Just one more thing

The perils of patient handovers

BELOW are just a few of my favourite patient handover lines:

“Nothing much happening”
“No-one’s sick”
“Nothing for theatre”
“Here’s the page. Have a good one.”

Brief lines like these could individually or together represent the totality of a handover. Would you feel secure and set for your shift having only the above to go by? If so you’re a braver soul than I.

That’s the way to do it

No less than the World Health Organisation, The Royal College of Physicians and the GMC all stress the importance of effective patient handovers, but that doesn’t necessarily translate into good practice on the frontline. Take a wander over the web and you’ll encounter horror stories to strike fear so deeply that you’ll feel it’s probably best to never leave work rather than hand over responsibility. You’ll also find analogies likening handover to the weak point in the chain of care and suchlike. Look even further and you’ll uncover examples of good practice – standardised handovers, audits of handovers and other shining, selfsatisfied gems.

There are many types of handover within clinical practice: changes of shift within a department or ward, transfer from A&E to ward, theatre to ICU/HDU, GP to hospital, hospital at night meetings, and hospital to hospital to name a few. Handovers involving individual patients may occur three times a day and so it is essential that there isn’t a progressive degradation and perversion of the facts until Mr M, 63, with an MI and ongoing analgesic issues is handed over as Mr M, 36, requiring an IM injection with ongoing anal issues.

Don’t I know you?

We have all heard this before but it’s only because it’s true – preparation is key. Often there may be a lull prior to the end of a shift but even if there is no let-up, you still need to take a pause to ensure you know your patients. You can’t hand over what you don’t know.

The website of the RCP refers to studies that demonstrate a stunning volume of information lost over subsequent handovers if they are purely verbal. The improvement with written notes is marked and even more substantial if standardised template forms are used. We live in an evidence-based world, therefore some form of standardised template for at least those patients that are complicated, acutely unwell or in some state of flux, would seem a cracking idea.

In addition to key patient details, acute and chronic conditions, and treatment plans, some other facts are often useful. Note which consultant is responsible for the patient so it’s clear who to turn to should there be a problem. Are there any contingency plans for likely changes in the patient’s condition? What is the patient’s resuscitation status?

Let’s talk

Ensure adequate time for handovers is factored into rota construction. This requires an overlap of shifts and not just reliance on someone to start early or leave late. Make sure time is available within your rota and join with your colleagues in demanding or extending it if need be.

The common handovers for trainees are changes of shift and hospital at night (H@N). Both are opportunities to do more than simply spout a wealth of clinical information and then leave. At the very least it is a chance to discuss complex patients and take others’ opinions and fresh outlooks. If the handover is a two-way process then there is a greater likelihood that the receiver of the information will draw out the salient points to be able to then give an opinion on management.

At H@N meetings the group atmosphere will need to be controlled to prevent a four-hour handover and a discussion on the best restaurant for work nights-out. A chairperson can focus the group, let each person make their contribution and see that a plan of action is in place. That also includes opportunities for learning. If a registrar is talking about a condition that you’re unfamiliar with or a treatment option you’ve not encountered, then ask questions. Multi-specialty handover meetings can be a great chance to keep up-to-date with your favoured specialty even if your current post is elsewhere in the hospital.

And now for someone completely different

At any handover involving more than a single patient, a degree of prioritisation will need to take place. Be clear which patients need reviewed and the timeframe expected. A common pitfall is handing over patients in the process of being investigated. This is especially true in emergency medicine and many teams now gather at shift changes and formally discuss the patients in the department. In such situations you must remember to document in the notes that you are handing over the patient, what remains to be done and who you are handing over to.

Do not take anything for granted. I have seen a handover of a patient when working in A&E who, at the time of handover, was in the radiology department for a chest X-ray. The patient returned, underwent further investigations and was admitted to the wards. No-one reviewed the X-ray until later that day on a ward round; the patient had a pneumomediastinum and unilateral pneumothorax. It was admittedly a rare example of Boerhaave syndrome but, sadly, a poor example of clinical care. This should not happen.

We can work it out

In the busy post-EWTD clinical setting with foundation doctors frequently working a three-shift system and changing team or consultant on a weekly basis, it is hard to maintain a sense of teamwork and to be an authority on all your patients. Now, more than ever, it is crucial to utilise the handover as a formal, thorough and consistent part of the daily routine.

So make it an educational discussion. Write it down. Prioritise and assign tasks. Foundation doctors will possibly see more patients than anyone else during a shift and have the most to gain from properly conducted handovers; lead the way and you, and your patients, will benefit.

So the next time the pager is tossed your way with a cheery wave as they head to the door, do your best Lieutenant Columbo impression and catch them with a: “Just one more thing.”

Mr Tom Berry is an StR 3 in general surgery in Glasgow

  

Helpful online resources

● Royal College of Physicians Handover resources

● WHO Collaborating Centre for Patient Safety Solutions - Communication During Patient Hand-Overs