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It’s 07:20 AM and you’re about to finish your 12-hour shift in the Emergency Department (ED).  It was a shift that had you running from call bell to call bell.  It had you treating the extremely pleasant gentleman in bed 6 for his MI, hanging blood on another patient for her GI bleed and helping Mrs. Smith back into her bed for the umpteenth time.  You greeted numerous EMS colleagues, participated in multiple discussions with the RCMP and conversed regularly with patients and their loved ones.  It was a shift that resulted in nearly 17,000 steps on your Fitbit.  And now, the only thing standing between you and your warm bed is the arrival of your colleague to fulfill the necessary procedure of patient handover.  In a “get ‘er done” kind of fashion, the task is complete and soon you are curled up in bed ready for a much-deserved rest.

Does this sound familiar to you?  It certainly does to me.  And I’ve been thinking about it more and more after an article I recently presented at our first ever Collaborative Journal Club session this past week¹.  It has me realizing that the ‘how’ is as important as the ‘what’ during our handover process.

Patient handover is “a real-time process of passing patient specific information from one caregiver to another or from one team of caregivers to another for the purpose of ensuring the continuity and safety of the patient’s care”².  It is a high-risk endeavour that plays a critical role in the care and safety of our patients ³.  We complete this task day in and day out, often overlooking the complexity and importance of patient handover⁴.  Moreover, failure to complete an ideal handover can result in potential medical error as well as unnecessary stress and frustration with our colleagues.

As mentioned above, I was recently approached to present on patient handover in the ED at our first ever Collaborative Journal Club.  Needless to say, I really had no idea what to expect.  As an RN, we do not organize nor do we have these exercises provided for us.  I have to say, what a fantastic experience it was to discuss relevant issues and articles (pertaining to emergency medicine) in collaboration with other RNs, physicians, paramedics and medical learners!  Oh yeah, the beer didn’t suck either!  Below is my article review along with some topics we addressed around the table.  So, let’s get on with it.

What was it?

This study by de Lange, Eden and Heyns was published in International Emergency Nursing 2018¹ and was conducted in a 19-bed ED in South Africa.  Although our ED is larger than this, it would most certainly be comparable to our 19-bed Acute Care area – an area that one could argue has the most potential for error during the handover process.  In this qualitative study, the authors attempted to “explore…existing patient handover practices… in the ED.” They observed the handover process between emergency care practitioners (EMS/Emergency Personnel transporting patients to the ED) and healthcare professionals (nurses/physicians).

How was it conducted?

All participants in the study were invited to attend information sessions, given opportunities to ask questions and gave informed consent prior to study commencement. The researchers used an observational tool to conduct 20 observed handover sessions between participants in the ED. The timing of these sessions varied between weekdays and weekends, as well as between both day and night shifts. Each session lasted approximately 15 to 20 minutes. Observation sessions did not interfere with the patient handover practices.  Patient’s triaged as CTAS 1’s were excluded from the study as these patients were deemed as extremely ill and often involve a different type of handover process.

All participants were then invited to collaboratively analyze the data. This resulted in eight participants that were divided into two groups that consisted of one emergency care practitioner and three nurses. Data were analyzed individually, together with a co-participant and finally by both groups. All participants and groups were asked to develop dominant themes seen within the data. This then resulted in an overarching central theme entitled disrespectful behaviour – a behaviour that could negatively influence patient handover and therefore ultimately patient outcomes.

What did they find?

The authors found that disrespectful behaviour stems from two categories: 1) task-oriented behaviour and 2) indigenous language.

The subcategories witnessed under task-oriented behaviour were as follows:

1. Over-looking the importance of a greeting

I make attempts to greet colleagues and coworkers throughout my shift in the ED; however, I am not perfect and therefore miss greeting my EMS, RN and physician colleagues from time to time. The authors concluded that lack of a greeting was perceived as disrespectful behaviour and resulted in lack of awareness of new patients presenting to the ED.  This subsequently led to delayed patient care.  We are all capable of a simple “hello” or “hi” prior to handover.  In fact, make it a point to try and address colleagues by name, even if you have to cheat with a name badge.  These authors suggest that a simple greeting may make us all feel more valued, respected and enhance teamwork thus improving patient outcomes.  I would tend to agree.

2. Inattentive listening

This involved nurses “start(ing) management” on patients prior to obtaining handover from the emergency care providers.  In addition, nurses were found to be talking to the patient or to one another instead of actively listening to handover.  This led to repetition of questions that were already answered during handover, driving frustration within prehospital care providers and sometimes patients.  I know I am guilty of this.  Whether its transferring patients to stretchers prematurely or placing cardiac leads on patients, I personally feel I need to improve on this type of behaviour.  Despite any of our abilities, in my opinion, no one has the ability to 100% listen to and fully comprehend handover while beginning to initiate management on any of our patients.

3. Exclusion of emergency care practitioners

This involved nursing staff closing curtains around patients, in order to obtain ECGs, thereby creating a physical barrier between themselves and prehospital providers.  This, as you can most likely guess, led to perceived disrespectful behaviour as prehospital providers ceased the handover process at that time.  I am guilty as charged on this one!  Much like inattentive listening and beginning active management on a patient, this carries it one step further by actually placing a physical barrier between health care providers.  Think about how rude this must look to our paramedics!  Incomplete handover due to behaviour like this could lead to inappropriate patient care.  Moving forward, let’s all make an effort not to “wall-out” our colleagues.

