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Design and trial of a new ambulance-to-emergency department handover protocol: ‘IMIST-AMBO’
  1. Rick Iedema1,
  2. Chris Ball1,2,
  3. Barbara Daly3,
  4. Jacinta Young4,
  5. Tim Green5,
  6. Paul M Middleton6,
  7. Catherine Foster-Curry7,
  8. Marea Jones6,
  9. Sarah Hoy8,
  10. Daniel Comerford8
  1. 1University of Technology Sydney, Centre for Health Communication, Sydney, New South Wales, Australia
  2. 2HSPIB, NSW Ministry of Health, North Sydney, New South Wales, Australia
  3. 3Emergency Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
  4. 4Ambulance Service NSW, Bellingen Ambulance Service, Urunga, New South Wales, Australia
  5. 5Emergency Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
  6. 6Ambulance Research Institute, Ambulance Service of NSW, Sydney, New South Wales, Australia
  7. 7Emergency Department, John Hunter Hospital, Newcastle, New South Wales, Australia
  8. 8NSW Health, Health Services Performance Improvement Branch, Sydney, New South Wales, Australia
  1. Correspondence to Professor Rick Iedema, University of Technology Sydney, Centre for Health Communication, PO Box 123, Broadway NSW 2007, Sydney, NSW 2007, Australia; r.iedema{at}


Background Information communicated by ambulance paramedics to Emergency Department (ED) staff during handover of patients has been found to be inconsistent and incomplete, and yet has major implications for patients' subsequent hospital treatment and trajectory of care.

Aim The study's aims were to: (1) identify the existing structure of paramedic-to-emergency staff handovers by video recording and analysing them; (2) involve practitioners in reflecting on practice using the footage; (3) combine those reflections with formal analyses of these filmed handovers to design a handover protocol; (4) trial-run the protocol; and (5) assess the protocol's enactment.

Method The study was a ‘video-reflexive ethnography’ involving: structured analysis of videoed handovers (informed by ED clinicians' and ambulance paramedics' comments); ED clinicians and ambulance paramedics viewing their own practices; and rapid at-work training and feedback for paramedics. A five-question pre- and post-survey measured ED triage nurses' perceptions of the new protocol's impact. In total, 137 pre- and post-handovers were filmed involving 291 staff, and 368 staff were educated in the use of the new protocol.

Results There was agreement that Identification of the patient, Mechanism/medical complaint, Injuries/information relative to the complaint, Signs, vitals and GCS, Treatment and trends/response to treatment, Allergies, Medications, Background history and Other (social) information (IMIST-AMBO) was the preferred protocol for non-trauma and trauma handovers. Uptake of IMIST-AMBO showed improvements: a greater volume of information per handover that was more consistently ordered; fewer questions from ED staff; a reduction in handover duration; and fewer repetitions by both paramedics and ED clinicians that may suggest improved recipient comprehension and retention.

Conclusion IMIST-AMBO shows promise for improving the ambulance-ED handover communication interface. Involving paramedics and ED clinicians in its development enhanced the resulting protocol, strengthened ED clinicians' and ambulance paramedics' sense of ownership over the protocol and bolstered their peers' willingness to adopt it.

  • Handover
  • ambulance
  • emergency department
  • protocol
  • communication
  • health policy
  • never-events
  • near-miss
  • safety culture
  • shared decision making
  • quality improvement
  • process mapping
  • patient safety
  • prehospital care
  • evidence-based medicine
  • evaluation methodology
  • critical care
  • management

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The rising complexity of healthcare services places increasing emphasis on effective communication among clinicians. One weak point is proving to be the handover communication relaying clinical tasks and responsibilities1 between clinicians, teams, departments and institutions. Analyses of critical incident reports and malpractice cases have confirmed that communication during a clinical handover is a frequent source of, and contributor to, problems and incidents.2–4 These analyses further suggest that an accurate and effective handover communication is central to ensuring continuity of care, and to preventing inappropriate modification or omission of any component relating to critical treatment.5 ,6

