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Improving Communications Between EMS and the Emergency Department
As an EMS manager in Broward County, FL, I frequently dealt with negative hospital/rescue interactions. Like most of my peers in EMS management, I handled each incident and each hospital individually and accepted that these interactions were the cost of doing business. However, toward the end of my time at Margate Fire Department (while preparing to become a 50-year-old retired local character), I began to realize it was possible to improve the situation.
Addressing the Problem
After my initial retirement, I began work as an EMS training officer with Coral Springs Fire Department, which is led by Chief Mark Curran, and took on the job of training on-duty paramedics. I soon noticed that before, during and after every class, medics talked about how they were treated at the local hospitals--the same hospitals I had been dealing with for 30 years--and it gave me an idea. Some of the staff nurses I knew were now in administration and still my friends, so I began calling them, renewing old ties and assessing their professional (and personal) expectations in the area of rescue/hospital relationships.
My idea was to invite representatives from each hospital to sit on a panel and hear grievances from the Coral Springs medics, and to let panel participants share their concerns with the medics. The hospitals fully embraced the project and provided staff nurses, doctors and even administrators to sit on the panel. Other hospital employees came on their own time and sat in the "audience" with our medics, along with off-duty firefighters and paramedics from other local departments and an independent emergency room physicians management group. Whether the crowd showed up in hope of seeing mayhem and injury or simply out of curiosity, I was witness to a room overflowing with professionalism and an infectious enthusiasm to solve problems and rise above.
To allow all three fire department shifts to participate, we ran the workshop seven times over three days. Each time, we had a completely new panel, a new "audience" of on-duty medics, and an entirely new "peanut gallery" of interested parties. Nadene Giudice, a dedicated ED nurse, and I were in attendance at every panel session. She served as a panel member; I served as facilitator and crowd control. We were both moved by the level of success achieved, and surprised by the many common elements presented by both panels and audiences.
Every one of the city's 150 medics, plus a couple of rescue teams from Margate Fire Dept., had an opportunity to interact with our panels and other audience members. Our fire chief's assistant, Ms. Lotus Boss, took copious notes at the proceedings, and one firefighter was chosen to list pertinent points on the board in problem/solution format, focusing on issues, not personalities.
Finding Solutions
Topics were wide-ranging and fascinating. Hospital participants got an earful about how a paramedic feels getting chewed out by a doctor or nurse in front of a patient and his or her family. Medics learned how a hardworking, frequently overwhelmed ED staff member who sees 150 patients in a day feels when the 19-year-old medic comes in looking for a smile and a "My hero!" look from ED staff. The problems we dealt with can be summarized rather easily; the solutions are varied and will take time and real commitment to accomplish.
The main message from hospital staff to medics was: "Be patient with us. We see that these problems are real, and we will fix them." Their one request was that medics who have a problem with hospital staff need to get the hospital supervisor involved and avoid one-to-one confrontations with staff members.
The medics' main complaints involved delivering patients to distal facilities. Each time a patient requests a distal facility, or the medics think the patient needs to go to a distal facility, hospital staff tend to question the medics' judgment, often in a rude way. In response to this complaint, higher-level hospital administrators expressed doubt that this in fact occured; mid-level administrators said it happened and was wrong, but was rare; and ER staff nurses thought the medics were oversensitive and misunderstood their intent when they asked, "Why are you here instead of the closest facility?" According to one staff nurse, the nurse asking the questions may have only wanted to know what special care the patient needed. Hospital participants agreed to be clearer about why they are asking and to avoid that particular question.
Medics raised the issue of telemetry calls not being heard and said "on the air" staff often sound rude and will do anything to "turf" the patient to another hospital. When one nurse manager doubted the complaint about on-air rudeness, our communication officer, Chief Steve Fry, brought in a department radio and charger, showed her how to use it and told her to "call me in a couple of weeks and I'll pick it up." The nurse listened at home, brought the radio to work and let her staff listen to transmissions across the county. It proved to be an eye-opener to all of them.
Another problem brought up by medics was the angry manner in which doctors and nurses say to them, in front of patients and their families, "You should have been able to get this IV," or "This patient looks different than you described," or "You couldn't get him intubated? Why?" The point was made that most ED staff have little knowledge of our protocols, and that the attitude has more to do with the tired, overworked ED staffs' bad moods than a desire to teach and improve care.
There was discussion about the appropriateness of ED staff teaching on-duty medics after calls. It is part of our tradition and can be an invaluable aid, but it should be done by senior nursing staff and physicians as teaching, not lecturing or punishing.
One issue that came up in each workshop session was the blank stare medics often receive when they show up at the hospital with a patient. To quote several medics: "They know we are coming from telemetry or telephone calls. They see us in front of them with our patient on the stretcher. We are in uniform. The sign outside says Emergency Room, but they look at us like deer caught in the headlights who aren't sure what action needs to be taken with this unexpected event. What we want to hear is 'Bed 3, guys.'"
There was consensus that the negative cycle we're in could be fixed with a simple two-step process: When the medics arrive, staff could say, "Hey guys, whatcha got?" Then, the nurses would write down the report we give. It would make it better for all of us.
The final major problem concerned our local trauma hospital. For 30 years, I've had the same medical director, Dr. Wayne Lee, whom I greatly admire and respect. He is an ex-military doctor (Vietnam) who has been involved in EMS longer than I have. From Day 1, Dr. Lee has said, "Put your patient in the same hospital you would put your mother in. If you're going to make a mistake, make it on the side of life." This is the advice I have always passed along to my troops. In Broward County, we have three excellent trauma centers for patients with severe injuries. One of the difficulties with these centers is that some staff have an attitude that "borderline" or "high-index" patients should go to the closest hospital, and they are not comfortable with paramedic judgment to get "borderline" patients in the trauma center ER. Our medics believe the staff go out of their way to belittle them for trying to get patients to safety and the best care possible. Trauma nurses seemed to understand where we were coming from and promised to remind the trauma surgeons and ER docs that the medics are there for the good of the patients.
Conclusion
We are presently developing a Bill of Rights for ED staff that will help medics know what pitfalls to avoid in the ED and show the medics how to be more helpful to them. The medics will develop the same kind of document on how nurses can treat medics better. Over the next year, our union will invite the local ED staffs to our department picnics, and the hospitals are planning a Fireman's Ball, where we can interact with their staffs off duty.
In general, everyone thought the workshops were time well spent. Reports will be written and solutions tried. Our medics are reporting what they perceive as positive change in their interactions with local EDs. Hopefully, it will last.
Chief David Foster, RN, EMT-P, grew up in a small town in Pennsylvania, served in Vietnam and returned a seasoned flight medic. He moved to Florida, got his RN degree in 1976 at Broward Community College, then completed firefighter/paramedic training. He participated in the governor's EMS Advisory Board, worked in EMS for many years and took his first retirement as a division chief in charge of rescue at Margate Fire Dept. One of the proudest moments of his career was helping Margate Fire Rescue win the first EMS Magazine Gold Award and attending EMS EXPO in Dallas, TX, to receive it. He is still working/writing a little, training medics and mentoring the junior members of his family: daughters Kathleen and Casey, and very favorite nephew David Cook Foster. His wife, Chris, keeps him from taking himself too seriously and his faith and church keep him looking up.
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