The Art of the Handover.

A conversation the other morning on Twitter got me thinking about how we go about handing over patients to medical staff at hospital.  Some were looking for some information on how to hand over and what the hospital staff wanted to know.  This is of course very important. However it is only one side of the picture: what about what paramedics want?

I’m not trying to sound petulant, merely point out that communication is a two way process. First of all I’ll talk about how I do handover.  I don’t think there is a right or wrong way of doing a handover, so long as the pertinent information gets delivered to and understood by the people who need it.  There are mnemonics about like MIST to help people remember what to include in handovers.  I struggle with mnemonics as I can never remember what the letters stand for.  Nevertheless the point is that handover should be done essentially the same every time.

First of all, I park myself near the foot of the bed so I can face the team leader and speak directly to her/him.  I address my handover to the team leader (who is typically a consultant)  because they are the ones ultimately responsible for what happens next, so they are the ones that have to know what has happened.  Usually the other two important people are also standing with or near the team leader at the head of the bed: the anaesthetist and the surgeon.  I then try to modulate my voice so that it is loud and clear and cuts through the hubbub of the trauma bay.  This does not mean shouting!

I take a “top to bottom” approach with my trauma handover, so a typical handover may sound something like this: “This is John Doe, 24 years old, no known history or medications. He was the driver of an older model sedan which has hit a tree at high speed.  Seatbelt appears to have been worn, however he has hit the steering wheel and windscreen, with the steering wheel being bent in half. On my arrival John was unconscious with snoring resps and decorticate posturing and was hypoxic, hypotensive and tachycardic:  SpO2 X, BP Y, Heart Rate Z.”

Now the team will have an idea of mechanism of injury (for what that is worth) and hopefully a reasonably clear idea of how unwell the patient was when I arrived at the scene.

I then move on to what I found on secondary survey, starting at the head and working my way down, then out.  I try to include pertinent negatives.

“There appear to be multiple facial fractures with bilateral peri-orbital bruising and blood from the left ear.  Left pupil is dilated and not responsive.  Neck appears uninjured, no subcut emphysema, no tracheal deviation.  Chest has a flail segment right side with poor air entry and subcut emphysema apparent.  Abdo appears soft, not distended” and so on down the line and including the back.

I could probably leave out the negatives and just give a list of injuries I found.  What I hope is that by giving a detailed account I demonstrate that I have been thorough, and hopefully this will translate into trust from the team that I have done a reasonable job.

I will then tell them what I have done:  “Patient’s chest was decompressed with free air from the cannula and increase in BP/SpO2.  He was then RSI’d with X, Y, Z, a Size eleventy tube placed with a grade one view, good air entry bilaterally, good waveform.  Pancuronium was given at xxxx and a fentanyl/midazolam infusion has been running at X mg/hr.  He has had 54 litres of normal saline (or something)  Last vital signs were HR X, BP X, EtCO2 X, SpO2 X, Temperature X”
I then ask if there are any questions, and usually go over to the scribe nurse to ensure she got all of the details, as I am aware that little of what I have said will sink in.

So what I have tried to do is tell a story of everything that is important from when I arrived, to when I get the patient to hospital.  I probably talk a little more than some, but I try to keep it succinct, and none of this should take more than about a minute to get across.

So that is what I do.  So far I have had no complaints.  Although to be fair, I have had no feedback whatsoever, so perhaps I shouldn’t be so happy with this.  I would, like many, love to know what the Physicians I hand over to would like to hear from me.  What information is important, what is not, how is it best delivered and so on.  So if anyone wants to give any feedback here, I would greatly appreciate it.

With that being said, communication is always a two way street, so it is time to tell you (doctors and nurses) what I want when I give a hand over.  It’s pretty simple really, and I suspect that what I want is the same as what most paramedics want.

I want someone to listen to what I am saying.

Easy!  Ideally a little feedback at some stage would be nice, but I appreciate that there are many things to do and little time, so I don’t expect too much.  What I want is someone to acknowledge that they have received and understood the information; to close the loop of communication.  It is important to ensure that the information has been passed on and received as much information is lost in handover (which is part of why I try to maintain the same approach each time) and this can have a negative impact on the patient.

We have two major trauma centres where I work.  One hospital takes a great interest in information flow and handover and it shows.   When we notify them of a major trauma they have a full team assembled, gowned, gloved and with labels on to let everyone know who is who when we arrive (Team Leader, Surgeon, Airway Nurse, Scribe and so on on big, bright easy to read labels stuck to their gowns) We offload our patient, everyone pauses whilst a handover is given and questions asked, then the patient is assessed in a methodical, thorough fashion.

At the other trauma centre, none of these things happen.  On the rare occasion that there is anyone assembled in the trauma room when we arrive, it is an unmitigated chaotic mess with various people doing what they want, when they want and with no systematic approach at all.  Handover is an exercise in futility with often not so much as the scribe taking down details.

