Emergency medical service (EMS) providers handoff approximately 28 million patients every year in the United States (Federal Interagency Committee on Emergency Medical Services, 2012). A patient handoff refers to the transfer of information, through either physical or mental process, from one healthcare provider to the next (Patterson et al, 2004). Inaccuracies in this critical and unavoidable process contribute to the 44 000 to 98 000 deaths that occur every year due to medical errors (Kohn et al, 2000). In a recent study, 98% of survey participants from two large urban medical schools reported witnessing an error in a written handoff and 64% of those same participants witnessed an error due to a verbal handoff (Arora et al, 2013). While at high risk for communication errors and adverse events, patient handoff education has not been formally addressed in primary EMS education. The National Standard Curriculum makes mention of an oral report only once in its 962 pages by stating: ‘The paramedic must also be able to accurately report orally and in writing, all relevant patient data’ (Stoy and Margolis, 1998). Absent from the text is a standardised approach to how this should be accomplished.
In an effort to address this educational gap, the Ambulance Service of New South Wales, Australia developed and implemented a national protocol to improve EMS to emergency department handoffs. This approach utilises the acronym IMIST-AMBO and contains the following information: identification, mechanism/medical complaint, injuries/information relative to complaint, signs/vitals including GCS, treatment and trends, allergies, medications, background history, and other (Iedema et al, 2012). By standardising the communication between EMS and the emergency department staff, patient handoff accuracy and completeness were dramatically improved with less confusion and less information being repeated.
These results from New South Wales provide evidence that IMIST-AMBO could serve as a framework for a patient handoff curriculum. The goal of this pilot study was to evaluate the feasibility and effectiveness of implementing lecture-based training involving the IMIST-AMBO mnemonic in paramedic education using simulation-based assessments.
Figure 1. Example simulation report using IMIST-AMBO mnemonic
This is a 25-year-old male trauma patient who was the backseat passenger in a head-on motor vehicle collision. He has a GCS of 9 with pain in his abdomen, right forearm and left ankle. Vitals include a heart rate of 120, blood pressure 100 over 60, respiratory rate of 20 and pulse ox of 98 percent. We immobilised his ankle and forearm, placed him in a cervical collar and started a large bore IV with one litre of normal saline hanging. During transport he has become less responsive with persistent tachycardia. He has no medical history, no medications and no allergies. His family is aware of the accident and are on their way to the hospital.
Methods
Study design
A literature search was performed to determine previously used key elements of possible prognostic value in trauma patient EMS handovers. (Carter et al, 2009) The study group used these previously studied elements and incorporated the IMIST-AMBO protocol (Table 1) to develop a standardised simulated trauma case and data collection form. Paramedic students were randomised into a control group of standard national paramedicine curriculum and an intervention group who received an additional EMS patient handover lecture including IMIST-AMBO protocol.
| I | Identification (patient) |
| M | Mechanism of injury/medical complaint |
| I | Injuries/information related to the complaint |
| S | Signs and symptoms including GCS and vital signs |
| T | Treatment given and trends noted |
| A | Allergies |
| M | Medications (patient's regular medications) |
| B | Background history (patient's past history) |
| O | Other information (scene, social, valuables, advanced directives, family informed) |
To evaluate effectiveness of the educational intervention, students then participated in either a high- or low-fidelity simulation session. The high-fidelity simulation involved a computer controlled, life-sized mannequin in an ambulance and ER setting, while the low-fidelity simulation was conducted at a table without a mannequin. This yielded one of four evaluation groups for each student: high-fidelity control group, high-fidelity intervention group, low-fidelity control group, and low-fidelity intervention group.
Population and setting
The study population consisted of 24 paramedic science students at a Level I American College of Surgeons Trauma Certified large urban academic centre. The paramedic students participated in the intervention as part of a course within their first year curriculum and were randomly assigned to work in simulated two-person EMS crews.
Intervention
An interprofessional education model was developed by a group of physicians trained in emergency medicine with specialised training in simulation, medical education, and EMS. These physicians worked alongside a cohort of paramedic and nursing educators to design a 1-hour handover lecture utilising IMIST-AMBO.
One physician educator delivered the handover lecture to paramedic students randomised to the intervention group. The lecture included a discussion on the importance of safe patient handoffs, the elements that comprise IMIST-AMBO, general information regarding interprofessional communication, and a question and answer discussion to reinforce and practice the newly learned mnemonic. The lecture was designed to be interactive and students were blinded to the fact that they would be later observed giving EMS patient handoffs.
