Handover of care is one of the most perilous procedures in medicine; when carried out improperly can be a major contributory factor to subsequent error and harm to patients, writes Debbie Guy
Continuity of information underlies continuity of care. Handover constitutes the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis.
The fundamental aim of any handover, therefore, is to achieve the efficient transfer of high-quality clinical information at times of transition of responsibility for patients.
Hospitals typically operate several shift patterns with a necessity to pass patient handover information, condition and task details seamlessly between clinical teams in order to maintain patient safety and continuity of care.
There are three types of patient information being exchanged and discussed at this point: information on clinically unstable patients; tasks still to be completed; and a summary of the pertinent real-time information required for the care of each patient.
Whereas the patient record is a detailed document that is recorded and stored in a structured way, handover information is unstructured and the method of recording is variable. In fact, in some cases the handover information is recollected from memory and exchanged face to face, or on scribbled notes, with little or no governance in place.
‘The fact that there remain so many incidents caused by poor handover indicates the challenge is more complex than it appears’
Handover is clearly a time when errors or omissions in key information can have critical consequences. Statistics from the National Confidential Enquiry into Patient Outcome and Death showed that in 13.5 per cent of cases where patients died within four days of admission, poor communication − between and within clinical teams − was an important issue contributing to the adverse outcomes.
Changing operational structures and shift patterns − driven by essential economic considerations and regulations such as the European working time directive − combined with the increasing complexity of healthcare, have led to a patient pathway that is much more dependent upon a broader clinical team that is often spread across the hospital. This has increased the challenges of consistently delivering a safe handover and therefore increased the need for more stringent handover processes.
Best practice: going mobile
That these risks still exist is not down to a lack of focus or effort. Many hospitals have tried a range of approaches, combining process and technology initiatives. The fact that there remain so many incidents caused by poor handover indicates that the challenge is more complex than it appears. The National Patient Safety Agency has highlighted that perceptions and practice of handover vary across the country, between trusts, specialties and even within a single unit, and handover solutions that meet the needs of one group are often found to be unsuitable for others.
‘Without a simple list of the patients to go through methodically, a whole patient handover could be missed without knowing’
The fundamental issue that remains to be resolved therefore concerns the flexibility and timeliness of the information shared. Currently, the information collected and passed between clinical staff is not collected or accessed in real time. All too often, handover notes are made towards the end of the shift in preparation for the handover and not during the shift.
And whether collated on an e-handover system in the ward, or in notes on paper, they still rely on the busy clinician’s recollection of events and the individual nuances of the staff involved. In fact, without a simple list of the patients to go through methodically, a whole patient handover could be missed without knowing.
Capturing real-time information
Manual notes do not meet auditable governance requirements, and e-handover systems in the ward only do in some cases, but this is still looking at data in the rear-view mirror, rather than looking at information in real time. It is of little help to the clinician if something critical is miscommunicated or at worst, left off the notes altogether.
Supporting the capture of real-time handover information at the point of care reduces errors and ensures completeness, as well as providing a governed track record of changes. By providing this information directly to clinicians’ smartphones, anywhere in the hospital, they can make immediate, informed decisions − reducing the risk of avoidable deterioration.
This data doesn’t have to be collected at the bedside – it could be as a result of a multi-disciplinary team meeting between clinicians discussing a patient and confirming a course of action. The key difference is that as soon as it is entered into the mobile device, it is there for all to see and access, ensuring that at the handover process itself there is a complete and accurate record of the information pertaining to each patient.
A mobile handover process
Correct and up-to-date information and the communication of it clearly play a critical role in the care of a patient. Communication is vital between the various teams and professional groups and becomes even more important during handovers.
Placing real-time patient information in the hands of clinicians and providing the ability for this to be updated and accessed during the shift and at handover reduces the potential for missing key information. This will increase patient safety and improve efficiency of the process.
Introducing mobility to the handover process − not just making it electronic − is key to bringing about the shift in emphasis and focus from the handover itself to the continuous, real-time updating of the handover information. This information, accessed by all, will bring efficiencies in the process of data collection, reduce the potential for errors and increase the control and expedition of patient care. This puts patient safety first and allows for a safe handover, reducing the risk and potential for harm.
At this point, handover information transitions to real-time patient status information, becoming relevant, timely and so simple that it positively affects continuity of care, rather than just being something that happens at the end of a shift.
Debbie Guy is director of clinical operations at Nervecentre Software