Handover and Transport Decisions

The first decision is not where, it is whether. A large proportion of event presentations are treated and discharged, and that is the model working rather than failing. What matters is that the threshold is clinical.

The test is what the patient needs that you cannot provide. Somebody who needs imaging, observation, a specialist opinion or an operation needs a hospital, and no amount of on-site capability changes that. The pressures at an event run both ways and neither is clinical: the tent is busy and the queue is visible, which argues for discharging, and the ambulance is right there and loading somebody is easier than holding them, which argues for conveying. Both are worth noticing in yourself.

Where the patient goes is a shared decision with a clear division. You contribute the clinical picture and a view on urgency and the level of care needed. The ambulance clinician selects the destination, using their findings, the local pathways and the regional networks. Your job is to give them what those pathways need to be applied properly, which brings you back to the handover.

Two event-specific points. A patient who declines transport is exercising a right, and the conversation and record around that sit on Duty of Care, Consent and Records. And private transport is not automatically a failure: a stable patient going to hospital in a friend's car may be entirely appropriate, provided it is a decision somebody made rather than something that happened while nobody was looking.

ATMIST is a widely used UK pre-hospital handover structure, particularly for trauma, and it is what a crew will be expecting: age, time of the incident, mechanism, injuries, signs, and treatment given. For a medical patient it can be adapted, with the medical complaint in place of mechanism and injuries, though other structured tools exist and local ambulance and trauma network protocols vary. Use the one your service and your receiving unit actually use.

The letters are the easy part. What separates a good handover from a bad one is how it is delivered.

One clinician gives it, concisely and without interruption, to an identified receiver rather than to the room. It takes about a minute, and local protocols put it anywhere from thirty seconds upwards. The treating clinician should be there. Questions and clarification come afterwards rather than throughout, because a handover interrupted three times is three partial handovers.

What does not stop is the patient's care. Essential resuscitation continues through the handover, and a team that halts compressions so that somebody can speak has misunderstood the point of speaking.

Have it written down before you start. Nobody improvises a structured message under pressure, and information written on a glove goes into a clinical waste bin. Some services use a handover card or slate for exactly that reason, and there is evidence it improves both technique and satisfaction.

The pre-alert is a different message with a different job, sent before arrival so the receiving team can prepare. Current guidance on major trauma sets out what it must contain rather than which mnemonic to use: age and sex, the time of the incident, the mechanism, the suspected injuries, the observations including the Glasgow Coma Scale, the treatment given, the estimated time of arrival, any special requirements, the ambulance call sign and the details of the call. ATMISTER is one way of organising much of that, extending ATMIST with the estimated time of arrival and requirements.

The mechanism is the part nobody else can supply, and it is the part most often reduced to a word.

'Head injury' tells the receiving team nothing. That he was struck by a swinging boom at speed, went down without protecting himself, was unresponsive for forty seconds and then walked to the touchline unaided tells them a great deal, and none of it is available from any other source once you have gone home. The hospital can repeat your examination. It cannot repeat the event.

The same goes for the trajectory. You saw what the patient looked like at two minutes and at twenty, and that difference is often the whole diagnosis. A runner who was confused at the finish and is now lucid, and a runner who was lucid at the finish and is now confused, look identical at handover and mean opposite things.

And the treatment. It is a letter of its own for a practical reason: an analgesic given in the tent and given again in the department is a preventable harm that one sentence would have avoided. Give the name, the dose, the route, the time and what happened afterwards.

Then the paperwork. Relevant documentation, or a secure copy of it, accompanies the patient or is made rapidly available to the receiving team. The original may need to stay with whoever controls the record, which is a question covered on Duty of Care, Consent and Records. A verbal handover and a written record do different jobs, and a crew leaving with only one of them will be reconstructing the rest.

• •ATMIST, meaning age, time of incident, mechanism, injuries, signs and treatment, is a widely used UK pre-hospital handover structure, particularly for trauma, and is described by the Royal College of Emergency Medicine as the mnemonic preferred in the UK national ambulance guidelines. Other structured tools exist and local protocols vary.
• •Best practice is a single clinician delivering a concise, uninterrupted handover to an identified receiver, with the treating clinician present and questions taken afterwards, while essential care continues. Reviewing the handover before arrival and using a structured card improves technique.
• •Current NICE guidance on major trauma sets out the content of a structured pre-alert: age and sex, time of incident, mechanism, suspected injuries, observations including the Glasgow Coma Scale, treatment, estimated time of arrival, special requirements, ambulance call sign and call details (NG40). ATMISTER organises much of that information.
• •Relevant documentation, or a copy, accompanies the patient or is made rapidly available to the receiving team, and medicines given are recorded with the name, dose, route, time and response.

• •ATMIST: age, time, mechanism, injuries, signs and treatment given.
• •One clinician delivers it, uninterrupted, to an identified receiver.
• •Essential resuscitation continues; questions come after the handover.
• •Guidance sets the content of a pre-alert rather than the mnemonic used.
• •Record medicines with the name, dose, route, time and the response.
• •The mechanism is the element nobody else can supply once you have left.