Handovers in medicine
I am going to start off with a case which we all seen on a regular basis and explain how we should handover in different situations:
CASE 1
A 80 year old gentleman has been admitted to ED with shortness of breath, cough productive of yellow sputum. He has low oxygen saturations, ABG shows Type 2 respiratory failure with normal pH and lactate.His WCC, CRP are raised and his chest x ray is hyper-inflated.
Background: COPD ( known type 2 respiratory failure) , osteoarthritis ( mainly affecting his knees), Type 2 diabetes, ischemic heart disease.
Social : Lives with wife, struggling with activities of daily living.
On examination: Bilateral wheeze , heart sounds normal, abdomen soft non tender, legs and calves: soft, non tender, no clinical evidence of DVT, no oedema. Neurology: Grossly normal, AMTS: 8/10
ECG: normal
Management in ED:
Salbutamol nebs
Ipratropium nebs
Prednisolone
Doxycycline
EWS in ED: 0
BP: 120/10
SO2: 90% on A - target saturation: 88 to 92%
HR: 84/min
Temperature: Apyrexial
RR: 16/min
ED HANDOVER FROM SHO/ FY1 TO ED REGISTRAR/CONSULTANT:
I am going to start with a handover from an ED SHO to the ED registrar/consultant:
This 80 year old has been admitted with bilateral wheeze. BG of COPD, lives with wife and is struggling with ADLs, high WCC, CRP . I have given him nebs, steroids and antibiotics. His ABG shows chronic type 2 resp failure with normal pH. His EWS is 0 and I think he is safe to transfer to a medical ward where he can be clerked.
Tips:
The reg/consultant in ED is interested in these things:
1. Whether this patient can be transferred to a medical ward to be clerked ( and thus empty a bed where a patient waiting in the corridor/back of an ambulance/waiting room can come and be assessed) or does this patient need to be seen by the medical registrar/ITU team ( if warranted).
- The ABG, EWS and a brief handover clarifies that he is safe for transfer.
2. Whether the management in ED has been given ( nebs, streoids, antibiotics for infective exacerbation of COPD)
3. Whether the investigations have been done ( ie ABG, CXR, bloods)
What the reg/consultant in ED is NOT interested in:
1. Background of osteoarthritis - is this an acute issue? No! Hence please do not mention such conditions.
2. The whole description of his FBC, U and E's, LFTs - keep it simple and to the point. Mention the relevant positive investigations.
3. His medication list - The ED senior has agreed with you that this patient needs admission. Do not waste your time going through the 20 medications the patient is on.
This is what the ED registrar/ consultant needs to decide:
1. Whether this patient can go home?
2. Whether this patient needs to be assessed by the relevant specialty urgently?
3. Whether this patient is safe for transfer to the specialty ward?
My tips:
1. The ED team is extremely busy. Keep it relevant and try to think like the registrar/consultant
2. Use a SBAR format of presenting your case:
S - Situation This 80 year old has been admitted with bilateral wheeze.
B- Back ground BG of COPD, lives with wife and is struggling with ADLs.
A - Assesment High WCC, CRP . I have given him nebs, steroids and antibiotics. His ABG shows chronic type 2 resp failure with normal pH. His EWS is 0
R - Your plan and I think he is safe to transfer to a medical ward where he can be clerked.
3. Of course, escalate when concerned or when you are not sure. But always follow the aforementioned format.
4. Start doing the same with the new FY1 who has just started in ED - ask him/her to give you a SBAR. This will make your thinking process change and you will be able to improve your leadership skills this way.
Ward handover
There are different types of handovers:
HANDOVER FROM ED NURSE TO AMU NURSE:This is when the patient is transferred from the emergency department to the acute medical unit
The SBAR as above PLUS
1. Social issues: whether the patient lives alone and is struggling ( the nursing staff can then start involving therapists, ie PT/OT as soon as the patient is medically fit to delay discharges)
2. Any safeguarding concerns
3. Any outstanding jobs
4. Any sores, wounds, etc ( so that tissue viability team can be involved and the nursing team can get special air mattresses and change the position of the patient on a regular basis if (s)he is bed bound)
PLUS
The local protocols of the trust - The nurses usually have a few nursing documents to fill in themselves when they take over care of a patient and it varies from trust to trust so the aforementioned list is not 100% accurate.
HANDOVER FROM SHO CLERKING PATIENT TO THE POST TAKE TEAM DURING MEDICAL HANDOVER
In some trusts, every patient admitted overnight is discussed in the morning AMU doctors handover. It is led by the night registrar and is attended by the medical consultant. Again, this is not always the case in other trusts but I find this quite useful as things which may be missed by the clerking team can be urgently done by the post take team.
