CLINICIAN'S CAPSULE
What is known about the topic?
Clinical handover between emergency medical services (EMS) and emergency departments (ED) and/or the trauma team is suboptimal and can compromise patient safety.
What did this study ask?
What are handover patterns and areas for improvement between EMS and the trauma team at Canada's largest trauma centre?
What did this study find?
Handover characteristics included a lack of active listening, discordant expectations between team members, and inconsistency in content and structure.
Why does this study matter to clinicians?
Handover quality improvement in the setting of trauma can reduce critical incidents, optimize team performance, and improve patient care.
INTRODUCTION
Transitions of care between health care providers represent a serious risk to patient safety and are, therefore, important to optimize.Reference Shah, Alinier and Pillay1–4 Emergency medical services (EMS) play a crucial role in the trauma pathway of care, and their involvement usually ends with handover to hospital staff, which entails the transfer of information and accountability from paramedics to the trauma team.Reference Shah, Alinier and Pillay1,Reference Jeffcott, Evans, Cameron, Chin and Ibrahim5 At the interface of EMS and hospital personnel, clinical handover has been noted to be suboptimal, which can lead to critical incidents, reductions in quality of patient care, and potential litigation.Reference Shah, Alinier and Pillay1–4 Previously identified flaws include a lack of active listening and perceived disinterest from receiving staff.Reference Jeffcott, Evans, Cameron, Chin and Ibrahim5–Reference Yong, Dent and Weiland9 These factors can contribute to the information loss that can occur in handover, with studies reporting that up to 30% of information transmitted by EMS is not recorded by the receiving trauma team.Reference Carter, Davis, Evans and Cone10,Reference Evans, Murray and Patrick11
Several studies have examined the effects of framework and mnemonic implementation to improve handover and have been met with improvements to handover structure and process.Reference Iedema, Ball and Daly12,Reference Fahim Yegane, Shahrami, Hatamabadi and Hosseini-Zijoud13 In the United States and the United Kingdom, as well as a number of other countries, some studies have examined only the state of handover between EMS and emergency department (ED) staff or the trauma team at their institutions, without applying an intervention, with the purpose of identifying areas for improvement.Reference Thakore and Morrison6,Reference Carter, Davis, Evans and Cone10,Reference Evans, Murray and Patrick11,Reference Bruce and Suserud14–Reference Goldberg, Porat and Strother16 While these studies evaluate either the perceived quality of handover or information loss during this process, there is an overall paucity of research to provide a complete understanding of the state of EMS handovers, particularly in the setting of trauma. Additionally, few studies have examined discordance in the perceptions of the quality of the handover process across disciplines. In this study, we sought to build on previously published work and provide a Canadian perspective of handover practices in the trauma bay, with the ultimate goal of identifying areas for focused improvement.
METHODS
Study design and time period
Following a preliminary review by the hospital Research Ethics Board, our study was deemed exempt from a full review, and did not require board approval, as it was an observational quality improvement study. Data were prospectively collected by a single observer during nine consecutive weeks from June 4, 2018, to August 3, 2018, including an initial one-week pilot period of refining our data extraction form. A randomly generated observation schedule was adhered to, consisting of five 8-hour blocks per week and included mornings, evenings, nights, weekdays, weekends, and holidays, so as to capture a representative breadth of trauma handovers.
Study setting and population
This study was conducted at an adult level one trauma centre in an urban, academic hospital located in Toronto, Ontario, with approximately 2,000 trauma activations per annum, approximately 50% of which have an Injury Severity Score (ISS) of ≥ 16. The study population consisted of trauma patients aged 16 years or older brought to the hospital via EMS.
