Professor Rick Iedema Director of the Centre for Health Communication, UTS Dr Robert Herkes, Director of Intensive Care

Services RPA Sydney Eamon Merrick RN MHSM, Research Fellow Centre for Health Communication, University of Technology Sydney Royal Prince Alfred Hospital Intensive Care Services, Sydney South West Area Health Service

•  Objectives: participants will be able to: –  See, as a fly on the wall, how handovers are conducted in intensive care. –  Discuss the function of handover in maintaining continuity of patient care. –  Reflect on the challenges that confront attempts to improve handover. –  Plan strategies for the improvement of handovers.

“ … 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”3. “… to provide accurate information about a [patients] care, treatment, services, current condition and any recent or anticipated changes….. The information communication during handoff must be accurate in order to meet [patient] safety goals”4.

Behvioural Health Psych Unit 5% in Hospital 5% Psych Hospital 12%

Emergency Dept 5% Loss of Function 9% Hospital Psych Hospital Hospital 73% Psych Unit in Hospital Behvioural Health Emergency Dept Med error 19%

Other 22%

Death 69%

Wrong site surg 29%

OP/post-op 25% Suicide 27% Wrong site surg Suicide OP/post-op Med error

In your groups discuss the challenges inherent in maintaining accurate handover: • People involved in handover
• skill levels, expertise, professional types

• The types of information required by participants? • Where, who synthesizes this information? • Where, what, a potential sources of error? • How would improve these situations?


Content standardisation
Listing of specific information that should always be mentioned in a handover


Topic standardisation
Specification of general topic areas that should be covered in handover


Performance standardisation
The process that work groups develop/deployed for the ongoing evaluation of handover performance

What makes handover effective? • Understanding levels of clinical expertise • Understanding clinical roles • Understanding (intuitively) team dynamics • Skill mix • Organisational dynamics • Service dynamics • Understanding & synthesizing clinical need “We must be alert to all the functions of handoff activity”

•  •  •  •  •  •  • 

Level of care uncertainty (Non) standard time(s) for handover (Variable) location where handover is conducted (Different) participants in the handover (mono- vs multi-disciplinary interaction) (Different) informational needs of participants (Changing) length of time devoted to handover Spatial organisations and arrangements (where is handover conducted?)

In your groups identify: Where handover occurs. What about?
Multidisciplinary communications Patient/ family involvement Educational functions Professional development Supervision Plan how you would improve these handovers.


Content Standardisation

•  Prescriptive Guides •  Role specification during handover •  Ongoing review, mentoring, and supervision (formal/informal) •  Creating space for different modalities of communication •  Environmental arrangements/ location of handover •  Situational Guides (ESBAR, MIST, FASTHUG) •  Supporting multi-disciplinary communication (behavioural change)
Topic Standardisation

•  Participation •  Observation •  Filming •  Reflexive Sessions •  Implementation •  Ongoing self-evaluation

• Lack of clinical ‘ownership’ of patient care (nursing) • Planning of care inadequately implemented due to lack of interdisciplinary communication • Dangers of discontinuity of care • Nurse led (facilitated by senior medical staff) handovers at ward round • Improved continuity of care • Educational opportunities • Clinical team building

• Communication is prone to interruptions • Out-dated information • Time intensive >45mins • Handover at the patients bedside led by the senior registrar • Visual verification of information • Precise • Concise • Professional format • Time reduced <15-30, mins

• Opportunities for dialogic education • Coordination between disciplines • Availability of contemporaneous information • Early insight into emerging, potential, or previously unrecognised problems • Opportunity for the negotiation of supervisory support

“We must be alert to all the functions of handoff activity”

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Bedside patient check Multi-disciplinary handover Cross-hierarchy communication Checklist support Agreed interruption rules Systematized documentation process

Coiera, E., Jayasuriya, R. A., Hardy, J., Bannan, A., & Thorpe, E. C. (2002). Communication loads on clinical staff in the emergency department. Medical Journal of Australia, 176, 415-176.