Communication at clinical handover

Structured clinical handover has been shown to reduce communication errors within and between health service organisations, and to improve patient safety and care, because critical information is more likely to be accurately transferred and acted on.^{1, 2} This is especially important at transitions of care, when communication errors are more likely and there is an increased risk of information being miscommunicated or lost. Ineffective communication at clinical handover is also associated with clinicians spending extensive time attempting to retrieve relevant and correct information.³ This can result in inappropriate care, and the possibility of misuse or poor use of resources.^{4, 5}

Structured clinical handover at transitions of care

Implement and support the use of structured clinical handover processes in the organisation’s service context. This criterion is linked to Action 6.4b, which requires organisations to have clinical communication processes at transitions of care, across all levels of the organisation. Transitions of care occur when all or part of a patient’s care is transferred between healthcare locations, clinicians, or different levels of care within the same location. This includes when:

• There is a change in clinician (for example, shift change)
• A patient is transferred to another health service organisation (for example, from hospital to an aged care home, another hospital, community nursing or a palliative care service)
• A patient is moved within an organisation (for example, to the general ward after surgery)
• A patient’s care is discussed during multidisciplinary team rounds
• A patient is transferred for a test or appointment
• A patient is discharged.

Transitions of care are not limited to these times, but consider these situations as a minimum requirement for clinical handover policy and processes, if they occur in the organisation.

Under an effective standardised and structured clinical handover process, all relevant participants know the minimum information that needs to be communicated when handovers take place, the purpose of the handover, the structured format to aid communication, and how responsibility and accountability are transferred.¹

Communication can be a highly variable process, which poses a high risk for patient safety. Variability can result from:

• The situation, such as during
  • shift changes
  • patient transfer within or between a hospital, unit or service
  • patient admission, referral or discharge
• The method, such as
  • face to face
  • by telephone
  • using written orders
  • aided by electronic handover tools or systems
• The place in which clinical handover takes place, such as
  • at the patient’s bedside
  • in a common staff area
  • at a hospital or clinic reception
• Who is involved in the clinical handover process, such as
  • individual clinicians within the same organisation (for example, junior doctors, nurses and consultants)
  • a treating clinician and a patient with their family or carer
  • multidisciplinary teams
  • clinicians across organisations or services (for example, ambulance officers and emergency workforce).

Therefore, although standardisation improves the efficiency and effectiveness of clinical handover, there needs to be some flexibility. Processes should not minimise communication or set guidelines that interfere with what the workforce deems to be the most critical information. A flexible, standardised approach will provide the structure for handover and allow for flexibility to fit the service context and work practices.

Some States have developed a clinical handover solutions matrix, which considers the format clinical handover might occur in and recommendations for how clinical handover should be delivered. Examples of these matrices are available at:

• NSW: Implementation toolkit: Standard key principles for clinical handover
• WA (updated Oct 2018): Clinical handover

In considering how clinical handover is delivered in your service, it will be important for you to check your State or Territory policy on clinical handover, and consider any risks associated with your local context.

Defining the minimum information content

The minimum information content for a particular handover will depend on the context and reason for handover. Be guided by best practice, and determine the minimum information content in consultation and collaboration with the patients, carers and clinicians who are active participants in the clinical handover process.

When defining the minimum information content, consider actions across the NSQHS Standards that require and support communication of relevant information at transitions of care (Table 2).

Table 2: Actions in the NSQHS Standards that support communication of relevant information at transitions of care

Key principles of clinical handover

The purpose of clinical handover is to ensure that relevant, accurate and current information about a patient’s care is transferred to the right person or people, action is taken (when necessary) and continuity of patient care is maintained. To ensure that these events occur, all clinical handover policies and processes need to reflect the key principles of clinical handover. This is required under Action 6.8 and includes:

a. Preparing and scheduling clinical handover

b. Having the relevant information at clinical handover

c. Organising relevant clinicians and others to participate

d. Being aware of the patient’s goals and preferences

e. Supporting patients, carers and families to be involved in clinical handover, in accordance with the wishes of the patient

f. Ensuring that clinical handover results in the transfer of responsibility and accountability for care.

Clinical handover is more than the transfer of information, which is ‘irrelevant unless it results in action that is appropriate to the patients’ needs’⁶ – it is about maintaining continuity of care.

Effective communication and teamwork between all the people involved in providing patient care, including the patient and their carer, are vital to ensuring effective clinical handover.⁷ Actions under this criterion are closely linked to Actions 5.5 and 5.6 in the Comprehensive Care Standard, which require systems to be in place to support collaboration, teamwork and comprehensive care planning.

Engaging patients and carers in clinical handover processes

Patients, carers and family members are key participants in transition communication processes, and the patient’s preferences and choices should be known and respected. Patients can have important insights into their conditions, and the circumstances that may affect their ongoing care and needs. Patient engagement and communication at transitions of care improve patient care outcomes, prevent adverse events during care and reduce readmissions to hospital after discharge.^{2, 8, 9}

If practicable, implement systems to engage patients early, and support patients, carers and families to participate in clinical handover and transition of care processes. Consider the organisation’s processes, including when handover is occurring, and identify opportunities to engage with patients, carers and families. Ensure that participation is in accordance with the patient’s wishes, and include careful consideration of the patient’s level of health literacy, language barriers and culture.² Consider how actions link to requirements in the Partnering with Consumers Standard.

Resources to support patient–clinician communication at transitions of care are available on the Commission’s website.

Communication at transitions for patients with cognitive impairment

The importance of communication at transitions is highlighted for people with cognitive impairment, particularly if they are unable to communicate required information. Information from a person’s general practitioner, family, carer or substitute decision-maker, and healthcare record about the patient’s medical history, medicines list, recent cognitive changes, advance care plans and goals of care is crucial for accurate diagnosis, medication reconciliation and appropriate treatment decisions (see Actions 5.29 and 5.30). During a hospital stay, family members may be the first to notice changes in cognition and behaviour that should prompt assessment for delirium (see Actions 8.5 and 8.7).

Any diagnosis of delirium or concern about ongoing cognitive impairment needs to be communicated so that arrangements can be put in place for post-discharge assessment, management and support.

A Better Way to Care sets out suggested strategies for health service organisations in early recognition, prevention, treatment and management of cognitive impairment.

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