Clinical Guidelines (Nursing)

Nursing clinical handover

  • Introduction

    Aim

    Definition of Terms

    Management Responsibilities

    Clinical Handover

    Companion Documents

    Links

    Evidence Table

    References 

    Introduction

    This guideline sits under the procedure Clinical Handover. The purpose of this guideline is to provide nurses across the campus with a structured approach for the safe communication of clinical handover.

    Aim

    To provide a framework for nursing clinical handover at the RCH.

    Definition of terms

    • Clinical handover: Transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person / family / legal guardian or professional group on a temporary or permanent basis
    • ISBAR: acronym that stands for Identification – Situation – Background – Assessment – Recommendation/Response
    • Group handover: may be facilitated as a large group with all nurses commencing the shift and/or within smaller groups of nurses working together in a pod
    • Bedside handover: direct patient handover that occurs at the patient’s bedside and includes patients and parents/ carers 
    • EMR Review: process of working through the EMR activities to collect pertinent patient details

    Management Responsibilities 

    The Nurse Unit Manager’s (NUM) has responsibility for compliance with the clinical handover. The operational leadership of handover and allocation of nurses to patients is usually the role of the Associate Unit Manager (AUM). 

    The NUM and/or AUM has the responsibility to ensure that the following principles are applied: 

    • Patient care, as required, continues while handover is occurring
    • The Electronic Medical Record (EMR) is available for nurses
    • The venue, starting times and duration of the handover are set
    • Group handover reflects time available and clinical demands of the shift (e.g. large group with all nurses commencing their shift or in smaller groups of nurses working in a pod)
    • Nurses have a clear understanding of the structure and expectations of handover
    • Disruptions are minimised
    • All relevant nurses attend handover
    • ISBAR is the format used to structure communication 
    • Allocation of patients to suitable competent nurses   
    • Audits of the handover process are completed as required

    Clinical Handover

    Group Handover (inpatient, ward based)

    • Occurs every day at the time of the shift change-over or start of shift
    • Takes place in a designated area 
    • All nurses, including student nurses, commencing a shift attend the group handover 
    • Group handovers are led by the AUM in charge of the shift 
    • ISBAR format applied to structure handover (EMR handover report function may be useful) 
    • Handover is respected with minimal disruptions (no mobile phones or pagers to be answered)
    • At the conclusion of group handover, any important messages pertaining to the ward or hospital are discussed e.g. staffing, potential issues relevant to running of the unit
    • Group handover is completed allowing adequate time for bedside handover before nurses finish the previous shift
    • Handover for nurses working in the community allows adequate time to review all documented handovers

    Bedside Handover (inpatient, ward based)

    • Handover occurs by each patients’ bedside including patients, parents/ carers 
    • Handover occurs between the nurse that holds responsibility for care and the nurse who will be assuming responsibility for the care of the patient
    • Positive Patient identification process occurs during bedside handover confirming full name, date of birth and Medical Record Number (MRN) to the EMR as per the RCH Patient Identification Procedure
    • Clinical alerts are identified (e.g. FYI flags, allergies, infection control precautions) 
    • ISBAR format is applied to structure handover 
    • Patients and parents/ carers are encouraged to participate in bedside handover and be aware of the plan of care for the next shift
    • Patients, parents/ carers and nurses are encouraged to utilise the communication boards in the patient room as a tool for handover between the multidisciplinary team 
    • The handover is documented within EMR  
    • Following handover at the bedside, an EMR review takes place
    • In specified clinical areas (e.g. Wallaby & Pre-op Hold) direct patient care handover may only occur in electronic documentation within the EMR 

    Break Handover (inpatient, ward based)

    • Handover occurs between the nurse that holds responsibility for care and the nurse who will be assuming responsibility for the care of the patient
    • ISBAR format is utilised to structure handover focusing on ISR – identification of the patient, current situation and any risks or recommendations for break interval 
    • The handover is documented in the EMR 

    Transfer of patient within the hospital (for procedure, treatment or to another ward)

    • All patients transferred to from one clinical area to another clinical area require handover to be documented in the EMR. This includes details of the transfer time indicating a transfer of professional responsibility and accountability
    • Positive Patient identification process occurs to confirm full name, date of birth and Medical Record Number (MRN) to the EMR as per the RCH Patient Identification Procedure
    • Clinical alerts are identified (e.g. FYI flags, allergies, infection control precautions, MET modifications) 
    • The handover is documented in the EMR 
    • A patient can be transported by CARPs, parents/ carers if the patient is assessed as:
      • Stable
      • Predictable 
      • Having no fluids or blood product transfusions running
      • Requiring clinical observations <4 hourly
      • Handover can be conducted over the phone to the receiving nurse/ AUM/ appropriate health practitioner who will then assume responsibility and accountability for the patient 
    • A patient must be escorted by the nurse if the patient is assessed as:
      • Unstable
      • Having fluids or blood transfusions running
      • Requiring clinical observations <4 hourly
      • Handover occurs between the nurse that holds responsibility for care and the nurse who will be assuming responsibility for the care of the patient
    • Inpatients to theatre
      • Handover occurs between the nurse that holds responsibility for care and the pre-op hold  nurse who will be assuming responsibility for the care of the patient
    • Rosella and Butterfly patients to theatre
      • For Rosella inpatients being transferred to & from theatre, clinical handover is required from the bedside nurse to the anaesthetist 
    • Ambulatory Care patient to another clinical area
      • The nurse transferring care contacts the relevant AUM of the receiving clinical area to ensure patient is expected and handover is given
      • Relevant local administrator (Desk Staff, Ward Clerk) to be notified of transfer or admission by the AUM

    Non Clinical Activities

    • Parents, carers, teachers, volunteers etc. can escort a patient off the ward if they have been assessed as safe to leave the ward without a nurse as per the Supervision and movement of inpatients across RCH and access to inpatient areas procedure
    • If the patient is deemed safe without a nursing escort document in the EMR

    NB Patients colonised with a multi-resistant organism may only leave ward/room with agreement by treating team or Infection Prevention and Control  

    Patient Discharge

    • On discharge home patients are provided with written discharge advice about the patient’s hospital stay
    • An After Visit Summary (AVS) can be printed for the parents/ carers, along with any attendance certificates, which has a minimum data set including: 
      • name of consultant
      • diagnosis
      • medication plan 
      • follow up information 
      • phone number to contact if more information required 
    • The clinician documents in the EMR that the discharge advice has been given to the parents/ carers and the time of discharge. 

    Companion documents 

    Links

    Evidence table

    Evidence table for Nursing Clinical Handover Nursing Guideline


    Please remember to read the disclaimer


    The development of this nursing guideline was coordinated by Danielle Mee, Nurse Educator, and approved by the Nursing Clinical Effectiveness Committee. Updated August 2019.