Prehospital Communication: Pre-Alerting and Ambulance Handovers

Ambulance crews use structured tools to communicate with receiving medical staff both as part of the formal clinical handover of a patient and also as a pre-alert message delivered in advance of their arrival. Understanding the format and content of these tools will aid in the accurate communication of prehospital care rendered and hopefully minimise clinical errors (e.g. duplicate administration of medications already given outside the department).

Ambulance pre-alerting of patients

Depending on the patient’s presentation or vital signs an ambulance crew may pre-alert the receiving Emergency Department in order to prepare for the patient’s arrival. The structure of this message (normally relayed via radio or phone) for trauma patients in the United Kingdom is recommended to include the following (as recommended by NICE):

• Age and sex of the injured person
• Time of incident
• Mechanism of injury
• Injuries suspected
• Signs, including vital signs, and Glasgow Coma Scale
• Treatment so far
• Estimated time of arrival
• Special requirements
• Ambulance call sign

This information is structured into an ATMISTER message by several Ambulance Service Trusts (South, 2018) as outlined above.

Clinical example

“A 30-year-old male, at 1300 hours had a rollover road traffic collision and has a suspected pelvic fracture. Vital signs are as follows: respiration rate: 20, heart rate: 120, blood pressure: 110/70, SpO2: 95%, temperature 37, GCS 15. A pelvic binder has been applied and the patient is immobilised on an orthopaedic stretcher. 10mg of IV Morphine has been administered. ETA 10 minutes, call sign 422.”

In Ireland, the pre-alert message format that is recommended is ASHICE (Prehospital Emergency Care Council, 2019). This format is used for both medical and trauma patients alike:

• Age
• Sex
• History
• Injury/injuries
• Condition (vital signs, clinical status: life-threatening, serious, non-life-threatening)
• ETA

Depending on the local ambulance service procedure, this message could be relayed via an Ambulance Service Dispatcher or the clinician with the patient directly to the receiving hospital. Another variation of this format involves only conveying abnormal vital signs as part of the message as it minimizes unnecessary chatter.

Clinical example

“A 30-year-old male had a rollover road traffic collision and has a suspected pelvic fracture. Vital signs are as follows: respiration rate: 20, heart rate: 120, blood pressure: 110/70, SpO2: 95%, temperature 37, GCS 15. Serious not life-threatening clinical status. ETA 10 minutes.”

Ambulance handover of patients

In hospital settings, practitioners will already be familiar with the SBAR communication tool to structure a handover between departments, however, there is often a knowledge gap in handovers that cross different care boundaries and professional backgrounds (Sujan, et al., 2013). As a result of this, the SBAR tool has been adapted into an ISBAR tool (with the identity of the patient representing the I) by some prehospital clinicians as a handover structure. However, this has been found to be less specific than IMIST AMBO which is discussed below (Shah, et al., 2016).

The IMIST-AMBO protocol captures other information in addition to that already included in ISBAR:

• Identification of patient
• Mechanism of injury or medical complaint
• Injuries or information related to the complaint
• Signs (observations)
• Treatment or trends

Pause for questions

• Allergies
• Medications
• Background
• Other information

This format is the recommended structure in Irish prehospital care (Health Service Executive, 2013) and also in some Australian services (e.g. Queensland Ambulance Service, 2016). This protocol has been shown to enable the transfer of large volumes of information during handover in a more structured format, resulting in fewer questions from receiving staff and an overall reduction in handover duration (Iedema, et al., 2012).

Clinical example

“The patient is John Smith, a 30-year-old male. He was involved in a rollover road traffic collision as a driver, wearing his seatbelt. There was no loss of consciousness and there is a suspected pelvic fracture.”

“Vital signs are within normal ranges except for an elevated heart rate of 120.”

“He has had pelvic binder applied, 10mg Morphine IV administered and he has been immobilised in an orthopaedic stretcher.”

Pause for relevant questions

“No known allergies”

“Doesn’t take any medications”

“Normally fit and well”

“Airbags deployed, windscreen intact, no intrusion into passenger cab”

Other considerations for the handover

Ensure that a defined procedure is in place for the handover to take place, for example before or after the patient is physically moved onto the hospital trolley, as this means that all clinicians are aware of when the sharing of information is set to begin.

Allow Paramedics to convey their full handover before asking questions.

Paramedics are a valuable source of information and often can provide extra details regarding the patient’s presentation, past medical history and social context.

References

1. Ambulance Service of New South Wales, n.d. IMIST-AMBO Handover Protocol. [Online] Available at: [LINK]. [Accessed 6 March 2020].
2. Health Service Executive, 2013. Handover of Ambulance Patients in Emergency Departments. [Online] Available at: [LINK]. [Accessed 6 March 2020].
3. Iedema, R. et al., 2012. Design and Trial of a new ambulance to emergency department handover protocol: “IMIST-AMBO”. BMJ Quality and Safety, 21(8), pp. 627-623.
4. National Institute for Health and Care Excellence, 2016. Major Trauma: Service Delivery NICE Guidance [NG40]. [Online] Available at: [LINK]. [Accessed 1 March 2020].
5. Prehospital Emergency Care Council, 2019. Field Guide. [Online] Available at: [LINK] [Accessed 2 March 2020].
6. Queensland Ambulance Service, 2016. Clinical Practice Procedures: Other/Clinical Handover. [Online] Available at: [LINK] [Accessed 6 March 2020].
7. Shah, Y., Alinier, G. & Pillay, Y., 2016. Clinical Handover between paramedics and Emergency department staff: SBAR and IMIST-AMBO acronyms. International Paramedic Practice, 6(2), pp. 37-44.
8. South, A., 2018. South Western Ambulance Service NHS Foundation Trust Clinical Guideline CG05: ATMIST Early and Pre-Alerts.. [Online]
9. Sujan, M. A. et al., 2013. Emergency Care Handover (ECHO Study) across care boundaries: the need for joint decision making and consideration of psychosocial history. Emergency Medicine Journal, 32(2), pp. 112-118.