There is no question that good patient care handoffs lead to better communication, fewer errors, and easier transitions in the hospital setting. However, this is often overlooked during transitions from prehospital care to in-hospital care. The EMS handoff is important when assuming care of critically ill or injured patients from the prehospital team.
Why is the EMS Handoff Important?
The absence of good mechanisms for transitioning patient care from the prehospital team—whether it be a ground-based ambulance or paramedic unit or aeromedical unit like a helicopter or fixed-wing—can be detrimental to patient care. In contrast to handoffs between inpatient teams, where the process is generally well defined, transitions from emergency medical services (EMS) providers to hospital teams are often ambiguous.
Emergency medical technicians, paramedics, nurses, nurse practitioners, physician assistants, and physicians all may play a role in caring for a patient from point of injury or illness to arrival in the emergency department, trauma bay, or intensive care unit. Therefore, it is important to have a good handoff to avoid loss of valuable information that could lead to misdiagnosis, delays, or inefficiencies in patient management.
At a minimum, a good handoff from EMS should include the following:
- Chief complaint or mechanism of injury with associated signs and symptoms.
- Description of the scene or environmental factors that could have contributed to illness or injury, including details of extrication or rescue, as appropriate.
- Vital signs (first set on arrival and repeat/trended if change in status).
- Summary of patient care interventions and responses.
- Identification of any critical interventions not yet performed or achieved that should be addressed by accepting team on arrival.
- Opportunity to answer questions and provide clarification as requested by accepting team.
It is difficult to go back and obtain or clarify information that is not shared at the time EMS delivers a patient. Therefore, it is essential that all receiving team members take time to listen to the handoff. This should ideally occur once at the bedside and involve key members of the team accepting the patient, including the treating physician.
Physicians, like other members of the care team, are often busy with multiple patients and clinical tasks, but should prioritize getting to the bedside for the handoff of critically ill or injured patients to get this information firsthand and ask any clarifying questions.
Research has shown that EMS clinicians can become frustrated when there is a lack of an effective handoff process when they arrive at the emergency department or destination facility. For example, a 2014 study by Meisel, et al. found that EMS providers desired to “(1) communicate directly with the ED provider responsible for the patient’s care; (2) increase interdisciplinary feedback, transparency, and shared understanding of scope of practice between out-of-hospital and hospital-based providers; (3) standardize some (but not all) aspects of the handoff; and (4) harness technology to close gaps in information exchange.”
Standardized Tools Help Ensure an Effective Handoff
Many EMS agencies have implemented protocols and tools to standardize handoff communications and provide consistency between individual jurisdictions to allow for a uniform process in the emergency department or trauma bay. One commonly used example of such a tool is the DMIST handoff tool, which can be used immediately on arrival (stable patient) or after the patient has been transferred to the stretcher and a primary survey or critical interventions are performed (critical patient).
The key elements of the DMIST tool include the following:
D – Demographics
Patient age, gender, height and weight (if known)
M – Mechanism of Injury / Medical Complaint
Trauma: time of injury, type of injury (fall, MVC, assault, etc.), speed, type of collision, height of fall, type of weapon, safety devices
Medical: OPQRST (onset, provocation/palliation, quality, radiation, severity, timing)
I – Inspection/Injury/Illness
Trauma: Trauma assessment findings (head-to-toe)
Medical: SAMPLE (signs/symptoms, allergies, medications, pertinent medical history, last oral intake, events leading to illness), focused physical exam, other relevant findings (e.g., EKG, blood sugar, stroke scale)
S – (Vital) Signs
GCS, pulse, BP, respirations, SpO2, etCO2, temperature (if known)
T – Treatment
Summarize what was done and response to treatments (e.g., oxygen, wound care, splinting, tubes, IV/IO access, chest decompression)
To be effective, the handoff should occur during an EMS timeout, which should last no more than 15-30 seconds and during which all personnel in the room should remain quiet to receive the EMS report. Questions or clarifications should be requested at the conclusion of this report.
In addition to the verbal report, key information should also be provided in a written or electronic format. This should include any information required for “optimum care of the patient, including examples include vital signs, treatment interventions, and the time of symptom onset for time-sensitive illnesses.”
- It is important to have a formal handoff process between prehospital providers and in-hospital teams to communicate key elements of patient condition and any interventions/treatments rendered prior to arrival at the hospital.
- Standardized tools, like DMIST, ensure a consistent format for the EMS handoff to reduce errors or opportunities for lost information.
- The receiving team should ensure that an EMS timeout is performed to allow for the EMS handoff report to be delivered in a distraction-free setting with opportunity for clarifying questions from the receiving team.
- The verbal EMS handoff report should be followed by a written or electronic report to allow for continuity of care and should be added to the patient’s medical record to be available to all members of the care team.
- Meisel, Z. F., Shea, J. A., Peacock, N. J., Dickinson, E. T., Paciotti, B., Bhatia, R., … & Cannuscio, C. C. (2015). Optimizing the patient handoff between emergency medical services and the emergency department. Annals of Emergency Medicine, 65(3), 310-317.
- Pennsylvania DMIST Program. Pennsylvania Trauma Systems Foundation. Accessed April 23, 2021 at: https://www.ptsf.org/documents/pennsylvania-dmist-powerpoint/
- Transfer of Patient Care Between EMS Providers and Receiving Facilities. ACEP Clinical Policy. October 2013, Reaffirmed January 2019. Accessed April 24, 2021 at: https://www.acep.org/patient-care/policy-statements/transfer-of-patient-care-between-ems-providers-and-receiving-facilities