Better patient handovers

Above: A patient is loaded onto a gurney during a medical evacuation exercise at Fort Hunter Liggett, California, 2012 (Spc. Jacqueline Guerrero)

Arriving at an emergency room after an accident, or landing at a specialist hospital after a flight from a local medical centre, a patient feels a sense of relief – being in the right place to receive comprehensive treatment is an important step on the journey to recovery. But this is also a critical moment in terms of their safety. A slip, forgetfulness or confusion could have serious consequences. Taissa Csáky spoke to air medical professionals from Australia, Canada, Germany, the US and the UK about their experiences of handovers and their take on best practice – how do they minimise risk to patients at the moment of handover?

Initial contact
In most cases, the first contact between a flight crew and receiving hospital begins well before the patient arrives.
Dr Gregor Lichy of DRF Luftrettung specialises in emergency medicine, intensive care medicine and anaesthesia. He’s the doctor in charge at DRF’s helicopter base Christoph 51 and gave us an overview of communications between flight crew and hospital: “If a patient is being flown directly to hospital from an accident site, the emergency doctor calls in by mobile phone while the helicopter’s in the air, briefly describing the incident and giving a preliminary diagnosis, and also advising whether the patient is intubated. This gives the hospital the information it needs to raise an emergency room alert.
“In the case of a transfer from one hospital to another, the initial contact is between the doctor at the hospital discharging the patient and the doctor at the receiving hospital. After that, the doctor at the discharging hospital alerts the dispatch centre by phone. The dispatch centre records the essential information about the patient and passes it on to the helicopter crew. The helicopter doctor now contacts the discharging doctor and checks through all the patient information. Only when this ‘doctor-to-doctor’ conversation has taken place can the mission begin.”
Greg Beer is an air crewman who flies in the helicopters of Queensland Government Air (QGAir), which provides helicopter rescue for the emergency services of Queensland, Australia. He comments: “On shorter emergency flights we try and do all the communication before we get airborne so we can concentrate on flying the helicopter once we’re in the air. The medical crew in the back also try and share information about the patient before take-off so they can concentrate on treatment. If the patient’s condition dramatically changes when we’re in the air, we use cell phones or satellite phones to call that in, but in general we try and get all the information across before we fly. Twenty minutes out we’re required to give hospital security our ETA so they can prepare the landing site. At that point we might also pass on additional requirements for the patient.”
Dr Lichy of DRF Luftrettung adds that in the particular case of heart attacks, electrocardiogram (ECG) readings are transmitted directly from the incident location, or even from the helicopter while in the air on the way to the hospital, so that everything can be made ready for a cardiac catheterisation before the patient arrives.
In-air transmission of patient data is an area which Dr Nick Crombie, clinical lead at Midlands Air Ambulance (MAA) in the UK, identifies as an area for significant future development: “The next five years will see more emphasis on telemetry, passing live information such as ECG, images and vital signs from scene and in transit directly to the waiting teams. These advanced electronic systems are already being rolled out in some regions of the UK.”

Face to face
Whatever communication has taken place before the patient arrives, there is a formal handover when the air crew and hospital medical team meet in person. Dr Bruce Sawadsky describes a routine handover for Ornge of Ontario, Canada: “We’ll take the patient into the hospital, transfer them to the hospital bed, then give the report. Generally, we’d be talking to the nurse in charge, but if it’s an ICU patient, then sometimes the attending physician will be there. We tell them everything from the initial presentation: how we managed the patient, how they responded to any of the medication we gave them, and the vital signs.”
Chris Postiglione is chief flight nurse at Travis County STAR Flight in Texas. STAR Flight makes the formal report before physically transferring a patient to the hospital bed, he explains: “The patient does not get moved over until the report is given. There’s a structured pause – when the patient’s ready to be moved we call a time out and everyone listens to the report. At the end of that, the person recording the report will ask, ‘Do you have any other information for us?’ When we say ‘no’ it’s time to move. It’s important to report first if the patient has experienced a trauma, a high impact, or a fall, because that affects the transfer. If someone’s got an unstable spinal column or a tube in their throat, moving them too quickly is going to be dangerous.”
The experts we spoke to agreed that formally debriefing the whole team is a vast improvement on the handovers that took place just a few years ago. Richard Miller, a critical care paramedic and operations medical support at Wiltshire Air Ambulance (WAA) in the UK for the last 14 years, says: “I’ve noticed huge improvements over my career. The main one is having a single person to speak to when handing a patient over and not various staff members. This became a disjointed hand-over and wasn’t in the interest of the patient.”
Chris Postiglione thinks other ingredients of a successful formal handover include having all staff in the room when the report is given, having a dedicated recorder writing everything down, leaving contact details for follow-up questions, and ensuring that everyone in the room is paying attention: “You have to have a formal way to create a space. When you walk in, there are so many things that can be done immediately – IVs, bags, untangling things and switching them over – if you don’t separate that moment of physically transferring the patient, if you don’t give that space, you’ll never get a good report.”
Dr Lichy concurs: “During the verbal briefing, everybody listens and nobody handles the patient.”

