Effective Communication in Clinical Handover

From Research to Practice

Suzanne Eggins, Diana Slade, Fiona Geddes, Suzanne Eggins, Diana Slade, Fiona Geddes

• Publisher: De Gruyter
• Year: 2016
• Print ISBN: 9783110378863
• eBook ISBN: 9783110387407
• Edition: 1
• Topic: Medicine
• Subtopic: Communication Studies

Based on detailed multi-disciplinary analyses of more than 800 recorded handover interactions, audits of written handover documentation, interviews and survey responses, the contributing authors identify features of effective and ineffective clinical handovers in diverse hospital contexts. The authors then translate their descriptive findings into practical protocols, communication strategies and checklists that clinicians, managers and policy makers can apply to improve the safety and quality of clinical handovers. All the contributors are affiliated with the International Research Centre for Communication in Healthcare (IRCCH), an international multidisciplinary organisation of over 90 healthcare professionals from more than 17 countries committed to improving improving communication in healthcare systems around the world.

'The authors have created a new and tightly woven systems safety net that will, if implemented, significantly reduce the occurrence of errors resulting from cumulative communication failures.' -H. Esterbrook Longmaid III, MD, FACR, President of Medical Staff, Beth Israel Deaconess-Milton Hospital, Milton, MA USA

'Uncommonly valuable for the rigorous, original communication research it reports and for the careful translation of the research findings into practical strategies that actually improve clinical handovers in the real world of practice.' -Professor Suzanne Kurtz, Washington State University

'This clear, plain English book is an outstanding resource for the training of all involved in healthcare.' -Elizabeth Trickett, (Former) Director of Safety and Quality, ACT Health, Australia

Section 1

Background: safety, quality and communication in clinical handover

This book presents the outcomes of the Effective Communication in Clinical Handover (ECCHo) project. As chapter 1 explains, the ECCHo project was a three-year empirical multi-methods translational research project investigating communication in medical, nursing and mental health clinical handovers at four hospital sites across Australia. The ECCHo research was carried out by a multidisciplinary team of linguists, applied linguists, human factors specialists, healthcare practitioners, policy makers and managers, and this book is intended to be accessible and relevant to a similarly diverse readership.

Each chapter of this book presents either findings from the empirical research into different specific handover contexts studied in the national project or a set of resources developed from the preceding research chapter. The two chapters in section 1 provide the background to the ECCHo project (chapter 1) and present clinicians’ perspectives on the issues and challenges of clinical handover (chapter 2).

The remaining chapters are grouped into sections according to the types of handovers the chapters explore. Section 2 reports on communication in clinical handovers when clinicians move during shift changes. Chapters 3, 4 and 5 cover research and applications based on medical handovers in emergency departments. Chapters 6 and 7 report on communication in bedside nursing handovers and communication training to improve bedside handovers.

Section 3 explores communication in clinical handovers when patients move, for example when patients are transferred between wards. Chapter 8 tracks communication across an individual patient’s journey and evaluates the risks and protections in the interactions with and about the patient. Chapter 9 reports on a clinical audit of written documentation during patient transfers from rural to metropolitan hospitals.

Section 4 explores clinical handover communication among interprofessional teams. Chapters 10 and 11 explore and refine the effectiveness of the clinical handover tool iSoBAR in interprofessional student ward handovers, and chapters 12 and 13 investigate communication in mental health handovers.

In section 5, we draw the separate findings and practical applications together in a conceptual model that we call iCARE3. This model emerged as our multidisciplinary team pooled national research findings and issues.

To explain the background of the ECCHo research, we turn now to review the issues and challenges posed by the routine hospital activity of clinical handover and explain the methodology and translational research goals of the ECCHo project.

1Effective communication in clinical handover: challenges and risks

Diana Slade, Suzanne Eggins, Fiona Geddes, Bernadette Watson, Elizabeth Manias, Jacqui Bear and Christy Pirone

1.1Setting the scene

This book on effective communication in clinical handovers was motivated by the urgent need to minimize avoidable patient harm caused by communication failures. It is motivated by real stories of human suffering, such as the one which follows.

A patient we will call Mandy was admitted to her local hospital in Australia to give birth to her second child. Mandy suffered from schizophrenia, but had been coping well in the community with regular use of the antipsychotic medication clozapine. Her psychiatric care was managed well by a community mental health team, and she regularly saw a psychiatrist. When Mandy fell pregnant, her psychiatrist provided verbal and written handovers to her general practitioner. These outlined the potential risks of Mandy’s mental illness to herself and her baby, and the need for special monitoring. Her general practitioner then transferred Mandy’s care to a colleague, who became responsible for coordinating and sharing Mandy’s care with the obstetric ward at the local hospital.

However, the handover that Mandy’s psychiatrist gave her general practitioner was not passed on to the hospital when she was admitted for the birth. This meant that the clinical team dealing with Mandy‘s delivery did not understand the significance of her condition or her medication.

Although Mandy took her medication to hospital, staff did not store the medication or give it to her. This was contrary to hospital policy. Mandy stopped taking the medication, but staff did not realize this. She had a relapse of her mental illness and was transferred to the mental health unit. Once again, in the handover between the obstetric and mental health units, the significance of Mandy’s medication and condition were not handed over.

