Usage of documented pre-hospital observations in secondary care: a questionnaire study and retrospective comparison of records

BACKGROUND The patient handover is important for the safe transition from the pre-hospital setting to secondary care. The loss of critical information about the pre-hospital phase may impact upon the clinical course of the patient. METHODS University Hospital Emergency Care registrars answered a questionnaire about how they perceive clinical documentation from the ambulance services. We also reviewed patient records retrospectively, to investigate to what extent eight selected parameters were transferred correctly to hospital records by clinicians. Only parameters outside the normal range were selected. RESULTS The registrars preferred a verbal handover with hand-written pre-hospital reports as the combined source of clinical information. Scanned report forms were infrequently used. Information from other doctors was perceived as more important than the information from ambulance crews. Less than half of the selected parameters in pre-hospital notes were transferred to hospital records, even for parameters regarded as important by the registrars. Abnormal vital signs were not transferred as often as mechanism of injury, medication administered and immobilisation of trauma patients. CONCLUSIONS Data on pre-hospital abnormal vital signs are frequently not transferred to the hospital admission notes. This information loss may lead to suboptimal care.