4. Non-involvement of patients and their significant other

Despite all patients being awake, alert and orientated the authors found some patients, as well as their significant others/loved ones, were completely excluded from the handover process. This would even occur when patients and their family members were observed to be both “willing and sometimes desperate” to be part of handover. Now I know we’ve all been witness to this. We may view this as interruptive when we are trying to initiate management and gather information from prehospital providers, hospital records, special care homes and pharmacies. But shouldn’t the patient and/or family member be part of this process? Don’t you think they should take an active role in their own care? Patients and family members that are left to feel voiceless can potentially lead to complaints against healthcare providers, reduce patient satisfaction with the health care system and more importantly negatively impact patient care.

On top of task-oriented behavior, the occasional use of indigenous language was viewed by some as disrespectful behaviour. This I found to be extremely relevant to our department as we work in a bilingual province. I believe that all of our patients have the right to be treated in the language of their choosing; however, the use of two languages amongst a team of healthcare providers when said providers may not understand both languages can be frustrating, drive negative emotions and potentially negatively impact patient care. The authors of this paper concluded that the inability to understand handover was not only unacceptable practice, but also considered disrespectful.

Discussion

As stated above, I found this article to be both interesting and relevant to my practice. In fact, it’s relevant to all healthcare providers in both the prehospital and hospital setting.

There were some limitations to the study however. Firstly, this is a single centre study and as such may not represent patient handover practices in other EDs.  Secondly, there is potential for both observer bias and altered subject behaviour within this study.  Observers attempted to reduce the potential of the Hawthorne effect (having participants alter their behaviour during the study due to their awareness of being observed) by wearing their uniforms in attempt to blend in to the workplace environment. Lastly, despite invitation, physicians did not participate in either the observation sessions or data analysis. Furthermore, patients and their significant others we’re also not involved in data collection or analysis. It would’ve been useful to have input from these two sources.

This article drove a much larger and longer discussion than I anticipated. It was absolutely fantastic to hear everyone’s thoughts and reactions around the room after presenting this paper. We had nursing colleagues discussing handover practices they’ve witnessed at other areas of work, which included a 45 second to one-minute window allocated for prehospital providers to provide handover to the accepting healthcare team. One physician talked about the need to have a “hands off, eyes on, mouth shut”⁵ moment for all patients presenting from the prehospital setting not requiring ongoing CPR and/or an immediate life-saving procedure.

Further discussion centered around the number of times handover occurs within our department (see figure below), how it is analogous to the game of telephone and the importance of getting it right every time.

This promoted even further discussion on ways to ensure a proper handover is completed. This included conversation around a more structured approach such as the SBAR or ATMIST tools to guide handover (see figure below).

Others at the table stated the need for handover to be treated much like a “sterile cockpit” moment⁶ (a term used in aviation when a plane falls to below 10,000 feet).  All non-necessary information and tasks are ceased at that moment. The use of visual aids or bright colors to inform healthcare workers that handover is occurring is likely of benefit. Only an urgent life-saving request would be an acceptable interruption of patient handover.

Lastly, we talked about the importance of team handover (involving all members rather than simply having physician-to-physician, nurse-to-nurse or paramedic-to-nurse handover), the ability to “bottom-line” the information being transferred (give what is only necessary) and the necessity to close the loop (repeating back important information to acknowledge you have heard it).

Conclusion

I believe both myself and the entire group present at Journal Club gained a valuable learning experience from this article.  We should all try to greet our colleagues, pause to be active listeners and include all team members and potentially patients and their loved ones during the handover process.

Remember to provide the language of choice to the patient but be mindful to ensure all team members are on the same page with respect to information and treatment plans.  Have some sort of structured approach to giving accurate handovers to your colleagues and remember that workplace culture, or “the way things are done around here” should always be challenged and re-looked at in order to provide our patients with the absolute safest and best care.

Let’s keep working better, together!

Guest post by Christopher Johnson (RN)

References

1. de Lange S, van Eden I, Heyns T. Patient handover in the emergency department: ‘how’ is as important as ‘what’.  International Emergency Nursing 36 (2018) 46-50.
2. Joint Commission Centre for Transforming Healthcare ,2014, p 2.
3. Jorm CM, White S, Kaneen T. Clinical handover: critical communications.  The Medical Journal of Australia 190 (2009) 108-109.
4. Davies S, Priestley MJ. A reflective evaluation of patient handover practices.  Nursing Standard 20 (2006) 49-52.
5. St. Emlyn’s. Handover. Process, practice and controversy.  December 11^th, 2018.  Simon Carley.  www.stemlynsblog.org/handover-process-practice-and-controversy-icssoa2018-st-emlyns/
6. Kapur N, Parand A, Soukup T, Reader T, & Sevdalis N. Aviation and healthcare: a comparative review with implications for patient safety. Journal of the Royal Society of Medicine (2015) open, 7(1), 2054270415616548. doi:10.1177/2054270415616548

Make sure to check out our post on the Zero Point Survey as another means of incorporating patient handover.