A neglected aspect of safe handover
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