To address inherent communication shortcomings during handovers, researchers have developed standardised communication protocols ranging from checklists7 to acronym-based prompts.8 By simplifying the process of communication with respect to what is conveyed, and the order in which matters are conveyed, protocols may mitigate the negative impact of human factors. Protocols may reduce avoidable reliance on memory by cueing the information provider about what to address next, thus creating common ground by aligning the expectations of information providers and receivers.9

In their extensive overview and the researching of clinical handover, Cohen and Hilligoss10 list 19 different handover acronyms. In their overview article, Riesenberg and colleagues review 24 handover mnemonics.11 Both overview studies note that Situation, Background, Assessment, Recommendation (SBAR)8 and variations thereon, currently appear to be the most favoured, particularly for structuring communications with junior staff. The authors also note that SBAR prescribes an order of general topics of information (the exact clinical content of which is left for the clinician to determine), rather than specific clinical contents (such as ‘vital signs’ and ‘allergies’). As a mode of topic standardisation, SBAR's popularity may be explained by its generality enabling it to be applied across multiple contexts. By the same token, lacking content specification, SBAR presumes high levels of common ground and shared purpose.

The foregoing may explain why mnemonics like ‘MIST’ (mechanism of injury/illness, injuries sustained, signs, and treatment given) and ‘AMPLE’ (allergies, medications, past illnesses, last meal, events) have traditionally been regarded as more appropriate for the paramedic-to-emergency department staff handovers. Different training, with limited (ambulance) treatment options and street-based practice, mean that paramedic care-in-transportation harbours fewer clinical-medical commonalities with the emergency department and other medical specialties, than those that hospital specialties may share with one another. In contrast to SBAR, MIST and AMPLE are prescriptive about the clinical details that are to be handed over. The latter protocols' greater content specificity aids communication across significantly different institutions, aims, practices and educational backgrounds.

Limited research conducted in the domain of ambulance-to-emergency department handovers11 suggests that paramedic-to-emergency staff handover communication is not optimal. MIST appears to be the mnemonic of choice, but limited evidence supporting its use12 has meant that ambulance services have been hesitant to integrate MIST-based handover training into their curricula. Adding to concern is a study (albeit small) showing that training paramedics in the use of DeMIST (where ‘De’ stands for details: sex, approximate age, etc) led to paramedics' accuracy in conveying information to emergency clinicians (those receiving the information) being judged to have decreased.13 There is general agreement now on the need to address the general problem of low levels of memory retention on the part of emergency staff in the matter of information handed over by paramedics.14

The study reported on here set out to improve communications at the paramedic-emergency department staff interface. Unique in approach, the study involved practising paramedics and emergency clinicians in critiquing and redesigning existing handover practices. This was done using real-time video-filmed evidence of paramedic handovers, as well as subsequent trial and assessment of handover practice following paramedics' adoption of the new protocol.15 The study's overall aims were to: (1) identify the existing structure of paramedic-to-emergency staff handover by video recording and analysing in situ handovers; (2) involve practitioners in reflecting on their practice using video footage; (3) use those reflections in combination with formal analyses of these filmed handovers to design a handover protocol; (4) train paramedics in the new protocol and educate emergency clinicians about it; and (5) assess the new protocol by filming post-training handovers and by eliciting emergency triage nurses' perceptions about paramedics' pre- and post-intervention handover performance.


Study population

Paramedics employed by the Ambulance Service of New South Wales, and medical and nursing clinicians from two large teaching hospitals (one metropolitan, one regional) were recruited to participate in this study. The study ran for a period of 7 months (April–October 2010) in the emergency departments (EDs) of the two hospitals.


