Implementation of a Clinical Handover Diary at a Rehabilitation Hospital
Clinical handover is “the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis”1. Handovers are vital for safe and effective continuance of care. Clinical handover between doctors is a high-risk activity for patient safety due to the potential for communication errors. Effective clinical handovers can reduce these errors2. The National Clinical Handover Guidelines for maternity Hospitals in Ireland (published in Nov, 2014) recommend that clinical handover should be conducted 1. face to face where possible, 2. verbally and 3. be supported with relevant documentation3.
An audit was performed at the National Rehabilitation Hospital (NRH) to investigate and improve the quality of clinical handover within the doctors by introducing a handover diary in addition to the verbal face to face handovers following the on call shift to maintain the continuity of care and to assist doctors in clinical governance. The aim was to trial a structured communication tool promoting standardization of practice and minimizing of variability thus reducing risk for patients. The handover diary was placed in the doctor’s room and all new doctors starting work in the NRH were advised to fill it on a daily basis at the time of induction. It was kept simple by implementing a minimum data set to be filled. There were 6 domains to be documented: Patient’s name/ Date of birth, Location (ward), Clinical details, Actions Taken, Doctors name and Doctors signature.
The handover book was reviewed after 34 days. On n=13 (38.2 percent) days, patients identity was not documented. N=15 days the location of the patient, n= 14 the clinical details and n= 13 the actions taken were not noted also the name and signature of the doctor wasn’t mentioned in 50 and 52.9 % of the cases (n= 17 and 18). The results were circulated amongst the doctors and discussed. Six patients were transferred to SVUH for acute medical conditions in this period, which were documented in the handover. Reasons of unplanned discharge included ischemic chest pain, recurrent aspiration pneumonia, COPD exacerbation, hypercalcemia and need for urgent blood transfusion.
Subsequent re-audit was carried out after a month. Data of another 34 days was collected that showed compliance in documentation of all the above sections. Results showed that patients ID was documented on n=31 (91.1%) days out of 34. Patients location documented n=30 (88.2%) , clinical details n=31 (91.1% ), actions taken n=31 (91.1% ), name of doctor n=25 (73.5 % ) and signature of doctor documented on n=25 (73.5 %) days.
Four patients were transferred to acute care due to bilateral pulmonary emboli, lower respiratory tract infection, urosepsis and to rule out fracture after a fall which were clearly documented in the handover diary.
The handover diary turned out to be a simple yet useful tool, a “ fit for purpose” solution in the overall handover process at the NRH that did not involve unnecessary steps or requirements. It assisted in highlighting the patients who required significant levels of attention or immediate care, who could deteriorate or were deteriorating and ones that had to be transferred for acute medical reasons to SVUH. The diary has now become a permanent feature of the handover.
Dr. Aaisha Khan, Dr. Jacinta McElligott,
National Rehabilitation Hospital Dun Laoghaire, Dublin
Dr. Aaisha Khan, Specialist Registrar in Rehabilitation Medicine, National Rehabilitation Hospital Dunlaoghaire, Dublin
- National Patient Safety Agency. Safe handover: safe patients. Guidance on clinical handover for clinicians and managers.Guidance on clinical handover for clinicians and managers London: British Medical Association/National Patient Safety Agency/NHS Modernisation Agency. 2004. Available from: https://www.bma.org.uk/-/media/files/…/safe%20handover%20safe%20patients.pdf
- Australian Commission on Safety and Quality in Health Care. Sydney: ACSQHC; 2011. Implementation Toolkit for Clinical Handover improvement. Available from: http://www.safetyandquality.gov.au/wp-content/uploads/2012/02/ImplementationToolkitforClinicalHandoverImprovement.pdf
- Communication (Clinical Handover) in Maternity services, National Clinical Guideline No. 5. Available at: http://health.gov.ie/wp-content/uploads/2015/01/National-Clinical-Guideline-No.-5-Clinical-Handover-Nov2014.pdf