This document is a summarised version of OP-GC1-Clinical Handover, OP-CC5-Hospital Patient Transfers and OP-GC1-Patient Identification. 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 the relevant PPG’s if they require further information
This QRG provides staff an overview of the process of clinical handover during the transfer of a patient within the hospital. Clinical handover should take place with every transfer of a patient from one clinical area to the next. This requires documentation within the clinical notes & the structured approach of ISBAR (Identify Situation Background Assessment Request).
This is applicable to all staff who work within Western Health & includes any staff member who has direct contact with a patient. It is the responsibility of all Western Health managers to ensuring compliance & implementation of the clinical handover process.
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.
What this looks like in practice
- Handover has been provided over the phone to the receiving nurse who will assume the responsibility & accountability. Ensuring to use ISBAR.
- Identify any clinical alerts including food & drug allergies, infection control precautions & modify MET call & code blue criteria.
- Documented handover within the clinical notes. Detailing of the transfer time, area & person taking responsibility & accountability (Figure 1).
- Complete ward transfer paper work. Documenting the time of discharge on the back of the nursing chart.
- Undertake a set of vital signs 15 minutes before departure.
- Undertake the three-step patient identification process including confirming patient name, date of birth & identification number with accepting staff member.
- If the patient is to be transported by a hospital orderly, the nurse needs to assess if the patient is stable & predictable. There needs to be NO current blood products or intravenous drugs running.
- Ensure the patient requires four hourly observations unless being transferred to a high dependency unit, theatre or ICU.
Figure 1: How to document handover in the clinical notes:
The acronym created to help standardise clinical handover. Aiming to reduce failures in communication amongst health care workers. ISBAR has been seen to improve the quality & safety of patient information from staff member to staff member. Improving patient outcomes. All patients need to be informed of bedside handover & its purpose.
The patient should be escorted by the nurse when:
- Receiving Blood products or intravenous drugs.
- Require frequent observations or are in a spinal collar.
- Confused or combative.
- Under the mental health act or duty of care.
Low risk patients
Can be transferred by an orderly without a nurse. Either by trolley or wheelchair.
Prior to transferring the patient
Record a current set of vital signs & complete handover over the phone using ISBAR within 15 minutes of transfer. All paperwork needs to accompany the patient for the transfer.
Complete the pre-Ward COVID screen in the EMR
High RISK patients are classified as
- ICU HDU or CCU admissions requiring cardiac monitoring.
- GCS less than 14, confused or agitated.
- Unstable vital signs requiring a MET call or Code Blue.
- Intravenous fluids other than Normal saline or Hartmans running.
- Intravenous medications.
- Intercostal catheters.
- Receiving an epidural infusion, PCA or syringe driver.
- Direct transfer to theatre.
- Requiring cardiac monitoring.
- Invasive or non-invasion ventilation.
- High flow oxygen.
- Intravenous sedation within the last hour.
- Any patient who you have a concern about.
||Transfer of Patient within the Hospital
|Date of scheduled review:
|ED Leadership Team
||ED Leadership Team