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Abstract
Background Clinical handover plays a vital role in patient care and has been investigated in hospital settings, but less attention has been paid to the interface between prehospital and hospital settings. This paper reviews the published research on these handovers.
Methods A computerised literature search was conducted for papers published between 2000 and 2013 using combinations of terms: ‘handover’, ‘handoff’, ‘prehospital’, ‘ambulance’, ‘paramedic’ and ‘emergency’ and citation searching. Papers were assessed and included if determined to be at least moderate quality with a primary focus on prehospital to hospital handover.
Findings 401 studies were identified, of which 21 met our inclusion criteria. These revealed concerns about communication and information transfer, and themes concerning context, environment and interprofessional relationships. It is clear that handover exchanges are complicated by chaotic and noisy environments, lack of time and resources. Poor communication is linked to behaviours such as not listening, mistrust and misunderstandings between staff. While standardisation is offered as a solution, notably in terms of the use of mnemonics (alphabetical memory aids), evidence for benefit appears inconclusive.
Conclusions This review raises concerns about handovers at the interface between prehospital and hospital settings. The quality of existing research in this area is relatively poor and further high-quality research is required to understand this important part of emergency care. We need to understand the complexity of handover better to grasp the challenges of context and interprofessional relationships before we reach for tools and techniques to standardise part of the handover process.
- pre-hospital
- prehospital care
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Introduction
Clinical handovers play a vital role in the delivery of patient care. Research on handover communication has tended to focus on hospital settings, particularly on ward-based handovers and conversations between physicians and/or nurses,1–5 but there is an emerging literature on handover in prehospital settings and involving emergency care staff. Good handover has been shown to be associated with improvements in patient safety1 ,3 ,6–8 and record keeping,1 ,9 as well as continuity of patient care7 and improved decision making.10
Outside the hospital setting handover is a complex process that can involve a number of different people, professionals, patients and the public, and a range of communication technologies and formats. Handover of important clinical and social information may occur at the scene of an incident (such as the road side), in patients’ homes and social and nursing care facilities and at the interface between prehospital and hospital care. In the UK, handovers of information between prehospital and hospital staff about patients may include prealert, by radio or phone, either via ambulance control or directly from healthcare staff or ambulance crew, and a variety of face-to-face verbal, digital and written transfers of information between ambulance, emergency service and hospital-based personnel, and between these staff and members of the public (such as carers or accident witnesses) and other professionals (such as general practitioners or social workers). Once the care of the patient has been transferred to the receiving hospital or care facility, various written and digital documentation has to be filled in11 to complete the handover process.
Since the publication of ‘Zero tolerance—making ambulance handover delays a thing of the past’,12 there has been particular attention paid to the need to reduce handover delays in the National Health Service (NHS). This followed a UK National Audit Office review of ambulance services in June 2011, which showed that only 80% of handovers met the expectation that handovers from an ambulance and emergency department (ED) should take no more than 15 min. From April 2013, Clinical Commissioning Groups (CCGs) took responsibility for commissioning ambulance services and hospitals, and ambulance services and the CCGs are expected to share ownership of the agenda for improving ambulance handovers. This paper reports a review that was conducted in the context of this UK agenda and was intended to inform the policy debate and future research about the quality and effectiveness of prehospital to hospital handover. Much of the evidence base on this topic is derived from qualitative and mixed method studies or from quantitative research using surveys. This is not an area where it is practical, appropriate or ethical to conduct large-scale randomised controlled trials that are usually seen as the gold standard for evidenced-based practice. Nonetheless, this research can tell us about important features of handover between, and in, prehospital and hospital settings. In keeping with established methods for synthesising evidence from research involving these methodologies,13 ,14 we conducted a literature review focused on the broad, and deliberately flexible, question, “What does published research tell us about handover in prehospital settings?” For the purpose of this review, we defined ‘prehospital’ as including work undertaken outside the hospital environment and at the interface between emergency and secondary care, involving ambulance crews, healthcare professionals and staff outside secondary care, as well as hospital staff involved in transfer from emergency care to hospital facilities.
