Transitions in care

Transitions in care are a high-risk period for patient safety. Properly structured handovers allow for the sharing of sufficient information to enable the transfer of responsibility and accountability for a patient or group of patients between healthcare providers. ¹

Handovers occur frequently

Common examples of handovers involving physicians include:

• to a new resident care team on a teaching unit
• to an oncoming colleague at the end of a shift in an emergency department, intensive care unit (ICU), or ward
• to an on-call physician overnight or on a weekend
• to a covering colleague when going on vacation
• to a new consultant on a consulting service
• to one institution from another
• to one department from another, e.g., from the ICU to the ward
• to a specialist of another service at the same or a different facility

Sometimes, especially if the clinical situation is unclear or evolving, a handover may be an opportunity for those assuming care to provide a fresh perspective on the patient's diagnosis, investigations, or treatment.

What information should be included?

The structure and content of handovers can be tailored to address the situation. Whatever the format, the goal should be to create a shared mental framework between the outgoing and incoming care providers, as it pertains to the management of the patient. To this extent, the information to be discussed may include:

• the patient’s current clinical condition
• the status of investigations and treatments
• the currently anticipated clinical course
• possible problems and consideration of strategies should problems arise
• responsibility for ongoing care

Ideally, the handover process should include opportunities to discuss the meaning of the information, seek clarification, and ask questions.

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The following factors may contribute to problems with handovers:

• lack of a shared mindset about the importance and purpose of handovers
• settings that are not conducive to handovers
• time constraints
• reliance on e-communication alone
• hierarchies in healthcare teams that impede effective communication
• missing information
• lack of training on safe patient handovers

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• making handing over a priority at the institutional, team, and personal level
• performing handovers face-to-face 
• choosing a physical environment where the number of interruptions will be limited
• arranging a designated time for handovers
• prioritizing discussions on the sickest patients
• using a structured communication tool to increase efficiency
  • EMRs may allow for the creation of templates pre-populated with important patient data, to shorten face-to-face time ²
• using clear and unambiguous language
• encouraging speaking up and questioning

Standardized communication

Standardizing the way teams communicate can help address many of the barriers to handovers and make information sharing more reliable and efficient. Standardized communication could include the following components:

A brief retrospective view:

• background information, history of present illness

A prospective view:

• the current provider's assessment of the current clinical state
• what the patient and family have been told
• a differential diagnosis, if the diagnosis is not yet confirmed

A recommended plan of action:

• a pending task list
• contingency plans if a particular scenario occurs

Keep in mind that sharing suggestions and contingency planning does not obligate the new most responsible physician (MRP) to follow that plan. Nevertheless, the sharing of such information helps build situational awareness.

As issues arise, the information handed over may help physicians better assess the situation and make decisions that are as well informed as possible.

Standardized communication is improved by allowing for interactive questioning. This allows team members to:

• verify their understanding of the situation
• assess the reasonableness of the recommendations being proposed
• read back critical information

During handovers, it is important to beware of labelling patients. Comments made during handovers may inadvertently contribute to misdiagnosis or inappropriate treatment because of the influence of cognitive biases and stereotyping. For example, labelling patients as "frequent flyers," "drug seeking," “demanding,” or “histrionic” may, in some cases, contribute to an underestimation of the clinical condition.

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A number of structured communication tools exist. These tools allow for the presentation of all relevant information in an organized and logical fashion. They can play an important role in bridging gaps in communication styles, aligning mindsets, and flattening hierarchies.

The actual tool used to structure handovers is less important than the process of handing over information in a structured way. Appropriate discussion about the meaning of the information and opportunities to seek clarification and ask questions are important. Some tools may be better suited to certain clinical situations than others, and your healthcare organization may prescribe the use of a particular approach or tool. Here are two examples amongst many to be considered:

SBAR

Situation

• problem, patient's symptoms
• patient stability or level of concern

Background

• history of presentation
• background information

Assessment

• impression and differential diagnosis
• where you think things are headed

Recommendation and Repeat back

• recommendations and action plan
• what you have done
• what you would like the other person to do

I-PASS ³

Illness severity

• stable, "watcher," unstable

Patient summary

• events leading to admission
• hospital course
• current condition
• treatment plan

Action list

• to-do list
• timeline and who is responsible for follow up

Situation awareness and contingency planning

• what's going on?
• plan for what might happen

Synthesis by receiver

• closing the loop—read back
• further questions

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During illness, the patient and family can play a helpful role in ensuring continuity of care. The increasingly recognized value of patients and their family members as active members of the healthcare team creates an opportunity to involve the patient (and, with the patient's permission, the family) directly in the handover or rounding process (“patient-centred rounds”). By holding daily rounds and handovers at the bedside, teams can better:

• inform the patient when there is a change to the team or most responsible physician
• allow for clarification of the history and correction of any misinformation
• provide an opportunity to address any questions and concerns

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Important information can be lost when multiple handovers occur

Clearly documenting handovers in the patient’s chart, contributes to the establishment and maintenance of team situational awareness and is invaluable in enhancing the safety of care.

If you are assuming care of a patient, it may be prudent to reconfirm the clinical history directly with the patient, and to document key elements of handover information as required to inform the specific situation.  Documentation at shift change within the same call group on a hospital ward will be different than that expected in a clinic environment or in the case of transfer to another specialty or unit.

One study has shown that the use of an electronic SBAR template resulted in more complete documentation and increased the frequency of documentation of communication between physicians and nurses. ^{4, 5}

To help save preparation time, certain EMRs can automatically populate customized handover tools with key patient information. In addition, such an approach may serve to streamline documentation of handovers and make important information easily available to anyone accessing the record. Templates should not however, replace a structured and interactive handover process.

In addition to serving as a way to review key information on a patient, the documentation of handovers helps clearly establish which healthcare provider is the most responsible physician (MRP) at any given time.

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