Clinical handover of the trauma and medical patient: a structured approach

Barriers to effective handover

Previous work has identified numerous problems associated with patient handover (Thakore and Morrison, 2001). Such difficulties can include a lack of structure, duration of handover, gaining the attention of receiving medical staff, lack of training, noise and other distractions, and difficulty recalling important multiple facts and complex information (Thakore and Morrison, 2001).

The principle failures with handover are i) the apparent lack of structure and ii) the lack of handover training. A previous study found that only 19% (n=13) of ambulance staff reported receiving specific handover training and 83% (n=56) of those who had received no training identified a need for it (Thakore and Morrison, 2001). Ye et al (2007) recognised that a handover ‘gold standard’ would help standardise information handed over in the emergency department. In one survey conducted in the UK, 53% of ambulance staff reported they used a structure while only 39% of emergency department personnel were aware of this (Budd et al, 2007).

Whilst published evidence suggests handovers are of variable quality there is no published evidence regarding the most appropriate handover method (Wong et al, 2008). A paper published by Evans et al (2010) discussed the use of a potential handover template and concluded there was support for its adoption but further evaluation was required.

Aims

To review several commonly used handover templates in use by pre-hospital services, evaluate the advantages and disadvantages of each and suggest methods to improve clinical handover from pre-hospital to hospital personnel.

Existing handover templates

Several handover templates already exist and are used in clinical practice. We have encountered four commonly used templates in our practice: ASHICE, SBAR, AT MIST and the Kent, Surrey and Sussex HEMS template (adopted from the London Air Ambulance template).

ASHICE refers to Age, Sex, History, Injuries, Condition and Expected time of arrival. This has been adopted as the preferred method of translating initial information from the pre-hospital environment to the waiting trauma team via ambulance control or direct radio/phone communications within the SECamb area. It is a well-recognised structure by both pre-hospital and hospital clinicians (Budd et al, 2007). The ASHICE structure does include most of the points required at handover, the main omission being exclusion of a format to allow for the input of any interventions performed by the clinician. ASHICE also does not include incident timings.

SBAR refers to Situation, Background, Assessment and Recommendation. This has been widely used as an effective template when communicating patient handover information in a hospital setting. The strengths of SBAR are the simplicity and familiarity of the template within the hospital setting (NHS Institute for Innovation and Improvement, 2008). However, a potential disadvantage of the SBAR format for the major trauma patient is that it does not prompt the clinician to cover key points, such as mechanism of injury, clinical interventions or suspected injuries.

AT MIST refers to Age, Time, Mechanism, Injuries, Sign and Treatment. This has been extensively used by the military (Berry and Nicholson Roberts, 2012) and is also a pre-hospital key performance indicator for the management of trauma (Stannard et al, 2008).

Compared to the HEMS template, the AT MIST format relies on the clinician to remember to add salient points such as initial GCS. One disadvantage is that it lacks specific details of inclusion for the injured patient, which may be important to those clinicians who are unfamiliar with the major trauma patient. We believe that the adoption of the AT MIST structure for pre-hospital alerts will increase familiarity with the structure and therefore its effectiveness.

The Helicopter Emergency Medical Service (HEMS) handover template has eight set headings for the trauma template and six set headings for the medical template.

The Trauma template

The Medical template

The HEMS handover is similar to the AT MIST template. The strength of the HEMS template is that it provides specific headings that allows for a greater emphasis of scene description and initial clinical examination. Another benefit of the HEMS template is that the patient is identified as being either ‘stable’ or ‘unstable’, which in effect negates the need for the verbal inclusion of lengthy patient observations such as blood pressures, pulse rates and oxygen saturations which can be difficult to retain and recall. The disadvantage of both the trauma and medical handover are that neither of the templates form an acronym and therefore are potentially less memorable without a written template as a guide. Although the HEMS handover template is derived from a modified AT MIST, there is a requirement for the headings to be in this order, making an acronym difficult to formulate.

The hospital team receiving the handover

In addition to improvements made by pre-hospital clinicians, efforts need to be made in hospitals to address the way handovers are received (Sutcliffe et al, 2004). Hospital clinicians need to be encouraged to actively listen to handover and considerations need to be given to environmental factors such as noise reduction and avoiding distractions (Evans et al, 2010). However, as the focus of this paper is on describing the pre-hospital elements of handover, further exploration of hospital handovers will not be undertaken.

Using the handover templates

To effectively use a handover template, the information under each of the titles must be kept short, clear and concise. When reading through the template, the handover will start at the top (name/age/time) and flow through each of the headings. To reinforce the structure of each handover section, announcement of the titles should precede the section information.

Discussion

Handovers are an essential part of clinical practice when transferring information and professional responsibility between different members of a healthcare system (Evans et al, 2010). Several factors need to be considered when choosing the ideal handover template. Length of handover is important—too short and important information may be lost and a handover which is too long may result in unnecessary delay to patient treatment (Sutcliffe et al, 2004). Use of a pneumonic can aid recall of handover templates. The use of a template can improve the relevance and consistency of information shared between the prehospital and in-hospital clinician. In most cases, the initial pre-alert to the hospital is made either directly by the ambulance crew or by ambulance control (Evans et al, 2010). This initial pre-alert can be short and succinct. On arrival at hospital, a further, more detailed handover is required. As discussed, there are various handover templates that give structure and clarity with both advantages and disadvantages. These are discussed in detail below.

