Transfer of care, or, patient handover, is a critical component of the emergency care process. This begins with the initial notification to the receiving facility, continues through potential offload delays, and is completed with a report to the receiving clinician who will be assuming responsibility for the patient’s ongoing care. A well-organized handover is essential for maintaining continuity of care, preventing communication gaps, and promoting patient safety. Handover report frequently occurs during high-stress medical emergencies, where competing priorities and environmental distractions can make it easy to miss pertinent patient information. Regardless of the receiving clinician or setting, it is important to ensure priority information and concerns are clearly communicated.

By the end of this tip, paramedics will be able to deliver a structured patient handover using the ISBAR framework to communicate critical information clearly and support safe continuity of care.

You arrive at the emergency department with a patient involved in a high-speed MVC. The trauma team is preparing equipment and your patient is being moved to the hospital stretcher. You begin giving your report and realize that your notes are out of order and you’re having difficulty organizing your thoughts from memory, all while the clinicians are asking you multiple questions. You walk away wondering whether everything important was communicated.

Does this sound familiar? A structured handover can help keep your report organized, even in the middle of the chaos.

ISBAR: A widely recommended standardized framework for care transitions is the ISBAR tool (Identification, Situation, Background, Assessment, Recommendation/Concern). This is also a guideline for facilitating online medical consultations (OMC). The use of this tool promotes interdisciplinary teamwork among healthcare professionals, also favoring patient safety and comfort. It allows the paramedic to provide the important patient information in an organized manner that prevents ‘storytelling’ or unnecessary information (see image below).

Communicate Trends: Receiving clinicians often need to know what changed during transport, rather than just the last blood pressure or heart rate. Include in your report:

• Significant changes in vital signs
• Patient response to paramedic interventions
• Changes in patient condition (e.g., mental status, work of breathing, pain)

Closed-Loop Communication: A good handover is a two-way conversation. Pause briefly after your report to allow questions, clarify uncertainties, and confirm that critical information was received. If you're interrupted during handover, return to the ISBAR structure rather than restarting the story.

Commonly Missed Information:

• Trends in vital signs
• Medications administered en route (e.g., TXA infusion dose)
• Allergies and pertinent history
• Time-sensitive events
  • Last known well
  • Time of injury
  • Symptom onset
  • Time of ROSC
• Real-time updates regarding changes in patient condition during offload delay

Using ISBAR, a strong handover report for the high-speed MCV may look like this:

Remember that handover is about transferring responsibility, not just information. A structured handover improves patient safety by ensuring critical information is communicated clearly, consistently, and without unnecessary delays.

The next time you are providing a handover report to a receiving clinician, recall the ISBAR framework in order to organize patient information and ensure a safe and organized transfer of care.

Recognizing Acute Altered Level of Awareness in Older Adults

When evaluating an altered LOA, the geriatric population throws out the standard rulebook.

Older adults may present atypically because reduced physiologic reserve, blunted compensatory responses, comorbid illness, and polypharmacy can mask expected findings. A subtle change in attention, behaviour, or level of awareness may be the earliest sign of infection, shock, occult trauma, stroke, medication toxicity, or metabolic illness. The most important first step is to establish whether the patient has acutely changed from their usual baseline.

By the end of this tip, paramedics will be able to identify an acute change from baseline, recognize high-risk atypical patterns, and complete a focused assessment for reversible causes of altered LOA in an older adult.

The “normal vitals” trap
You respond to an 84-year-old woman described by staff as “a little more confused and sleepy today.” She is normally conversational and ambulates with a walker. No fall has been reported. HR 78, BP 108/66, RR 22, SpO₂ 94% on room air, temperature 36.1°C, and BGL 7.0 mmol/L. During your assessment, she is inattentive and repeatedly drifts off.

Do the apparently acceptable vital signs reassure you, or increase the importance of identifying what has changed from baseline?

Establish baseline and recognize a delirium pattern

Do not rely on orientation questions alone. Determine whether the patient has changed from baseline and assess attention, thinking, and level of consciousness.

Looking beyond “Confusion” - Four clinical patterns that should raise concern

High-yield Assessment – Use a broad, structured assessment to identify reversible causes

1. Collateral History & Baseline – ask family, caregivers or staff what has changed, when it began and what the patient can normally do.
2. Focused Neurologic/Stroke Assessment – Look for subtle or fluctuating deficits.
3. Head to Toe – Look for unwitnessed falls, head injuries, pain, dehydration, urinary retention, etc.
4. Infection & System Review – Assess for respiratory, urinary, skin or wound, abdominal, and device-related sources of infection rather than relying on temperature alone.
5. Cardiorespiratory Assessment – Respiratory effort, SpO2, perfusion and rhythm. Consider 12 lead ecg and ETCO2 (if available). 
6. Medication Review – Identify recent starts, stops, dose changes, duplicates, missed doses and high-risk medications.

Bottom Line: In older adults, acute confusion is not a normal consequence of aging. Identify the change from baseline, search for a reversible high-acuity cause, and reassess frequently – even when the first set of vitals appear normal.

Apply it on your next call: With your next older adults with altered LOA, can you clearly state: what has changed? When did it change? Has it fluctuated? Which high-risk causes did I actively assess?

Early Transport Decisions in Cardiac Arrest

Out-of-hospital cardiac arrest management requires paramedics to balance the benefits of on-scene resuscitation with the potential advantages of rapid transport. High-quality CPR, rhythm analysis, defibrillation, and airway management are often best performed in a controlled on-scene environment. However, some patients who are unlikely to meet Termination of Resuscitation (TOR) criteria may benefit from early transport, and this is not limited to the H’s and T’s of reversible causes. The decision to transport prior to 20 minutes of resuscitation should be guided by objective clinical factors and the ability to maintain high-quality resuscitation throughout extrication and transport.

Mastering the Clock and the Card: Optimizing Field Stroke Assessments & Bypass Protocols

When an acute ischemic stroke occurs, millions of neurons die every minute, making rapid reperfusion therapy the highest priority. The Paramedic Prompt Card for Acute Stroke Bypass Protocol (see image below) acts as the guideline for this life-altering care, assisting paramedics to determine when to bypass local hospitals in favor of designated Regional Stroke Centers. However, the success of this hinges entirely on the quality of field assessment by paramedics. Accurate Identification of the Last Seen Normal (LSN) window, swift calculation of large vessel occlusion (LVO), and medical history are what allow the emergency department stroke teams to immediately assess and determine the appropriate treatment including the administration of thrombolytic medication like Tenecteplase (TNK) or other potential treatment pathways.

By the end of this tip, paramedics will be able to accurately calculate and document a patient’s LSN time, correctly apply the LAMS score for LVO screening, and gather the critical anticoagulant data required to optimize the acute stroke bypass.