Methods
A computerised literature search was conducted using online databases Embase, Medline and CINAHL. Published articles were retrieved using combinations of six key search terms: ‘handover’, ‘handoff’, ‘prehospital’, ‘ambulance’, ‘paramedic’ and ‘emergency’. Both natural language and thesaurus terms were used in each database. The abstracts of the articles were reviewed for their relevance and inclusion in the literature review. The inclusion criteria were papers with a primary focus on prehospital verbal and/or written handover. Articles that focused on prehospital alerts or in-hospital handovers were excluded. The search was also limited to peer review journals and English-language publications. We searched the literature from January 2000 to March 2014 to maximise the literature available and to cover the period since paramedics became registered NHS professionals.15
Papers were read and reread by the review team, and the lead reviewer (KW) extracted and coded key findings. The codes and findings were discussed with the rest of the team, and a thematic approach was used to structure our interpretations and discussion.
Results
Of the 401 papers identified, from scrutiny of the abstracts 51 met our initial inclusion criteria (figure 1). Full-text papers were obtained and 30 papers were then excluded as secondary research, editorials or conference abstracts. The remaining 21 papers were given a score using a six-point checklist based on Greenhalgh16 and CASP17 rating tools. Five papers received scores below four losing marks due to lack of details about ethical approval and/or discussions of reliability, but all 21 papers were assessed as at least providing moderate quality evidence and were therefore included in the review.
PRISMA 2009 flow diagram. From: Moher et al.45
Seventeen of the papers were published in the last 7 years. Studies were carried out in Australia (5) and the UK (7), the USA/Canada (3), Italy (1), Sweden (2), the Netherlands (1), Italy (1) and Norway (2). The provenance of one paper by Manser et al18 appears to be from the UK/Switzerland. Eleven studies were quantitative, eight were qualitative and four used mixed method designs (see online supplementary table S1).
Discussion
The literature was analysed using a thematic approach appropriate for the methodologies of the research reported. After the initial familiarisation phase in which reviewers read and reread the papers, the team then met to identify and prioritise subthemes according to the frequency of occurrence and relevance to the review. The group discussion resulted in 32 subthemes including ‘active listening’, ‘relationships between clinicians’, ‘information retention’ and ‘environmental impacts’. Similar subthemes were then amalgamated, a process that happened with little debate between reviewers due to a great number of interlinking topics. Four major themes are used to focus the following discussion: communication, context, interprofessional relationships and standardisation of handover (including use of mnemonics).
Communication
Interviews with clinicians noted the importance attached to ‘clearly stated’ handovers,9 and the requirement that paramedics were ‘confident and succinct’,19 assertive and able to speak loudly.10 Effective handover was characterised by attentive receiving personnel9 who actively listened.19 This finding was supported by studies that showed that lack of active listening,20 lack of attention7 ,21 and the receiving teams’ divided attention10 ,22 lead to frustration for ambulance personnel23 and poorer handover.
Where handovers lacked structure,22 ,24 this was felt to be a source of miscommunication.10 ,21 ,25 Some studies reported that clinicians found that handovers contained irrelevant information,19 ,21 ,23 but this finding was contradicted by Yong et al.26 One communication problem appeared to stem from the lack of feedback from receiving personnel,7 ,22 ,25 combined with a lack of a shared cognitive picture10 so that handover communication was inadequate and could not be improved.
Information loss was identified by clinicians in an interview study25 as a discourse analysis of data transfer27 and a separate survey.26 In a video analysis of 96 trauma handovers in the USA, only 72.9% of the key prehospital data points transmitted by ambulance staff were documented by the receiving hospital staff28 and Australia showed that in a similar analysis only 67% of information given by paramedics to the in-hospital team was documented.29 This same study noted discordance between paramedics’ verbal handovers and their own documentation.29 Elsewhere anomalies between prehospital and in-hospital documentation have been shown: a UK-based study of 100 resuscitation room records reported that 26 had at least one instance where information recorded by the ambulance crew was either omitted or altered during transfer.30 A comparison of patient records conducted in Norway revealed that less than half of patient readings that were outside normal parameters were transferred to the admission documentation.31 Sujan et al27 reported that less than 2.8% of handovers of elderly patients reported relevant psychosocial information. One US study concluded that doctors appear to recall paramedic verbal reports about trauma patients poorly,20 and this was corroborated by Sarcevic and Burd's22 video analysis of 18 trauma resuscitations.
