How Can Florida PEDReady Champions Support Children in the Bahamas?
The Florida EMSC and PEDReady programs are closely watching the impact of Hurricane Dorian on the children of the Bahamas. We know that many of our EMS, ED and pediatric colleagues are participating in relief efforts. Stay tuned for additional information in upcoming PE 2 ARLs and consider the following:

  • Many children are evacuating to Florida and may seek care by our EMS agencies and EDs. Think about this during triage and history-taking.
  • Extraordinary levels of post-traumatic stress and grief symptoms are anticipated in children (and adults) for quite some time, including anxiety, nightmares, depression and new physical symptoms. 
  • Post-hurricane conditions may lead to the development of diseases we do not treat often, for example: mosquito-borne illnesses such as dengue fever or tetanus. 

Please email pedready@jax.ufl.edu if you have pediatric-specific input or ideas regarding how Florida PEDReady can assist in recovery efforts.
Quick Links:
Encourage others to sign up for the PEDReady weekly newsbrief, the PE 2 ARL, by sharing this link: http://bit.ly/flpearl
September 19, 2019
Focus | Improving EMS to ED Handoffs
What is a handoff?  A hand-off is a transfer and acceptance of patient care responsibility achieved through effective communication. It is a real-time process of passing patient-specific information from one caregiver to another or from one team of caregivers to another for the purpose of ensuring the continuity and safety of the patient’s care. (The Joint Commission)

Handoffs occur in a variety of settings both medical and nonmedical. Patient care handoff communications have been identified as a critical safety and quality problem.
  • In 2014, ACEP stated: “The most dangerous point in a patient’s ED journey is the handoff and transition of care.”
  • The Wall Street Journal referred to patient handoffs as “the Bermuda Triangle of healthcare.”

Inadequate handoffs can cause:
  • Treatment delays
  • Treatment errors
  • Avoidable hospital readmissions
  • Increased treatment costs
  • Other minor and major patient harm and inefficiencies

Handoff examples:
Pediatric emergency handoffs can occur from EMS to dispatch, dispatch to the ED, EMS to the ED provider, EMS to transport team or flight crew, ED to ICU or hospital provider, etc. Pediatric and EMS to ED handoffs are particularly difficult due to time constraints, patient acuity, multiple patients, noisy environments, language barriers, nonverbal patients, joint management of the pediatric patient plus their family members and more!

Why are EMS handoffs so important and unique?
  • EMS providers usually have only one opportunity to convey information about a patient to ED personnel
  • If handoff information is not received in real time, ED clinicians often must track down run sheets or wait for records to be copied or downloaded
  • ED providers often focus on their own initial assessment of the patient, which distracts from listening carefully to the EMS crew’s key information
  • Any information that was not handed over verbally, not recorded on patient report form, or not retained by ED staff may be lost forever after the EMS crew leaves

How do we improve transitions of care and handoffs?
  • Use experience from other high-risk industries, such as aerospace and aviation
  • Concise communication, preferably directly to the ED provider responsible for the patient’s care
  • Consistent scripted and standardized handoffs
  • Checklist or memory trigger
  • Opportunity to ask and respond to questions
  • Nonthreatening setting
Sample Tools for ED and EMS Handoffs

SBAR:
  • Situation—Identify the general problem and any focused priority
  • Background—Focused history of present issue/injury, prior care and relevant history
  • Assessment—Key findings and vital signs, including the patient’s current state
  • Recommendation—Identify the patient’s immediate needs, if any

SBAT:
  • Situation/Scene
  • Background
  • Assessment
  • Treatment

MIVT or MIST (trauma patients):
  • Mechanism
  • Injuries
  • Vitals/Symptoms
  • Treatment

