Safe handoverBMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4328 (Published 09 October 2017) Cite this as: BMJ 2017;359:j4328
All rapid responses
Brendan Fletcher makes a very sensible suggestion that recipients should try harder to listen and not interrupt the cognitive flow of those who are trying to hand over information about patients.
This seems to be the opposite of what we try to get doctors to do when passing information on to patients. Communication skills training suggests that we try to establish what the patient wants to know, answer those questions and fill in the gaps afterwards.
It may well be that the most important person in the process of handover is the recipient, not the giver of the information. It is she who must rapidly file information into her internal model of what is going on, to use it to deal with the situation over the next few hours. It is her cognitive processing that should be facilitated, not the story tellers. I suspect that most of you have seen students or colleagues clerking a patient and asking a question that the patient has only recently answered minutes beforehand, I suspect because the information has been given outside the listener’s readiness to process it.
What is the best, the safest way to conduct handover? I don’t know, but I do know that it should be possible to test out different models to try to answer the question of who should be in control of how the information is structured. Before we press to control handover so tightly, we should ask ourselves which methods are best for patients.
Competing interests: No competing interests
We read your article in the BMJ published on 14th October 2017, Safe handover: practical guidance with great interest.1 As a trainee doctor, I found this article very helpful.
I recently presented an audit in the clinical governance meeting regarding clinical handover in acute medicine and I would like to take this opportunity to share my audit findings with the wider audience.
While working in the Emergency Assessment Unit (EAU) in Dudley, I noticed a few incidents, which were primarily due to a lack of proper handover practice and ineffective communication between doctors and the nursing staff. Based on these incidents I audited the handover process when patients were transferred from EAU to other medical wards.
The standards for my audit were based on NICE guidelines, which state that healthcare organisation’s policy on communication (clinical handover) is explicit about when and to whom the transfer of responsibility occurs, during and following interdepartmental and shift clinical handover.2 NICE also emphasises on the provision of validated training to the staff by the healthcare organisation and monitoring of the handover process.2 The Royal College of Physicians recommendations for good clinical handover state that, handover should be tailored to the local unit needs. The handover should be recognised as a multi-professional team activity.3
This was a retrospective audit; data were collected from 50 case notes using a data collection form. The handover section in the clerking pro forma for doctors and the nursing transfer checklist were audited. These were the tools currently being used by the trust for the handover process.
The results showed that the doctors completed only four percent handover pro formas, whereas 32% of the nursing transfer checklists were completed. These results were quite concerning, hence I did a survey amongst the junior doctors and physician associates working in EAU. This survey was done using a questionnaire. The results of the survey reflected the findings of the audit. Seventy percent of the clinical staff that participated in the survey was not aware of the handover pro forma; hence they never completed it before the transfer of the patients. A similar number of surveyed staff commented that they had not received any formal training for the handover process. Although, 50% were aware of the guidelines and 70% were aware of the risks associated with the poor handover.
This audit was an eye opener for all of us. As a result of this audit and the survey, it was recommended that all staff should be provided with appropriate training for handover. Handover training should be included in the induction programme for junior doctors and physician associates. Since our trust will soon be digitalised, the e-handover process should be in place by then. The handover process should be regularly audited and monitored in line with the NICE recommendations. Communication should be improved between doctors and the nursing staff. We will repeat this audit after one year and monitor the progress in improving clinical handover practice in acute medicine.
1. Merten H, van Galen LS, Wagner C. Safe Handover: practical guidance. BMJ 2017; 359:j4328.
2. Communication (Clinical Handover) in Acute and Children’s Hospital Services. National Clinical Guideline No. 11 November 2015. ISSN 2009-6259.
3. Acute care toolkit 1: Handover-May 2011. Royal College of Physicians.
Dr Muhammad Shoaib Talib
Trust Grade Doctor in Acute Medicine
Dr Mohan Thomas
Consultant in Acute Medicine
Dr Shahid A. Kausar
Chair Clinical Governance, Clinical Audit and CME meeting for Medical Specialities
Russells Hall Hospital, Dudley
Competing interests: No competing interests
The “Essentials Safe Handover: practical guidance” by Merten, van Galen and Wagner in the October 14th BMJ caused me to reflect on a neglected aspect of safe handover: listening.
As the included diagram illustrates, the Emergency Department, particularly in a hospital operating a ‘single front door’, is an environment where handovers are both delivered and made with significant frequency and in a number of modalities: from answering a standard pre-alert call, to receiving a protocolised trauma or major incident alert to taking details for secondary trauma transfers, as part of a Major Trauma Network. This is in addition to the more routine handover of individual patients and, at an operational level, whole departments, at shift changeovers.
When dealing with handovers from pre-hospital teams, pitfalls might include less purposeful questioning by the receiving team over the phone, directed towards a single-handed practitioner in the back of an ambulance treating an acutely unwell patient, whilst their colleague drives, that are not immediately answerable or relevant. On arrival of an acutely sick patient, time-critical interventions may have to occur before handover or transfer between trollies.
In the context of major trauma, it may be that a large team has formed, or is in the process of forming, when the patient arrives and thus handover is repeated many times or that important information is not audible. It can be an intimidating experience, even for experienced practitioners, to handover critically unwell patients to teams that may well not know. To mitigate against this, the Trauma Team Leader takes charge and sets the tone.
Referrals are an important subset of handovers and are clearly a mainstay of Emergency Department practice. Empirically, preferences seem to vary between receiving specialities and individual clinicians within each receiving specialty. Problems I have noted include the following:
- Inconsistency in the modality of referral: sticker-in-book, electronic (including the need to gain access to another specialty’s electronic systems, such as for burns or neurosurgery in our region), phone, face-to-face
- Inconsistency in preferred method: systems vs SBARD vs other
- Expectation that the most senior person in the department should refer when they, in fact, may not know the patient
The process issues above are important but, in my view, the more pressing issue is the failure to listen to a handover. This is frequently due to questions from the receiver that are asked during the handover, rather than at the end. I believe that is very rare for a question to be so pressing that it cannot wait until the end of the handover. In addition, if the question was indeed so pressing, it is less likely to be forgotten. I think that such questions demonstrate poor listening skills by the receiver and interrupt the cognitive flow of the deliverer. Sometimes it can also give the impression of rudeness or trying to impress.
My practice is to put my hands behind my back and count the questions I have and ask them at the end. I have seen my more confident colleagues challenge questions asked during the process.
For this reason, I think part of the discussion about improving handover processes should be focussed not just on the delivery of handover but on the receipt of handover as well.
Competing interests: No competing interests