This document is a summarised version of OP-GC1-Clinical Handover. The summary has been created to combine best practice information into one document specific to the Emergency Department, and has been endorsed by the ED Leadership Team. Staff should review OP-GC1-Clinical Handover if they require further information.
This QRG aims to provide ED staff with a structured approach for a safe clinical handover.
Clinical handover is the transfer of professional responsibility and accountability of patient care from the clinician who currently holds responsibility to the one assuming responsibility.
This QRG applies to all presentations to the Emergency Department.
It is the responsibility of the Nurse Unit Managers and Directors of the Emergency Departments of each site to ensure the relevant staff are familiar with this QRG, that it is implemented according to the guidelines as outlined within, and that there is compliance by all staff members.
Principles of Clinical Handover
- Staff are required to prepare themselves prior to the handover process, having access to all patient documents including observation charts and pathology results
- Inclusion of patients and their carer, as well as other clinicians, helping to gain information that may not have been available previously
- Keep patient/carer informed and involved with care plan, progress and treatment options
ISBAR is the acronym created to help standardise clinical handover. Aiming to reduce failures in communication, while improving the quality and safety of patient information transfer. This process should be followed for all handovers at Western Health.
Identify: Introduce self and role and undertake three step identification process
Situation: What is the current plan and reason for the presentation?
Background: Past medical history and relevant information
Assessment: Relevant assessment of the patient. It should be concise, clear, and factual
Request: Plan of care, goals to be achieved, actions, or pending results to follow up
It is to be reminded that patients who are at the highest clinical risk should receive handover first.
What does this look like in practice?
- All handovers should include the patient and, if available, family members and designated carers, allowing them to have an understanding of their treatment and care
- Both clinicians will undertake a three-point patient identification process at the bedside confirming full name, date of birth and patient identification number
- The identification and communication of all clinical alerts such as drug and food allergies, infection control precautions and modified MET Call and Code Blue criteria
- A review of the EMR to ensure medication administration and clinical orders have been completed.
- Handover should then be documented in the patient’s clinical notes using the handover sticker (Figure 1) and each nurse signs the bottom of the sticker
Figure 1: Emergency Department Handover sticker
A site-specific handover sticker is used in the following situations:
- Nursing handover shift to shift
- Nursing handover POD to POD
- Nursing handover to medical imaging
- Nursing handover shift to shift
- Nursing handover cubicle to cubicle
- NB: Medical imaging handover uses WHAD215.1e form (Appendix 2)
Nursing Group Handover
Includes a brief handover from the Nurse in Charge of the previous shift to the oncoming shift. This briefing will provide staff allocation, a high level overview of the status in the department, and will outline any current/potential risks. Handover is a protected time, interruptions should be minimised.
During group handover the following should also be made known:
- Any patients who will require more immediate attention or monitoring
- Those who are classed as high acuity or at risk of deterioration
- Those that require extra safety measures or infection preventative precaution
- Those who are awaiting a transfer or discharge
- Any update on current staffing and allocation
After the group handover, all nursing staff will complete patient bedside ISBAR handover. When a patient changes location within the ED, a bedside nursing handover should occur if a nursing escort is required. If no escort is required, the handover will occur via phone.
A patient transferring from ED to the ward will have an ED to ward checklist, EMR documentation and the ED nurse will handover via the phone prior to transferring the patient. The nurse will escort the patient to the ward if they meet nursing escort criteria. Patients that are transferred from ED to Theatre or ICU always require a nurse escort and face to face bedside handover upon arrival. Paediatric patients being admitted to the Children’s ward will be collected by a Children’s ward nurse and face to face bedside ISBAR handover will take place in ED prior to transfer.
Nursing Handover to Medical Imaging
||Within business hours
||Out of hours
||Handover sticker tool is completed and placed in clinical notes. If escort required, nursing staff will accompany patient and either handover to Medical Imaging nursing staff OR remain with the patient.
|The handover sticker is completed and placed in clinical notes. All patients, except general X-Ray patients NOT meeting escort criteria, will have a nurse escort with them while in medical imaging.
||The WHAD215.1e form (Appendix 2) is used for all transfers to Medical Imaging where a nurse escort is not required to remain.
|All patients are escorted by ED nursing staff and formal handover is not required.
The ED medical handover is conducted in a group on a shift to shift basis, where transfer of care is conducted. The ED medical team will liaise and hand patients over to treating specialty teams across Western Health. This handover is conducted over the phone or in person.
External – The ED medical team will liaise and hand patients over to treating speciality teams across Western Health. This handover is conducted over the phone or in person.
Internal – The ED medical handover is conducted in a group on a shift to shift basis, where transfer of care is conducted.
Pediatric Medical Team Handover – SHED
Medical Handover is at 0800, 1530 and 2300 each day. At approximately 0815 each day a virtual handover/huddle takes place with the inpatient unit handover to facilitate care and situational awareness across the campus.