Outcome measures
Our data collection form was based on a standard handover mnemonic known as the IMIST-AMBO framework (I: identification, M: mechanism of injury, I: injuries identified, S: signs and symptoms—including vital signs, T: treatment and trends, A: allergies, M: medications, B: background history, and O: other information), with a minor adjustment to include symptoms in the category of I: injuries identified.Reference Iedema, Ball and Daly12 Importantly, in this study, EMS were not trained to use this mnemonic and were not mandated to use any mnemonics in general. However, we opted to use the IMIST-AMBO framework as a means of guiding our data collection because of the specificity and breadth of information that is captured and because it was successfully trialled and validated for handovers from EMS to the trauma team in an Australian setting.Reference Iedema, Ball and Daly12 Our data collection form divided the verbal handover into a formal section (formal handover), consisting of the trauma team pausing to listen to the EMS report, and an informal section (informal handover), consisting of any subsequent verbal interactions between EMS and members of the trauma team as the trauma team continued delivering care to the patient (e.g., EMS moving to the charting nurse and answering questions). Final data collection metrics included: 1) characteristics of the transfer to hospital; 2) patient characteristics; 3) information contained in the handover according to the IMIST-AMBO framework; 4) information related to the process and structure of the handover; 5) the presence of parallel conversations, defined as ongoing conversations between other members of the trauma team as EMS delivered verbal handover; 6) duration of the formal and informal handover; 7) questions asked to EMS from the trauma team as interruptions and non-interruptions; and 8) a bidirectional Likert scale, distributed to EMS, the charting nurse, and the trauma team leader immediately following the handover. We captured team members’ perceptions regarding three categories: amount of information in the handover as it related to clinical decision-making, duration, and structure.
Data analysis
All statistical tests were conducted using IBM SPSS version 24.0 software (IBM Corp, Armonk, NY). Descriptive statistics were used to calculate handover characteristics and are expressed as means and standard deviations or proportions/percentages. Where relevant, chi-square tests of independence were used to assess for non-random correlations between variables, and Student's t-test was used to calculate non-random differences in means. A p-value of <0.05 was considered statistically significant in all calculations.
RESULTS
Handover flow
Figure 1 demonstrates aggregate handover flow over the data collection period. One patient in extremis was transferred to the trauma bed without any verbal handover. Of the 79 formal handovers, 51 (65%) had a subsequent informal verbal component. Most physical patient transfers from the EMS stretcher to the trauma bed occurred before formal handover (77%), 22% occurred during the handover, and one occurred after (1%). Table 1 demonstrates demographic data of trauma patients for which handovers were observed and of the trauma team.
Figure 1. A flowchart of all handovers during the eight-week data collection period.
Table 1. Characteristics of trauma patients and the trauma team
EMS = emergency medical services; IQR = interquartile range; SD = standard deviation.
In 61% of formal handovers, there were parallel conversations among other members of the trauma team. Formal handovers with parallel conversations had a greater number of interruptions by team members to ask questions (3.15 v. 1.81, respectively; p = 0.001). The presence of parallel conversations in formal handovers was also associated with a greater number of total questions asked (3.58 v. 2.23, respectively; p = 0.001). Formal handovers with an associated informal component were significantly longer than those without one (3:19 v. 1:50, respectively; p < 0.001).
Handover content
The most consistently provided information in handovers included identification (99%), injuries identified and/or symptoms (97%), mechanism of injury (96%), and any mention of physical signs (92%) (Table 2). However, information communicated less frequently included details regarding the background history, including past medical history (present in 75% of handovers), en-route treatment and trends (68%), medications (59%), and allergies (54%). While examining the sub-categories of identification and physical signs, information was also inconsistent. For example, EMS personnel never identified themselves (0%) and only mentioned the patient's name in 43% of handovers. With respect to the physical signs, information regarding airway status (present in only 22% of handovers) and breathing status (54%) was often lacking. Of the 79 handovers, only 10 (13%) included complete information pertaining to all airway, breathing, circulation, and disability.
Table 2. Information flow of formal and informal handovers by EMS according to the standard items of the IMIST-AMBO tool
EMS = emergency medical services; N/A = not available.
*Categories with sub-categories (e.g., identification, signs) were marked as being present if any sub-categories were present (e.g., patient's name, A: airway status).
Questions during handover
During formal handovers, there was a mean of 3.05 (standard deviation [SD] 1.95) questions from the trauma team to EMS. Overall, 86% of these questions interrupted the formal handover. During the informal handover, there was a mean of 4.32 (SD 2.75) questions. There were significantly more questions referencing previously provided information in the informal handover compared to the formal handover (58% v. 13%, respectively; p < 0.001). Overall, including both the formal and informal handover, there was a mean of 5.84 questions per handover, with 35% of the questions inquiring about information already provided.
In the informal handover, the most common types of questions asked concerned signs (41%), information in the category of “Other” (33%), treatment and trends (27%), the patient's medical background (19%), and injuries and/or symptoms (2%). Concerningly, 15% of questions were requests for the entire handover to be repeated (Table 2).