Outcomes
Emergency physicians, simulation experts, and paramedic educators worked together to create a simulated patient experience for evaluation of handoff performance. The patient used throughout the study was a ‘25-year-old male who was the restrained driver of a pickup truck that collided head on with another truck on the interstate road. The patient required a 20-minute extrication by firefighters and was secured to a long back board and placed on a wheeled stretcher prior to the arrival of the student paramedics to the scene.’ The condition of the patient was designed to prompt students to perform a physical exam, place a cervical collar, provide supplemental oxygen, establish intravenous access, treat for haemorrhagic shock, splint the patient's right forearm and left ankle and reassess. All students were allowed a locally utilised written patient information sheet.
The simulated patient experience was delivered in one of two ways: tabletop simulation or high-fidelity simulation. Tabletop simulation students received a written narrative of the standardised case and were allowed up to 10 minutes to review and play out verbally. After a verbal description of resuscitative measures, the two-person paramedic student team was required to give a role-playing patient handoff to a simulated ‘nurse’ and ‘doctor’. High-fidelity simulation students began in the centre's transport room, which features a decommissioned ambulance van body wired for simulation. An appropriately moulaged Laerdal 3G wireless SimMan served as the patient. The students worked in a two-person team, initially caring for the patient in the back of the ambulance for ‘10 min transport’ before unloading and wheeling the patient across the simulation centre, and delivering them to a simulated emergency department room. The two-person paramedic student team performed patient handoff to the emergency department team consisting of emergency medicine residents and nursing students playing the roles of ‘doctors’ and ‘nurses’.
The IMIST-AMBO lecture lasted 30 minutes, while all interactions for both simulation modalities were conducted over 15–20 minutes and were video recorded for review by blinded research assistants. To assess the effectiveness of the educational intervention, the study group chose to measure changeover performance in all four groups: The completeness and accuracy of information was compared between students from all four groups: high-fidelity control group, high-fidelity intervention group, low-fidelity control group, and low-fidelity intervention group. The primary outcome of interest was percentage of time that subjects reported the elements of the IMIST-AMBO mnemonic. A secondary outcome was total time spent giving report.
The Indiana University Institutional Review Board approved this study. Written informed consent for videotaping observations was obtained from all subjects.
Results
There were 12 paramedic student teams who participated in this pilot study. To evaluate effectiveness of the educational intervention, the data from the tabletop exercise and high-fidelity simulation were pooled together. The reporting of each of the specific components of IMIST-AMBO was similar between the intervention and control groups (Table 2). The group who received the lecture did report on average more items, 7.5 versus 6.3 (of 9 total items). There was a difference in the mean total time of the handoff, with the control group at 49.2 seconds and with those receiving the lecture at 78.2 seconds. Due to the small sample size, p-values were not calculated.
| Control (n=6) | Intervention (n=6) | |
|---|---|---|
| % Identification | 100.0 | 100.0 |
| % Mechanism | 100.0 | 100.0 |
| % Injuries | 83.3 | 83.3 |
| % Vital signs | 100.0 | 100.0 |
| %Treatment and trends | 100.0 | 100.0 |
| % Allergies | 16.7 | 33.3 |
| % Medications | 16.7 | 66.7 |
| % Background history | 16.7 | 66.7 |
| % Other information | 100.0 | 100.0 |
| Mean IMIST-AMBO (SD) | 6.3 (1.4) | 7.5 (1.4) |
| Mean report time in seconds (SD) | 49.2 (19.7) | 78.2 (18.6) |
Discussion
This was a pilot study looking at the feasibility of teaching a standardised method of performing patient handoffs from paramedics to doctors. The focus was on standardised change-over education and not the specific content of that lecture. We were successful in implementing this formal education. However, the small size limited the ability to adequately compare the success of the lecture on improving patient handoffs.
Preliminary data demonstrated a trend for more total IMIST-AMBO categories (allergies, medications, and background) to be included in the handoff from those who received the lecture beforehand. However, those that received the lecture gave a report that was longer on average than the control group. If the report is going to take longer, then it should provide the benefit of providing patient safety by ensuring more of the important information gets transmitted. With more practice and repetition, it is possible that this difference would disappear as the paramedics became efficient in their hand-offs.
Patient handoffs are a critical aspect of the job of a paramedic and formal training is needed on this subject. It is important for patient safety and to improve communication between paramedics and the healthcare team.
It is unclear what the best method of teaching patient handoffs is and more studies looking into the effectiveness of different techniques are needed. The effectiveness would have to include both quality of information transmitted as well as the length of time required for the handoff. Future studies should look into the effectiveness of lecture compared to simulation or tabletop exercises as well as a combination of these. It would also be useful to evaluate and compare the efficacy of teaching modalities in clinical settings and on retention months after the training.
Conclusions
We were successful in implementing formal education on patient handoffs. The small size of the study limited our ability to make conclusions about the effectiveness of it. More studies are needed to evaluate the effectiveness of formal education and which modalities work the best.