Following relevant Ethics Committee approval, paramedics and ED clinicians were invited to take part in the study. Participation was voluntary; however, incentives were that paramedics who took part in the study were entitled to receive Clinical Training Points, which are cumulative throughout the year and count towards re-certification. Varying numbers of points were awarded depending on the level of participation, ranging from consenting to be filmed, attending pre- and post-focus groups and participating in the new handover protocol trial. Across both sites, 291 participants consented to take part in the study, 75% of whom were paramedics. Participants came with varying levels and ranges of training, expertise and background.

Study design

The study was designed as a video-reflexive ethnographic study16 made up of six distinct phases, including conducting focus groups, feedback of video footage and collaborating on the design of practice solutions (see table 1).

Table 1

Protocol development and assessment using video-reflexive ethnography—method specification


Phases 1–4—protocol development

A paramedic-to-emergency department staff protocol was developed by combining results derived from video footage analysis of existing practice with feedback comments received from the video-reflexive meetings with ED clinicians and ambulance paramedics. Detailed analysis of the contents of 73 handovers revealed a tentative or ‘tacit’ structure in the way paramedics presented their information. Pre-intervention handovers tended to be ordered as follows (for further detail, see results presented below): identification of the patient; an outline of the medical complaint or mechanisms of injury; details about the complaint or the relevant injuries; and vital signs and GCS.i Other components of information occurred rather less predictably or not at all: treatment given; patient's response to the treatment; allergies; medications used by the patient; and additional medical and social issues.

We presented this analysis and the footage it was based upon to participating paramedics. In their responses they began to identify the need to structure handover. Building on ‘IMIS’ as inchoate structure already embedded in their practice, paramedics articulated a minimal data set. Then, drawing on an earlier protocol design,ii the stakeholder reference group (see table 1—phase 4) endorsed Identification of the patient, Mechanism/medical complaint, Injuries/information relative to the complaint, Signs, vitals and GCS, Treatment and trends/response to treatment, Allergies, Medications, Background history and Other (social) information (IMIST-AMBO) for trauma and non-trauma handovers.

Phases 5–6—protocol assessment

Upon in-principle endorsement of IMIST-AMBO from study participants, the researcher (CB) asked non-participant paramedics and ED clinicians at their workplaces if he could briefly explain to them IMIST-AMBO's genesis, structure and enactment. Over a period of 3 weeks at one site and 2 weeks at the other, the researcher accomplished the following three tasks with the help of the day staff: providing visiting paramedics and emergency staff with rapid IMIST-AMBO training, filming people's handovers, and in cases where this was possible, involving people in providing feedback about their performance using fresh video footage.

As with the pre-intervention footage, the second batch of video data was again analysed with respect to data content and data structure (order of information components), handover duration (per triage category), questions during handover (from ED staff), repeated information (by paramedics), and mutual eye contact (see phase 2, table 1). The analytical results, in detail, are specified in what follows.

Data content and structure

Out of a total of 73 pre-intervention video-filmed handovers, 100% of paramedics commenced the handover by identifying the patient, 63% then communicated information relating to the reason for presentation to hospital, 55% then delivered information surrounding this reason for admission, and a further 36% then communicated the patients' vital signs. Note that this tentative sequence—‘IMIS’—mirrors part of ‘MIST’. The remaining information components were delivered with too little predictability, or none at all, to warrant specification here.

Analysis of the footage of 63 post-intervention handovers revealed a strong uptake of the protocol. Now, the first information component delivered was patient identification in 100% of handovers, second in 98% of handovers was the mechanism/medical complaint, third in 98% of handovers was injuries/information that was relative to the complaint, fourth in 65% of handovers was vital signs, and fifth in 28% of handovers was treatment administered. This increase in appropriate sequencing of the information components according to the IMIST-AMBO protocol evidences enhanced protocol adherence.

Handover duration (per triage category)

The overall average pre-intervention handover lasted 96 s. The duration of handover increased, depending on patient severity, from an average of 64 s for a triage category 5 to an average 115 s for a triage category 1 patient. The duration of Post-intervention handover dropped considerably from an average of 96.4 to an average of 77 s, with no triage category now requiring more than a total of 100 s (table 2).

