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.