What Nurses Should Know about EMS Handoff Reports

A Type 3 Ford E-Series ambulance belonging to Stewarts Ambulance Service of Maine, parked at the Massachusetts General Hospital emergency room.
Mangocove, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons

Few things present as much opportunity for error and miscommunication than verbal reports from one provider to another. In some future reality, our EMS reports will just drop right into the patients hospital record and the verbal report will be a courtesy.

Currently, the verbal handoff is a necessary and consequential interaction, despite the frequent and well documented frequency of errors.1, 2, 3

Compounding the confusion is that a handoff report is a very difficult and sometimes subtle skill which is not commonly taught in school. We are called upon to take everything we’ve learned during the interview, physical assessment, vitals, treatments, etc., and condense that massive amount of information into about a minute of highly efficient communication.

There have been attempts to standardize the EMS handover report, most notably the IMIST AMBO mnemonic,4, 5 which just on its surface looks like a real challenge to memorize. EMS training has a plethora of initialisms and acronyms which seem to be mostly made for EMS and not by EMS. I find students are more successful when they understand the reason behind what they are doing rather than just memorizing a format, and that is what we will attempt to do here.

Radio Reports

You have a patient, and you’re on the way to the hospital. It’s time to let them know you’re on the way. The information they really want out of this report are when you will be there, if they need any resources on arrival, and if the patient can go to triage. There is a bit of game playing here, because we can’t directly tell them most of that. Saying that a patient is appropriate to go to the lobby is generally frowned upon by transporting agencies due to liability reasons.

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In fact, you should never answer that question. Sometimes they will ask over the radio or in person whether a patient is triage appropriate. That’s a trap. That is a decision the receiving facility needs to make. Likewise, requesting specific resources be available is generally frowned upon by the receiving facility. So, you need to tell them the information they want to know without directly telling them. Also, you have to consider that the patient is sitting right in front of you while you’re talking so you may want to have some discretion regarding what you say out loud.

The general format of radio reports is as such:

  • Age
  • Urgency
  • ETA
  • General Complaint
  • Observations
  • Interventions
  • Vitals
  • Extras

Age

Fairly self-explanatory, but important for the hospital to know. An 82 year old with weakness and fever has a much different prognosis than a 24 year old with the same symptoms.

Urgency

Light and sirens, or no lights and sirens. This is your chance to tell them how urgent you consider this patient to be. Note that this doesn’t have to reflect how you are actually driving. If you are down the street from the hospital and don’t actually need to put the lights on you can still tell them lights and sirens to get the message across that you will need resources on arrival. The hospital will take this as a consideration in the context of the rest of your report. If you say lights and sirens and give a non-urgent report, they may not have anything ready for you or even ask on the radio why exactly you are transporting emergently.

ETA

This one is so important I usually say it twice, once at the beginning and again at the end. The timing of when you give your report can be very important. If your transport is less than 10 minutes, I would give the radio report very early. If this is a specialty activation like stroke, STEMI, or trauma you may want to consider calling while still on scene when you have a short transport. On the other hand, more than 20 minutes early doesn’t do a whole lot for the ER. The department will be a whole different place by the time you get there.

General Complaint

What is the ER going to treat? Keep in mind that this is not necessarily why the patient call 911. If they called for abdominal pain, then say abdominal pain. But if they called for weakness and during your assessment you find that they are also complaining of 10/10 crushing chest pain you should tell the ER “Chest pain and weakness.” It’s your job to figure out what the most potentially life threatening thing the patient is complaining of and let the hospital know.

Observations

Did you find anything during your assessment? This should be follow up information related to the complaint. If its chest pain, you should briefly describe the 12-lead. For shortness of breath a room air SpO2 and lung sounds are pertinent. If abdominal pain, is there nausea and vomiting? This is your time to let them know what you found!

Interventions

The hospital now knows what the patient is complaining of and what you found, but what have you done about it? This should flow from the complaint and observations you just made. Saying “the patient is complaining of shortness of breath, has bilateral expiratory wheezing and we’ve given nebulized albuterol” makes sense and is efficient. On the other hand, saying “the patient is complaining of nausea, is febrile, and we’ve given fentanyl” is confusing. We are aiming to give a concise snapshot of the patient’s condition at the time of report.

Vitals

Vital signs, including any changes. If you started with a hypotensive patient, and they are now normotensive you should report what you found on scene. All reports should contain a blood pressure, respiratory rate and heart rate, but some of the others can be complaint dependent. Confused patients should have a blood sugar reported, respiratory patients should have Spo2 and EtCo2, etc.

Extras

They will also want to know any pertinent details that will affect their placement at the ER. For example, if they are not ambulatory or are confused at baseline, they will not be able to sit in the waiting room. If your patient is agitated or in restraints, they should know that so that they can get the appropriate resources available.

I tend to leave patient sex out of the report unless it is pertinent to the complaint, but hospitals sometimes ask. Just check in with patient regarding what their gender identity is (again, only if pertinent). Something along the lines of: “The patient is non-binary and was assigned female at birth” or “the patient identifies as male” will get the information across.

