1. Clinical Support and Development
Clinical Handover
Rona Rinosa
Clinical Support and Development
The Alfred Hospital

2. Overview The importance of clinical handover
Problems encountered with handover
The components on what make a good clinical handover
ISBAR
What next? What can we do to improve our practice?

3. World Health Organization
“..the process of passing patient-specific information from one caregiver to another, from one team of caregivers to the next, or from caregiver to the patient and family for the purpose of ensuring patient care continuity and safety.”
Clinical handover is one of the most important aspects of our care; it is the main tool that nurses, doctors and other members of the multidisciplinary team use to communicate vital patient information to each other8.
I will be highlighting the importance of clinical handover in our practice with specific focus on nursing bedside handover in the recovery room and including patients and their families in the handover process.

4. Modes of Handover
Face to face: at the patient’s bedside, nursing station or staff meeting room
Taped
Written
Over the phone
In theatres we often do face to face handovers.
In recovery it’s usually done at the patient’s bedside

5. How often do we handover?
At the beginning and the end of a shift
Transferring a patient from one department to another
Temporarily relieving someone
Updating medical and nursing staff
Updating patients and families
Discharging patients
At the Alfred operating suite, we take hand over:
When the patient arrives from the ward into the pre-op bay
Before the patient goes into the theatre from pre-op nurse to anaesthetic nurse
When we give our colleagues breaks or relieve them for the shift
Anaesthetic nurse to the recovery in charge nurse before the patient enters recovery
Anaesthetist – recovery nurse when the patient enters recovery
Recovery nurse – ward nurse before the patient leaves recovery

6. Without Clinical Handover
It can lead to incorrect patient diagnosis
The patient not receiving the appropriate treatment that they require
Errors in medical and nursing interventions
Deterioration in patients condition
Increase risk of adverse effects

7. The importance of clinical handover
Patient involvement
It is vital for the transfer of critical information, maintaining patient safety, ensuring that important interventions are acted upon 16 and also promoting continuity of care6
From a nursing perspective, handover better equips nurses to carry on the care of the patient and ensure that individual patient needs are met. 4
There has been evidence to suggest that involving patients in the handover process decreases the time of recovery and also helps with patient compliance1.
Involving patients in the handover process also helps with patient assessment, visualising the patient and gathering a baseline assessment3.
It allows for a better nurse-patient rapport and allows the nurses to get to know their patients better and minimise errors in patient management3. It also builds trust and improves patient perception of the nurses3.
Hand over also promotes a teaching-learning environment, whereby the nurses feel empowered to apply their knowledge and experiences to help plan for the next shift4.
It is also a chance for junior nurses to learn and gain some education from senior staff members4. It encourages team work and encourages nurses to support each other11.
Promotes a teaching-learning environment

8. Identifiable risks in Handover
Breakdown in communication
Frequency of interruptions
Lack of space
Time constraints
Handover during the weekend
We need to be able to decrease the risk by highlighting where we are going wrong2
Breakdown in communication: when there is no structure or handover tool or there is poor compliance with the handover tool there is an increased risk for patient safety6,16. This can not only lead to unnecessary treatments and tests but also lead to a longer period of recovery and increased patient disatisfaction6.
Frequency of interruptions: background conversations, trolley carts passing by, patient buzzers going off, telephones ringing. This reinforces the need for a designated handover room to minimise the number of distractions6.
Lack of space
Time constraints: rushing the handover or not having enough time to discuss all the important information because of other patient care needs6,12.
Handover during the weekend: when there are less medical staff available, new admissions in the absence of the principle home team5.

9. Identifiable risks in Handover
Incomplete or omitted information
Irrelevant information and repetition
Speculation
Non- compliance
Incomplete or omitted information: This may include test results that are pending, medication issues, any issues that the patient is having.6,8
Irrelevant information and repetition: Not only prolongs the handover process but also takes away the focus from relevant information. It can become a time for trivial conversation and distraction and can also lead to a sensory ovrload4,6.
Speculation: The information transferred is very subjective and can also have negative consequences that cause biased opinions from the health professional which are then carried onto the next shift and develop into negative prejudices towards the patient. This is where the handover turns into an outlet for professionals to vent or voice their views and therefore undoing interpersonal relationships between health professionals and patients4,6.
Non- compliance towards using the handover tool established by the health care organisation13.

