The need for effective communication is not unique to medicine alone but is vital to other high-risk, high-stake professions. Much of the evidence-based guidelines for improving in-hospital handoff and teamwork have come from these other industries (eg, aviation, National Aeronautics and Space Administration, nuclear power plants). Despite the notable differences among these fields and medicine, there exists a common thread, the need for effective and efficient communication.⁴

Multiple US and international agencies have identified the tenuous nature of transitions of care. The IOM comments “it is in inadequate handoffs that safety often fails first.”⁵ The Joint Commission, an independent, not-for-profit organization that accredits US health care facilities, introduced efforts to improve communications dating back to 2006. The goals of this project have included improving “effectiveness of communication”⁶ and “implementing a standard approach to ‘handoff’ communications.”⁷ The World Health Organization’s (WHO) “High 5 Initiative,” introduced in 2007, was an international effort to improve patient safety by addressing five challenges to patient safety, one of which was “communication during patient care handovers.”⁸

It is clear that the dangers surrounding transitions of care and the potential breaches in patient safety are not unique to the hospital-based environment. Bigham et al. reviewed EMS patient safety literature from 1999 to 2011. They found that out of 88 studies referencing patient safety, 6 identified miscommunication as a safety concern.⁹ Evans et al. studied EMS patient handoffs to hospital-based trauma teams, noting that up to 9% of information verbally passed on to hospital providers was not documented in either the hospital record or the EMS written report and was therefore considered “lost.” Additionally, discrepancy occurred between verbal and written communication in 7 out of 25 (28%) instances, including allergy status and sites of injury. Most commonly missed areas of documentation included patient presenting signs and symptoms as well as out-of-hospital therapies provided.¹⁰ Shields et al. reviewed an Australian study observing patient handoffs over a 7-day period and noted that patient verbal reports fell into two categories, defined as “detailed handovers” and “minimal handovers.” These researchers went on to examine the implications of each handover and discovered that the type of patient verbal report had significant implications on subsequent patient care, noting that the detailed patient verbal reports lead to “decreased nursing time and enhanced patient care,” whereas minimal verbal reports lead to “poor patient care.”11

Dawson et al. reviewed the medical literature attempting to identify patterns associated with EMS to hospital handovers that could be improved. The authors reviewed literature between 2001 and 2012, identifying 17 articles addressing out-of-hospital transitions of care.¹² Concerns identified in patient handoff were divided into the following categories:

1. Professional relationships, respect, and barriers to communication: 11 out of 17 studies discussed the importance of social and human factors (behavior, communication, professionalism, and a working relationship) because it pertains to transitioning care. Poor communication was found to be rooted in behaviors, such as a lack of active listening and poor eye contact, as well as relational problems, such as mistrust and misunderstanding. Lack of trust on the part of receiving emergency services staff, or even a perceived lack of trust, can undermine effective out-of-hospital or EMS to hospital communication. Multiple studies also specified the importance of the receiving providers being non-judgmental. Equally important is the principle that receiving staff should feel comfortable asking questions and clarifying details. The transferring providers should invite clarifying questions to promote a dynamic transition of care.¹² Specifically, in a 2012 study, Bost et al. noted that increasing trust and being more receptive during handover may enhance identification of signs and symptoms, minimize delays in treatment, and ultimately prevent adverse outcomes. Furthermore, Bost et al. recognized the benefits of teams having a shared mental model in which members of both teams are aware of “each team member’s knowledge, skills, attitudes, strengths and limitations.”¹³ Familiarity with providers during handoff, use of common language or a “cognitive picture,”¹⁴ and allowing for dynamic conversation were all strategies that broke down communication barriers.

