Handover communication between paramedics and hospital receiving staff in the emergency department (ED) involves a transfer of responsibility, continuation of patient care and a formal hospital admission. This communication includes a verbal handover as well as documentation, which may be paper-based or electronic. However, little is known about handover communication in the UK military and how this might differ from civilian practices. According to Hodgetts and Mahoney (2009), there are potential benefits from studying civilian and military health care while acknowledging their differences.
Handover communication protocols between medical emergency response teams (MERTs) and hospital receiving staff are governed by the Ministry of Defence's (MoD) (2013) joint service publication Clinical guidelines for operations (2013) (now under review). The objectives of the current literature review were to understand more about handover communication in civilian and military emergency care settings and how they might differ from one another.
Method
This literature review was divided into two parts, in response to the advice of specialist librarians, and it used search concept tools. The first part considered handover communication in international civilian emergency care settings, and the second examined UK military handover.
The following databases were consulted: CINAHL Plus; EBSCO Discovery Service; Medline; and PubMed Central. Individual subject-specific journals were consulted in addition to a hand search of references and enquiry with experts in the field. A further web search was conducted to identify relevant grey literature.
The strategy for selecting papers involved the database search followed by screening titles and abstracts. Studies that met the inclusion criteria were subject to critical and thematic analysis.
Eligibility criteria
The review included papers that referred to handover communication between paramedics and hospital receiving staff in EDs in civilian and military settings. Papers that referred to handover communication in other settings; those that omitted paramedics; or focused on paediatric handover were all excluded. This literature review was international in scope but confined to papers in the English language. The timeline encompassed studies published from the year 2000 until completion in August 2018. The review considered different methods of communication such as patient report forms (PRFs) but excluded technological trials and prospective models for reorganising emergency medical services (EMS). Papers were assessed using the Critical Appraisal Skills Programme (CASP) (2013) and those that did not meet these criteria were removed.
Results
Evans et al (2010a) explain how the Mechanism, Injuries or Illness, Signs, Treatment (MIST) handover mnemonic (a variant of ATMIST) is used in the military, and question both its appropriateness for use in civilian settings and its effectiveness. Jensen et al (2013) acknowledge that MIST has been adapted from the military and explains what it stands for, but does not discuss the suitability of introducing military practices into civilian health care.
The literature review on handover communication in military emergency care settings returned only nine papers. On closer examination, only two of these met the CASP criteria so a narrative review was conducted of all nine papers. Four themes were identified in the civilian handover communication literature (Table 1).
| Number | Theme |
|---|---|
| 1 | Civilian handover is complex and takes place in less-than-ideal conditions |
| 2 | The quality of civilian handover is variable and affected by human behaviour |
| 3 | Standardisation |
| 4 | Patient-related factors and how they affect handover |
Theme one
Civilian handover is complex and takes place in less-than-ideal conditions
Handover is a transfer of responsibility from the prehospital team to the hospital receiving team and the formal admission of a patient into an institution (Knutsen and Fredriksen, 2013; Sujan et al, 2014; Goldberg et al, 2017; de Lange et al, 2018). This transfer of responsibility is documented and involves transferring the patient from ambulance trolley to hospital bed (Bledsoe, 2013). The prehospital and hospital receiving team are engaged in communication but have different information requirements and this complicates handover (Sujan et al, 2015a; 2015b; Goldberg et al, 2017; Najafi Kalyani et al, 2017).
The transfer of responsibility and communication exchange takes place in a busy ED where staff are frequently interrupted (Bost et al, 2012; Dawson et al, 2013); space may be restricted and noise can hinder verbal communication (Wood et al, 2014; Najafi Kalyani et al, 2017).
The literature suggests that the complexity of handover communication and the less-than-ideal circumstances in which it takes place create risks to patients (Owen et al, 2009; Ebben et al, 2015; Meisel et al, 2015; Campbell et al, 2017; Najafi Kalyani et al, 2017; de Lange et al, 2018). The picture in the UK is further complicated by performance management targets, which create competing organisational priorities (Sujan et al, 2015c).