Handover structure
The handover structure was largely inconsistent, as compared with the standard IMIST-AMBO tool (Table 3). Overall, 85% of handovers began with identification, with 49% of all handovers continuing with the mechanism of injury, and there was little consistency in category order beyond this. There was a dedicated question and answer (Q&A) period in only 28% of formal handovers, which would have involved paramedics explicitly asking the trauma team if they have any questions or providing a period of silence to probe for questions implicitly.
Table 3. Distribution of handover structure according to the standard IMIST-AMBO tool features
Additionally, the structure was further lacking with regards to the order in which information was presented, with EMS providers returning to a category of information unprompted in 84% of cases. The median number of categories to which EMS returned was two (minimum 0, maximum 6), with categories of information repetition delineated in Table 2.
Perceptions of EMS-trauma handover
Information regarding team perceptions of handover information, duration, and structure was collected from nurses (survey response rate: 62/79, 78%), EMS (71/79, 90%), and trauma team leaders (survey response rate: 71/79, 90%) and are presented in Figure 2a-c. When ratings on the bidirectional Likert scale were reduced to ideal (a score of 0) and non-ideal ratings (a score of -5 to -1, or + 1 to + 5), differences between ratings among providers were statistically significant for ratings of information, duration, and structure (p < 0.05), with EMS being most content with their handovers and trauma team leaders the most critical. For example, 77% of EMS thought that the structure of their handover was ideal, as compared with 47% of nurses and 38% of trauma team leaders. This trend persisted across information and duration of the handover.
Figure 2a. Distribution of EMS, nurse, and trauma team leader perceptions on the amount of information provided by EMS during handover, with -5 representing “too little,” 0 representing “ideal,” and 5 representing “too much.”
Figure 2b. Distribution of EMS, nurse, and trauma team leader perceptions on the duration of the EMS handover, with -5 representing “too short,” 0 representing “ideal,” and 5 representing “too long.”
Figure 2c. Distribution of EMS, nurse, and trauma team leader perceptions on the structure of the EMS handover with -5 representing “structure lacking”; 0 representing “ideal”; and 5 representing “structured, but too complex.”
DISCUSSION
Clinical handover has often been flagged as a process susceptible to communication failures and adverse events in various settings.Reference Carter, Davis, Evans and Cone10,Reference Fahim Yegane, Shahrami, Hatamabadi and Hosseini-Zijoud13,Reference Bruce and Suserud14,Reference Bost, Crilly, Wallis, Patterson and Chaboyer17,Reference Cohen and Hilligoss18 In the setting of trauma, high patient acuity, overcrowding, and the time-sensitive nature of communicating patient information can paradoxically increase the risk that information is misinterpreted or not properly delivered.Reference Bruce and Suserud14,Reference Leape19,Reference Scott, Brice, Baker and Shen20 Using the IMIST-AMBO framework as a reference, we have identified key areas for improvement to increase team performance and improve patient care and safety.
EMS providers were most consistent (>90%) in delivering key information that impacts patient outcomes, including patient identification, mechanism of injury, injuries identified and/or symptoms, and any mention of signs.Reference Carter, Davis, Evans and Cone10 However, other important information that might impact patient outcomes, such as airway status, breathing status, circulation, and disability, were inconsistently transmitted, demonstrating a need for improvement of handover content.Reference Carter, Davis, Evans and Cone10
A lack of active listening and the general repetition of information have been identified as two pertinent modifiable factors that frustrate EMS providers.Reference Thakore and Morrison6,Reference Jenkin, Abelson-Mitchell and Cooper7,Reference Yong, Dent and Weiland9,Reference Bruce and Suserud14 In our study, the high proportion of handovers with parallel conversations and a large degree of questioning already provided information suggest inadequate active listening. The presence of parallel conversations was also associated with an increased number of questions as interruptions. One possible explanation for this is that parallel conversations increase the need for interrupting questions to keep the team and handover on track, as parallel conversations make it difficult to hear or focus on the handover. Changing environmental behaviour and cultivating a culture that encourages active listening during these handovers may have the potential to reduce parallel conversations and repetition of information.
In the formal handover, only 28% of handovers had a dedicated Q&A period. The lack of dedicated blocks of time to ask questions explains why the vast majority of questions during the formal handover period were framed as interruptions. One qualitative study noted that trauma team members became dismissive of paramedics when they “rambled on” about information that might not have been critical to transmit.Reference Evans, Murray and Patrick15 It may be possible that there is a mismatch between the information that the EMS deems important and the information that the trauma team requires, resulting in the high frequency of interrupting questions during the formal handover. This hypothesis is strengthened with our survey results that demonstrate the difference in perception of handover quality (information, duration, and structure) among team members. Setting clear expectations about information content may improve the succinctness of EMS handovers and reduce the number of interrupting questions from the trauma team. Additionally, establishing the expectation that there will be a dedicated Q&A period during the formal report and ensuring that the trauma team knows this and will anticipate it could also reduce the number of interruptions.