ASHICE

Many ambulance services use the ASHICE format as the preferred method for the exchange of clinical information between the pre-hospital clinician and ambulance control (Brown and Warwick, 2001). The ASHICE handover template does not place emphasis on the treatment phase of care and therefore may inadvertently leave out important clinical information. Another weakness of the ASHICE system when prealerting the receiving hospital is that information is passed between several people often including nonclinical clerical staff in call centres, this increases the risk of error. Likewise it appears not all information including a full set of vital signs always reaches the receiving team (Brown and Warwick, 2001). We feel that more work is needed to improve the effectiveness of this template, despite its familiarity with ambulance crews it has numerous weaknesses associated with it. Ideally, handover should take place face-to-face between clinicians, with only minimal essential information passed over the phone.

SBAR

Used primarily as an intra-hospital handover template the SBAR format is easy to remember; however, it lacks detail and there is no emphasis on vital signs or injuries found, making it less suitable as a generic handover tool for the pre-hospital clinician. The SBAR handover template is a recognised format that is used within the hospital environment. The NHS ‘Institute for Innovation and Improvement’ website offers advice for staff in the clinical setting and in particular inexperienced staff who need to communicate ‘up the hierarchy’ (NHS Institute for Innovation and Improvement, 2008). In addition to the information that the NHS website offers, other studies confirm the benefit when using SBAR in-hospital. A study by Wacogne and Diwakar in 2010 found that the use of SBAR when conducting a handover reduced patient reporting time by 70%, whilst improving elements such as patient safety (Wacogne and Diwakar, 2010). This template is the recommended method by the World Health Organization (World Health Organization, 2013).

AT MIST

The AT MIST template is an effective template, it is both easy to remember and can be easily applied by the clinician. As with all templates which form an acronym, there is a need for the clinician to be familiar with the headings and enter all the required points correctly. A study conducted by Evans et al in 2010 concluded that the MIST handover, (which is the same as AT MIST without the inclusion of the A of age and the T of time) was an effective template but potentially lacked the elements such as ‘critical interventions’ and Glasgow Coma Score amongst others (Evans et al, 2010). Evan et al also proposed that the MIST template includes a series of tick boxes under each of the headings. For example, ‘mechanism’ has boxes labelled ‘roll over’, ‘motorcyclist’ etc. The use of a very specific template like this has the benefit of simplifying the process and providing an aide memoir, but could lack flexibility for the clinician delivering the handover. One advantage of AT MIST is having an easy to remember format, therefore offering the clinician the option not to rely on a written handover template. It is worth noting that a study by Fernandez et al discussed how acute stress affects memory formation and documented the adverse effects of acute stress on neural memory function (Fernandez et al, 2009). We therefore feel that simple pneumonics are not an important issue when deciding which handover template to use, i.e. ASHICE, SBAR, ATMIST. On the contrary, we would encourage clinicians to use a written template as a checklist. We know cognition declines with stress and that the simple introduction of a checklist reduces error and improves outcomes (Hales and Pronovost, 2006). An effective checklist highlights essential criteria to the user, improves standardisation and formats information in the more easily understood list rather than paragraph format. Checklists should not be viewed as replacing professional judgement but as aid to good practice and there are numerous examples in medicine where their introduction has lead to improved outcome and adoption of best practice (Hales and Pronovost, 2006).

HEMS template

The HEMS handover format offers the clinician full headings as opposed to a single letter. These headings require the clinician to document specific information. We feel that the HEMS handover builds upon the efficiency of AT MIST whilst promoting the explanation of injuries and interventions. The disadvantages are that the HEMS template does not offer an acronym and therefore requires the clinician to have a pre-prepared written template. The HEMS template is in use with the Kent, Surrey and Sussex HEMS teams (personal communication, Loseby J, 2013) and provides structure for patient handover. The template is carried on the teams’ flight boards.

Points to consider when using a handover template are that handovers can vary from clinician to clinician. Using a template that is too short can result in the loss of important clinical information, particularly the description of the scene and the patient's initial clinical findings. Conversely, the use of a template that requires extensive information can make the handover elongated and potentially losing the focus of the ED team. The advantage to using a pre-headed template is that the clinician has ‘prompts’ to follow and thus should ensure the inclusion of only relevant information.

Conclusions

Handovers are vital to the continuity of patient care and can influence patient outcome. Several structures exist to facilitate handover delivery but further work is needed to prospectively evaluate them. We advocate the implementation of a suitable pre-hospital handover template and the introduction of handover training. We believe the introduction of trauma networks into the UK provides the ideal opportunity to prompt hospitals and ambulance services to co-operate to standardise the approach to handover, improve training and carry out further prospective research into the most effective methods of patient handover.