Theme two
Quality of civilian handover is variable and affected by human behaviour
The literature suggests that the quality of handover is variable and this effects communication. Murray et al (2012) found that of 100 ED records, 26 contained inconsistencies when compared with PRFs. Increasingly, ambulance services are using electronic PRFs but it is not clear whether this improves handover communication.
Knutsen and Fredriksen (2013) surveyed 29 ED registrars, who considered the verbal paramedic handover and any referring GP letters to be the most pertinent source of information, while a review of patient documentation showed less than half of vital information was transferred from prehospital to hospital notes.
Cram et al (2017) found that physicians in Ontario Canada ‘commonly’ take care of patients without viewing the ambulance documentation, while Shelton and Sinclair (2016) discovered that administrative staff in Toronto did not understand that ambulance reports contained information not provided during verbal handovers.
Carter et al (2009) videotaped handovers in a trauma centre and showed that only 72.9% of transmitted items were recorded on the ED chart but were unclear of the reasons why. Scott et al (2003) discovered that physician recall of paramedic reports was only 36% and suggested that this might be because of inadequate paramedic handovers, as well as physicians failing to listen to them, although this was speculative. Bradley et al (2017a) found problems with prehospital documentation in another Canadian province, British Columbia, including airway and physiological data and Glasgow Coma Scale (GCS) in 43–49% of cases, and Evans et al (2010b) established that only 67% of information was documented in ED charts.
De Lange et al (2018) observed practitioners in a South African ED and reported that hospital receiving staff were distracted by task-orientated behaviour, inattentive listening and using indigenous languages. This was consistent with Owen et al (2009), who discovered ‘tensions between ‘doing’ and ‘listening’ in their Australian interview-based study.
A literature review by Shields and Flin (2012) identified a gap in knowledge regarding paramedics' non-technical skills. Fitzpatrick et al (2018) undertook a small-scale study of a pre-alert tool in Scotland but, while this study found favour among paramedics, it failed to establish an objective quality measure for handover communication.
Verbal handover is affected by human behaviour and paramedics complain that hospital receiving staff did not listen to handover communication and required repetition (Jenkin et al, 2007). On the other hand, hospital receiving staff have reported that handovers lacked structure (Thakore and Morrison, 2001).
A literature review by Dawson et al (2013) identified problems with professional relationships, obstacles to communication, repeated handovers, and identification of ED staff. In contrast, an observation of 621 handovers by Yong et al (2008) in an Australian ED found handover was perceived as ‘useful and accurate’ by hospital receiving staff in 80% of cases.
Theme three
Standardisation
Although standardisation remains a contentious issue in the literature (Jenkin et al, 2007; Iedema et al, 2012; Dawson et al, 2013; Wood et al, 2014), attempts have been made to improve handover communication through standardisation tools.
Francis et al (2010) developed standard operating procedures including check boxes and Bost et al (2012) noted that the ATMIST mnemonic was used in the resuscitation room followed by an opportunity to ask questions but did not comment further on its use.
Iedema et al (2012) used video-reflexive ethnography and pre and post surveys of 137 handovers to assess the use of the following mnemonic: Identification, Mechanism, Injury, Signs and Symptoms, Treatment and Trends—Allergies, Medication, Background history, Other information (IMIST-AMBO). This Australian study found that the mnemonic helped to provide structure to handover and reduced repetitions and interruptions (Iedema et al, 2012). It also mentioned the lack of evidence for IMIST but did not refer to its military use (Iedema et al, 2012).
Wood et al (2014) urged caution with employing mnemonics because they had an insufficient evidence base, especially for complex patients. Harmsen et al (2017) reported on a study from the Netherlands which produced a mnemonic designed to remove ambiguity in handover.