Formal frameworks
There are a variety of frameworks in current use for passing on information. The value of following a fixed protocol is that there is less chance of forgetting something important. It is also easier for receiving staff to take complex information onboard when the framework is known in advance.
In the UK, the WAA and MAA teams follow National Health Service guidelines known as ATMIST. This acronym sets out the order and content of a handover, with variations for trauma and medical patients. For trauma patients, it signifies Age, Time of incident, Mechanism of injury, Injuries top to toe, vital Signs, and Treatment. Richard Miller of WAA calls ATMIST the ‘gold standard for handing a patient over to a receiving facility’. Dr Crombie says that using the ATMIST protocol, ‘a structured, relevant and complete handover’ can be made in 30 to 45 seconds. Ornge and others in North America follow the SBARR (Situation, Background, Assessment, Recommendation, Readback) protocol.

Professional skills
Dr Bruce Sawadsky points out that protocol can’t eliminate all error – the communication skills of air medical staff play a vital part: “We know that handover time, of any time in critical care, is the highest risk time for any patient. If communication errors occur, that can lead to negative patient outcomes. So the verbal skills that go into the patient handover are really important.”
Dr Lichy emphasises the need for professional respect: “Good, respectful communication within teams and between teams, and sticking to procedure, will ultimately lead to a safe patient handover.”
Chris Postiglione underlines the importance of understanding the needs of the hospital team. “Difficulties in giving reports arise when care providers fail to put themselves in the other team’s shoes. A lot of times, we come in without much information. We may have picked somebody up at night after an accident and not know anything about them. At times, that’s frustrating for the hospital. They don’t understand how we can possibly not know anything about the patient or what happened. We have to be understanding, too. The hospital may contact us on the radio when we’re on the way in and ask us, say, to repeat the patient’s blood pressure. That can be aggravating when we’re working hard in the back of the helicopter, but from their perspective flipping the switch for an emergency alert costs them $10,000, so they have to be sure the situation is real.”

Physical handover
Physically moving a patient is another critical moment. Greg Beer points out the importance of keeping monitoring equipment securely attached: “When we bring the patient out of the aircraft, we make sure all the leads and everything from the monitoring equipment that’s on the patient is secured well, because critical equipment can get dislodged. That’s an area [where] we’re really cautious. If you accidentally pull a lead out, that could cause lack of information and lead to a bit of angst straight away.”
Ornge brings patients into the hospital on the helicopter stretcher. Dr Sawadsky said: “A critical care patient could be on a transfusion, so would need switching from our pump to the hospital pump, and the risk when you switch over is that you don’t replicate all the same settings – when you switch over you’ve got to make sure it’s running at the same rate. That kind of detail is really important.”
Sawadsky also pointed out the benefits of minimising physical handover. Rather than changing vents when transferring a patient from a fixed-wing air ambulance to a ground ambulance, he would rather leave the vent with the patient.
DRF follows a step-by-step process for the physical handover, changing one piece of equipment at a time, to ensure there is no moment where the patient is not being monitored.