Table 2

Handover duration per triage category (in seconds)

Questions during handover

Pre-intervention, 93% of handovers elicited questions from receiving emergency staff. Of these, 38% were for information that had already been provided during the handover, pointing to difficulties in information retention and comprehension on the part of the receiving clinician. Post-intervention handovers showed a marked decrease in the number of questions asked by triage nurses. Now, only 41% of handovers elicited questions. Of these, only 15% related to information already provided (table 3).

Table 3

Questions asked and information provided

Repeated information

Pre-IMIST-AMBO analysis revealed that in 67% of handovers, paramedics repeated information during the handover. Post-IMIST-AMBO this was reduced to 33%. This is a reduction from 2 in 3 to 1 in 3 handovers involving information repetition (table 4).

Table 4

Information repetition

Eye contact

Eye contact serves a range of functions, one of which is the signalling of attention and interest.17 As figure 1 shows, the shorter the handover, the higher the level of eye contact.iii The average duration of pre-intervention handovers without any eye contact was 111 s; average duration reduced to 103 s with 0–30% of the handover including eye contact, and it fell to 85 s when more than 30% of the handover involved eye contact. Post-intervention handovers showed a similar pattern. Here, 0% eye contact did not occur; 0–30% was associated with handovers of around 80 s; and >30% eye contact associated with handovers of 77 s.

Figure 1

Eye contact between paramedic and triage/emergency department (ED) nurse during handover.

ED triage nurses' perceptions of the change in effectiveness of handover

The 416 questionnaires completed by triage nurses after receiving pre- and post-IMIST-AMBO handovers revealed a rise in their strong agreement, but also an equal drop in agreement, about the adequacy of the structure of the handover, information relevance, and the need to ask questions (figure 2A–B). There was some improvement in agreement about the adequacy of the duration of handover, but an almost similar drop in strong agreement that the duration was adequate (figure 2C).

Figure 2

(A) Emergency Department (ED) triage nurse perceptions of handover information. (B) ED triage nurse perceptions of handover information structure. (C) ED triage nurse perceptions of handover duration.


The analysis of video footage of 74 pre- and 63 post-intervention handovers, combined with results from the ED staff questionnaires, points to an improvement in communication between ambulance paramedics and ED clinicians following the introduction of the IMIST-AMBO protocol. Improvement was evident from the video data analysis on the following fronts: a more consistent ordering of the information components; a greater frequency of the necessary information components; reduction in information repetition and asking of questions, possibly suggesting better comprehension and retention of information by recipients, and eye contact between paramedics and ED clinicians associating with the reduction in handover duration, intimating that eye contact may improve the efficiency of information exchange.

For their part, the survey results showed slightly greater satisfaction about paramedic handovers among ED staff. Clinicians' perceptions about the length of handover and its relevance were less confirming, however. These mixed results may have been due to the limited number of paramedics (just over 10% of the state-wide paramedic workforce) having been educated in IMIST-AMBO. Because they were not informed about who was and who was not educated in the protocol, triage nurses were not able to return survey responses only for paramedics who were educated. Hence, the post-IMIST-AMBO survey responses included triage nurses' perceptions of handovers delivered by all paramedics, even if they had not been trained in the new protocol.

While a larger study is necessary to ascertain the significance and sustainability of the present study's findings, IMIST-AMBO appeared to provide paramedics with cues for components they regard as critical, while also matching informational expectations of ED clinicians. Application of the mnemonic appeared to reduce repetition of the information components, and mitigated the need to ask for clarification or repetition on the part of ED staff. Further, IMIST-AMBO helped structure information delivery in the order of clinical criticality, tying in with information priorities of ED clinicians. Finally, the mnemonic ensured that a greater amount of information was consistently handed over.

