Handover; skills to enhancing the PHEM – EM interface

Handover is the physical and professional transition of care from one provider to the next. The handover of the pre-hospital critical care patient carries significant potential risk. Misunderstanding or misinterpretation of information can have significant adverse impact on patient outcome. Although empirical evidence is scarce in this area, in-hospital reported medical error associated with handover has been reported to be almost 34%,⁹ and in England, during 2010-12, handover was explicitly established as the main contributor in 5% of patient safety related deaths.¹⁰ The pre-hospital hospital transition carries additional potential hazards due to the time critical nature and the multiple human factors involved.

This module will aim to:

• Clarify what information a pre-hospital practitioner can provide.
• Explain how information is shared from the pre-hospital team including the pre-alert and face-to-face handover.
• Introduce ATMIST AMPLE handover tools.
• Team resource management techniques to enhance handover
• Advocate for a hands-off handover when safe to do so and a zero-point survey.

The WHO (2007)⁹ suggested an effective handover is a structured, standardised, focused brief that avoids repetition or interruption and allows time for questions or read-back. Solet et al, 2007 advocated that handovers should be precise, unambiguous and face-to-face.

There are numerous examples of handover tools with the most common in the United Kingdom including AT-MIST and AMPLE which provide a structure to handover. However, to have an effective handover there are additional team resource management skills that need to be utilised to create a shared mental model.

Learning bite

• A handover should be structured, standardised and focused to avoid repetition and allow for questions.
• Handover tools should be used to provide a common structure and a shared mental model.

Pre-hospital information regarding an incident is collected from a variety of sources to gain a rapid, accurate assessment of the mechanism and background to an incident. Information can be obtained first hand, directly from the patient or witnesses or indirectly by interpretation of the physical scene, or from other agencies such police, fire and ambulance crews. All relevant information is collated by the pre-hospital practitioner to create a holistic understanding of the scene in regard to mechanism and the likely consequences. Clinical information and parameters are added to the understanding of the mechanism to plan on-scene treatments and appropriate triage.

An example of relevant information gathering follows. Please review these two pictures. At both scenes you find an unconscious driver. However, the scene might suggest different causes and treatments required. The pre-hospital practitioner should be able to read this scene but needs to share this relevant information with the receiving hospital to enhance a patient’s onward care.

Picture 1 shows a car that had come to a stop off the carriage way, there was no damage, no skid marks and no environmental causes to come to a stop. This is suggestive of a medical event as a preceding event. (Owned and provided by S Jefferys)

Picture 2 by comparison shows a car with severe damage, skid marks and oil on the road surface suggesting a high velocity RTC, making a medical cause less likely. (Owned and provided by JP Loughrey)

The information a pre-hospital practitioner can provide aims to support a patient’s onward treatment, triage and discharge risk stratification. However, this information can only be appreciated by the hospital practitioner if shared effectively.

The Improving the Quality of Ambulance Crew Handovers study found that information decay was more acute when multiple handovers were required with either loss or change of the information by the provider. An audit of pre-hospital and Emergency Department resuscitation room records in 2012 identified 26% of records had inconsistencies including timings of incidents, patient’s allergy status, medication omissions and conflicting anatomical references. Whilst this was prior to the UK Major Trauma system, it highlights that system changes and standards are needed to enhance performance.

Fitzpatrick et al., showed many of the difficulties associated with in-hospital handover can be attributed from issues in the pre-hospital environment. Information is gathered from multiple agencies, in challenging environments with competing pressures such as clinical care. The introduction of a common standard handover format with an associated tool has shown improvements when introduced. Findings included greater volume of information shared per handover, fewer questions from ED staff, a reduction in hand over duration and fewer repetitions.

Learning bite

• Prehospital information should be sought to risk stratify patients’ onward care.
• A handover tool helps to structure relevant pre-hospital information and a shared mental model.

There are many handover tools that are used throughout a patient journey to good effect, but only a few that have been validated. NICE in 2017 wrote about structured patient handover but did not go as far as recommending a structure for the pre-hospital to hospital handover.  Common to all of the tools is a structure that provides the whole team with a common language and predictable sections.

ATMIST and IMSIT-AMBO are the most frequent tools used for handover in the pre-hospital setting. Both aim to tell the receiving team who the patient is, what happened, what injuries have been found, the physiological changes and treatments delivers so far. ATMIST is the Joint Royal College Ambulance Liaison Committee (UK National Ambulance Guidelines) preferred mnemonic, particularly for trauma. IMIST-AMBO is an alternative used in Australia but not by the NHS.

_{(Images courtesy of Dr D Maxwell)}

SBAR is well known, used in the inpatient setting and advocated by the WHO. In the pre-hospital setting it may be useful for a pre-alert but studies have shown it is least favoured by pre-hospital clinicians.

SBAR; Situation, Background, Assessment, Recommendation.