I have no documented evidence that this results in worse patient outcomes between these two specific hospitals, although it would seem self evident.  What it does do though is result in worse relationships between pre-hospital staff and the hospital.  Paramedics hate taking patients to this hospital.  They hate it because they perceive the standard of care to be lower (again, I don’t know if it is, but that is the perception)  They also hate it because it treats the paramedics with contempt.  By ignoring the handover of paramedics, it relegates them to a lesser role, telling them that their contribution to patient care is not important, and by association, that they are not important.  I hope this doesn’t sound petty (it probably does) but it really does seem to be important to have good working relationships between services to ensure the best care is provided to the patient.  At least I think so.

Communication is a vital part of the care of the sick and injured, but sadly it is a part that – at least in my education – is very much overlooked.

So, communicate with me now.  Let me know what you do to handover, let me know what you would like to hear or see in handover, let me know how we can improve our communication between pre-hospital and hospital.

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9 Responses to The Art of the Handover.

  1. Ma'am s says:

    In regards to feedback about hand overs, when I was undergoing my ICP training, my mentor / preceptor would, when appropriate, ask the consultant for a few moments to give some constructive feedback about the handover that I’d given to them. Obviously not able to do so in all cases, but the majority of them the consultant was quite happy to help out when it was explained to him that I was still training.

  2. Adam says:

    Silly iPad. Name above should be Adam

  3. john Wood says:

    Another great post – thanks a lot – agree with all your sentiments and observations!

  4. Tingles says:

    Great discussion about an important topic! Handover should be viewed as a process, not a one way delivery of information. Our process is:
    – identify yourself and patient.
    – state any immediate needs (or not)
    – move patient across to resus bed
    – 30-45 second handover using mnemonic of your choice (we use ISBAR). During this time only active resuscitation activities occur. Everyone else keeps hands off and listens!! Any longer and the resus team gets fidgety
    – ask if there are any questions
    – leave the room and let them do their thing
    – come back after completion of paperwork for questions / clarification. This is often when the finer detail can be discussed, which would complicate the original handover.

    Seems to work for us, but only because we have put in a lot of work to ensure everyone is on the same page.

  5. ki-docs.org says:

    Great post…. Brither, I know where you are coming from…both as the receiving doc in ED taking patients from (mostly volunteer) crews AND as the referrign doc when local retrieval service comes to collect – often good, but probably 1 time in 3 they dont listen to the same ISBAR handover mentioned above.

    We all want to get hands on with the patient – but taking 45 secs to stop and listen wouldnt hurt unless peri-arrest.

    Do we need a resus room safety offic to remind us to hurry up and slow down?

  6. Laurie Smith says:

    Thanks for your excellent thought on this often neglected but crucial part of our patient care. Our local trauma hospital sounds very much like your “other” less organised hospital – but we can never let this get in the way of our attempts to give our best possible handover. If they choose to ignore our handover, the loss is theirs, (and the patient’s), not ours.
    I always like to think of handover as a piece of theatre for the recieving audience – you don’t have them for long, and if you don’t make it interesting, you will lose your audience.

    • Laurie, I think that is an excellent analogy. It is very hard to get an appreciative audience sometimes and at others the performance can leave a little to be desired!

      Tim, the idea of a safety officer is an excellent one. I know it is discussed most often in the setting of RSI or other high risk procedures, but I think an officer with a checklist (or several) would be an exellent addition to ensure that all aspects of care such as handover, initial assessment etc are covered off.
      I believe the Alfred hospital in Melbourne are developing, or have developed, a computerised system that prompts for specific things in specific timeframes. I think the idea was to guide people through trauma retrieval, especially those who don’t do it often. I don’t know much more than that, but I think it is an intriguing idea.

  7. Pingback: PODCAST #22 – Chatting to ‘Angry Ambulance Driver’ Rob Simpson « Rural Doctors Net

  8. KIdocs.org says:

    Just re-read this gem of a post
    Bottomline
    – handover is two-way communication and vital for safety
    – so everyone needs to STFU and LISTEN
    – quiet, calm communication, no shouting, no crosstalk
    – handover before moving patient off trolley to bed (prevents people from busying themselves with cables/monitors etc and ensures they LISTEN)
    – use a structures approach. AT-MIST, ISBAR, whatever is agreed & appropriate for organisation
    – confirm essentials, clarify any Qs
    – pack up and go, but not before recieving team have given FEEDBACK
    I’d prefer this to a handover where
    – handover is not structured
    – members of receiving team busy themselves with BP, IV etc and miss info…then turn around and ask Qs of information already delivered to team leader
    – patient is moved from bed prior to handover (whoops, I meant to tell you about their broken neck of femur, but her screams have probably given the game away now)
    – no feedback
    – shouted instructions and questions, lots of crosstalk
    – did I mention unstructured?
    Professionals vs Amateurs. Make yer choice…
    Maybe needs to be emphasised in training … The mob at ETMcourse go some way towards this and the whole enchilada of resus room management.

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