Examples

Rampart General, this is Squad 51. We are en route to you non-emergent with an ETA of 15 minutes. On board we have an 84-year-old patient with a gradual onset of weakness and increased confusion. The patient is hot to the touch and reports pain with urination. We have an IV established and have given a 250ml bolus of lactated ringers. On arrival the patient was hypotensive at 98/47. After the fluid bolus she is now at 108/72 with a heart rate of 88, respiratory rate of 18, and a blood sugar of 92. The patient is coming from a memory care facility and is confused at baseline. If no questions, we will see you in 15 minutes.

Regional Hospital, this is Medic 42. We are en route to you non-emergent with an ETA of 10 minutes. On board we have a 54-year-old patient complaining of 8/10 upper right quadrant abdominal pain that started one hour ago after eating. We have an IV established and have given 50mcg of fentanyl. Vitals signs are currently heart rate of 104, blood pressure of 114/78, and respiratory rate of 18. The patient is ambulatory and may need an interpreter. If you have no questions, we will see you in 10 minutes.

You’ve just given them an immense amount of information in about 30 seconds, which is possible because of the shared mental model of healthcare you share with the nurse. It would be much easier to say, “Hey we’ve got this guy that probably has gall stones, but we gave him some pain meds and he can probably sit in the lobby – see you in 10,” but that sounds terrible. Radio communications can potentially be overheard by anyone, so it’s important to be professional.

Low-Acuity Hospital Handovers

Most of the time you will be able to give your report to the hospital at your leisure. While the handoff may feel casual, it is a very complicated interaction. If you are looking for a mnemonic device, IMIST AMBO4,5 is good to communicate the EMS OPQRST, SAMPLE, GCS, VS, and DCAP BTLS ASAP to the ED RN.

Instead of that though, let’s look at what they want to know and why. The hospital is most interested in the things that only you can tell them. Where are they coming from? If it was a traffic accident, what were the details of the accident? Are there safety issues at the house? What were they like before you started treatment? What did you do? What were the results of those interventions? What happened during transport? They can see how the patient is doing now. They know what their vitals are now. If they are efficient, they already have their records pulled up and know more about their medical history than you ever will. If you want to be helpful and make the nurse like you, can also be hooking up the patient to the hospital equipment and getting a first set of vitals for them.

Here Is How I Like to Structure These Reports

  • Why are they here?
  • What did you find?
  • What did you do?
  • Pertinent Details
  • Any questions?

Why Are They Here?

If the patient called, why? What is their concern? If someone else called, what was the reason?

What Did You Find?

What did you observe? This includes both the patient and the living situation. We’re there physical findings? Abnormal vitals? How about beer cans everywhere or drugs on the table? What is their baseline mobility? Do they use a walker? What is their baseline mentation?

If the patient is confused at baseline that’s probably information you’re going to need to get from a bystander. Are they on oxygen at home, and if so, how much? These are all bits of information that are easily obtained by EMS but can be very difficult for the hospital to discover.

What Did You Do?

What were your interventions and what were the results? Every intervention should have some associated information. If you started an IV was any fluid given? If you have albuterol what were the lung sounds after? Whatever the intervention was supposed to be doing is what you should report on when you mention it.

Pertinent Details

This is where you pass on any additional information that the hospital may want to know. If they are coming from a facility, which one? An address and phone number is even better. People get stuck at the hospital shockingly often just because they don’t know where they came from. Is there family, and if so, are they coming to the hospital? Most people do not get admitted to the hospital and if the patient can’t get home by themselves there needs to be a plan to get them there.

Blood thinners are important to mention here, especially for any kind of fall. You can also pass on safety information. If the patient is confused at baseline but is living alone, that should be mentioned. Any suspicion of abuse or neglect should be both reported to the appropriate hotline and the receiving facility. You are the eyes and ears of the hospital in the patient’s home, which puts us in a very unique position to help.

Any Questions?

If you haven’t given medical history or vitals already, be prepared to give them here. And don’t forget that if the facility asks something you don’t know, just saying “I don’t know” is a completely appropriate response.

Let’s Look at Some Examples

Hi, this is Chuck. Chuck is 60 years old and coming in from home today for some 5/10 substernal chest pressure that started one hour ago and radiates to his left arm. Chuck has a history of a previous MI and has had one stent placed. Vital signs on scene were a blood pressure of 114/72 and a heart rate of 62. His 12-lead is a normal sinus rhythm with no noted elevation, depression, or ectopy.

We have an IV established and we have given 324mg of Aspirin and 0.4mg NTG, which has not changed his pain level. He is typically on home O2 at 2pm for COPD and uses a walker. His daughter is on her way here. I have his most recent vitals and more information on his medical history if you would like that. Any questions?