Learning bite

• ATMIST and AMPLE are the common handover tools used in the UK.
• ATMIST is the JRCALC preferred mnemonic of choice particularly for trauma.
• Being familiar with your local handover tool is vital.

A pre-alert aims to forewarn a hospital of a critical patient’s arrival with pertinent information. Before leaving a scene, the pre-hospital practitioner will aim to share relevant information including if a patient is intubated. The pre-alert was a key outcome of the NCEPOD 2007 report, Trauma: Who cares?

“Ambulance trusts and emergency departments should have clear guidelines for the use of pre-alerts in the severely injured patient population… to ensure an appropriate clinical response is available immediately.” (NCEPOD, 2007).

There have been significant system improvements since the NCEPOD report including establishing major trauma networks in the UK since 2012. In 2016, NICE guideline 40 updated the parameters for major trauma service delivery, which included that standard for a trauma pre-alert. The minimum data recommended is;

1. ATMIST
2. Crew call sign
3. Estimated time of arrival
4. Any special requirements such as cardiac bypass.

For medical patients there is good evidence that a pre-alert for patients improves clinical outcomes by ensuring timely clinical care on arrival. Work in 2020 from Manchester has shown that by refining the pre-alert process the door to scan time was significantly reduced. This work highlights the importance of accurate triage decision, pre-alerts and refinement of processes locally.

A pre-alert aims to include all the relevant information to ensure the receiving hospital is best prepared. Due to clinical need or equipment limitations the ‘expected’ information may not be possible for every case, for example an AVPU is an acceptable alternative to GCS. The use of pre-agreed structure allows both the caller and receiver to know what information to give and what order to expect the information. ATMIST (UK standard) or ASHICE are the common handover structures.

Use of a proforma for the call receiver aims to enhance bandwidth, prevent missed information and allows dissemination of information to the wider team. This step helps enhance the shared mental model and primes the handover. Below is an example, blue pre-hospital pre-alert proforma and the red hospital pre-alert form.

_{(Images Courtesy of Dr D Maxwell)}

A pre-alert should come to an agreed single point, either a standby phone or radio. It is important to note that this call may be made by a call handler or clinician not present at the scene which will limit additional information.

Learning bite

• Pre-alert should be expected for all critically unwell patients.
• The ATMIST is the standard pre-alert tool in the UK.
• When you are next at work find out what structure your current hospital uses. But ask yourself critically does it give you all the information you need as the receiving unit? If not consider developing your local tool.

The pre-alert allows time to prepare the department for the next patient. Zero-point survey has been advocated as a tool to allow the Emergency Department resus lead to pre-plan to best meet the needs of the expected patient. It is described as the stepping stone to the primary survey. A zero-point survey uses a STE-PUP assessment with the STE being relevant after the pre-alert;

1. Self – Perform self-assessments of personal, physical and cognitive readiness.
2. Team – leader identified, team roles allocated and briefing.
3. Environment – danger, space, light, noise, crowd-control.
4. Patient
5. Update
6. Priorities

With critical care patients a pre-alert may allow additional considerations around team and equipment. This is especially relevant to ensure the appropriate PPE state is achieved prior to the patient’s arrival due to the Covid-19 pandemic. Additional tasks such as pre-alerting relevant members of the hospital team or instigating a major haemorrhage call and preparing the blood warmer rely on an accurate pre-alert to prevent waste of valuable resources.

The handover should be like a relay race where the patient is handed to a team who are already up and running to take over the care rather than at a standing cold start. Having a good working relationship between local pre-hospital providers and emergency departments aids best practice. The use of trauma networks and clinical governance days to share best practice and develop areas for change should be standard.

Learning bite

• A zero-point survey uses the STE-PUP assessment to prepare a department.

An ED is responsible for a patient from arrival in the ambulance bay. There is a requirement for Acute Trusts to accept handover of a patient within 15 minutes of an ambulance arriving in ED or other urgent admission facility.

As the team leader the face-to-face patient handover is vital as it may be the only information regarding mechanism, interventions, past medical history and identity of the patient immediately available. Ensuring this process is uninterrupted and given to all members of the team at once is key. To achieve this, a hands-off handover should be the standard, if safe to do so, ensuring 1 minute of silence.

If there is a need for on-going continuous critical care to be provided, such as active CPR or a critical airway intervention, there may be the need to perform these limited clinical interventions before a whole team handover. Any immediate interventions that are required on arrival should be clearly articulated to the team leader and co-ordinated. If not articulated the team leader should clarify if any immediate interventions are required.

A hands-off handover will aim to ensure the whole team is attentive and allows questions to be asked. This ensures that all members of the receiving hospital’s team hear the same information, once.  Whilst this may seem to delay care initially, it aims to facilitate initial planning by the trauma team leader and allows rapid horizontal care after handover without delay.

