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.
To meet National Safety and Quality Health Service (NSQHS) Standard 6: Communicating for Safety
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. See
Clinical Handover for more information.
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:
- Nurses have a clear understanding that 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
As per the RCH Patient Identification (procedure), positive patient identification should occur during at clinical handover or when patient transfer occurs, using three patient identifiers Name, DOB and MNR number.
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
- 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 handover, see below for more information.
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 by confirming full name, date of birth and Medical Record Number (MRN), the patients ID band and 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 completion of handover is documented in 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 see below for more information.
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
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
- ISBAR format is utilised
- Clinical alerts are identified (e.g. FYI flags, allergies, infection control precautions, MET modifications)
- A patient can be transported by CARPs, parents/ carers if the patient is assessed as:
- Stable, observations within normal limits, no altered MET criteria.
- Predictable
- Having no IV 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
- Have IV fluids or blood transfusions running
- Requiring clinical observations
<4 hourly
Bedside handover occurs between the nurse that holds responsibility for care and the nurse who will be assuming responsibility for the care of the patient
Transfer of inpatients to pre-op hold
- 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
- For Rosella/Butterfly inpatients being transferred to & from theatre, clinical handover is required from the bedside nurse to the anesthetist
- For acutely unwell inpatients consider the need for the bedside nurse to handover to the anesthetist.
Transfer of Ambulatory Care patient to another clinical area/inpatients to Ambulatory Care
- The nurse transferring care contacts the relevant nurse in charge 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/CNC
- Patients transferring/discharging to Ambulatory teams require a referral, via EMR, which is submitted during transfer/discharge planning
Electronic Handover (Ambulatory Services Only)
Nurses who work autonomously, providing care in the community do not perform shift to shift handovers. Electronic handovers replace bedside handovers in this instance as follows:
- All nurses working in Ambulatory services, including students, commencing a shift start by reviewing Electronic handovers
- These staff members access each patient’s handover within the patient chart in EMR
- Staff review the handover, orders or plan of care every day at the time of shift commencement
- Review of electronic handovers takes place in a designated area
- ISBAR format is applied to Handover/Plan of Care in EMR for structure/clear communication
- Handover is respected with minimal disruptions
- It is the responsibility of the nurse to clarify any information from the handover with the AUM/CNC on the shift
- It is the responsibility of the nurse to update the handover/Plan of Care for every patient on their shift for the next visit. Any changes to therapy/care enacted in consultation with the MDT must also be verbally handed over to the AUM/CNC and included in patient progress note.
Group Handovers/Communication in Ambulatory Care
- Important messages pertaining to the team/hospital (e.g. staffing, potential issues relevant to running of the unit) are relayed:
- During group handover in the Complex Care Hub
- Individually, to the nurses on shift when onsite and/or via email as needed in the Wallaby Ward
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
- This should be documented 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
Australian Commission on Safety and Quality in Health care; Communicating for Safety Standard.
https://www.safetyandquality.gov.au/standards/nsqhs-standards/communicating-safety-standard (accessed 20/01/2023)
Evidence table
Evidence table for Nursing Clinical Handover Nursing Guideline. -- Coming Soon
Please remember to read the
disclaimer
.
The revision of this nursing guideline was coordinated by Stacey Richards, CNC, Nursing Research, and approved by the Nursing Clinical Effectiveness Committee. Updated February 2023.