Methods

This was a descriptive survey using two questionnaires to gauge current opinion. The first questionnaire was designed for medical staff to complete and the second was for ambulance staff. The questionnaires were completed anonymously. A single abstractor who was unblinded to the purpose of the study extracted the information.

Questionnaires were distributed to all 47 medical staff in two teaching hospital accident and emergency (A&E) departments, seeing a combined total of approximately 120 000 new patients per annum (appendix 1). They were also distributed via ambulance officers to all 110 ambulance personnel in the Tayside region of Scotland (appendix 2). The questionnaire asked ambulance staff if they had received any formal training in the transmission of information to colleagues, and about their confidence in handovers in a number of different clinical situations. Medical staff were asked their perception of the handovers given by ambulance staff in the same clinical situations. They were also asked if they had any opportunity to feedback their opinion to ambulance staff. The clinical situations enquired about included, multiple trauma, serious head injury, chest pain, self poisoning, paediatric emergencies, and cardiac arrest.

Opinions were asked regarding other aspects of the handover, these were; the perceived quality of prehospital radio reports, that handovers delay patient transfer, the quality of handovers vary a great deal, medical staff pay attention to handovers, and enough time is available to give an adequate handover. Questions relating to confidence had set responses. These were categorised into five groups, namely, strongly disagree, disagree, unsure, agree, and strongly agree.

Results

In total, 30 medical and 67 ambulance staff completed questionnaires representing a 64% and 61% response rate respectively. The response to general questions regarding the handover, in different clinical situations, is shown in figure 1. Figures 2 and 3 show the responses to questions of confidence in the quality of history and vital signs provided by ambulance staff. All figures present the percentage of respondents who agreed or strongly agreed with the statement posed in the questionnaire. The perception of the handover seem positive among both groups. Medical staff were slightly less positive about handovers, particularly in the context of self poisoning and chest pain. They were also generally less positive about the quality of vital signs reported during a handover.

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Figure 1

General perception of the handover given by ambulance staff.

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Figure 2

Perception of the quality of history given by ambulance staff.

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Figure 3

Perception of the quality of vital signs given by ambulance staff.

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Appendix 1

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Appendix 2

Sixty nine per cent of medical staff felt that the quality of handovers varied a great deal between ambulance crews. Some 65.5% agreed that prehospital notification was used appropriately, but only 35% agreed that radio reports were well structured. Only 17% of medical staff felt that the handover delayed the transfer of patients onto the trolley in the resuscitation room. Some 89.4% of ambulance staff were confident about which cases to notify in advance and 83.3% were confident about their ability to structure a radio report. Altogether 72.7% felt they had enough time to give an adequate handover but only 24.2% felt medical staff paid attention to their handovers.

Ten (33%) of medical staff felt they were able to give feedback to ambulance crews on their management of patients en route to hospital and seven (23%) felt able to give feedback on the handover received. Thirteen (19.4%) ambulance staff received formal training in giving a handover. Of those who did not receive training, 44 (83%) felt there was a need for training.

Discussion

The patient handover is an important part of daily nursing duties^{1, 2} and, with changing work practices, increasingly a part of junior doctors duties.³ The handover is important in maintaining continuity of care, patient safety and teamwork.¹ Important prehospital information care can be passed on by general practitioners⁴ and ambulance staff, both before arrival,^{5, 6} and in the resuscitation room.⁷

It is encouraging that both groups have a generally positive perception of the handover process. The opinion of medical staff with regard to the handover in medical emergencies is slightly less positive than ambulance staff. This may indicate a need to improve training of ambulance crews in acute medical emergencies. There is a notable lack of confidence in both groups regarding paediatric handovers. This may be explained by the added stress of the situation and also by the fact that they are less commonly seen However, medical staff are more positive about the quality of these handovers. It is therefore unfortunate that there does not seem to be a system in place to allow feedback to ambulance crews. Such a process may improve the confidence of both groups.

Ambulance staff report a lack of formal training in giving a handover, a view apparently confirmed by medical staff conveying their belief that handovers were very variable between crews and that they did not feel radio reports were well structured. However, the validity of medical staff opinions may be questioned as it seems ambulance staff do not feel that medical staff listen to their reports. The probable reason for this is that medical staff are distracted by their desire to start assessing the patient. One solution is to listen to a handover without anyone touching or talking to the patient unless they had an immediately life threatening problem. Alternatively a member of the receiving team could be nominated as the person who takes the handover while others continue to treat the patient.

There have been no previous studies into the handover between ambulance and medical staff in A&E. This study has some limitations, firstly, the abstractor was unblinded to the purpose of the study. The findings are based on questionnaires rather than actual handovers and are therefore a collection of opinions. Direct observation of the handover in the form of audio or video recording would be an alternative. However, the presence of such equipment would change the behaviour of staff and hence potentially bias any results. This questionnaire based study highlights perceived problems that are important to appreciate when starting to investigate this area. Although the number of subjects is small, this study gives an initial picture of current problems and provides the basis for further studies.

A better, more consistent structure to the handover will improve the dissemination of information in all types of emergency. Ambulance and medical staff training should be based around a system where patient details are followed by a concise history of the events, general medical condition and salient physical and vital signs.⁷ The aim being a smooth and efficient transfer from prehospital agencies to A&E staff.

Appendix 1

Appendix 2