Here is a great example f rom Central Ohio Trauma System :
Key Pediatric Tips to Consider in EMS to ED/TC Reports
  • Weight in lb/kg or color zone
  • Site/details of accident: child passenger restraint device, helmet, airbags
  • Any danger to child: setting, violence, etc.
  • Family member presence or contact information if known
  • Were parents or caregivers injured?
  • Impaired driver or parent
  • Legal guardian if known- bring a caregiver/family member if possible
  • Language barrier or developmental delay/disability
  • Law enforcement or DCF at the scene or notified
  • Was patient out of car or walking at the scene?
  • Relay confidential information
Five Ways to Perfect the Patient Handoff
Reporting:

1. Eye contact: This helps identify that the handoff is beginning, which individuals are reporting and receiving, and sends the message that “We are communicating now, you and I.”

2. Environment: Whenever possible try to minimize noise, interruptions and distractions.
3. Ensure the ABCs: If there is a priority critical care that must be initiated or continued, this must be immediately conveyed to and addressed by the receiving clinician or team. The receiving clinician should either direct the reporting provider’s team to continue care during the handoff report or direct the receiving team to take over the priority task.

4. Structured report: There are numerous standardized report formats. Mission-critical communications research has shown use of a structured format improves efficiency and reduces errors, but little evidence shows any one system is better than another. The important point is to pick a structured format and use it, preferably one familiar to both reporting and receiving providers.

5. Supply documentation: The verbal report should consist of the patient’s priority issues, prior care, current state and immediate needs. Numerous other details should be transferred on paper or by electronic report.

Receiving:

1. Eye contact: For the same reasons as above, maintain eye contact.

2. Environment: Many hospitals now establish a “moment of silence” during trauma, cardiac, stroke and sepsis handoffs. When eye contact is established (or another trigger, such as the reporting paramedic standing on a designated spot in the room or the EMS cot being placed next to the hospital cot), the receiving physician announces “moment of silence!” and all team members quiet down and stop noncritical care actions to listen to the handoff report. This is intended to increase efficiency of the handoff, reduce errors and improve the shared mental model among the receiving team so care can be prioritized and coordinated better.

3. Ensure understanding: Once the handoff report has been given, the receiving clinician should ask questions as necessary to clarify and correct any issues.

4. Summarize: Summary is verbalized so reporting provider and receiving team can ask questions or identify any critical errors to ensure the shared mental model is correct.

5. Supplementary documentation: It has been shown that, where possible, patient monitoring (ECG, key vital signs, etc.) should be located so the information is visible to the entire receiving team. This helps keep clinicians aware of the patient’s current state, maintaining that shared mental model.

In a 2012 study in which some of these recommendations were implemented, handovers were shorter, the number of handovers where ED staff asked questions was reduced from 93% to 41%, and requests for paramedics to repeat information were cut by more than half. Dean E. Maintaining eye contact: how to communicate at handover. Emerg Nurse, 2012 Mar; 19(10): 6–7.

A key point is that bedside handover needs to be distinct from moving the patient to the bed!
Resources and Videos:
Literature:







  • Iedema, R., Mesman, J., & Carroll, K. (2013). Designing an ambulance paramedic to emergency triage staff handover protocol. In Visualising Health Care Practice Improvement : Innovation from Within (pp. 153–170). Ailton Park: Taylor & Francis Ltd.

  • Sochet A, Ryan K, Bartlett JL, Nakagawa T, Bingham L. Standardization of Pediatric Interfacility Transport Handover: Measuring the Development of a Shared Mental Model. Pediatr Crit Care Med. 2018 Feb;19(2):e72-e79. doi: 10.1097/PCC.0000000000001396.




PEDReady Champion of the Week
Thomas DiBernardo, Florida Department of Health CARES Coordinator
Thanks to Tom DiBernardo for being a PEDReady champion! In his role as Florida Department of Health CARES Coordinator, Tom travels around the state visiting EDs and EMS agencies. Over the last month, he added PEDReady Toolkits and materials to his packing list! 
Upcoming Pediatric Emergency Events
AAP Return to Learn ECHO
Apply by September 22 | Multiple, virtual meetings
Hosted by: American Academy of Pediatrics

School-based personnel are invited to join this learning collaborative for the most up-to-date guidance on concussions (also called mild traumatic brain injury: mTBI). Participants will meet virtually for 5 weekly sessions, which will include presentations by national experts, discussions and recommendations.

