Handing Over Patients

Introduction

This article will focus on handing over patients, including what clinical handover is and how you handover.

What is handover?

Handover is the system by which responsibility for both immediate and ongoing care is transferred between healthcare professionals.¹

Effective handover is required to maintain patient safety and ensure that the team looking after them is aware of the anticipated goals of their care and problems that may occur.

Handover can take a variety of formats depending on the environment (i.e. emergency department handover may look different to a handover on a medical ward) but generally will involve members of a team who have had responsibility for the patient to this point transferring information about their patient to the team who will have ongoing responsibility for the patient’s care.

There are several handovers a day due to changing responsibilities for patients, and information must be handed over accurately so that safe patient care is provided.

Handovers can be verbal or via electronic systems (such as Nervecentre), where a summary of the patient’s condition and problems up until that point are displayed.

How does handover work?

As there are several circumstances in which the handover of care can take place, the format of clinical handover may change.

For example, there may be more ‘formal’ handovers at the beginning/end of shifts which involve multiple healthcare professionals, which will look very different to how you might hand over if you are asking a colleague to take responsibility for looking after your patients whilst you are at teaching/having a break!

The Royal College of Physicians recommends that clinical handover should be structured using a standardised proforma, and ideally with information written down to improve the retention of vital details.¹

Different types of handover

Board round

Board round is a multidisciplinary handover where, typically, all patients in one ward are discussed.

This could be a morning board round involving medical, nursing and allied healthcare professionals. Typically, this type of handover will be led by the consultant/registrar or nurse in charge.

Out of hours/hospital at night

The outgoing on-call team hands over any patients that the incoming on-call team need to be aware of during their shift out of hours – this may be in case they deteriorate or specific jobs may need doing. These handovers usually happen twice a day: for the night team handing over to the day team, and vice versa.

This handover is generally led by the most senior doctor on site (typically the medical registrar) with support from the Hospital at Night Team. Not all patients in the hospital will be discussed (as it would take far too long!). Typically, only those patients anticipated to require input from the hospital out-of-hours team over the shift are discussed.

Abbreviated handovers

Abbreviated handovers may occur when one healthcare professional needs to hand over responsibility of care to another healthcare professional for a short period: in the case of a foundation level doctor this may be because they need to go to teaching, or take a break.

This will often occur in an enclosed confidential space (such as the doctor’s office) and include any anticipated issues or tasks that may need doing.

Structure of handover

Some key components of the handover will remain the same despite different environments and teams, but there will be variances in the handover structure.  

Two of the most common ‘formal’ handovers are board round and out-of-hours handovers, outlined in further detail below.

Board round

When: typically takes place in the morning on most wards.

Who: this is a multidisciplinary handover, generally involving medical, nursing and allied healthcare professionals (such as physiotherapists, occupational therapists and discharge coordinators)

What order: generally, patients are discussed in the order of bed spaces on the ward i.e. Mr Bloggs in Bay 1 Bed 1, then Mr Smith in Bay 1 Bed 2

What is discussed: typical issues discussed include whether the patient is due to be discharged that day, or if not, what are they waiting for if they are medically optimised; any outstanding investigations for patients; any outstanding specialty reviews

Sick patients need to be highlighted, but they will generally be discussed in bed order. These patients have become more unwell and are likely to have required input from the Out of Hours team.

Out of hours/hospital at night

When: between out-of-hours shifts, typically twice a day (early morning, then evening)

Who: all members of the outgoing on-call team and all members of the incoming on-call team. This could include various grades of doctor, advanced nurse practitioners and sometimes a medical student or two!

What order: as this handover covers all the patients in the hospital, not all patients will be discussed. Generally, the most sick patients are discussed first (particularly if they require an escalation of care), including any interventions so far.

What is discussed: multiple areas are discussed, including introductions for the team (as they may not have worked together before); allocation of resuscitation roles (i.e. compressions/airway management/gaining IV access/scribe); hospital bed state (primarily to aid the team leader with patient flow out of hours. Additionally, planned reviews or jobs will be handed over by the outgoing team, which could include chasing urgent scans and reviewing patients who have been unwell on the previous shift.

Sick patients: the outgoing team will highlight and discuss any patients that have either been handed over to them at the beginning of their shift, or they have seen during their shift, that the incoming team need to be aware of or see during the ongoing shift

Handovers in acute areas (e.g. admissions areas/emergency department/intensive care unit)

When: typically, at least in the morning and evening, but some departments may have an afternoon handover too.

Who: all members of the outgoing team to all incoming team members. Generally, this will include consultants, registrars, junior doctors, and any advanced care practitioners working in that area. The nurse in charge will often be in attendance, too.

What order: generally, the sickest patients are discussed first, although in smaller areas (such as ICU), patients may be discussed in bed order

What is discussed: any jobs required for patients by the incoming team, and any outstanding tasks (such as awaiting a specialty review of a patient). Escalation plans for patients may also be discussed, particularly with deteriorating patients.

