This study, which is abefore and after interventionstudy (described as a ‘video-refexive ethnography’), examines ambulance staff toemergency department (ED)handover in two centres inNew South Wales in Australia.
In the frst stage of thestudy, participants wereinvolved in one of ten focusgroups where membersof the Centre for HealthCommunication (CHC)worked with participantsto explore the complexitiesand challenges encounteredduring patient handover.
The next stage involvedobservation of handoverswhich included video-recording 73 handovers (33 atone hospital; 40 at the other).This data was analysed lookingfor emerging similarities and/or differences focusing onboth verbal and non-verbalcommunication patterns;duration of handover etc.
In the pre-interventionobservations in 93 % (68)of cases the ED staff askedquestions during thehandover, with 38 % (26)asking questions about issuesthat had already been coveredby the paramedic. In 67 %(49) of cases the paramedicrepeated information duringhandover. Handover timevaried according to factorssuch as severity of patients’condition (higher categorytriage appeared to have longer handover times thannon-urgent patients), orseniority of the paramedic(more senior grades tooklonger). The amount of eyecontact appeared to infuencehandover time, with less eyecontact culminating in longerhandover times.
The next stage involvedrefexive focus groups lookingat edited footage of handoversand the preliminary analysisof the data. These activitiescombined with refexivefeedback from staff workingin these areas enabled thedevelopment of a model forhandover known as IMIST-AMBO.
This comprises:Identifcation, Mechanism/Medical complaint, Injuries/Information about complaint, Signs, Treatment & Trends,Allergies, Medications,Background, Other issues.
Three additional factorswere identifed as importantto accompany this protocol:an interruption free zone;20 seconds of ‘Hands off/eyes on’ where eye contactis deemed as essentialbetween the two parties andreceiving staff were asked tominimise patient/equipmenthandling (unless it was timecritical as in cardiac arrest) toallow them to focus on thecontent of the paramedics’handover; and clinical leadersin ED need to be more easilyrecognisable which couldbe achieved by wearing adifferent coloured uniform.
This system was thenintroduced to all paramedicsexposed to the EDs of thetwo participating hospitals.The CHC worked with ambulance educators andambulance services to providetraining and feedback tothe paramedics; in additionposters and pocket sizedlaminates outlining theprotocol were introduced intothe ambulance service. In total373 staff were trained (108 EDclinicians; 220 paramedics; 45paramedic educators).
Post-intervention evaluationwas achieved by video-recording and analysing 63handovers; and by distributionof a brief Likert style survey toED clinicians.
The post-interventionanalysis showed: a reductionin the number of questionsbeing asked during handoverfrom 93 % to 41 % with lessrepetition of information;improved sequencingand ordering of handoverinformation; a reduction oftime spent on handover (insome cases) with an increasein information being delivered(partly due to the decreasednumber of interruptions);increased eye contact whichthe authors suggest isindicative of a higher level ofshared attention.
Recommendations fromthe study include: adoptionof a standard protocol forhandover which should beused in all hospitals so thatprehospital staff do not haveto change their approach according to the hospital;investment in education sothat all staff engaged in thistype of patient handoverreceive development; anemphasis on handoverprotocols in curricula forstudent paramedics andtrainee ED clinicians so thatthe process is familiar fromthe start.
This is an innovativestudy where the participantswere actively engagedin the development of astandardised handoverframework/instrument toimplement into their practice.
Limitations include alack of generalizabilitywhich is common withinqualitative studies; howeverthe fndings clearly havetransferable elements whichcould be relevant to the UK.Further research is requiredto investigate whetherdevelopment and/or adoptionof similar frameworks wouldimprove the quality of thisimportant component of thepatient’s care while beingtransferred from prehospital toin-hospital care in UK settings.