Hi, this is Alex. Alex is 25 years old and was involved in a motor vehicle accident. Alex was the restrained driver of a small car that was rear ended while stopped at a light. There was moderate damage to the rear of the vehicle with no compartment intrusion. The airbag was not deployed and Alex self-extricated. They are complaining of 2/10 left shoulder pain which increases with movement and is consistent with the placement of the seatbelt. Vital signs were unremarkable. No interventions were performed during transport. Do you have any questions for me?

Hi, this is Joan. Joan is 72 years old and coming in from a skilled nursing facility. Staff at the facility report increased weakness and confusion over the last several days. Joan is normally alert and oriented at baseline. Her vital signs on scene were 101/68 for a BP with a heart rate of 104, which was a sinus tachycardia on the monitor. She has a blood sugar of 98 with a temperature of 101. Joan does have a urinary catheter which is noted to be dark and cloudy. We have a 20g IV established in her left forearm and we’ve given a 250ml bolus of lactated ringers. Her heart rate has decreased to 94 with a similar blood pressure. Joan typically uses a walker outside the home and a cane inside. The facility address and phone number are listed on the paperwork. Do you have any questions?

High-Acuity Handovers

Sometimes there isn’t time for all the details. If you’re doing the fast walk into a room full of nurses and doctors you need to keep it very short and very pertinent, otherwise they will start ignoring you. You’re going to be talking to a room full of people so speak loudly and clearly. Keep the details down to what they need to treat what is affecting your patient at this very moment. Once that is done, find the actual nurse and give any other details you want to pass on. Here are some examples :

Hi everyone, this is Bob. Bob is 54 and had a sudden onset of chest pain 20 minutes ago. He appears to have an inferior MI. We’ve given Aspirin and withheld nitro. There is an 18g established. He has a history of two previous MIs and three cardiac stents.

This is Ruth. Ruth had an acute witnessed onset at 0930 of slurred speech, right sided facial droop, and left sided upper and lower extremity weakness. She is hypertensive at 240/120 and takes Eliquis. Ruth has an advanced directive stating no CPR or intubation.

This is Josh. Josh was riding a motorcycle at approximately 50mph and impacted the back of a stopped car. He was ejected up and over the vehicle with about 20 feet of separation from the motorcycle. A helmet was worn. Unknown loss of consciousness. He is alert but confused. He has bilateral femur fractures, with the right one open. A tourniquet was placed on the right leg at 2312. We’ve given 200mcg total of fentanyl.

How to Get Better

You’re not going to be good at this when you first start, but you can definitely get better. Listen for the follow up questions that they ask. Some nurses want more, less, or different information than others so don’t get discouraged if they ask questions you don’t know the answer to. Also make sure to listen to other providers’ radio and in person reports.

You’ll find things that you like that you want to incorporate into your practice, as well as things to avoid. I also like to say something along the lines of “It was a pleasure meeting you, I hope you feel better,” or “My friends here are going to take care of you from here” so the patient also knows that their time with you is over and that they are now being taken care of by the hospital.

As always, never stop learning and improving so we can get our patients the best possible treatment at the end of our time with them.

The author would like to thank his (regrettably former) partner Eve Hatfield, EMT-P; Allison Henderson, RN; and Catherine Teeling, RN, for their contributions to this article.

References

1. Goldberg SA, Porat A, Strother CG, Lim NQ, Wijeratne HR, Sanchez G, Munjal KG. Quantitative Analysis of the Content of EMS Handoff of Critically Ill and Injured Patients to the Emergency Department. Prehosp Emerg Care. 2017 Jan-Feb;21(1):14-17. doi: 10.1080/10903127.2016.1194930. Epub 2016 Jul 15. PMID: 27420753.

2. Panchal AR, Gaither JB, Svirsky I, Prosser B, Stolz U, Spaite DW. The Impact of Professionalism on Transfer of Care to the Emergency Department. J Emerg Med. 2015 Jul;49(1):18-25. doi: 10.1016/j.jemermed.2014.12.062. Epub 2015 Mar 21. PMID: 25802157.

3. Lubin JS, Shah A. An Incomplete Medical Record: Transfer of Care From Emergency Medical Services to the Emergency Department. Cureus. 2022 Feb 21;14(2):e22446. doi: 10.7759/cureus.22446. PMID: 35345754; PMCID: PMC8942169.

4. Iedema R, Ball C, Daly B, Young J, Green T, Middleton PM, Foster-Curry C, Jones M, Hoy S, Comerford D. Design and trial of a new ambulance-to-emergency department handover protocol: ‘IMIST-AMBO’. BMJ Qual Saf. 2012 Aug;21(8):627-33. doi: 10.1136/bmjqs-2011-000766. Epub 2012 May 23. PMID: 22626739.

5. Shah, Yousaf & Alinier, Guillaume & Pillay, Yugan. (2016). Clinical handover between paramedics and emergency department staff: SBAR and IMIST-AMBO acronyms. International Paramedic Practice. 6. 37-44. 10.12968/ippr.2016.6.2.37.

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