At handover the scribe will need to note down all relevant information. A dedicated scribe for the team needs to be familiar with the paperwork. A scribe does not need to be clinical and overnight in smaller trauma units may be a role for ED admin staff with adequate support. It is worth considering, in your department overnight, who is best to provide this role and ensure appropriate training and support. Carter et al, 2018 showed that only 72.9% of key prehospital data points verbally handed over were documented by the receiving hospital.  To prevent degradation of information the use of a structured handover sheet that mirrors the pre-hospital handover with a dedicated scribe should be encouraged.

_{(Image courtesy of Dr D Maxwell)}

Learning bite

• On arrival of an ambulance the Acute Trust is responsible for the patient.
• Handover should be facilitated as soon as possible
• Handover is the formal full clinical handover of a patient
• To maximise the information shared the whole team should be present and hands off.
• A scribe should capture the handover in the patient’s notes. Consider within your ED who is best for this role at all points in the day and night and incorporate this into any departmental SIM.

Team resource management is defined as the use of strategies to best utilise all available resources including information, equipment and people to optimise the safety and efficiency of a team. Initially these were skills focused on in the aviation industry but they have been adopted by medical teams. Team resource management considerations optimise the safe passage of information during handover, ensuring that the whole team has all the relevant information before the pre-hospital team leaves.

As the pre-hospital team, a single team member should deliver a structured, 60 second handover, facing the receiving team and encouraging questions on completion of ATMIST and again at the end of AMPLE. The treating pre-hospital clinician should be with the patient during handover. The handover details should be reviewed prior to arrival. Some services have utilised the use of a structured service wide system to avoid the need to jot notes down on gloves or back of hands. Fitzpatrick et al showed the use of an ATMIST handover slate given to all members of an ambulance service was a simple solution that improved handover technique and user satisfaction.

As the receiving team, the trauma team leader needs to ensure the whole team is present for handover, listening and not distracted by the patient or other tasks. The team leader should identify themselves and ensure the team understand this will be a hands-off handover. The term ‘hands off, eyes on’ provides the instructions for the 60 second period when the patient remains on the trolley to facilitate handover. The handover information should be captured contemporaneously. The handover should be interruption free but with questions asked between the ATMIST and AMPLE handovers.

Learning bite

• Handover should aim to be hands-off.
• A structured handover should take 60 seconds.
• As a trauma team leader, team resource management skills need to be practiced.

Vital information must be shared in an accurate and timely manner between the pre-hospital and hospital practitioner to ensure early and relevant care is provided.

The use of a pre-alert facilitates continuous care of a patient on arrival to the hospital and forewarns the hospital to allow planning by means of a zero-point survey to ensure minimal disruption to the whole department and maximum immediate input for the patient.

Handover tools prevent degradation of information but must be pre-agreed between the pre-hospital and hospital teams to ensure a shared mental model.

Use of aide memoires and pre-printed handover sheets should be encouraged and developed as a whole team, involving both pre-hospital and in hospital teams.

A hands-off handover should be advocated to enhance team resource management during the handover.

1. Manser T, Foster S. Effective handover communication: an overview of research and improvement efforts. Best Pract Res Clin Anaesthesiol. 2011 Jun;25(2):181-91. doi: 10.1016/j.bpa.2011.02.006. PMID: 21550543.
2. Solet DJ, Norvell JM et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005 Dec;80(12):1094-9.
3. World Health Organisation. Communication during patient hand-overs. Switzerland. WHO Press, 2007.
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8. NICE Guideline 32; Structured patient handovers. 2017.
9. JESIP Interoperability guideline; M/ETHANE.
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11. Budd HR, Almond LM, Porter K. A survey of trauma alert criteria and handover practice in England and Wales. Emerg Med J. 2007 Apr;24(4):302-4.
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13. National Clinical Guideline Centre (UK). Major Trauma: Service Delivery. London: National Institute for Health and Care Excellence (UK); 2016 Feb. (NICE Guideline, No. 40.) 7, Pre-alert processes. 
14. Sheppard JP, Lindenmeyer A, et al. Prevalence and predictors of hospital prealerting in acute stroke: a mixed methods study. Emerg Med J. 2016 Jul;33(7):482-8. doi: 10.1136/emermed-2014-204392. Epub 2016 Feb 23. PMID: 26949969; PMCID: PMC4941194.
15. Ashton C, Sammut-Powell C, Birleson E, et al. Implementation of a prealert to improve in-hospital treatment of anticoagulant-associated strokes: analysis of a prehospital pathway change in a large UK centralised acute stroke system. BMJ Open Quality 2020;9:e000883.
16. C Reid. Analysing Difficult Resuscitation Cases. Zero Point Survey. Resus.Me. 2018. [Accessed October 12, 2020].
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Additional Resources

• Handover, Twitter.
• Handover. Process, practice and controversy. #ICSSOA2018. St Emlyn’s. 2018.
• Handover, The Resus Room. 2017.