Handovers

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By Dr Suzi Hamilton

Consultant Emergency Physician

“Handover of care is one of the most perilous procedures in medicine, and when carried out improperly can be a major contributory factor to subsequent error and harm to patients.”

So said Sir John Lilleyman, medical director of the NHS Patient Safety Agency, at the beginning of his 36 page report on the value of handovers. What follows here is a far more concise, but equally important post to ensure we all give brief, accurate and relevant handovers in the Emergency Department.

The more critical the patient, the more important a handover is, yet it remains an essential aspect of every patient’s care. Many variations on the theme exist, such as DeMIST, ATMIST, ISBAR, but all are based on the need to concisely and accurately transfer information.

In Christchurch ED we have adopted the DeMIST format of handover, to ensure everyone gives the same information, in the same order, when communicating about a patient.

Details: age, sex of patient.

Mechanism

Injuries

Signs: ABCD, ECG, Glucose

Treatment

In real life it looks something like this:

De:          75yr old male

M:            cyclist hit by car

I:               right chest injuries, ?C-spine injury, right forearm fracture

S:              own airway, RR 35, sats 90% on 15L O2, HR 140, BP 105/70, GCS 15, BSL 6.2

T:              needle decompression right chest, 2 x IVs, 250ml saline, 5mg IV morphine, 5mg  IV ketamine

This instantly paints a picture (major trauma patient), tells us what equipment we need to get ready (chest drain, ultrasound machine, analgesia), which staff we need present (trauma team, radiology), where the patient is likely headed (CT scan, cardiothoracics and ortho care).

You can see from the attached image the DeMIST format includes are the exact same details that we collect when ambulance officers radio through on the R40. Sticking to the same format allows this chart to be easily completed in minimal time, so everybody knows what’s going on. The final line on the chart is for the team leader to decide if we need to activate a trauma call, a stroke call or the cath lab, to expedite patient care. As illustrated above, your information allows us to do this and lets everyone prepare appropriately.

 

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When we give or receive handovers at the bedside, it’s important to acknowledge what different people want to get out of each handover, as this goes a long way to improving our handover performance. For the paramedic who’s just spent hours doing a difficult extraction and managing a challenging patient with severe head injury on warfarin, they may relish this as an opportunity to tell their story, and receive recognition for their efforts. However for the doctor who’s desperate to get the CT scan ordered and get on the phone to neurosurgery as they know the registrar is about to start a case in theatre, they want the handover to be as brief as possible so they can set the wheels in motion. The ideal handover should last less than 45seconds, should be audible to all in the room, and should contain facts, not opinions. In most cases there is ample time for discussion, sharing clinical impressions, and viewing photographs of car crashes or nasty wounds, after the official handover is done. This enables the rest of the team to be getting on with their jobs, which have usually been allocated before the patient arrives in ED.

We encourage the ED doctors to have the whole team still and quiet whilst the bedside handover is being given, so everyone hears the same information and has that shared mental model – an essential component of good teamwork. Unless the patient has an urgent airway, breathing or circulation compromise, there is always time to take 45seconds and listen to a handover, before transferring the patient to the ED bed. Once they’re on the ED bed, it’s impossible for ED staff to keep their hands off them! Hence as the prehospital team bringing the patient in, please state if you need to urgently transfer them across, or would like to give your handover first.

It’s not just status 1s and 2s where handovers are important. For every patient, the change in responsibility warrants a good handover, and in an ideal world a verbal handover would occur between the St John staff and the ED staff taking over every new patient’s care. In many situations for the lower acuity patients this just isn’t possible, but is something we should still be striving to achieve. The written handover is just as important and heavily relied upon when we assess patients. Hopefully the recent observation shifts on the ambulances and in ED has enabled each team to gain perspective of the challenges faced by their colleagues.

Next time you’re involved in a patient handover, listen for the information given, and whether it followed a structure. Was there unnecessary chat in there? Were the essential details given? If you’re giving the handover, take a minute before hand to make sure you know the info. It’s the same for ED staff making a phone referral, or handing over between shifts, and occurs at many more points in the patient journey. As always, it’s about good teamwork and communication.

Please note the St John CPGs which recommend an almost identical format of DeMIST / IMIST. The AMBO part of the handover is great for when you’re in ED giving the bedside handover, however isn’t very relevant for the R40 calls. Make your life easier and save it for the bedside!

 

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