10. Components that make a good Handover
Communication
“...Communication is linked to the safety of the patient and the continuity of his/her care.” (Guevara, Maryory & Ligia, 2015, p421.)
Clear
In a timely fashion
Involve the Patient in the Handover process
It is the most important aspect of patient hand over, it is the time where health care professionals exchange any changes that occurred during the shift and ensuring that relevant information is carried onto the next shift3,12.
Information needs to be delivered:
clearly – When you’re including the patient, you are ensuring that you are not using too much medical terminology to confuse them.
In a timely fashion - the longer the hand over the less time spent caring for the patient4.
In recovery, the patient has the opportunity to participate in handover

11. Components that make a good Handover
Taken from WHO (2007) Communication during patient handovers

12. Benefits of Bedside Handover
Patients were better informed
It gives patients the opportunity to be involved in their care
Increases patient satisfaction
Minimise errors
Improving nurse-patient relationship
The literature suggests that:
patient’s wish to be involved in the handover process and enjoyed bedside handover because they felt better informed1.
Some studies have underlined the patient’s wish to be involved in the handover process and enjoyed bedside handover because they felt better informed1.
minimise errors3 and also increase recovery
Allows the patients to get to identify the health care professionals caring for them, therefore improving nurse-patient relationship3
Equipped patients to take better care of themselves and have a better quality of life7.
In the recovery room, it helps patients to build a trusting relationship with their nurse and also helps introduce the nurse who will be taking over their care.
Allows health care professionals to get to know the patient better by gathering additional information from the patients and being able to immediately confirm the previous shifts reports3.

13. ISBAR Identity Situation Background Assessment Recommendations
There is strong evidence to support that when there is no structure in the handover process, there is an increased risk to patient safety5.
The SBAR tool originally developed by the US NAVY for submarine duty handover9 was later adapted by the World Health Organisation (WHO) as a standardised tool to assist health care professionals in handover12.
As per National Safety and Quality Health Service Standards (NSQHS), Health care organisations in Australia have adopted this ISBAR tool to ensure that all patient information is covered and transferred in a systematic order13,16.
The ISBAR tool is also a good learning tool for junior staff to structure their information8.
ISBAR is used in all areas of our practice and can be tailored to the specific setting
Identity: Who is involved in the hand over?
Identifying yourself as the health care provider, ask the patient for permission to undertake bedside handover and identifying who you are handing over to.
Confirm the identity of the patient, this includes checking the patients ID band for name, date of birth and hospital identification number.
Ensure you have the attention of the recipients of the handover
 Situation: avoid using clinical jargon that may confuse the patient
Presenting problems
current diagnosis
Current status
Background:
Any relevant past history
Assessment:
Up to date information on the patient’s current condition
Changes that happened during the last shift
Current treatments and investigations
Problems/ issues
Completed and pending tasks13
Going through documentation and ensuring that information is accurate6
 Requests:
Things that need to be actioned
What the most recent care plan is for the patient9
Allow time for questions
Confirm that all recipients of the handover understand all the key points
Agreement of transfer of responsibility between the health professionals

14. The Future, what next?
“Like a bicycle, a healthcare system is dynamically stable only when receiving constant inputs and feedback from practitioners” (Hill & Nice, 2010, p47).
To improve clinical handover there needs to constant evaluation of the ISBAR tool, further education to increase compliance and reflection of our current practice to determine what we can do to move forward.

