Clinical Guidelines (Nursing)

Nursing clinical handover

  • Introduction

    This is a local guideline which sits under the overarching procedure titled: Clinical Handover. The purpose of this guideline is to provide nurses across the campus with a consensus based approach to communicating handover requirements of patients in their care

    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. It is an evidence based communication model that assists the speaker by providing a framework to organize and convey information.
    • Nurse: means a registered or enrolled nurse registered by the Nursing and Midwifery Board of Australia and employed by RCH.
    • Short break: any time away from the patient for 10-15 minutes – For example:  transferring of patients from another area, picking up patients from another area, bathroom break.
    • Long break: any time away from the patient that is greater than 15 minutes – For example: meal breaks, multidisciplinary patient meetings, assisting with sedation procedure, education sessions.

    Management 

    Nurse Unit Manager (NUM) and Associate Unit Manager (AUM) /  Liaison Nurse (LN) Responsibilities

    • It is the NUM’s responsibility to ensure compliance with the RCH Clinical Handover guideline. The day – to – day operational leadership of handover may be undertaken by the NUM or delegated to the AUM/ LN.
    • The NUM or AUM/LN has the responsibility to supervise handover, and to ensure the following principles are applied:
      • Patient care( as required) continues while handover is occurring
      • the EMR documentation tool required for the handover is available for staff
      • the venue, starting times and duration of the handover are clear
      • that staff have a good understanding of their role in the handover
      • disruptions are minimised
      • all relevant staff must attend handover
      • ISBAR is adhered to as the communication tool
      • feedback (both positive and negative) is given to staff about their participation in handover by the AUM/Manager in charge
      • audits of the handover process are completed as required
      • Allocation of patients to suitable competent nurses  

    Group handover 

    • In inpatient, ward based areas, handover occurs every day at the time of the shift change-over/start of shift, in a designated area.
    • The group, shift or pod handover must be attended by all nursing staff (including students) who are commencing their shift
    • Shift handovers are chaired by the AUM/LN in charge of the oncoming shift
    • Pod handovers are supervised by the AUM to ensure they are structured in compliance with this procedure
    • All nurses providing handover should do so in the ISBAR format (utilizing the handover report function in EMR)
    • All staff are to respect the chairperson and abide by the Code of Professional Conduct for Nurses with minimal disruptions (no mobile phones or pagers to be answered)
    • Any questions should be asked in relevant context and at the appropriate time by the RN receiving handover
    • At the conclusion of the group handover, any important messages pertaining to the ward/hospital should be discussed e.g. staffing, potential issues relevant to effect the running of the unit
    • The group handover should be completed in time to allow adequate time for bedside handover prior to staff finishing their shift. In context of RNs working in the community, handover should allow for adequate time to review relevant documents to ensure all written handovers has been read
    • Group handover is recorded in the EMR handover report

    Direct patient care handover (in ward based, inpatient areas)

    • Handover should occur by each patients’ bedside. If not appropriate, it should occur outside the patient room.
    • Parents are encouraged to participate in handover and should be aware of the plan for their child for the next shift (unless specific reasons exist to exclude them e.g. child protection)
    • Occurs between the staff member that holds responsibility for care and the staff member who will be assuming responsibility for the care of the patient
    • Handover should be completed in the ISBAR format utlizing the handover function in EMR
    • Patient identification is to be incorporated as per the RCH Patient Identification procedure
    • Clinical alerts need to be included eg allergies, infection control precautions
    • The handover must be documented in the EMR
    • Patient/family communication boards updated
    • In specified clinical areas (eg Wallaby & Preop Hold) this handover may occur only in electronic documentation in EMR

    Short break handover (in ward based, inpatient areas)

    • Occurs between the nurse responsible for the patient and the nurse who is assuming responsibility for the patient
    • Comprises of a short verbal handover focusing on the greatest risk for patient 

    Long break handover or  Patient/Nurse reallocation during shift 

    • Occurs between nurse responsible for patient and the nurse who is assuming responsibility for the patient
    • Comprises of a verbal handover in ISBAR format  (ISR) – identification of patient; current situation and any risks or recommendations for break interval
    • Documentation of handover and transfer of professional care needs to be recorded in the the EMR 

    Transfer of patient to another clinical area (for procedure, treatment or transfer)

    • All patients transferred out of the unit to another clinical area require handover to be documented in the EMR
    • Documentation of transfer time indicating a transfer of professional care needs to be recorded in the patient’s Care Plan
    • For inpatients being transferred to & from theatre, clinical handover is required from the bedside nurse to the receiving nurse in pre-op hold. This handover is to be documented in the EMR
    • For Rosella inpatients being transferred to & from theatre, clinical handover is required from the bedside nurse to the anaesthetist. This handover is to be documented in the EMR
    • Handover should include communication regarding infectious risk and precautions.
    • If the patient is unstable, requires clinical observations of less than 4 hourly, or has fluids or blood product transfusion running, the nurse must escort the patient and handover to a receiving nurse or qualified health professional.
    • If the patient is assessed as stable, predictable and has no fluids or blood product transfusion running, and does not require frequent clinical observations (4 hours or longer) to be performed; the patient may be transported by CARPs, family or carers, and the handover from the bedside nurse may be conducted over the phone to the receiving nurse and documented in the EMR
    • The receiving staff member will then assume responsibility and accountability for the patient.
    • When a non-admitted/Ambulatory Care patient is being transferred to another clinical area, the nurse transferring care should contact the relevant AUM to ensure patient is expected and handover given.    Relevant local administrator (Desk Staff, Ward Clerk) to be notified of transfer or admission.  

    Non clinical activities

    • Parents, carers, teachers, volunteers etc. may escort patients off the ward if they have been assessed as safe to leave the ward without a nurse escort – as per the Supervision and movement of inpatients across RCH and access to inpatient areas procedure. Document the nursing assessment (if the patient is deemed safe without nursing escort) within the EMR.

    NB Patients colonised with a multi-resistant organism may only leave ward/room with agreement by treating team/infection prevention and control 

    Discharge planning

    • On discharge home from the unit, all patients should receive written discharge advice about their child’s hospital stay using the ADT Navigator.  An after visit summary (AVS) can be printed for the family along with any attendance certificates. This includes a minimum data set which incorporates: name of consultant, diagnosis, medication plan, follow up information phone number to contact if more information required. 
    • Clinicians are to document in the progress notes that the discharge advice has been given to the parents and time of discharge.

     Companion documents 

    Links

    Evidence table

    See attachment for evidence table. 


    Please remember to read the disclaimer


    The development of this nursing guideline was coordinated by Melody Truman, Director of Nursing Education, and approved by the Nursing Clinical Effectiveness Committee. Updated December 2015.