Keep it BASIC When Handing Off Your Stroke Patient

We’ve all been there. You arrive at the ED after managing and rapidly transporting a patient you suspect is suffering from a time-sensitive pathology like a STEMI or stroke. You’ve followed protocol and provided the ED with an early notification from the scene. On arrival at the ED, you transport the patient to the designated room where the team is waiting for your report. Shortly after beginning your report, the attending physician abruptly turns away and begins interviewing and assessing the patient, before you can finish reporting out. Reflecting on the call, you feel alienated. You think to yourself “I followed protocol and organized all my information to give a valuable handoff report. What happened?”

The handoff report has been described as “a fragile point in healthcare during which there is an elevated risk for medical error that could negatively impact a patient’s course of treatment.”¹ Several case reports have cited poor patient handoff as one of the contributing factors leading to an adverse patient event.^2,3 Clear, concise handoff reports are essential to ensure the most crucial information about the patient is relayed to the receiving team, especially with time sensitive pathologies. Failing to capture relevant information increases the likelihood of medical errors and poor clinical outcomes.^2,3 Cheetam, et. al., found that EMS to pediatric ED handoffs “frequently lack important patient information and that ED clinicians engage in communication patterns that hinder organized, efficient, and complete handoff.”⁴ Janagma et. al., found that “out of 99% of sign-out encounters between EMS and ED staff, less than half of the recommended content was included.”⁵ Goldberg, et al, confirmed the findings from previous literature that demonstrated “poor hand-off quality from EMS to ED clinicians in critically ill and injured patients.”⁶ 

To solve this problem, several standardized tools have been developed to improve peer to peer communication. Examples include SOAP (Subjective, Objective, Assessment, Plan), SHARQ (Situation, History, Assessment, Results/ Recommendations, Questions), and the ubiquitous SBAR (Situation, Background, Assessment, Recommendations).⁷

These tools have been endorsed by various institutions and have been reported to reduce the risk of adverse events and improve provider satisfaction.^8-10 While there is no shortage of standardized tools designed to streamline hand off reporting, there is a paucity of standardized tools designed for EMS use.

One tool, MIST (Mechanism, Injuries, Vital Signs, Treatment) has been promoted for use by EMS, especially in the setting of trauma. In my experience, MIST has not gained widespread adoption, and I have not personally observed MIST in use. Maadry, et. al. examined whether MIST improved inpatient documentation when used as a handoff tool.¹¹ The authors found “a mixed value on inpatient documentation”¹¹ The team found that while there was “higher agreement for mechanism and location of injury, agreement was lower for vital signs and treatments.”¹¹ Beyond this, there is scant literature outlining why MIST specifically is not more widely used. Several studies, however, have outlined factors that have negatively influenced handoff reporting. This suggests it is not the hand-off tool, per se, but interpersonal and institutional barriers that prevent more widespread use.^12,13 Troyer and Brady identified twelve barriers, organized them into four categories, to “effective EMS-to-ED handover.”¹³ These include “disinterest and disrespect, environmental factors, variation and lack of standardization, lack of feedback, and lack of training.”¹³

With this context in mind, I am introducing two tools specifically designed for transferring care of stroke and STEMI patients. These tools, along with MIST, have the potential to improve the transfer-of-care hand ff, reduce the risk for medical errors, and improve outcomes. These tools are not intended to replace a comprehensive handoff report. Rather, they are intended as memory aids to cue EMS clinicians to lead their reports with these most critical elements when time is a factor.

For patients suspected of suffering from stroke, keep your report “B.A.S.I.C.”

• B: Blood glucose and blood pressure
  • Rationale: Hypoglycemia and hypertension (typically a systolic blood pressure greater that 180 mmHg) are contraindications to thrombolysis.¹⁴
• A: Age and sex
  • Rationale: Older age has been associated with adverse effects after thrombolysis.¹⁵
• S: Stroke screen findings including LKW
  • Rationale: Regardless of the stroke screening tool used, the more signs or symptoms of stroke present increases the likelihood a stroke is occurring.¹⁵ The last known well (LKW) is the most important since this will be the determining factor whether the patient receives thrombolysis or not.^{16, 17}
• I: Interventions/IV access
  • Rationale: What interventions were completed based on your local protocols?
• C: Contraindications and contact information
  • Rationale: Reporting any contraindications to thrombolysis can inform the attending physicians’ decision making.¹⁴ If possible, obtaining the contact information of a reliable witness can help verify the reported LKW times.

For STEMI, simply remember “S.T.E.M.I.”

• S: Signs and symptoms
  • Rationale: Clinical signs and symptoms play a prominent role is evaluation of a patient with an AMI.¹⁸
• T: Time of onset
  • Rationale: Durations of signs and symptoms can be helpful in distinguishing patients suffering from AMI and non-AMI in the 20–59-minute time interval.¹⁹
• E: EKG findings
  • Rationale: Report the leads where ST elevations are found and any other significant findings such as STEMI equivalents.²⁰
• M: Management/Medications
  • Rationale: What interventions have you performed and at what times. Todoroski’s findings suggest a benefit from administering nitroglycerin after aspirin in patients experiencing ACS.²¹
• I: IV placement
  • Rationale: Local protocols and PCI center processes may require multiple IV placements to facilitate direct to cardiac catheterization lab transitions.

After thinking about it, you decide to approach the doctor to discuss your feelings regarding the call. Your conversation is professional, and the physician tells you that with time sensitive pathologies, the most essential information is necessary up front. Taking this information back, you realize that the importance of patient handoff can’t be understated.

