Departmental Handover

Authors: Charlotte Davies / Editor: Liz Herrieven / Codes: SLO2, SLO8 / Published: 12/03/2024

All morning shifts start with handover, and I think that getting handover right sets the tone for the rest of the day. My priority is to get handover done as quickly and as safely as possible so the night shift can go home, and get some sleep. In an ideal world I expedite this by looking at the screen before handover starts so I’ve already identified the potential pitfalls. Handovers happen throughout the rest of the day, but rarely have the whole team there – but I follow the same approach for them all. 

My structure is:

• Hello, night team, how was the night?
• Any blue lights expected?
• Any problems with or concerns about all of these referred patients?
• Handover of all non referred patients, including those awaiting transport home.
• Resus handover
• Anything else to handover from the night team?
• Thank you night team, please complete your departs and travel home safely.

• Day team – role call
• Allocate team to areas, highlighting registrars
• Theme for the day
• Allocate each doctor their patient

This isn’t a strategy that works for everyone, or indeed everyone in my department, but it works for me. I think my approach would be different if we had an appropriate area for handover – but we don’t. Like many departments, handover is in majors, with constant interruptions from patients (especially those awaiting a mental health bed), relatives and other Emergency Department (ED) staff.

I like to start and end handovers on a positive note and start by not making assumptions that the night was “ok” because there’s only 100 patients in the department. 

I then like to see if any blue lights (ambulance priority patients) are expected so I can allocate the right resource to resus at this point. We don’t have enough doctors to allocate someone to resus to sit and wait for patients – normally not an issue as there’s plenty of resus punters, so I wouldn’t routinely allocate the resus doctor before handover had finished. We have a “pre-alert” option on our computer system, so at this point I put the pre-alert on the screen, so that all the managers and seniors looking at the screen in the bed meeting know that it’s not as good as it looks – resus may look like it has an empty bed, but actually 3 more are expected. 

I then ask briefly if there’s any concerns about referred patients, and check they’ve all been referred to a specialty with admitting rights (for example, not substance misuse, or cardiology). In my department, once the specialty team has seen the patient, they are then responsible for them. Of course we’re not going to ignore emergencies, but I simply don’t have the brain capacity to know about all of them – I’ll read the notes when it happens. I’ve worked in departments where handover is expected to include a summary of all the referred patients – all that happens is the night reg spends the last two hours of their shift preparing for handover. RCEM does have a Position Statement on clinical responsibility for referred patients and this might be different in your area. Hand over of un-referred patients is a given, and we’ll talk about that later.

I then do ask the night team to complete their paperwork, otherwise there’s a lot of admin for the day team to do and it affects patient care. This also is a subtle reminder to the day team that admin is important. I don’t formally check everyone feels safe to go home, but I try to make eye contact with them all before I let them leave. 

I then focus on the day team. I like to tick everyone off the list, and call them by their name- mostly to refresh myself, but also so the rest of the team knows who they are, and can provide collegiate support. I signpost which senior is in which area so that everyone knows who to ask for help when they need it – we have so many locum doctors, I don’t like to assume they know the Consultants and Registrars by name.

I then identify a quick theme of the day – something short like “treatments can be done in parallel – get the fluids in whilst the antibiotics are being drawn up” and dispatch the doctors to their areas. 

The GMC survey likes us to use handover as an educational moment, but I find this very difficult as the night team wants to get home, and we have no suitable area for handover making it hard for everyone to hear and not be distracted with queries coming their way.

I allocate all clinicians to a patient, as I’m impatient, and like to see the queue go down as quickly as possible and otherwise it takes a long time as everyone clicks on the same patient by mistake, and it takes a while to sort it out. By allocating, I can also match the patient to the skillset and learning needs of the Clinician.

As luck would have it, everything I do fits in with one study in the EMJ, subtly acknowledging the importance of handover as a wellbeing tool.

Handover of Patients

I like all patients to be handed over, even those who are getting a treatment then going home, as otherwise I’ve found no-one knows what these patients look like, or when they’ve gone and there’s inevitably problems. If there’s lots of patients waiting transport, I hand them over to one doctor who can do a “transport round” and check they actually leave. As the senior, I like to hear the handovers to check that nothing has been missed.

Handover of patients to start with a succinct summary, be structured and simple and directed to a particular Clinician who can then ensure they’re listening properly. A handover of “Mrs Jones has a significant postural drop leading to a fall, with no resulting injuries, she’s waiting for a fluid challenge to finish, and if her symptoms resolve she can go home” is much more useful to me than “Mrs Jones is a 94year old with hypertension, diabetes, macular degeneration and a knee replacement who came in with a fall. She said she stood up in the middle of the night to go to the toilet, felt dizzy, and fell to the floor. She has no injuries and has mobilised in the department. Her ECG is normal, her bloods are normal. Her lying BP was 120/80 and her standing BP was 90/60 with symptoms, so we’ve given her 1L of IV fluid and she needs a review). Read more about this on St Emlyn’s. I know that all my doctors read the notes of a handed over patient carefully, and that the handover is only a snapshot.

ATMIST and other handover tools are often used pre-hospitally, and, I think, they are less useful once the patient is in hospital (read about them here or here).

Structures for Handover

We used to have an ABCD of handover. I think much of this is less important now we have electronic records meaning we can instantly see if a patient has come back after absconding etc. Sadly, breaches are also so commonplace, I don’t think the doctors count them any more.

Improving but not leading handover

If you’re not leading handover, and it’s going badly, how can you help turn it around? Should you help turn it around? That will depend a lot on your department dynamics and why handover is going badly – here are a few suggestions. 

• Allocate yourself as the distraction diverter. Keep an eye out for those ECGs heading into the handover space and either ask them to come back when handover has finished, or review them yourself, away from the handover space. 
• Work out why all the alarms are bleeping, and turn them off so the noise stops distracting everyone. 
• Ask the patients to turn the volume on their mobiles down. 

• Put yourself forward. If someone is being interrogated about why they didn’t do xyz, offer to accept the handover and go and do xyz or ask xyz. 
• Offer to do a QIP on handover structure. 
• Prepare some handover quick education cards ready to give out.
• Listen well, and pay attention. Don’t engage in conversation with others – set an example. 

This is just one example of departmental handover technique. It’s not perfect, and certainly wouldn’t work for every department. Send us details of your handover tips and tricks, especially those on how to improve handovers from the sidelines!

References

1. Clinical Responsibility for Patients within the Emergency Department. RCEM Position Statement, 2023.
2. Park E, Roy S, Skinner J. 038 Junior doctors’ perceptions and experiences of the emergency department departmental handover: a qualitative study. Emergency Medicine Journal 2019;36:799-801.
3. May N. Miscommunication and Handover in the ED. St Emlyn’s, 2013.
4. Jefferys S, et al. Handover; skills to enhancing the PHEM – EM interface. RCEMLearning, 2021.
5. Duckworth R. Patient Handover. RCEMLearning, 2015.
6. Farhan M, Brown R, Woloshynowych M, et al. The ABC of handover: a qualitative study to develop a new tool for handover in the emergency department. Emergency Medicine Journal 2012;29:941-946.