2. Need for structure or handover tool: Dawson et al. discovered nine studies in the EMS literature that identified the use of structured handover tools. Multiple studies examined
the mnemonic tool MIST (Mechanism of injury/illness, Injuries, Signs/Observations, Treatment). Additional studies utilized a modified form of MIST.¹⁵ Although these revealed mixed results with limited statistical significance and power to determine the utility of MIST, several of the studies found mnemonics in general to be useful tools to assist in patient handoff. Others suggest a tool similar to SBAR (Situation, Background, Assessment, Recommendation) called ISBAR (Introduction/Identification, Situation, Background, Assessment, Recommendations), which may be best suited for the deteriorating patient.¹² The authors state that this tool provides staff with a rapid, more consistent, and direct handoff that covers the most vital patient information. This tool has been endorsed by the Australian Resuscitation Council¹² and the WHO¹⁶; however, its efficacy in emergency care still requires validation. In 2007, Budd et al. conducted a survey that found that 53.3% of UK Ambulance services utilized standardized handoff alerts (prior to EMS arrival) for trauma patients. Furthermore, their survey study showed the 86.7% of services are familiar with the mnemonic ASHICE (Age, Sex, History, Injuries, Condition, Expected time of arrival).¹⁷ Most authors suggest that a handover tool has benefits, especially in providing inexperienced providers with guidance and direction that highlights essential information necessary for downstream providers when performing a patient handoff. Additionally, handover tools that are agreed upon by both sending and receiving providers may eliminate the hierarchy of medicine that can be detrimental to effective communication.

3. Multiple/repeated handovers: In the reviewed literature, seven studies found that multiple or repeated handovers contributed to lost or changed patient information. The authors noted that a team-to-team handover minimized contradicting stories and reduced the number of unanswered questions. One Australian study showed that 91% of the time, paramedics handed a patient over at least twice.¹⁸ Paramedics preferred transitioning care to a team of physicians and nurses when patients are of higher acuity levels and wanted to ensure that they were communicating directly with personnel of greater clinical experience.¹²

4. Education and training in handovers: In one study, 19% of queried EMS providers report having formal training in patient handoffs. Of the remaining 81% of providers, 83% felt that formal training in patient handovers was necessary.¹⁹ Despite limitations and mixed results noted in many studies reviewed, education and training consistently promoted confidence in junior providers, which “fosters a sense of trust and respect among staff.”^{12,13,20,21,22} Multidisciplinary simulation and communication training are beneficial, especially for providers who are caring for critically ill and rapidly deteriorating patients.

5. Vital signs: Despite traditional EMS education emphasizing the importance of vital signs, eight studies noted a gap in obtaining, verbalizing, or documenting vital signs by the transferring team, as well as acknowledgment of receipt of vital signs by the receiving staff.¹² Vital signs are an essential part of both out-of-hospital and in-hospital evaluation and assessment. Incomplete communication of abnormal vital signs or concerning primary survey findings can directly lead to adverse patient outcomes secondary to delays in care. Simulated studies have found that information, such as vital signs, primary survey, and blood sugar measurement was lost in 40% to 50% of patient handoffs.²¹ Similarly, Carter et al. performed a video analysis of trauma handoff from out-of-hospital to emergency department (ED) staff. This simulated study revealed that only 72.9% of the out-of-hospital information was documented by receiving personnel. Information regarding hypotension, out-of-hospital Glasgow coma score, and pulse rate was only documented by receiving staff approximately 50% of the time.²³ General observations, such as changes in patient condition, mental status, vital signs, and primary survey (airway, breathing, circulation, disability), should be included as part of a comprehensive transition of care. Observing, documenting, and reporting these signs and symptoms are a fundamental component of out-of-hospital care, including WEMS. Mechanisms must be established to ensure accurate transition of these findings to receiving providers.

6. Documentation and other data formats: In addition to the verbal and physical transfer of care, out-of-hospital providers should provide written report and/or electronic documentation of all pertinent out-of-hospital care. Such written documentation acts as a “legacy of care” that exists well beyond the verbal transfer of care, offering a record of the wilderness provider’s efforts for all downstream out-of-hospital or in-hospital providers. Studies have shown that although emergency medical providers may not always refer to the documented out-of-hospital report,^13,18 when used it may reduce information loss and need for repeated handoffs.¹⁵ This documentation can be used longitudinally throughout the patient’s care (ie, on the inpatient services) to preserve continuity of care.^23,24 Short of directly contacting the WEMS team, documentation is the only form of communication available to the inpatient providers regarding out-of-hospital assessment and intervention. Other interview-based studies found agreement among out-of-hospital providers that the practice of using gloves, sheets, or scraps of paper to document patient information contributed to the loss of important data (eg, vital signs or
medications).¹⁰ Providers found value in utilizing checklists²⁵ or other preformed documentation that provides space for initial observations/assessment and trending vital signs.