If interested, please fill out their survey by September 22. Teams from rural districts are especially encouraged to apply. 
NAEMT EMS Safety Course
September 24, 2019 | 8:30-4:30 pm | Jacksonville, FL
Hosted by: TraumaOne Flight Services

This course covers crew resource management, emergency vehicle safety, responsibilities in scene operations, patient handling, patient, practitioner and bystander safety, and personal health.

Open to all EMS students, EMTs & Paramedics. Price includes morning refreshments, lunch, provider manual and NAEMT certificate for 8 hours of Florida and National Registry CE credits.

Webinar: 2019–2020 Recommendations for Influenza Prevention and Treatment in Children: An Update for Pediatric Providers (new)
September 26, 2019 | 2:00-3:00 pm
Hosted by: AAP and the CDC

Subject matter experts will discuss strategies pediatric providers can use to improve influenza prevention and control in children for the 2019–20 influenza season. Free continuing education credits are available.

Advanced registration is not required. A few minutes before the webinar begins, please click this link to join the webinar. You may also use the following dial-in options:
  • Phone: 646-876-9923 or 669-900-6833
  • Webinar ID: 779-319-056
Webinar: Providing Medical Safe Haven Patient Visits to Survivors of Human Trafficking
September 26, 2019 | 2:00-3:00 pm
Hosted by: American Hospital Association's Hospitals Against Violence

The Medical Safe Haven clinic provides a coordinated warm-hand access model of care for victims and survivors of human trafficking to receive full spectrum trauma-informed primary medical care and mental health services. Common issues ranging from prenatal care to PTSD management to pediatric care and more will be presented and discussed. 

NAEMT Emergency Pediatric Care Course
September 30 & October 3, 2019 | 8:30-4:30 pm | Jacksonville, FL
Hosted by: TraumaOne Flight Services

This 2-day (16-hour) Emergency Pediatric Care (EPC) course focuses on critical pediatric physiology, illnesses, injuries and interventions to help EMS practitioners provide the best treatment for sick and injured children. EPC is appropriate for EMTs, paramedics, emergency medical responders, nurses, nurse practitioners, physician assistants and physicians. Accredited by CAPCE; recognized by NREMT and Florida EMS for 16 CE hours.

Children's Disaster Services Workshop
October 11-12, 2019 | Tampa, FL
Hosted by: Child Life Disaster Relief

This is a specialized training for Certified Child Life Professionals only. Certified child life specialists are invited to register. Ten PDU’s are available.
NAEMT Principles of Ethics & Personal Leadership Course
November 6-7, 2019 | 8:30-4:30 pm | St. Augustine, FL
Hosted by: TraumaOne Flight Services

This 2-day (16-hour) course provides EMS and Mobile Healthcare (MHC) practitioners with the skills to effectively interact with patients and their families, other medical personnel, co-workers, supervisors and community residents. This course is appropriate for EMTs, paramedics, other MHC practitioners and emergency responders. Upon successful completion, students receive a certificate, wallet card
(good for 4 years) and 16 hours of CAPCE credit.

Pediatric Care After Resuscitation (PCAR) Course
Dec 2-3, 2019 | Jacksonville, FL

The mission of TCAR (Trauma Care After Resuscitation) Education Programs is to expand the knowledge base and clinical reasoning skills of nurses who work with injured patients anywhere along the trauma continuum of care, particularly in the post-resuscitation phase. 
Thanks for being a Pediatric Champion!
The Florida PEDReady Program
pedready@jax.ufl.edu | 904-244-8617