Case presentation:
He is an 80 year old gentleman, known COPD and chronic retainer, who was admitted with shortness of breath. His ABG was not acidotic and I have treated him for an infective exacerbation of COPD given that he was very wheezy on arrival, CXR was normal and he had a CRP of 70 and a WCC on 15.0 with oral doxycycline, steroids and nebs. He is struggling at home and will need OT/PT. His flu swab was negative.
HANDOVER FROM MEDICAL TEAM TO THE MDT
In every medical ward, there is a MDT which includes:
1. Discharge coordinators
2. Nurse in charge
3. Physiotherapists
4. Occupational therapists
5. Doctors
The purpose of the MDT is to:
1. Identify patients who are medically fit and need therapists input
2. Ask why patients need to stay in hospital
3. If the discharge coordinator can expedite anything to ensure the patient is discharged early.
Why is this a big deal?
1. This prevents patients for staying in for a long time and avoid deconditioning of elderly patients and avoid hospital acquired infections.
2. Everyone working on the ward knows what is going on with the patients.
3. The nurses do not have to go through each and every patients notes to find out what the plan from the consultant ward round is.
4. It builds communication and leadership skills for doctors - they ensure that they know the answers to these important questions: Why does the patient need to stay in hospital? What can we do to expedite his/her discharge ? What social issues need to be addressed.
An example:
This 80 year old gentleman was admitted for management of infective exacerbation of COPD. His OBS are stable and he is not requiring oxygen and we have switched his regular nebs to PRN. However his wife is struggling. He has osteoarthritis and there is no tenderness but he does struggle to mobilize independently. I think he could go home tomorrow if he does not require any PRN nebs in the next 24 hours and if our physiotherapists could assess him. I will prepare his discharge paperwork today for potential discharge tomorrow and I can authorize it tomorrow morning if he does not require any nebs. His target saturations are 88 to 92% and I have set these targets on our electronic system. The respiratory nurses have already seen him.
What is important here?
1. The patient needs a 24 hour neb free period
2. But the patient is approaching medically fit and the PT team can start assessing him.
3. The PT team know his social situation and the background of osteoarthritis- hence will know that his poor mobility is NOT secondary to an acute pathology ( like a fracture) UNLESS they assess him and find that he cannot weight bear at all, etc.
4. The discharge coordinators can ensure that if he is fit the following day, all the discharge paperwork is ready early.
5. Ensuring the nursing staff know his target saturations to avoid over saturating him.
What is not important?
1. His ABG - the MDT is not interested in this.
2. His detailed blood results , ECG, CXR findings.
CASE 2 - AN UNWELL PATIENT:
A 60 year old gentleman has been admitted to ED with shortness of breath, cough productive of yellow sputum. He has low oxygen saturations, ABG shows Type 2 respiratory failure with pH of 7.32 and lactate of 3.0.His WCC, CRP are raised and his chest x ray is hyper-inflated.
Background: COPD ( no spirometry available) , still smokes.
Medications: 2 inhalers.
Has never been admitted to hospital before.
Social : Lives with wife but otherwise independent.
On examination: Bilateral wheeze , heart sounds normal, abdomen soft non tender, legs and calves: soft, non tender, no clinical evidence of DVT, no oedema. Neurology: Grossly normal, AMTS: 8/10
ECG: normal
Management in ED:
Salbutamol nebs
Ipratropium nebs
IV hydrocortisone
IV tazocin
IV fluids
EWS in ED: 10
BP: 80/50 (3)
SO2: 85% on Air initially, now 88% on 28% (2)
HR: 120/min (2)
Temperature: 38.9 (1)
RR: 22/min (2)
HANDOVER TO THE ITU TEAM AND MEDICAL REGISTRAR ON CALL FROM ED:
Hello, I am one of the ED SHOs and I have just seen a 60 year old gentleman with known COPD , on inhalers, never admitted to hospital. On arrival he was very wheezy with an AMTS of 8/10.
His ABG on admission shows acute respiratory acidosis with a pH of 7.32, lactate of 3.0, p02 of 9.0, PCO2 of 8.7, bicarbonate 26.
I have given him nebulizers, IV tazocin, IV hydrocortisone .
I have set his target saturations to 88 to 92%. His WCC, CRP are raised and his chest x ray is hyper-inflated.
His observations are:BP: 80/50 (3)
SO2: 85% on Air initially, now 88% on 28% (2)
HR: 120/min (2)
Temperature: 38.9 (1)
RR: 22/min (2)
Which makes an EWS of 10.
I have moved him to the resuscitation bay for close monitoring.
I feel he may need NIV if his repeat ABG in an hours time is not improving. Can you please review him?