Challenging locations
Another factor that affects the ease and security of handovers is the location in which it takes place. Richard Miller of WAA says: “The best location for handover is to a fully staffed trauma team and for there to be quiet – this will allow all involved with the patient care to listen without distraction. Difficult locations are on the side of the road when it’s noisy, cold and wet.”
Chris Postiglione of STAR Flight finds handovers can be most difficult in remote medical facilities where staff may have less experience of handovers: “We went to a rural facility about 30 miles outside the city limits to bring a patient in. We went to the emergency room, took the report and flew back. The patient had a potassium level of 8.0 and a lot of arrhythmia and was diagnosed with a heart attack. And it was just down to the potassium level. It needed a simple correction. That information was available when we took the report, but we didn’t specifically ask for it so they didn’t tell us. So when you go to places with less experienced staff, you have to think hard about your questions, and consider what’s absolutely critical to know. And when you’re giving a patient to a hospital like that you have to take extra time for the report.”

Most organisations back up verbal reports with a written record. Ornge crews record vital signs and medication on a paper form that is handed over to the hospital team at the time of the handover. They also create electronic patient charts, recording information on a tablet en route. The form is uploaded to Ornge’s servers when the air crew returns to base and is later faxed to the hospital to be added to the patient’s records.
Travis County STAR Flight provides a formal written chart to the receiving hospital within 24 hours of handover – a requirement of Texas state law. Chris Postiglione says there may also be a more informal follow-up: “If there was an intubation or we gave blood, if the patient suddenly deteriorated in flight, if we gave CPR – if any of those type of events happens, I will do a formal follow-up in person, basically calling the hospital to ask how the patient is doing. That’s usually that, but there are times when the hospital may request we have a formal debriefing – if there’s some kind of problem, or something exceptional happened, their co-ordinator might call us together and discuss how things were done.”

Mass transit
These are the considerations for air medical providers working with individual patients. But how does the handover change when you are dealing with several, perhaps dozens of patients? The US Air Force (USAF) 86th Aeromedical Evacuation Squadron (86th AES), based at Rammstein in Germany, provides aeromedical evacuation for military personnel and civilians in the European Command region. This means regular flights from Rammstein to Qatar to collect patients from Afghanistan and other conflict zones in the Middle East, and return flights bringing patients to Rammstein for treatment, or on to the Andrews Air Force Base in Maryland, US.
The 86th fly in C-17s, which can carry up to 36 patients, in litters secured three or four deep to the side of the aircraft, with additional ambulatory patients travelling in regular seating. The medical crew has paperwork on every patient boarding the flight generated by ‘TRAC2ES’ – the USAF’s electronic medical record-keeping system. This tells the medical crew how many patients there will be, their medical conditions and what treatment they’ve had. They initially use this information to configure the aircraft, setting up the right number of litters arranged for a balanced load.
On arrival in Qatar, patients are brought to the aircraft by ‘ambus’. Each travels with a print-out of their medical records, but there is also a verbal handover. Captain Hendricks of the 10th Emergency Aeromedical Evacuation Flight explains: “The patients are accompanied by a nurse, and that nurse will give a report to our designated flight nurse. They’ll do a report on each patient.”
Over the course of the return flight, nurses and technicians keep written records of each patient’s condition and any treatment that is given to them. Records are written on a standardised SBARR form. These were introduced in the last few years, and Captain Hendricks says they are the single biggest factor in improved handovers during his time with the USAF. At the end of the flight, the chief nurse collects all the forms. Again the flight nurse is the only person involved in the handover of information, passing on the SBARR forms with the patient’s records, and giving a verbal briefing. Accurate record keeping and sharing is particularly important in the case of handovers at Andrews because patients will be going on to multiple other facilities – Air Force, Army and Navy hospitals in a number of locations.
Whether handing over one or multiple patients, everyone we spoke to agreed that communication is the most important factor to get right in a patient handover. Passing on accurate, relevant information about the patient’s condition and the treatment they have received in a calm and orderly setting is vital to their safety. As a contrast to the highly structured processes followed by the 86th in the relative calm of hospital-to-hospital transfers, and the work of civilian air ambulance crews, consider the situation of US MEDEVAC crews working in Afghanistan and other conflict zones. To keep track of patients in transit from the battlefield to hospital, they’ve been known to write information on duct tape and stick it on the patient – or even use marker pen to write directly on the patient.