15. The Future, what next? Tablets WiFi OpenKIMS Paper free
With developments in technology, literature suggests that handover tools will eventually be electronic5,6.
Using electronic devices such as tablets and the use of Wi-Fi networks to make information readily available may be the next step towards improving our practice5,6.
Studies suggest that information technology is accurate and constantly updating therefore preventing errors and minimising patient risk6.
One Melbourne hospital trialled “OpenKIMS” a computer application designed to document:
Admission notes
Progress notes
Handover charts
Operation reports
Outpatient notes
General letters
Discharge summaries
All patient data was entered into OpenKIMS database by all members of the multidisciplinary team and was easily accessible anywhere within the hospital by authorised personnel.
The information from the admission notes and progress notes was automatically transferred into a handover sheet. The nursing and medical staff were pleased with the application, stating that is was easy to understand and access5.
The use of mobile equipment such as tablets and computers on wheels allowed easy access to secure LAN and web browsers and made ward rounds easier for medical staff It also reduced the need for hard copy printing thus having an environmentally friendly impact5.
Further research needs to be conducted to investigate the use of technology for the handover process and with such positive feedback from the use of applications such as OpenKIMS, a paper free future doesn’t seem too farfetched.

16. The Alfred
At the Alfred, we have recently undergone training to roll out an electronic anaesthetic record.
We are removing the hard copy of our anaesthetic charts to input all the data electronically.
All the patient’s vital signs and anaesthetic is automatically transferred into the electronic anaesthetic chart and the anaesthetist inputs specific medications and interventions in theatre. When the patient comes out to recovery the anaesthetist hands over using a tablet device. All the data from the theatre is accessible through the device.
The pro’s:
Confidential and only accessible to specific staff member
Accessible anywhere
Up to date information
Legible
Easy to use
Environmentally friendly
Cons:
Resources in training
Equipment malfunctions
Back up network

17. Take Home Message: Safe handover = Safe patients
It’s all about communication, making sure that everyone is on the same page
Increases patient compliance
Increases patient satisfaction
Promotes team work
Empowers patients to take charge of their care

18. References:
Greaves, C. (1999). Patients’ perceptions of bedside handover. Nursing Standard, 14(12),
Hill, W. & Nyce, J. (2010). Human factors in clinical shift handover communication: Review of reliability and resilience principles applied to changes of shift report. Canadian Journal of Respiratory Therapy, 46(1),
Amil Kusain, T. (2015). Emphasizing caring component in Nurse-Patient-Nurse bedside reporting. International Journal of Caring Sciences, 8(1),
Priestly, D.S. (2006). A reflective evaluation of patient handover practices. Nursing Standard, 20(21),
Barnes, S.L., Campbell, D.A., Stockman, K.A. & Wunderlink, D. (2011). From theory to practice of electronic handover. Australain Health Review, 35,
Guevera, L., Maryory, A.M., & Ligia, P. (2015). The handover: A central concept in nursing care. Enfermia Global, 37,
Koberich, S. (2014). Nursing bedside handover does not influence cardiovascular surgery patients’ participation in nursing care decision making process: Results three months after implementation. International Journal of Caring Sciences, 7(3),
Eggins, S. & Slade, D. (2012). Clinical handover as an interactive event: Informational and interactional communication strategies in effective shift-change handovers. Equinox Online, 9(3),
Adams, J.M. & Osborne-McKenzie, T. (2012). Advancing the evidence base for a standardized provider handover structure: Using staff nurse descriptions of information needed to deliver competent care. The Journal of Continuing Education in Nursing, 43(6),
Scovel, S. (2010). Role of the nurse-to-nurse handover in patient care. Nursing Standard, 24(20), 35.
Australian Medical Association (2006). Clinical handover guide: Safe handover safe patients. Sydney: Australian Medical Association. Retrieved 19th of May, 2015 from
World Health Organisation (2007). Communication during patient handovers. World Health Organization Collaboration Centre for Patient Safety Solutions, 1(3). Retrieved 19th of May, 2015 from
Safe handover safe patients: Guidance on clinical handover for clinicians and managers (n.d.) British Medical association retrieved 19th of May, 2015 from
Allen, S. (2012). Accrediting Agencies Surveyor Workshop, Australian Commission on Safety and Quality in Health Care. Standard 6: Clinical Handover. National Safety and Quality Health Service Standards retrieved 20th of July, 2015 from
Australian Commission on Safety and Quality in Health Care. Safety and Quality Improvement Guide Standard 6: Clinical Handover (October 2012). Sydney. ACSQHC, 2012.
Alfred Health (2015). Clinical Handover Guideline. Retrieved June 16th, 2015 from Alfred Health intranet.

19. Images: