March 1, 2013
Volume 77, Number 3
Best Practices for Handover Communication
Nina Singh-Radcliff, M.D. Committee on Communications
In the perioperative setting, patient handover occurs when care is transferred by the anesthesia care team (delivery team) to a receiving team in the recovery room or intensive care unit. A tremendous amount of pertinent information needs to be communicated within a short period of time, including medical history, surgical procedure, intraoperative course and the need for continued care plans.
To complicate matters, the patient is also recovering from acute derangements that result from surgical insult and the effects of anesthetic medication that can often necessitate multi-tasking (e.g., treatment of airway obstruction, pain, delirium, hypotension, etc). Furthermore, the receiving team is often unfamiliar with the patient, has a different skill set and training, is taking care of more than one patient, and is performing patient assessment and carrying out surgical and anesthesia care plans. Both the delivery and the receiving teams face production pressures and often multi-task. Disorganized, incomplete or unnecessary information during the handover report can further exacerbate a situation that already poses a number of barriers to effective communication.
Further research is needed to determine if, and what, practice changes to the handover process can result in improvements in patient safety. At this time, there are several broadly supported themes that may improve this process:
Set aside time for handover communication and avoid distractions or multitasking.
• Prior to emergence or leaving the operative room, complete imminent and necessary tasks (e.g., ordering epidural bags, changing fluid bags, suctioning gastric tube, etc.). The period following emergence is often labor-intensive and requires continued monitoring on the anesthesia provider’s part.
• Prior to the handover, complete urgent-care tasks. In addition to avoiding multitasking, both teams are present to administer, or assist with, care to the patient.
• Limit the handover to patient-specific conversations (or urgent clinical interruptions).
• Limit speaking to one care provider at a time and allow for an opportunity for the receiving team to ask questions and clarify information.
• Utilize checklists to avoid missing information or being disorganized (see Table 1). According to studies, providing a filled out form to the receiving team in addition to a verbal handover may enhance information retention compared to verbal handovers alone.
• Document that a handover, and hence, transfer of care has been performed.
Formal training can assist with identifying barriers and avoiding a “one size fits all” solution to the problems of handover. The anesthesiologist’s handover process is usually learned through observing attendings and peers. They continue to adapt their style based upon their clinical interactions as well as perception of important clinical information and expectations of the receiving team. Several studies suggest that the lack of training and formal systems impede the good practice necessary to maintain high standards of clinical care.
• Define a relevant team structure to your practice and who needs to be present.
• Tailor handover improvements to the specific care setting and handover type (e.g., day surgery MAC cases on ASA Physical Status 1 patient versus pediatric cardiac surgery).
The handover report marks the closure of a phase of care by the delivery team but not the end of overall care. Effective patient handover by the delivery team is important to maintaining patient safety and the same quality of care that was delivered preoperatively and intraoperatively. It is not surprising, as a result, that studies have demonstrated an association between poor-quality handovers and adverse events.
Decreasing barriers and improving the quality of communication during the handover process should be a personal and professional goal. By proactively addressing the matter, it may also decrease the issue of external regulation. In 2006, the Joint Commission established a national patient safety goal that requires all health care providers to “implement a standardized approach to handoff communications including an opportunity to ask and respond to questions.” Although it was not specifically targeting the postoperative handover process, the wording clearly includes it.
Nina Singh-Radcliff, M.D. is
Attending Physician, Department of Anesthesiology and Perioperative
Medicine, Atlanticare Regional
Medical Center, Pomona, New Jersey.