Taken together, our data and analysis demonstrate that there is ample impetus for change. Standardization of the handover process has been associated with a shorter duration of handover and improved satisfaction and would mitigate potential latent safety threats.Reference Iedema, Ball and Daly12,Reference Fahim Yegane, Shahrami, Hatamabadi and Hosseini-Zijoud13,Reference Meisel, Shea and Peacock21 However, adequate training and education are required to ensure that the handover process and structure yield improvement.Reference Talbot and Bleetman22 The literature has also shown that EMS feel that they receive insufficient training on handover and would appreciate more.Reference Thakore and Morrison6,Reference Budd, Almond and Porter23
A diversity of frameworks and mnemonics exist to standardize handover.Reference Cohen and Hilligoss18,Reference Riesenberg, Leitzsch and Little24 In interdisciplinary settings, it has been suggested that more prescriptive and specific frameworks (such as IMIST-AMBO) be used in place of frameworks in which the content of the handover is determined predominantly by the provider (such as SBAR: situation, background, assessment, and recommendations). The handover between EMS and receiving staff represents an intersection of two organizational cultures, which may not share the same nomenclature, lexicon, or values.Reference Behara, Wears, Perry, Henriksen, Battles, Marks and Lewin25 Implementing a “shared mental model,” developed with input from both EMS and receiving staff, may be valuable in navigating challenges that arise from the merging of two organizational cultures, educational backgrounds, and heterogeneous practices during patient handover.Reference Gillespie and Chaboyer26 This could occur through a co-constructed handover model, limiting interruptions during handover and asking clarifying questions at the end of handover.Reference Behara, Wears, Perry, Henriksen, Battles, Marks and Lewin25 Providing a shared mental model in the form of a standardized framework for handover may allow for the facilitation of shared understanding and enhance team performance.Reference Gillespie and Chaboyer26,Reference Bruce and Suserud27
We have provided a comprehensive analysis of the state of handovers between EMS and trauma teams through an examination of the handover content, duration, and structure, handover processes, and perceptions of the handover according to various disciplines. Our adherence to a randomly generated schedule allowed us to capture handover data from a representative breadth of handovers.
Our study had several limitations. First, those involved in the handover may have been performing better than usual, given the possibility that they knew they were being observed. As such, our data may not represent true handover trends in an unobserved environment. Additionally, only a single observer was recording information about the handover. Observation conducted in duplicate may have yielded more robust data and reduced bias introduced by only a sole observer. Third, our data collection occurred in real time. Several other studies evaluating handover have done so using audio- or video-recording, allowing them to capture a greater breadth of information and permitting data abstracters to review data retrospectively to ensure accuracy.Reference Iedema, Ball and Daly12,Reference Fahim Yegane, Shahrami, Hatamabadi and Hosseini-Zijoud13,Reference Sumner, Grimsley and Cochrane28
CONCLUSION
Several categories of information were inconsistently communicated during handover, with significant repetition of information and a lack of active listening. Handover structure was largely inconsistent, and there may be a misalignment of handover expectations among EMS, nurses, and trauma team leaders. These findings point to the potential benefits that may result from standardizing handover. Doing so optimally requires the co-construction of a shared mental model with input from EMS, nurses, trauma team leaders, and other key stakeholders.
Acknowledgements
This work has been presented at the Trauma Association of Canada 2019 Annual Meeting, February 28–March 1, 2019, in Calgary, and the Society for Academic Emergency Medicine 2019 Annual Meeting, May 14–17, 2019 in Las Vegas. AJ, AN, HT, and LDL conceived the study and its design. AJ and LDL sought out and confirmed requirements and ethics approval. AJ and LDL conducted the data collection. AJ, AN, HT, and LDL played a role in quality control. AJ and LDL analyzed the data, with statistical advice provided by HT and AN. AJ, AN, HT, and LDL interpreted the data and drafted the manuscript, and all authors contributed significantly to its revision. AJ takes responsibility for the paper as a whole.
Competing interests
We have no conflicts of interest to declare. We have no financial relationships to disclose with regard to this manuscript. This research received no specific grant from any funding agency, commercial, or not-for-profit sectors.