After the birth of her child, and while still in the mental health unit, Mandy deteriorated further. She became psychotic, ingested a corrosive substance, and was secluded and restrained. Ten days after her admission to the hospital she had a cardiac arrest. Three days later she died in intensive care.

At the coronial enquiry, the consultant psychiatrist providing an expert opinion advised that people with a history of psychotic illness are at a high risk of developing psychotic symptoms during the first six weeks after delivery, particularly from the second to the sixth weeks (NSW Government Attorney General and Justice Department 2011). According to the specialist, postpartum psychosis is a common occurrence for such patients, rather than a rare event.

The coronial inquiry exposed the accumulation of oversights in communication – particularly the repeated failures to hand over accurate, relevant information – that contributed to Mandy’s deterioration and her tragic and preventable death.

The ECCHo research was motivated by our team’s commitment to better understand how we can improve communication in handover and minimize avoidable patient harm caused by communication failures. In this chapter we briefly outline the research our team did to answer this important question through the Effective Communication in Clinical Handover (ECCHo) study.

1.2Communication in clinical handovers

Mandy’s story demonstrates the urgent need to better understand and manage the risks posed by the process of clinical handover. Of the many factors affecting handover safety, published research has increasingly pointed to the quality of communication in clinical handover.

Clinical handovers are, by their nature, inherently communicative events – they can only be achieved through language, by clinicians talking and writing to one another. They are arguably the most frequent and significant communicative process between clinicians in the delivery of patient care.

Communication in handover involves a complex mix of formal and informal communication in both spoken and written modes. Spoken handovers occur through face-to-face interactions, by radio, telephone or by pre-recorded messages. Written handovers occur through fax, email, letters or electronic medical record. Handovers – whether spoken, written or a mixture of these – also typically incorporate visual elements (X-rays, CT scans and graphs) and supporting written documentation, such as patient charts and medical records.

Failures in communication during handover are now recognized internationally as a major cause of critical incidents (Garling 2008; WHO 2008) and are the trigger for a significant proportion of patient complaints (Ye et al. 2007; Chaboyer et al. 2009). Published research has identified a long list of risk factors associated with communication practices. These can be conveniently grouped into two categories: factors arising from the organizational or institutional context of clinical handover, and those associated with the actual handover process itself. We discuss these risk factors in sections 1.4 and 1.5.

1.3Recognizing the role of communication in clinical handover

In Mandy’s story we can see the failures of communication that can occur between clinicians when handing over information and responsibility for a patient. This process, known as clinical handover (the term we use in this book) or clinical handoff (as it is in North America), occurs when clinicians transfer responsibility and accountability for patients and their care to another clinician1 or team (AMA 2006).

Clinical handovers are key events in transitions within teams, between teams, between organizational units, within healthcare organizations and between different healthcare providers. Handovers occur formally and informally in a wide range of institutional settings and physical locations, including beside the patient’s bed, by the whiteboard, in meeting rooms, in ward rounds, at the nursing station and even in corridors.

The past decade has seen a significant increase in research into handover practices (see reviews in Cohen & Hilligoss 2010; Cummings et al. 2010; Bost et al. 2012; Raduma-Tomàs et al. 2011). To a lesser degree, there has also been an increase in the number of interventions proposed to improve handover (see e.g. Robertson 2014 for a review). An ever-accumulating quantity of international evidence confirms that handover is a high-risk moment in the patient’s hospital journey, as Wong et al. (2008: 3) point out:

There are now a large number of studies that have investigated various aspects of clinical handover and improved understanding of its complex and dynamic nature. These studies clearly confirm clinical handover is a high risk scenario for patient safety with dangers of discontinuity of care, adverse events and legal claims of malpractice.

The need to attend to the ‘high risk’ status of clinical handover is becoming ever more pressing as the number of clinical handovers increases with the growth and aging of populations (Sabir et al. 2006). Estimates put the number of handovers each year at over 300 million in the USA (AHA 2014, CDC 2010), more than 40 million in Australia (OECD 2011), over 100 million in England (HSCIC 2013) and about 15 million in Hong Kong (Hong Kong Hospital Authority 2013). At every handover, irrespective of the particular context or who is involved, there is a possibility of miscommunication or gaps or errors in information transferred, and with each of these errors or misunderstandings there are potential risks to patient safety.

Demographic changes are making clinical handovers both more frequent and more complex. Across the world, healthcare systems are under pressure from patients presenting with multiple co-morbidities and chronic conditions. Such patients may re-present frequently to healthcare services and may have many different specialists and treating agencies. The challenge is to ensure coordination of care across these increasingly frequent and complex clinical handovers. These demographic changes are also putting extreme pressure on healthcare funding. Few national budgets are able to keep pace with the rapid growth in healthcare costs. As funding falls but demand increases, the health sector is at risk of being inadequately funded to provide all the staff, facilities and organizational support to ensure safe handover practice (WHO 2014).

1.4Impact of organizational and institutional factors

A number of factors in organizational and institutional c...

Table of contents

• Cover
• Title Page
• Copyright
• Preface
• Acknowledgements
• Contents
• Contributors
• Transcription conventions
• Section 1
• Section 2
• Section 3
• Section 4
• Section 5
• References
• Index
• Footnotes