BMJ  2006;332:496 (25 February), doi:10.1136/bmj.332.7539.496

reviews

Personal views

"That's all I got handed over"

The introduction of the European Working Time Directive has led to many UK hospitals moving from the traditional "firm" based system of working in hospitals to a full or partial shift pattern. The feasibility of shift systems hinges on safe and effective clinical handover. However, little guidance or support for clinicians participating in handover has been issued. The Department of Health's evaluation report Hospital at Night (see www.modern.nhs.uk/workingtime) highlights clinical handover as a "critical element of the model," yet it recommends only that:

• Medical and surgical handovers should be combined
  
• It should be clear who is leading the handover
  
• All team members should attend, and
  
• Handover should take place in a dedicated room.
  

Patients are bewildered by the number of times they have to explain the same things to different doctors

The BMA paper Safe Handover: Safe Patients highlighted this potential problem in August 2004 and detailed a comprehensive plan of action to integrate safe handover into everyday working lives. Few of these recommendations have been adopted into clinical practice.

Current handover varies greatly between trusts, hospitals, departments, and even between clinicians. A handover may be anything from 5 minutes over coffee in which senior house officers discuss the events of the day to a 30 minute sit-down discussion with printed lists.

Many doctors may feel that formalisation of handover is patronising, but the incidence of problems related to poor communication and inadequate handover is overwhelming. Still, handover has clear limitations:

• Not all the important information about a patient can be handed over
  
• Attempts to increase the detail in handovers will inevitably lengthen the process and may lead to even less information being retained
  
• Adjuncts to handover (paper lists or reports from computer systems) can cause confusion or at best delay handover
  
• It is an already complex task that may be worsened by communication difficulties arising from an increasingly diverse NHS workforce with staff from many cultures and countries
  
• It requires the attendance of all team members
  
• Many members of staff (especially senior doctors) do not see it as applying to them.
  

I have yet to see active participation—let alone leadership—by registrars or consultants during handover. Another problem is that although the time allowed for the handover itself may be adequate, there is no time or support for preparation for the task. A lack of role definition means that handover is often conducted by two junior doctors, neither of whom is clear about whose responsibility it is to ensure that communication is adequate.

All too often the response the morning after a night shift is: "I don't know, that was all I was handed over last night." Investigations are repeated unnecessarily, patients' discharge date is delayed, and patients are bewildered by the number of times they have to explain the same things to different doctors. Without formal handover patients are neglected and left dissatisfied at the service they get. The potential for litigation is evident.

What is the best way to hand over? Medicolegally the most defensible option is to hand over patients' details while actually seeing every patient (in the style of a ward round). This would ensure that doctors arriving would physically see the patient and discover as much non-communicable clinical information as possible about the patient. It would also serve as a stimulus for the departing doctors to remind their incoming colleagues about information that had slipped their mind (such as other, less serious problems that need attention later). It is also a useful opportunity for doctors to get a glimpse of the observation charts and verify that since they last saw the patient no deterioration has occurred that may need attention during that shift and to address emerging problems.

Leadership and responsibility in such a handover must be taken by a senior doctor (registrar or consultant). Help to gather x ray, computed tomography, and investigation results in advance would dramatically increase the effective time available for the handover and make it less of a dreaded task.

Bleeper free handovers are a good idea, but many switchboards are not able to arrange this without redirecting the bleeps to another member of the team. Ideally, non-urgent bleeps should be met by a message instructing a request for a repeat bleep after handover, and urgent bleeps should be carried through.

Allocation of rooms and timing of handover are issues that need to be taken up locally by individual departments, but one lead clinician needs to be responsible. Monitoring is essential to ensure that high standards do not slip with the transition of doctors every six months.

At its best handover should make doctors aware of team management decisions, make them feel included in patients' treatment, and encourage them to share responsibility in care. It should minimise delay in attending to unwell patients and help reduce harm to patients. Safe and effective care can be maintained only by an efficient and formal clinical handover.

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Basildon University Hospital, Essex myooran{at}hotmail.co.uk

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This article has been cited by other articles:

• Horwitz, L I, Moin, T, Krumholz, H M, Wang, L, Bradley, E H (2009). What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff. Qual Saf Health Care 18: 248-255 [Abstract] [Full text]  
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