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Don’t drop the baton

Don't drop the batonGood handovers need good communication, says Dr Nigel Rajaretnam

It’s a Wednesday morning: you and your fellow colleagues crowd round a table. There is chatter of interns, house officers and registrars, talking about everything and anything. The night doctor is trying to start a handover of the patients to the new team. More chatter. Papers are flicked through, examined, and dissected. “I remembered I wrote down the findings of the CT somewhere” is muttered. The tired, overworked doctor is trying to make sense and handover a large number of patients to an audience who, unfortunately, are destined not to get the full picture of this patient. The potential for a Serious Untoward Incident (SUI) increases.

Rounds happen. “I was not handed that over” becomes the mantra of the day. Bloods get missed, CTs are not ordered, referrals are not done the next day. Sound familiar?

As health providers, good communication should be one of our strong points. With the advent of the European Working Time Directive (EWTD) and a decrease in working hours, the number of doctors sharing care of the same patient is increasing and handovers have to happen more often.

A good handover depends on the accuracy and completeness of the information, and whether it is received clearly and understood by the recipient

A good handover depends on the accuracy and completeness of the information, and whether it is received clearly and understood by the recipient. The lack of consistent processes, the absence of best practice guidelines and the limited use of protocols mean that handovers are fraught with risk. Poor handovers create discontinuities in care that can lead to adverse events and subsequent litigation. Why is it that we sometimes fail to get handovers right?

Communication is taught well in medical school. We learn to empathise, explain procedures, and problem solve, but we are not always taught practical tips on how to ensure a safe patient handover. We might take a lesson or two from our nursing colleagues – handover is a vital part of their day-to-day activity, and it is done with military precision. Having experienced three different health systems it is done in almost the same manner.

The idea that a patient’s care can be “shared” is often difficult and it predisposes us to be less open to receiving information about patients that we perceive to be “ours”. The end result is a very paternalistic and individualistic approach to what is very much a team effort.

Sometimes, the handover process itself can be flawed. Often, it happens without any clear format, chairperson, structure, or technology. Most handovers are never audited, and therefore no real change can be made without first studying the very nature of the process.

How can it be fixed? Handing over is not new in other professions. To avoid the same mistakes, we should take a leaf out of pages of others who have learnt what works best. As with anything, it could be improved. We are looking into incorporating a typed surgical handover, much like that done in the Adelaide and Meath Hospital in Dublin. This would allow fewer issues with illegible handwriting and provides access to information at a click of a button.

Other institutions use the ISBAR (introduction, situation, background, assessment and recommendation) as a pro forma for their handover. The take-home message is that if the handover is done in the same manner, in the same place, headed by the same person, using the same technology, there is significantly less chance of communicative errors which could result in a negative patient outcome.

What can you do today that doesn’t involve major change to the working week? I suggest starting with a debrief after a ward round. Perhaps the senior on the team discusses what tests/bloods need to be looked out for during the course of the day; what should be prioritised and who the sickest patients are. During this time, it would be ideal if the junior doctors could voice their thoughts or concerns, and, any potential issues could be dealt with at the outset instead of later in the day. Stay in communication with your team members with whatever method you think appropriate.

If the handover is done in the same manner, in the same place, headed by the same person, using the same technology, there is significantly less chance of communicative errors which could result in a negative patient outcome

A rolling problem list is another idea. Each patient has a problem sheet in the first page of their chart that can be updated, and tests put in (bloods, radiology, etc) and results entered as well. This means at a glance the inpatient activity for the particular patient is easily seen, without even having to open their chart. It might add a minute or two for each patient but it will allow a quick preview to whoever is seeing that patient (in particular, that very same overworked doctor at 2am who still has five reviews to see).

Also, to decrease the potential for error, consider small housekeeping jobs that to you might be simple, but could avoid potentially dangerous medication errors. For example, all patients should have a drug chart – even if it’s just for paracetamol and an anti-emetic. Warfarin dosages should be written up in anticipation for the weekend, if the patient’s INR is stable and there has not been any new medications added that could affect the INR. Drug charts should be rewritten in advance instead of waiting for the night doctor or weekend doctor to do so.

IV fluids should be reviewed – there have been many times I have reviewed someone’s fluid chart on the ward to see 5 NaCl 0.9% charted in a row. Ask questions: does the patient need the central line/PICC line/that cannula? Can the NG tube be removed? Why can’t this stable patient go home? We get so lost in our day-to-day work that these simple questions often do not get asked.

As a final word, I encourage you to sit down with your other colleagues, especially those passionate about communication, and see if you can come up with ideas about improving handover. As highly functioning individuals we are very good at coming up with ideas, but unfortunately not as quick to put them into action. An action group would work well, and has the potential to bring about major changes to the patient experience, which, at the end of the day, is why we are all here.

BOX 1: A good handover

Join me for what I perceive to be a good handover:  

It occurs at a set time, in a room fit for purpose, with a large table, plenty of space with several computers and a large screen to bring up x-rays, bloods, etc. In attendance is every team member and a senior registrar. The chairperson would be the most senior in the department, usually a fellow. It runs in the same manner daily. And it is audited, so that we can learn from how we do the handover, and make the changes necessary.

During the morning handover in my surgical department, we run through what operations were done overnight, what operations are on the list to be done today in the acute theatre and we determine the order they should be done in. At this time a consultant is usually present. Then we run through our handover list, which follows a set style:

  • patient label
  • presenting complaint
  • history of presenting complaint
  • past medical history
  • examination findings
  • relevant blood tests
  • CXR, AXR, MSU findings
  • presumed diagnosis
  • a problem list, together with what needs to be done for the said patient (pending results to be chased up, radiology to be ordered, etc).

We then outline and troubleshoot any potential problems as a team, before heading away on our daily duty. There is a similar style handover done in the evening and at night, with the consultant on the phone if they are not present in the hospital.

Dr Nigel Rajaretnam is currently a registrar in Pancreatic, Hepato-biliary and General Surgery in Waikato Hospital, Hamilton, New Zealand. Previously, he was a surgical trainee in Ireland

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