In this article, I have introduced two tools that can help standardize EMS provider reporting to ensure the safe and effective transfer of care for two patient populations where time is critical. Additionally, I’ve cited several barriers that have been identified as obstacles to effective EMS-to ED patient handoff. While overcoming these hurdles may prove challenging, with active EMS and ED leadership engagement, tools tailored to the needs of your EMS partners and hospitals and a robust quality assurance and improvement program, implementation can be successful.²²

References:

1. Lubin JS, Shah A. An Incomplete Medical Record: Transfer of Care From Emergency Medical Services to the Emergency Department. Cureus. 2002; 14(2). doi:10.7759/cureus.22446.
2. Tiwary A, Rinal A, Paudyal B, Sigdel KV, Basnyat B. Poor communication by healthcare professionals may lead to life-threatening complications: examples from two case reports. Wellcome Open Res. 2019; 22(4). doi: 10.12688/wellcomeopenres.15042.1
3. Manias E, Geddes F, Watson B, Jones D, Della P. Communication failures during clinical handovers lead to a poor patient outcome: Lessons from a case report. SAGE Open Med Case Rep. 2015; 29(3). doi: 10.1177/2050313X15584859.
4. Cheetam A, Frey M, Harun N, Kerrey B, Riney L. A Video-Based Study of Emergency Medical Services Handoffs to a Pediatric Emergency Department. J Emerg Med. 2023; 65(2): 101-110. doi: 10.1016/j.jemermed.2023.04.011.
5. Janagama SR, Strehlow M, Gimkala A, et al. Critical Communication: A Cross-sectional Study of Sign out at the Prehospital and Hospital Interface. Cureus. 2020; 12(2). doi: 10.7759/cureus.7114.
6. Goldberg SA, Porat, A, Strother, CG, et al. Quantitative Analysis of the Content of EMS Handoff of Critically Ill and Injured Patients to the Emergency Department. Prehosp Emerg. Care. 2017; 21(1): 14-17. doi: 10.1080/10903127.2016.1194930
7. Suganandam, DK. Handoff Communication: Hallmark of Nurses. The Indian Journal of Nursing Education 2018; 19(1). https://www.researchgate.net/publication/333866213_Handoff_Communication_Hallmark_of_Nurses
8. Starmer AJ, Spector ND, O’Toole JK, et. al. Implementation of the I-PASS handoff program in diverse clinical environments: A multicenter prospective effectiveness implementation study. J Hosp Med. 2023; 18(1): 5-14.
9. The EMS-ED Handoff: A Critical Moment In Patient Care. The National Association of EMS Physicians Website. https://naemsp.org/2017-7-27-the-ems-ed-handoff-a-critical-moment-in-patient-care/#:~:text=Handoffs%20are%20defined%20as%20the,to%20act%20as%20patient%20advocates Published: July 27, 2017.
10. Starmer AJ, Spector ND, Srivastava R. et.al. Changes in Medical Errors after Implementation of a Handoff Program. NEJM. 2014; 371: (1803-1812).
11. Maddry JK, Arana AA, Clemons MA, Medellin KL, Shults NM, Perez CA. Impact of Standardized EMS Handoff Tool on Inpatient Medical Record Documentation at a Level I Trauma Center. Prehosp Emerg Care. 2020; 25(5): 656-663.
12. Reay G, Norris JM, Nowell L, et al. Transition in Care from EMS Providers to Emergency Department Nurses: A Systematic Review. Prehosp Emerg Care. 2020; 24(3): 421-433.
13. Troyer L, Brady W. Barriers to effective EMS to emergency department information transfer at patient handover: A systematic review. Am J Emerg Med. 2020; 38(7): 1494-1503.
14. Thrombolytic Therapy. The StatPearls Website. https://www.ncbi.nlm.nih.gov/books/NBK557411/#__NBK557411_ai__ Updated: August 28, 2023. Accessed February 27, 2028.
15. Bluhmki E, Danays T, Biegert G, Hacke W, Lees KR. Alteplase for Acute Ischemic Stroke in Patients Aged >80 Years. Stroke. 2020; 51: 2322-2331.
16. Richards CT, Huebinger R, Tataris KL, et al. The Cincinnati Prehospital Stroke Scale Can Identify Large Vessel Occlusion Stroke, Prehosp Emerg Care. 2018; 22(3): 312-318.
17. Ischemic Stroke Clinical Presentation. The Medscape Website. https://emedicine.medscape.com/article/1916852-clinical#b1 Updated: February 21, 2024. Accessed: February 27, 2025.
18. History Taking. In: Miceli A, Raed, J, Khosravani H, Hopyan J, Gladstone DJ. The Stroke Code Handbook. Cambridge, MA. Elsevier; 2020: 1-13.
19. Soloman R, Nowak R, Hudson M, Moyer, M, Jacobsen G, McCord J. Is Duration of Symptoms Predictive of Acute Myocardial Infarction? Curr Probl Cardiol. 2021; 46(3). doi: 10.1016/j.cpcardiol.2020.100555
20. Palladino N, Shah A, McGovern J, et al. STEMI Equivalents and Their Incidence during EMS Transport. Prehosp Emerg Care. 2022; 26(1): 48-54.
21. Todoroski KB. The timing of administering aspirin and nitroglycerin in patients with STEMI ECG changes alter patient outcome. BMC Emerg Med. 2021; 21(137). doi: 10.1186/s12873-021-00523-2.
22. Wilson J, Schano G, Panchal AR, et. al. Collaboration: The Key to a Successful Patient Care Hand-off. JEMS. 2020. https://www.jems.com/ems-operations/the-key-to-a-successful-patient-care-hand-off/