The reasons for quick uptake of the protocol among paramedics may be the opportunity they were given to critique and reflect on footage of their own actual handover practice, and their prominent contribution to the development of the new protocol. This involvement may also have contributed to the ready uptake by their peers, even though they were not directly involved in the study. ED staff were similarly receptive to the new protocol. Important to them were the detailed clinical information the protocol requires of the paramedic to relay, and the opportunities structured into the protocol for them to ask questions (after IMIST and again after AMBO), and maintain attention on the person providing the handover (thanks to the protocol's ‘hands off/eyes on’ rule). The generally slow and tentative uptake of guidelines and protocols in healthcare18 renders the present study's results all the more important and encouraging.

Another reason why the present study's findings are noteworthy is that IMIST-AMBO appeared to increase (albeit in a limited way) ED clinicians' comprehension of what was handed over, thereby providing better grounds for them to make triage and care decisions. Strengthening the basis of triage decisions is critical, given current pressures on triage nurses from both ambulance paramedics, medical staff and from ED Nursing Unit Managers to provide justifications for their triage category decisions.19

The study harboured a number of limitations. First, only two hospital EDs participated in the study. This means the protocol is yet to be tested in settings where ambulance drop-off arrangements may differ substantially from those characterising large hospital EDs. It further means that only a fraction of the state's emergency department staff was involved. Second, only a limited amount of time was available to train paramedics in using the new protocol. The training needed to be rapid and was confined to those who appeared to be waiting so as not to unduly disrupt ongoing clinical processes. A final limitation affecting the application of the protocol, at times preventing effective handover and dispersing handover information, was that paramedics were not always able to effectively and quickly identify the ED lead clinicians to whom they needed to hand over. To overcome this, the study included a recommendation to the health department that ED team leaders improve their own identification.


Standardisation of the paramedic-ED staff communication interface led to improvements in how information was relayed by the paramedic, the amount of information that was relayed, the time it took to relay the information, the number and type of questions asked about the information handed over, and ED clinicians' perception of paramedics' IMIST-AMBO. The fit between original handover practice and its ‘tacit’ structure on the one hand, and the new protocol and its behavioural-interactive rules on the other, may explain the willingness among paramedics and their ability to adopt the new protocol's topic cues, and its norms pertaining to eye contact and when to deal with questions. It may further explain the NSW Ambulance's rapid integration of IMIST-AMBO into its state-wide paramedic training program.

While this study reached only 10% of the paramedic workforce and a fraction of the state's hospital emergency department staff, its overall outcomes are encouraging. This is the first study to anchor protocol design at the paramedic-ED staff interface to video-based analysis of existing communication practices. This approach ensured that protocol design encompassed more than people's idealised views of work tasks articulated during interviews and focus groups.20 In addition to representing an important advance in paramedic-to-emergency handover, the IMIST-AMBO protocol also symbolises the importance and potential of practitioner involvement in the codesign of patient safety solutions and improvements.


The authors would like to acknowledge Ms Samantha Bendall, Mr Paul Hudson, Ms Carolyn Hullick, Ms Clare Richmond, Ms Sharon White and all participants involved from the Ambulance Service of NSW, Royal Prince Alfred Hospital and John Hunter Hospital.



  • Funding The work was supported by funding from the New South Wales Ministry of Health on behalf of the Ministerial Task Force for Emergency Care.

  • Competing interests None.

  • Ethics approval Ethics approval was given by the Hunter New England Human Research Ethics Committee of Hunter New England Health, and site-specific ethics approval from Sydney South West Area Health Service, and Hunter New England Area Health Service.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • i GCS, Glasgow Coma Scale.

  • ii One of this study's authors, Jacinta Young, had conducted an earlier study that led her to hypothesise the potential usefulness of IMIST-AMBO.

  • iii Handovers occurring next to the triage computer may lead to the paramedic and the triage nurse concentrating on the computer screen, limiting eye contact also due to their proximity. Handovers occurring by the bedside may afford more opportunities for eye contact.