Woods et al. also reviewed similar literature between 2000 and 2013. These authors identified 21 primary studies relating to out-of-hospital transitions of care. In this review, the authors identified and prioritized 32 subthemes relating to EMS handoff including “active listening,” “relationships between clinicians,” “information retention,” and, particularly relevant for WEMS providers, “environmental impacts.” This group of authors interlinked these subthemes into four major themes, including communication, context (environment), interprofessional relationships, and standardization of handover (including mnemonics).²⁶

Addressing the importance of patient safety as it pertains to the transfer of care between EMS providers and receiving facilities, the National Association of EMS Physicians (NAEMSP) released a position statement in 2014 highlighting many of the themes reviewed by Dawson et al. and Woods et al. This position statement, which is also supported by the American College of Emergency Physicians (ACEP), Emergency Nurses Association (ENA), National Association of Emergency Medical Technicians (NAEMT), National Association of State EMS Officials (NASEMSO), identifies the handoff process as a critical opportunity to improve patient safety, reduce medicolegal risk, and integrate EMS into the health care system. The position statement emphasizes the need for both verbal and written/electronic communication, which includes key patient information (Box 6.1). Additional information may include basic patient demographics, patient allergies, other time parameters (on-scene time, transport time, etc.), past history, and baseline medications. Furthermore, NAEMSP calls for mutual and shared respect between out-of-hospital and hospital providers. This mutual respect calls for dynamic communication with active listening as well as opportunities for questions to be answered.²⁷

Scant literature exists on WEMS systems in general, with no literature found discussing transitions of care between WEMS providers and traditional EMS or hospital providers. All literature that was identified analyzes transitions of care between traditional EMS and emergency medical personnel or, alternatively, address in-hospital transitions of care. Although little literatures on this topic exist, many of the underlying issues in communication that exist between traditional EMS and hospital providers or within hospitals can be speculated to occur within the paradigm of a WEMS system, because many of the stresses that exist in other areas of the health care system are present in equal or greater measure in a WEMS setting. Additionally, the WEMS provider may fall prey to the same “hygiene-poor” communication environment that a traditional EMS provider encounters in the hospital. WEMS patients requiring hospital admission may be subject to multiple transitions of care. For example, a multisystem trauma patient calling 911 for assistance could receive initial care instructions from an emergency medical dispatcher, and then from first aiders on-scene, passing to the primary WEMS team responding to and caring for the patient in the wilderness, to the ambulance team transporting the patient to a helispot, to the air medical crew transporting them to a hospital and transferring care to ED staff, with final transferal of care to the medical or trauma service caring for the patient in the hospital. Finally, although WEMS education is unique and not all flaws of the traditional EMS education process can be assumed to exist in WEMS education, traditional EMS education does not always adequately prepare its providers for transitions of care, so it is possible that the WEMS education process also does not consistently educate providers in patient handoffs and communication. As hospital medicine and traditional EMS have begun to focus on adapting communications skills, the WEMS system must also value the importance of transitions of care and the lessons learned from nonrelated professions with high consequences for failure.

The EMR is the foundational scope of practice described in the traditional EMS system. This provider is trained in simple and immediate lifesaving skills for critically ill or injured patients (Box 6.2). This may include basic airway management, hemorrhage control, and use of an automated external defibrillator (AED). The EMR usually works within a system of care that includes other scopes of practice. Although the EMR may be present during patient transfer, this scope of practice is typically not the primary care provider during the transport phase of care. After initiating care, the EMR usually transfers care to a higher level provider. The traditional EMR scope of practice is limited to a very minimal pharmacologic formulary, in many cases including provision of medications for force protection alone.