Jenkin et al (2007) argued for national handover standards and technological solutions to improve handover based on a survey of 42 paramedics, 17 doctors and 21 nurses, and credited Hodgetts and Turner (2006) with developing MIST but did not mention its military application.
Talbot and Bleetman (2007) found that use of the mnemonic Demographics, Mechanism, Injury/Illness, Signs, Treatment given (DeMIST) led to a decrease in information retained by hospital receiving staff. This small study credited the development of MIST to Professor Tim Hodgetts and its use in the Johannesburg Trauma Unit but not the military context within which it evolved (Talbot and Bleetman, 2007).
Ebben et al (2015) attempted to improve standardisation through e-learning training on DeMIST but found no improvement in adherence to the mnemonic and failed to mention its military application, which was highly relevant to the intervention. Furthermore, only the EMS staff, not the ED receiving team, received training in its use (Ebben et al, 2015).
Dawson et al's (2013) literature review argued for a standardised handover tool and included a brief discussion of ATMIST variants but did not acknowledge military use. Campbell et al (2017) argued that transfer documentation between residential aged care facilities in Tasmania and the ED needed further standardisation to account for the complex needs of older patients, in contrast to Wood et al (2014).
A UK survey conducted by Budd et al (2012) indicated that paramedics were more familiar with ASHICE (Age, Sex, History, Injuries/Illness, Condition (which includes observations and interventions), and Estimated time of arrival) (86.7%) than ATMIST (15.4%), although ATMIST and its variants are more prevalent in the literature.
Concerns about inadequate handover and patient safety inspired Sujan et al (2015b) to analyse 203 handovers in three NHS EDs using discourse analysis. This comprehensive, large-scale study found that communication with ambulance services was descriptive and collaborative and aimed at joint decision-making. Sujan et al (2015a) warned against ‘procedural compliance’ and pointed at the lack of evidence underpinning ATMIST.
Theme four
Patient-related factors and their effect on handover
Handover communication improves when patients have easily identifiable problems and present an ‘ideal’ handover (Bruce and Suserud, 2005) or ‘best-case’ scenario (Carter et al, 2009). Bost et al (2012), in their ethnographic study conducted in Australia, identified two types of handovers—critical and non-critical—depending on patient acuity. This was similar to a study by Meisel et al (2015) who reported that hospital receiving staff were biased towards trauma rather than medical patients; however, the findings were based on focus group interviews solely with EMS personnel.
Narrative review of military handover communication literature
The two papers that met the CASP criteria were Arul et al (2015) and Cordell et al (2008). Arul et al (2015) surveyed 115 staff members who were involved in delivering care to patients admitted to Camp Bastion in 2012 including the ATMIST handover with battlefield injuries. It found that staff members were highly satisfied with the quality of communication. Cordell et al (2008), who conducted an audit of evacuation times in May–July 2007, reported that 75% met the target of 90 minutes from the message being received at the operations centre to the arrival of the helicopter at the field hospital landing site. This paper included information provided during the ATMIST handover, then known as MIST, but offers no further information on handover in the military.
The remaining seven papers contained references to handover between paramedics and hospital receiving staff but little in the way of analysis or evaluation. It is evident that little is known about handover communication in emergency care settings in the military.
Loseby et al (2017) produced a commentary which refers to the use of ATMIST by the military and describes it as an ‘effective template’ that is ‘easy to remember’. They advocated the use of written mnemonics because cognitive ability declines during stressful situations (Loseby et al, 2017). However, the paper is a commentary and its conclusions are not substantiated by a clearly defined literature review.
Morrison et al (2006), Horne and Smith (2011) and Nicholson Roberts and Berry (2012) refer briefly to the ATMIST handover but this is limited to an explanation of the headings. The paper by Hodgetts and Mahoney (2009) explains how and why military trauma systems differ from civilian ones and refers to MERT but does not describe military handover communication.