Sick patients: any patients who have been more unwell or are expected to deteriorate will be highlighted, including their current escalation plan.

How do you hand over a patient?

Although the structure of the handover may vary in terms of how ‘formal’ it is, there are still key bits of information that are needed for every patient that is handed over.

Information required to hand over a patient:

• Patient demographics: include their name, date of birth and hospital number as a minimum, so they can be accurately identified. You can do this more quickly by taking a patient sticker to the handover.
• Where is the patient? If you are handing over a patient during an out-of-hours handover, the team will be covering multiple wards, so need to know which one (and ideally which bedspace) your patient is
• What has happened that means you are handing this patient over? The context is important in ensuring the incoming team can best look after the patient. Have you needed to review them due to a high EWS score, or have you been asked to chase an imaging report demonstrating a finding that needs further action?
• What have you already done? For example, you may have taken blood tests that will need chasing, requested imaging that will need reviewing, or been referred to another specialty or a senior and are awaiting a review of your patient.
• What are you expecting the incoming team to do? Make sure the person you are handing over to knows what you expect them to do. For example, are you asking them to review blood test results or chase the report of a CT scan?
• Escalation status: if you have had to review a sick patient, then make sure you know what their ceiling of care is. Do they need to be moved to a high-dependency unit or intensive care? If they were to have a cardiac arrest, do they have a DNACPR?

Who do you hand over to?

If your patient is sick and you think they need to be seen by a senior clinician (if they haven’t already), or they may need an escalation in their care, then the senior responsible for that patient needs to know!

For all medical patients overnight, the main port of call will be the medical registrar, or the medical registrar may be involved if a non-medical patient has acute medical issues (such as a suspected myocardial infarction or pulmonary embolus).

If the job does not require a senior review (such as chasing a set of bloods taken for an episode of chest pain), then hand this over to a junior member of the incoming team (such as another junior doctor or ACP).

Most importantly, do not leave your shift before handover – generally, rotas are designed with built-in time for handover at the beginning and end of the shift!

What can you hand over?

What you can hand over and how appropriate it is will vary depending on the timing of the handover and what shift it refers to!

Handing over routine blood results to review on a morning board round would be appropriate but would be inappropriate for an out-of-hours shift.

Remember that handover is there for a reason – sometimes, despite our best intentions, we can’t complete our list of jobs. From this perspective, make sure you are kind to colleagues when giving and taking handover: don’t hand over jobs that you’ve intentionally left because you don’t want to do them, and don’t be harsh to colleagues who are handing over jobs.

Out of hours handovers

This part of the article will focus on the appropriateness of jobs when handing over in an out-of-hours context.

Types of jobs that can be handed over appropriately

Patient review: you might need the incoming team to re-review a patient you have seen on your shift, for example, to check whether any interventions you have done have worked.

Chasing results of investigations: this is typically for investigations that have been performed, but the results are not back before the outgoing team’s shift ends. This could be bloods taken for a sick patient, or imaging (such as X-ray or CT scan).

Types of jobs that should not generally be handed over 

Difficult conversations: if a conversation has been anticipated to occur and should have happened during daylight hours, it is inappropriate to hand it over. Examples include anticipated ReSPECT or escalation discussions that the team who were looking after the patient during the day could have had.

Examinations: generally you are expected to do your own examinations of patients. This means you shouldn’t hand over a digital rectal examination for the patient with a suspected UGIB, as that forms part of your review!

Discharge letters: discharge letters should not be left for the on-call team to do, especially overnight! Discharge letters should be done by the team who has overall responsibility for the patient’s care. There may be circumstances where you need to complete a discharge letter during daylight hours at the weekend, but these should generally have already been started or be very short (because they are being discharged from an acute admissions area).

Chasing routine blood tests: if the blood tests are being done for routine reasons, they shouldn’t fall to the out-of-hours team to review – there isn’t the capacity to review all the blood tests for multiple wards!

Prescriptions: if a patient needs an urgent prescription, you must do that yourself to avoid delay.

Referrals: if you review a patient and decide that a referral is needed, you would be expected to make that referral yourself rather than ask a colleague to review it from scratch. Circumstances where a referral may be handed over is if the referral is to be made following an investigation that isn’t back yet i.e. waiting for a CT head scan before referring to neurosurgery.

SBAR

If you are handing over a patient, you may wish to use the SBAR handover to structure your handover.

Situation: includes the patient details, a brief reason for why you are handing over the patient, and making sure that you are handing over to the right person, and that they know who you are

Background: any information about the patient’s admission and past medical history to this point that is relevant

Assessment: what have you found on assessment? What interventions have you done so far? What do you think is going on with the patient?

Recommendation: what do you need your colleague to do for the patient on their shift

Conclusion

Handover is an integral part of patient care, especially within the hospital setting, and must be done well to keep patients safe. It can take a variety of formats, but generally is between an outgoing and incoming team on a shift change.

References

1. Royal College of Physicians. Acute care toolkit 1: Handover. 2015. Available from: Acute care toolkit 1: Handover | RCP London