This descriptive, quantitative survey analysis of TTLs in all adult and pediatric lead trauma hospitals in Ontario is the first survey of this kind in North America. Good geographical representation and response rates were achieved throughout the province, especially between trauma centers in the higher population density areas of southern Ontario and those covering the more remote northern regions. In addition, response rates reflected a good balance of adult and pediatric voices. The key findings include moderate TTL satisfaction with the current trauma pre-alerts from Ornge, suggesting room for improvement. Regarding trauma pre-alert content, structure, and logistics, the survey provides useful insights into TTLs’ preferences, which can guide quality improvement interventions within Ornge and other EMS organizations. While specific research on trauma pre-alerts is limited, evidence exists on the use of structured frameworks during face-to-face handover from paramedics to hospital staff in the ED [11]. In this context, standardized framework tools are advantageous as cognitive aids for paramedics to consistently provide pertinent information despite the pressures of working in high-cognitive- load and resource-limited environments [12]. Barriers known to confound handovers in the ED include a lack of standardized processes, noisy and dynamic environments, organizational culture, and medical hierarchical structures [3, 13]. In the same way clinicians perform standard patient assessments, following a standardized handover mnemonic contributes to patient safety. Javidan et al. [7] reported that handovers performed without a framework tool use repetition, leading to a lack of active listening. As trauma pre-alerts share many of the challenges and opportunities of in-hospital handover, implementing similar standardized mnemonics would likely improve patient safety and system efficiency.

One mnemonic that paramedics use to facilitate handover in the ED is ATMIST, which is almost ubiquitous as both a pre-alert and in-hospital handover tool in the United Kingdom [14]. It contains the information ranked most consistently as important or very important by TTLs in our survey and, as such, would be a logical choice to trial for trauma pre-alerts in our organization. However, the implementation of new procedures needs to take into consideration pre-existing opportunities and limitations. In our study, the IMIST-AMBO was the second preferred tool for pre-alerts, after the ATMIST. Iedema et al. [15] found that IMIST-AMBO provided a logical sequence for information sharing and diminished repetition, thereby improving comprehension by the trauma team.

Moreover, a study of IMIST-AMBO conducted at Canada’s largest level-one trauma center demonstrated that the priority of information delivery aligns with the clinical criticality desired by ED staff [16]. This approach improved structure, flow, and duration while limiting the conveyance of unnecessary information [7]. The IMIST-AMBO framework has also been validated in an Australian trauma setting with a similar healthcare model and patient population density [17]. Before and during our study period, one adult trauma center and one pediatric trauma center adopted the IMIST-AMBO tool for the ED handover of trauma patients [16]. Therefore, to reduce variability and improve the probability of successful change management, working with these existing structures would be sensible. One such approach would be to use the IMIST part of the tool for pre-alert, while the full IMIST-AMBO is used for patient handover in the trauma bay. IMIST also largely overlaps with ATMIST, which was the highest-ranked tool in our survey. This process allows paramedics to complete pre-alerts and handovers of trauma patients with one tool, thus reducing cognitive load. This approach was previously described and favoured by paramedics and trauma team clinicians in a qualitative study by Evans et al. [18]. The outcomes from a study by Maddry et al. [19] validated this tool as conveying sufficient trauma pre-alert criteria for an appropriate duration. Two pieces of information not included in either ATMIST or IMIST-AMBO but were ranked highly by the TTLs in our survey are a global assessment of the severity of injuries (i.e. near dying, critical or stable) and the patient’s estimated arrival time. Both can be added to trauma pre-alert checklists, which can be provided to paramedics within a critical care transport organization.

Further suggestions for improvements from our survey relate to the logistical aspects of trauma pre-alerts. As in most time-critical and high-stakes scenarios, direct communication channels are usually preferable, which was confirmed in our survey. However, complexities arise with this practice as it requires TTLs to be paged through the trauma center switchboard. This process can take several minutes, which is impractical for paramedics providing care to critically injured patients. A possible solution to this issue would be to create a single number where TTLs can be contacted directly at each trauma center. This process will require extensive collaboration with individual trauma centers and serve as a reminder of change implementation, requiring stakeholder buy-in from all involved organizations [20]. Similarly, while this survey provides important information to guide change in practice from the perspective of TTLs receiving handovers, we will undertake stakeholder engagement and provide feedback opportunities from our paramedics before implementing any new process. Importantly, after change implementation and a settling-in period, we will repeat aspects of this survey to assess whether the implemented changes had the desired effects.

Limitations of our study include the exclusive focus on TTLs perceptions and preferences of trauma pre-alerts and the lack of a qualitative element. This focus on TTLs was not intended to diminish the importance of the multidisciplinary trauma team, in particular paramedics, ED nursing staff, dispatchers, and transport medicine physicians who provide logistical and medical support in the control centre. Due to logistical and research ethics limitations, we only had access to the TTL email distribution list and therefore focused on their perspective as the key receiver of information from trauma pre-alerts. While it is possible that other trauma team members would have had different preferences, it would not be practical to implement more than one handover structure to accommodate different trauma team members’ needs. As such, we believe that the focus on the TTL as the key information stakeholder is an appropriate approach to guide pre-alert content and structure in our system. Further research could use a mixed methods approach, adding qualitative interviews to ascertain a more profound understanding from participants of different backgrounds. For example, a focus group of paramedics, TTLs, RNs, and dispatchers could address the complexities involved in communication between mobile structures and heterogeneous providers in different regions of the province, while also allowing for interaction between the different stakeholders. While this approach would have certainly been interesting and provide meaningful results, it was outside the scope of this project. A final important limitation is the assumption that addressing TTLs’ trauma pre-alert preferences will actually result in improved processes. This assumption will be tested in future research, which will measure satisfaction as well as other key performance indicators such as accuracy and timeliness of information, following implementation of the standardized pre-alert structures outlined above.