Patient handovers are a complex activity performed in veterinary and human healthcare which are a vital component of a patient’s journey through the hospital. CanMEDS 2015 Framework defines patient handovers as a “temporary or permanent transfer of responsibility and accountability for some or all aspects of care for a patient or group of patients...using both verbal and written communication.” In 2006, The Joint Commission (TJC) reported that 65% of adverse patient events were caused by communication errors, and at least half of those errors occurred during patient handovers. This miscommunication can lead to a wide range of complications which can increase the risk of morbidity, mortality, hospital stay and cost of treatment. In 2010, TJC established a standard: The organisation’s process for hand-off communication provides for the opportunity for discussion between the giver and receiver of patient information. This topic is of increasing interest, with an explosion of research being undertaken into effective handovers and the addition of effective communications skills into junior doctor training programmes. Whilst there is currently no consensus or guidelines for veterinary handovers, this creates the opportunity to draw on similarities and best practice highlighted within the human literature.

When reviewing patient handover practices, consideration should be given to who should be involved (outgoing and incoming nurse team), when the handover should take place (at shift changeover), where it should take place (cage side), how it should happen (face to face) and what information needs to be handed over (standardised format). Whist shift changeover handovers are the most commonly used in the veterinary clinic, there are numerous situations when patient care and accountability needs to be transferred such as perioperative/intraoperative handovers, handovers during shifts, handovers to other teams/departments and handover to other clinics (first opinion to OOH to referral). In addition to the differences in specialties and subspecialities, the principles of achieving a successful handover can be applied across the board.

Many barriers and challenges have been identified that contribute to an ineffective handover such as interruptions and distractions, multitasking, hierarchical differences, fatigue, ambiguous team membership or roles, passive listening, time pressures, language and training. Some of these issues are easily resolved (for example, setting out ground rules during patient handovers, having clear structure, building a process that aligns with the clinic/team/situation and team training). It should also be acknowledged that many veterinary nurses are not formally taught how to deliver an effective patient handover during their training, despite handovers playing an integral role in ensuring communication across the team is clear and accurate.

There are a number of structures that are used in the human medical healthcare field with ISBAR (identification, situation, background, assessment, recommendation) receiving endorsement from the World Health Organisation. There is a consensus that the following information should be included in the patient handover:

• Signalment/demographic information
• Illness severity
• Admission diagnosis
• Relevant medical history, including code status
• Active issues
• A specific to-do list with timeline and ownership (including follow-up of any pending investigations)
• Anticipated issues and contingency plans
• Readback of key information

In addition to the format of the handover, there are other behaviours that can impact the success of information transfer between teams. A study in 2017 carried out a survey to describe the key communication behaviours identified by nurses that contributed to a competent patient handover at shift change. Streeter and Harrington (2017) published the following suggestions for best practice:

• Outgoing nurses should present pertinent, accurate patient information in an organised format, making use of a local checklist or structure. The outgoing nurse should also encourage clarification from the incoming nurse.
• Incoming nurses should ensure to listen and pay attention to the handover. They should ask questions and consider making notes during the handover. They should foster a respectful and supportive environment.
• Additional considerations: Features reported of the ‘best’ handovers were that they were in a bedside location and quiet environment with minimal distractions/interruptions. It was the responsibility of the team to work on building trust and a good rapport by greeting each other, speaking clearly and slowly, thanking each other for their work, and withholding criticism. Irrespective of the structure there should be clear recommendations or outstanding tasks highlighted, with the opportunity for a readback, questions or clarifications.

Whilst we do not know the full impact of handovers and their relation to adverse events in the veterinary field, there is likely room for improvement in how we transfer information about patients. When looking to implement a change to the current handover process, there should be a meeting to engage the team to discuss the positives that could be achieved by implementing a different method. This engagement allows team champions who are passionate about the idea to be identified. There should be a review of what resources are available and what the actual and perceived barriers might be so that the new process can be robust. After an agreed trial period of using the new handover format, an audit can be carried out to assess the strengths/positives and weaknesses/negatives. This allows for further team input and engagement and a continual cycle of adapting the process to suit the requirements of the clinic.

References

1.  Bismilla Z, Wong B. A resource to help teach, assess, and implement a handover improvement program. Royal College of Physicians and Surgeons of Canada. 2018. www.royalcollege.ca/rcsite/canmeds/framework/canmeds-handover-e.

2.  Streeter AR, Harrinton NG. Nurse handoff communication. Semin Oncol Nurs. 2017;33(5):536–543. https://doi.org/10.1016/j.soncn.2017.10.002.

3.  The Joint Commission. Inadequate hand-off communication. Sentinel Event Alert. 2017;58:1–6. www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea_58_hand_off_comms_9_6_17_final_(1).pdf.

4.  World Health Organisation. Communication during patient handovers. Patient safety solutions. 2007;1(3). https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/psf/patient-safety-solutions/ps-solution3-communication-during-patient-handovers.pdf.