Thomas (2014) provides a comprehensive overview of the role of MERT from a paramedic viewpoint. It authoritatively describes handover communication consistent with MoD (2013) guidelines, but it does not evaluate the MERT handover and details on ATMIST are limited. The final paper, by Bradley et al (2017b), provides an overview of combat casualty care over the past 100 years and refers briefly to the use of MERT and prehospital transportation to overcome long distances.
Discussion
The literature on civilian handover communication shows that it is complex and involves a transfer of responsibility, formal admission to hospital and continuation of care delivery (Knutsen and Fredriksen, 2013; Sujan et al, 2014; Goldberg et al, 2017; de Lange et al, 2018). Handover occurs in less-than-ideal circumstances because of noise and limited space, while health professionals have little control over infrastructure, service demand and performance management targets (Bost et al, 2012; Dawson et al, 2013; Sujan et al, 2015c). The quality of handover varies and is affected by human behaviour that leads to interruption and repetition (Jenkin et al, 2007; Owen et al, 2009; Bost et al, 2012; Meisel et al, 2015; de Lange et al, 2018).
The literature indicated significant issues with information transfer and retention by hospital receiving staff but the reasons for this are not clear, while electronic reports may not be consulted (Shelton and Sinclair, 2016). Moreover, handover communication takes place between different health professionals with different information needs (Sujan et al, 2015a; 2015b; Goldberg et al, 2017; Najafi Kalyani et al, 2017). The literature is divided on whether further standardisation is desirable and, while it appears that mnemonics can improve the transfer and retention of information, the picture is not entirely consistent.
The papers that refer to military handover communication are essentially descriptive and the MoD (2013) guidelines are under review. Consequently, there is limited information on how handover communication in civilian emergency care settings differs from that in the UK military. This suggests that caution should be applied regarding the introduction of military handover practices into civilian emergency care setting as there is a lack of awareness regarding the development of ATMIST and its variants, and how it was refined by the military to deal with a unique set of patient characteristics not comparable to those of the typical civilian patient.
The MIST handover is designed to take 20–30 seconds and delivered to an attentive hospital receiving team (MoD, 2013: 41) but human behaviour in the military is subject to the disciplines of rank, which are neither possible nor desirable to replicate in civilian settings. Civilian healthcare providers have different organisational goals and information needs. Moreover, there is an insufficient evidence base to justify MIST's use in civilian practice (Sujan et al, 2015b; Wood et al, 2015).
Bradley et al (2017b) have documented how warfare prompts medical advancements such as those for the care of burns victims in First World War and the administration of antibiotics in the Second World War. The conflict in Afghanistan may have led to advances in resuscitation protocols, trauma surgery and aeromedical evacuation (Bradley et al, 2017b); however, caution should be exercised before transferring military healthcare protocols without a sufficient evidence base.
Implications for practice and research
Debates around the extent to which standardisation is desirable in civilian emergency care settings should account for the collaborative nature of handover communication and the increasing complexity of patients' needs. There is an opportunity for military and civilian medical healthcare practices to learn from each other but the transfer of any protocols should be supported by an evidence base.
More research is needed on the communication challenges in the ED, including the use and availability of electronic reports. Within the UK, research should be conducted on performance management targets to assess their impact (Sujan et al, 2015c).
Conclusion
The literature on handover communication in civilian emergency care settings focuses on four themes: the complex nature of handover; its variable quality; standardisation; and patient factors. There is a literature gap on handover communication in military emergency care settings and, consequently, not much is known about how this differs from civilian practices. The handover communication literature on civilian emergency care settings frequently mentions MIST and its variants. However, there is little evidence of a wider understanding of how it is has been used by the UK military, how it was developed to deal with specific patient characteristics or the context of military operations in Afghanistan within which it evolved.
Medical advancements made during wartime are ancillary to military objectives. Therefore, further research is needed to establish how, as well as why, military medical protocols differ and whether it is appropriate to transfer them into civilian health care including handover communication in emergency care settings.