Although a survey showed that registrars in Norway preferred verbal handover to be combined with supporting paperwork,31 written documentation provided by ambulance crews was not always perceived as useful. The same study revealed that doctors found documentation from other doctors more useful than ambulance crew documentation.31 Yong et al26 reported that only 50% of ED personnel referred to ambulance documentation for patient care, and Al Mahmud et al25 found that receiving personnel often threw ambulance patient report forms in the bin without reading them. Bost et al32 suggested that ED personnel rely on memory when receiving a handover rather than written documentation. The literature suggested that paramedics often encounter difficulties recording data in the prehospital environment. The use of scraps of paper,22 gloves and bed linen,29 although common, was found to be impractical for recording patient information, but electronic systems were also regarded as impractical due to the time taken to enter data and difficulties in using these systems.19 ,22 Ambulance personnel expressed mixed views regarding the patient report form in terms of its clarity and usefulness.23
Context
Evans et al19 and Scott et al20 indicate that the transfer of verbal information is made difficult by the noise19 and chaos20 of the ED settings in which handover is conducted. These problems were found to be compounded by lack of adequate space and staff33 and the need for personnel to leave the room to carry out other duties.22 Handover effectiveness was associated with the availability of appropriate personnel to receive the handover.9 Workload32 and lack of time was identified as problem for handovers,9 ,22 although 72% of ambulance personnel felt they had enough time to give an adequate handover.7
Some papers showed that handover was often further compromised by interruptions,19 ,32 although Yong et al26 dispute this, reporting that 90% of handovers occurred with minor or no interruptions. Studies also show that handover is frequently repeated or duplicated. This repetition was associated with a need for clarification or new personnel entering the room32 or the absence of the nurse ultimately responsible for the management of the patient.23 Repetition was suggested as a cause for information loss10 but also identified as a strategy for handover improvement.23 Simultaneous handovers (over talking and parallel presentation of multiple cases) were shown to cause delays in patient treatment.22
Interprofessional relationships
A positive relationship between clinicians involved in handover was also a key facilitator of successful handover.9 ,32 ,33 Manser et al18 identified shared understanding and working atmosphere as key components of safe and effective patient handover. Against this, some of the research reported unprofessional attitudes, including disinterest from ambulance crews when presenting patients with ambiguous problems9 ,21; personnel who behaved unprofessionally during handover33 and dismissive attitudes of receiving staff causing frequent repetition of information by paramedics.19 A simulation study21 reported nurses’ lack of trust in paramedic information, and Knutsen31 suggested that information was judged differently depending on its source—such that doctors favoured information from other doctors.
Standardisation of handover
There have been many attempts to standardise handover practice, notably by using mnemonics, an alphabetical listing technique that aids information retention. Common mnemonics in the prehospital setting include mechanism, injury, signs, treatment (MIST) and injury, condition, time to hospital, with age, sex and history (ICE/ASHICE). Three papers focused on the use of mnemonics to standardise handover.19 ,34 ,35 One revealed only 20% of Australian paramedics and 53% of trauma team members were familiar with MIST.19 In contrast, 86.7% of ambulance personnel in the UK were familiar with ASHICE.24 The use of mnemonics was observed to improve handover consistency, increase the frequency of necessary information transfer and reduce questioning by ED personnel34 and to increase in elements communicated during handover.21 However, Talbot and Bleetman35 found that using a mnemonic did not improve information retention by ED staff (56.6% data retention using unstructured handovers vs 49.2% using structured handovers) or information recall. In addition, handover was not improved by an intervention to enhance paramedic communication skills.20
Studies indicated that there was a lack of training in presenting handover7 ,21 ,22 and in the use of mnemonics.19 However, paramedics were more likely to be given training than in-hospital personnel, but it appears that many staff learnt by observing peers.23 ,32
Conclusions
The handover studies reviewed here refer to handovers before, and at the point of transfer between prehospital and hospital staff and in community and secondary care settings. Recurring themes were identified across the literature from different countries that provide knowledge that can inform handover practices and improve ambulance services.
