Dr Peter Mallett | Dr Shilpa Shah
A (very) brief history of time…
Medical handover (or ‘handoff’ in the US) in one form or another has been around since the early days of hospital medicine. Naturally, when staff finished their shift, they would pass on key information about their patients to their colleagues. The on-call was over, the bleep (or pager) was passed on, and the vital information on the more unwell patients had been relayed to the next on-call clinician or team – on an informal, verbal basis.
As time passed, along with the evolution of healthcare provision and systems, including many factors such as team-based approaches, shift-patterns and working time directives, handover has evolved into a more formal process often carried out at several set times of the day in most units.
Changing the perception of handover
You may think that handover is just another routine part of the day, but in reality it is a potentially very dangerous place. Dangerous – really!?
True, it doesn’t seem as potentially dangerous as the resus room or the operating theatre, and it certainly doesn’t look as dangerous as this Cobra, but the reality is there are latent and blatant safety hazards all around the handover process.
In fact, the BMA & National Patient Safety Agency (NPSA) have gone so far as to say that handover is ‘one of the most hazardous procedures in medicine’
Organisations including the GMC, WHO, NICE and others have provided guidelines on what makes an effective handover. These include:
- Senior presence
- Adequate environment (e.g. dedicated room away from clinical area)
- Use of IT aides
- Structured handover tool (e.g. SBAR / I-Pass) to aide communication
- Multi-disciplinary involvement
- Dedicated time and appropriate length ( several points per day)
These bodies of work have been frequently added to with newer publications and frameworks to guide practice.
There are many possible barriers to effective handover. However – for me, the biggest challenge is non-urgent interruptions to the handover process. I want to highlight to you a concept (and I’ll admit it’s not rocket-science):
Effective communication is at the core of any handover process. It figures, right! Any interruption to this will impact on the quality of the handover – and more importantly, potentially have a negative influence on patient safety.
What does the College say?
Following on from the above guidelines, particularly the BMA & NPSA’s 2004 document ‘Safe handover: safe patient ‘the Royal College of Paediatrics & Child Health published its recommendations in ‘Good practice in Handover’ in 2005 with the pretty unequivocal stance:
“Handover should be designated bleep-free except for immediately life threatening emergencies”
In 2018, dare I ask, how do you think we are doing?!
There are countless examples of units and organisations all over the world that have a great handover setup. I have worked in units which have tried interventions like ensuring consultant presence, using a handover aide, empowering nurses to be involved in the handover process etc, to create a safer handover culture. In several of these units though, despite all the financial and personnel investment, a key ingredient was missed… yup you guessed it – no protected handover period. In many units (both within Paediatrics and beyond) there is an acceptance of the setup that facilitates persistent non-urgent interruptions (either physical interruptions or bleeps) to continually disrupt the medical handover process.
A quick glance at our colleagues in nursing, midwifery, and hospital coordinator roles, will show you that they have identified the need for a designated protected time from interruption for their handovers. Many have well established ‘bleep-free’ periods. It’s about time medics caught up!
What do the pilots do?
I promise I’m not going to bombard you with comparisons to the airline industry. Many of us have been to the human factors talks and have seen the videos. (For those who haven’t, for a brief insight into the world of human factors and errors in medicine check out this video)
Although there are significant differences between the aeronautical and healthcare industries, there are also many similarities.
Both industries are high-risk, safety-conscious areas, and are…. of course guided by humans with innate fallibility! What the airline industry has excelled at is relentlessly prioritising safety by designing safety-first systems. They integrate with their safety-conscious employees and helped developed a safety-must culture. That’s what we in healthcare are trying to do, and need to strive for better.
The Sterile Cockpit
This is a well known rule in the aviation industry. It essentially requires pilots and staff to refrain from non-essential activities during critical phases of flight, following a series of high-profile incidents. This revolutionised practice and was another step in their drive towards a true safety-first culture.
‘Critical phases’… ’that only happen several time per shift’… sounds familiar doesn’t it?! Translating that into a healthcare setting, then of course this should be applied to the handover room.
The ‘ Sterile’ Handover Room ?
Think back to your last few handovers in hospital.
Remember that phone-call through to the room with the non-urgent referral during handover, the staff member who walked in (with the non-urgent request) asking for someone to help with clinic tomorrow, or the non-urgent bleep received. Recall the times you then needed clarification on a job, or clinical information had to be repeated following these interruptions.
Were you truly focused receiving those messages with all the background noise? Did you lose your situational awareness? Is this a real-life example of ‘cognitive overload’? Can we all do better? I think so…
In a busy handover room, it is easy to lose situational awareness and become task-focused on a non-urgent interruption. We can demonstrate selective attention bias and miss other vital events that are occurring. Situational awareness can so easily be lost –
Spot the difference
Here is our brief simulated handover video, which we hope highlights the variance in efficiency and effectiveness of the handover process before and after implementation of a protected handover process.
In the second setup, spot how the messages don’t need repeating, the risk of mis-communication is less and the handover process is much clearer and safer.
Okay, so why is it better to practice like this?
A structured, organised and protected handover is:
- Better for patients- as protected handover reduces the risk of mistake or miscommunication of information. This decreases the risk of patient harm.
- Educationally of better value to the doctors, has been shown to reduce stress levels (promoting psychological safety), aids professional protection and improves job satisfaction.
- Better for the team- it helps improve efficiency and effectiveness of handovers. You’re less likely to finish late, which will have a good impact on staff morale.
Within any healthcare system, an inclusive approach to changing practice – involving all members of the multidisciplinary team – is the best way to deliver true patient-centered care. Changing your handover process requires team-work, diligence, patience, honesty and (like most things) a structured, collaborative approach.
An example of this initiative would be ‘ring-fence’ 3 x 30 minute protected, uninterrupted periods in the working day to facilitate teams to safely handover patient care between treating teams.
90 minutes in a 24 hour period is 6 percent of the total working day! Again, it’s not a lot to ask (as represented by this tiny slice of delicious cake) to help promote a safer handover process and environment.
Better handovers lead to stronger team dynamics, better communication and more efficient delivery of care. Clinical staff can be more readily available outside of these 3 handover times (rather than being tied up in unnecessarily prolonged handovers due to interruptions) to see patients, perform clinical tasks and expedite patient flow. This can lead to an improved patient journey and safer patient care.
I’m converted… But I need more help !
If you’re interested in this concept and keen to try introduce change to your area of work by introducing a similar protected handover process, stay tuned to Archives of Disease in Childhood. Our local pilot project and subsequent regional paediatric protected handover quality improvement initiative (with lots of references to things like PDSA cycles and run charts) and a link to our practical ‘how-to’ guide will be published in the not too distant future.
In the meantime, start a conversation with your patients, friends and colleagues about the handover process where you work. We can all help improve patient safety, starting with the basics.
Protected Handover periods:
Prioritise safer handover
Improve handover effectiveness
Promote safer patient care
Dr Peter Mallett, Paediatric Registrar, Education & Simulation Fellow (@SimEdRBHSC) Royal Belfast Hospital for Sick Children; Dr Shilpa Shah, Consultant Paediatrician, Craigavon Hospital, N. Ireland