Clinical handover is much more than the doctor and nurse interaction at the beginning and end of a scheduled time. It is the conversation that ensures information is passed on to the appropriate person on a timely manner and is carried out appropriately. The effect of poor clinical handover is an ineffective system at best and patient death at worst. The concern of enhancing clinical handover is gaining escalating attention as inpatient stay as well as medical working hours is reduced, whereas at the same time patient acuity augments. Poor clinical handover is connected with discontinuity of patient care and medical errors
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Clinical handover is important to ensure continuity of patient care and patient safety. It serves many functions and there are many factors that affect clinical handover. Poor clinical handover is associated with discontinuity of patient care and medical errors.
CH has been identified as a high priority in patient safety. In the US, interest in improving handover has increased with The Joint Commission issuing a requirement that hospitals implement a standardised approach to handover communications, including an opportunity to ask and respond to questions (Joint Commission, 2006).
Although CH has been researched for at least four decades, a comprehensive definition of CH has not been proposed or universally recognised (Wong et al, 2008). This has significant implications for establishing a common understanding of CH and determining how implementation of best practice in CH may be achieved. Additionally, CH has been studied and researched in particular clinical settings and so much of the evidence is context-specific (Cohen & Hilligoss, 2009). The term CH has typically been used to describe the process of ‘handing over’ patient care from one caregiver to another between shifts or on transfer of the patient from one health care setting to another. It involves the communication of patient care-related information and transfer, sharing and acceptance of responsibility and accountability for patient care among and between individuals and teams of health care providers across the health care continuum and between transitions of care (ACSQHC, 2008; Safety & Quality Council, 2005).
Understanding the nature of CH is central to understanding its associated problems. It is also the necessary starting point to proposing any comprehensive solutions or strategies for improvement. The two main elements of CH comprise communication of information and ‘handing over’ of responsibility and accountability in addition to other covert and ritual functions. CH is complex, dynamic, multifaceted and difficult to define (CRE-PS, 2007; Turner et al, 2006).
The consequences and effects of ineffective CH are numerous and far reaching. These impact on all levels of the health system, including the organisation, teams, individuals and patients and their families. A former Australian Safety & Quality Council (2005) literature review summarised the consequences of ineffective handover as follows:
Patient complaints (Bark et al, 1994)
Increased hospital length of stay (Zwarenstein & Bryant, 2002)
Increased health care expenditure (Zwarenstein & Bryant, 2002)
Delays in medical diagnosis (Pronovost et al, 2002)
Wrong treatment (Priest & Holmberg, 2000)
Life threatening adverse events (Bulau, 1992)
A range of other potentially preventable adverse events (In the Petersen et al (1994) study these were due to gaps in communication and patient care between cross-covering medical teams).
CH is paradoxical. It represents both a high-risk period for patient safety during the process of ‘handing over’ patient care information, responsibility and accountability, and an opportunity to catch errors through ‘fresh eyes’ (Clancy, 2006).
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During CH, changes in shifts, patient transfers and transitions in patient care, ‘gaps’ in continuity of care, communication and responsibility may arise, creating potential for error and resultant patient harm. Characterising gaps in continuity of care, understanding how they develop, how they manifest themselves in the work world in particular contexts, and how they impact patient care and safety is essential to designing effective means for creating continuity of care (Patterson et al in Bognor, in press) and preventing error and patient harm.
Modern day health care is performed by teams of health care professionals working in a “complex sociotechnical system” (Braithwaite et al, 2009). Due to its complexity, the healthcare system has to some degree lacked the structure, systems and processes to support effective transfer of information (Plsek & Greenhalgh, 2001). Information asymmetry aggravates or worsens patient care coordination resulting in fragmentation of care and discontinuity of care that can compromise patient safety (Arora et al, 2008). Communication needs are therefore increased in the context of increasing specialisation of health care. One of the goals of communication is to coordinate the actions of individuals through mutual understanding and obligation (Weigand et al, 2003).
