (50%) 0.79 1.33 concerning. Previous studies have shown that medication
correctly (42%) (.15-11.35) hand-off errors are common, and a significant percentage
identified all of ED visits may be related to medication-related
intravenous complications.13,14 Physicians who are unaware of medication
medications given by prehospital providers have the potential to double-
dose, overdose, or fail to appreciate response or lack of
This score ranged from “0” if none of these date were correctly response to treatment. It also represents a significant failure to
reported, to “3” if all were correct. The physicians reported all 3 address a recent Joint Commission patient safety goal to use
categories of data correctly in 14% of phase 1 and 39% of phase medicines safely.15
2 cases (p<0.0001). (Figure 2) The mean score was 1.95 out of Survey studies of prehospital and ED providers on
three in Phase 1 and 2.32 out of 3 in Phase 2 (p<0.0001). the transition of care from prehospital to ED found that
ambulance crews felt ED staff paid attention to their
DISCUSSION handovers only 24.2 % of the time. ED staff, on the other
Physician awareness of prehospital treatments in our hand, were satisfied with the quality of the information

Western Journal of Emergency Medicine 508 Volume XV, NO. 4 : July 2014
Waldron and Sixsmith Emergency Physician Awareness

received 35% of the time.16 The ideal handover with did not quantify data lost due to physician shift change or
respect to communication of information involved patients physician refusal to participate in the study, although we
with distinct medical problems as opposed to those with were not aware of any problems with cooperation.
significantly more complex medical issues.17 This is Although we tried to recreate the direct hand-off from
consistent with a previous study that revealed that more paramedic to physician, as occurs in other EDs, the RA
errors occurred when longer hand-off times were recorded involvement is not ideal. The RAs may have been perceived
per patient, and fewer occurred when written or electronic by physicians as extraneous to patient care and might have
support material was used.18 As in our study verbal been afforded less attention than a paramedic would have
communication, no matter how it is given, often loses much received. They also may have omitted some of the information
in transition. given by the paramedic to the triage nurse. Lastly, the
When the ED staff shows a lack of appreciation for transition process is necessarily specific to the receiving
the information provided by paramedics regarding their institution, the EMS system, and other local factors such
prehospital care, this is a failure of teamwork. The physicians as setting and census. Hence our observations might not be
and paramedics, having differing levels of ability, fail to generalizable to other facilities.
communicate effectively. In a prior study, this teamwork It is important to note that we did not measure what other
breakdown was shown to be a factor in 70% of closed information, such as patient history, was lost in translation either
malpractice claims involving trainees and medical errors.19 from paramedic to triage nurse/RA or from RA to physician. We
Some have suggested that hand-off tools may improve transfer did not measure what effect information loss had on ultimate
of care, but others have failed to corroborate this – highlighting the patient outcome, and whether there were adverse outcomes
need for further work in this area.10,12,18,20 Communication programs due to physicians not being aware of prehospital treatment. As
that include workshops, teamwork training, or simulation-based highlighted previously by other investigators, further research is
handoffs have been used to reduce information loss and may be a needed to identify what methods optimize information transfer
promising area of further research.18 during transitions of care.

LIMITATIONS CONCLUSION
The foremost limitation of this study is the heterogeneity Physicians in our ED were unaware of many prehospital
in treatment received between Phase 1 and Phase 2 patients. procedures and medications given to their ED patients
There were fewer procedures done and IV medications given regardless of the method used to provide this information.
to Phase 2 patients as compared to Phase 1. These differences The addition of a verbal hand-off report resulted in a modest
seem mostly due to the much lower percentage of patients improvement in overall accuracy.
with the chief complaint of altered mental status in Phase 2;
the reasons for this change in patient population are not clear.
Since the answer of “none” was considered a correct answer, Address for Correspondence: Address for Correspondence:
this may have biased the results in favor of greater accuracy of Rachel Waldron, MD, New York Hospital Queens, Department of
the report as more subjects in Phase 2 received no medications Emergency Medicine, 56-45 Main St., Flushing, NY 11355. Email:
at all. A possible direction for a future study would be to emsdoc@earthlink.net.
conduct Phases 1 and 2 simultaneously on alternating days
to avoid the influence of changes in patient chief complaints
between data-collection periods. Conflicts of Interest: By the WestJEM article submission
In addition to treatment heterogeneity, Phase 2 patient agreement, all authors are required to disclose all affiliations,
surveys were more commonly completed by a resident funding sources and financial or management relationships that
rather than an attending physician. This difference in level could be perceived as potential sources of bias. The authors
disclosed none.
of experience could affect results, as could the mix of
emergency medicine and off-service residents on any given
shift. Another limitation would be the possibility of change
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