Considerable research effort has been directed to the issue of standardisation of handover communication. While many authors continue to advocate the use of mnemonics in handover to achieve this, the evidence for their usefulness is inconclusive. Moreover, these technical ‘solutions’ to the problem of handover are predicated on an assumption that standardisation will resolve the inherent complexity found in healthcare settings and communication tasks. Our review suggests that a broader conceptualisation of the problem of handover between prehospital and hospital staff is needed.
A key finding of this review is the apparent poor communication practices rooted in behaviours such as not listening and relational problems founded on mistrust, and misunderstandings between different personnel. These are social and human factors that have also been identified in other healthcare and non-healthcare settings.36–38 In addition, the studies reviewed here point to the challenges presented by the context such as noise, chaos and interruptions, which, while not unique to the prehospital environment, clearly make communication more difficult, with or without a mnemonic. Non-technical skills that impact on patient safety are becoming an important focus in healthcare, with anaesthetists and emergency physicians using the crew resource management approach used in the aviation industry to improve competencies.
The challenging and pressured environment of prehospital and hospital handover, and indeed of emergency and trauma care, increases the danger that miscommunication and failures to listen or recall information will occur and this is evidenced in our review. Through qualitative observational research and high-fidelity simulation, we can understand handover better and future research will need to harness these approaches that can analyse social and contextual factors and help us understand complexity. Further research should focus on organisational and social factors and also attend to gaps in the evidence base—for example, looking in more detail at the interaction between technologies (such as computerised records and monitoring) and communication. The utility of the Electronic Patient Report Forms (EPRFs)39 that are currently being rolled out across ambulance services could be explored in the context of accuracy and perceived benefit of digital information transfer in the handover process. Other research could focus on teams, for example, looking at how these are rapidly formed during resuscitations and how hierarchies and positional power influence information exchange. Given the continued focus on the use of mnemonics in some settings such at the military, research should explore the factors that contribute to their effective use in such settings and uncover the lessons to be learned for civilian practice. Our review concurs with a recent literature review that has also proposed a need for studies to identify relevant paramedic non-technical skills that could lead to the development of rating systems linked to paramedic registration with potential benefits for the profession and patient safety.40
Our review has demonstrated that there is a limited amount of good quality research on handover at the interface between prehospital and hospital clinicians. Most of the empirical studies have been conducted in non-UK and therefore non-NHS settings. Two reviews on this topic have been recently published by colleagues in Denmark41 and Australia;42 both were undertaken independently to the review presented here and identified some different papers. While broadly supportive of our analysis, these reviews propose standardisation and training and have less to say about future research and how we might better understand the challenges to handover between prehospital and hospital staff.
While the themes discussed in this review are immediately relevant for NHS services, more high-quality research is needed to provide a greater understanding of the challenges to effective handover. In the context of the new NHS commissioning arrangements designed to put patient needs at the heart of decision making,43 it may also be worth noting that patients’ views and experiences of ambulance handover should also be investigated. Further studies on prehospital handover could lead to improvements in efficiency of care and service delivery, one of the emerging principles of the recently published Urgent and Emergency Care Review.44
Acknowledgments
This is an update of a review originally conducted as part of the Ambulance Handover Study, funded by National Institute for Health Research, Research for Patient Benefit programme, grant number PB-PG-0407-13084. This project was independent research commissioned by the National Institute for Health Research. The views expressed here are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Data supplement 1 - Online supplement
Footnotes
Contributors CP and RC designed and supervised the review and were responsible for conceptualising the main study and this review. KW, ER and CP reviewed the papers and RC discussed the themes with them, KW led the coding and data extraction and conducted the critical appraisal supported/checked by CP. All the authors contributed to drafting and editing of the manuscript.
Funding NIHR Research for Patient Benefit. Review partially funded by grant number PB-PG-0407-13084.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Full citations for all papers included in the review are provided in the paper. Details of the appraisal scores are provided in online file.