Adding to the problem of information asymmetry, organisational complexity involves both horizontal differentiation of labour as well as vertical divisions of hierarchy and power. Significantly, relationships among and between team members are shaped and determined by these divisions. These structures and differences in status have a powerful influence on not only how health care teams relate to one another but can also determine whether and how vital information is effectively communicated (Sutcliffe et al, 2004). Seniority, experience and expertise of in-coming staff, as well as changes in the surrounding conditions, such as transition from day to night hospital coverage, can also contribute to adverse patient outcomes, even if all the required information is perfectly communicated (Petersen et al, 1994; Cohen & Hilligoss, 2009).
Two contemporary trends that characterise today’s complex health care organisations are increasing specialisation and increasing rates of personnel change (Cohen & Hilligoss, 2009). Increasing patient encounters across specialties, rapid turnover of staff and patients, increasing acuity of care, technological complexity and increasing casualisation of the workforce, are all factors that impact on the safety and quality of health care (UTS, 2008). Health care necessarily involves multiple occasions where vital information must be effectively communicated and responsibility and accountability for patient care is transferred between or shared among caregivers. Health care providers are also faced with the inherent limitations of human performance from increased pressures due to time constraints, fatigue, multitasking and interruptions to their daily routines (Denham, 2008; Leonard et al, 2004).
Discontinuity of health care personnel and tasks during shift-to-shift handovers and fragmentation of care due to transitions in patient care across settings can lead to the risk of non-transmission or miscommunication of critical information (Lardner, 1999; Schultz et al, 2007). Variability in structure, type, extent and order of information exchanged between providers is thought to augment the probable for omissions of information and miscommunication as well as making it complicated to foresee what information will be received in handover, directing to wasted effort in looking for this elsewhere. It also makes it less efficient because the rules for handover need to be negotiated each time anew (Borowitz et al, 2008). The movement of patients across the health care continuum and between phases of care must be accompanied by mechanisms to support the transfer of high quality information and be supported by clear lines of responsibility and accountability for patient care between members of the health care team (AMA, 2006; Sutcliffe et al, 2004).
To date, in Australia, formal and comprehensive national and statewide healthcare policy guidance outlining information requirements, communication processes, and roles and responsibilities in CH, has been lacking (Quin et al, 2009).
Coupled with this, few health care education and training programs formally teach health care providers how to perform effective CH (Horwitz et al, 2006), leading to poor quality CH among trainees and associated adverse events, mistakes and near misses (Jagsi et al, 2005). This has largely been learned informally, on-the-job and by observing senior colleagues giving CH (Sharit et al, 2005). Furthermore, health care providers receive little or no training in non-technical skills such as teamwork and communication within interdisciplinary teams, yet they are expected to work effectively in interdisciplinary teams in the healthcare setting (Singh et al, 2007).
Education and training of health care providers such as doctors, nurses and allied health professionals has in the past typically focussed on communication with patients and individual technical skills for proficiency of specific tasks (Nestel & Kidd, 2006).
Health care providers are also educated and trained within their respective professions. Effective communication and teamwork between disciplines have been assumed and formal training and assessment in these areas has been largely absent (Leonard et al, 2004; Healey et al, 2008). Failures of communication are not merely the outcome of faulty transmission and exchange of information among health care providers, but also arise from lack of role clarity, role conflict and ambiguity, and struggles with professional status and interpersonal power differentials between individuals and within disciplines (Sutcliffe et al, 2004). Teamwork is an important pre-determinant of successful CH and is influenced by many complex, system-based factors (CRE-PS & ACSQHC, 2007).
Yet CH is highly variable within and across teams, disciplines and health care organisations and is often poorly performed (Arora et al, 2008). Strategies aimed at improving communication and CH between members of health care teams must therefore clarify roles and responsibilities of team members and bridge these differences in status and power (Weller et al, 2008).
In summary, there is no one size fits all strategy for CH across all QH clinical settings (Cohen & Hilligoss, 2009). The coordination of multiple approaches is more effective than reliance on an elusive “silver bullet” (Patterson et al, in Bognor, in press) and this requires extensive stakeholder consultation and flexible standardisation (Lillrank & Liukko, 2004; ACSQHC, 2009). The best identified strategies to provide a comprehensive improvement framework for CH combine both top-down (policy and implementation standard with roles, responsibilities and accountability in CH) with bottom-up approaches (interdisciplinary team based training in CH, communication and teamwork) to build capacity and resilience among interdisciplinary teams.
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