I have already informed my ED registrar who is in agreement
What is important in this:
1. The situation:
He is acidotic, in type 2 respiratory failure. Appropriate treatment has been given but he is at risk of deterioration.
2. Background:
He has COPD and has never been admitted to hospital before. He still smokes and is independent.
3. Assessment:On arrival he was very wheezy with an AMTS of 8/10.
His ABG on admission shows acute respiratory acidosis with a pH of 7.32, lactate of 3.0, p02 of 9.0, PCO2 of 8.7, bicarbonate 26.
I have given him nebulizers, IV tazocin, IV hydrocortisone .
I have set his target saturations to 88 to 92%. His WCC, CRP are raised and his chest x ray is hyper-inflated.
His observations are:BP: 80/50 (3)
SO2: 85% on Air initially, now 88% on 28% (2)
HR: 120/min (2)
Temperature: 38.9 (1)
RR: 22/min (2)
Which makes an EWS of 10.
4. Recommendation ( plan):
I have moved him to the resuscitation bay for close monitoring.
I feel he may need NIV if his repeat ABG in an hours time is not improving. Can you please review him?
I have already informed my ED registrar who is in agreement
This will give the ITU team and medical registrar an idea of how unwell the patient is.
This is what they both want to know:
1. How unwell is the patient?
2. If they are seeing another sick patient, do they need to delegate the responsibility of that patient to their colleague/ SHO or can they come in 20 minutes?
3. Whether the patient is for full escalation?
Their background helps in making this decision
They may recommend things like: doing a flu swab, giving IV boluses, catheterizing the patient. Such patients are reviewed urgently , however this depends on the workload of the ITU team and medical registrar.
My tips:
1. Introduce yourself. This is very important. You could be a medical student, a FY1 or a consultant - the person on the other line does not know.
2. Mention the important points. The above handover can be given in a minute or 2. The ITU/ medical registrar will be jotting down all of these points.
3. Have all the relevant investigations to hand. The ABG , bloods, OBS are very important. It is best to sit at a computer with everything open infront of you.
4. Keep a paper with you and jot down any advice they give. It is very easy to forget things especially in a high turn over area like ED.
5. Remember to keep an eye on such unwell patients EVEN if they have been seen by the relevant specialties. Ie, if there is a CRASH call on a medical ward and the medical registrar/ITU registrar cannot come to re- review the patient after they have been, you may have to do that ABG yourself - it takes 10 seconds to do and 1 minute to run on the machine (which even the ED resus nurses can do for you).
Overall, handovers are very important in the NHS. They vary from trust to trust. Some places have an electronic handover system but in my opinion, nothing beats a face to face handover. This way, the person handing over learns what is important to the team (s)he is handing over to, improves communication skills and improves overall management of the patient.
With time and experience, we get better at this. As doctors, we should do this on a regular basis.
In my opinion, this is what helps better management of a patient from the front door.
1. A quick SBAR, ABCDE assessment from the paramedics to the ED team
2. A SBAR from the ED to medical team
3. A SBAR from the medical clerking team to the post take team
4. A "huddle/MDT meeting' between the ward team and MDT focusing on these points:
- Why is the patient still in?
- How long will (s)he stay in?
- What does (s)he need as an inpatient
- Can we expedite any of these?
This way, we can ensure that the patient is managed appropriately from the front door to the discharge lounge.
As doctors, we can ensure that this can happen. It does not matter if we are foundation trainees, non trainee SHOs, registrars or consultants. Any of us can ensure that we implement this. You will see a significant difference in patient care and can avoid prolonged admissions this way.
CASE 1
A 80 year old gentleman has been admitted to ED with shortness of breath, cough productive of yellow sputum. He has low oxygen saturations, ABG shows Type 2 respiratory failure with normal pH and lactate.His WCC, CRP are raised and his chest x ray is hyper-inflated.
Background: COPD ( known type 2 respiratory failure) , osteoarthritis ( mainly affecting his knees), Type 2 diabetes, ischemic heart disease.
Social : Lives with wife, struggling with activities of daily living.
On examination: Bilateral wheeze , heart sounds normal, abdomen soft non tender, legs and calves: soft, non tender, no clinical evidence of DVT, no oedema. Neurology: Grossly normal, AMTS: 8/10
ECG: normal
Management in ED:
Salbutamol nebs
Ipratropium nebs
Prednisolone
Doxycycline
EWS in ED: 0
BP: 120/10
SO2: 90% on A - target saturation: 88 to 92%
HR: 84/min
Temperature: Apyrexial
RR: 16/min
ED HANDOVER FROM SHO/ FY1 TO ED REGISTRAR/CONSULTANT:
I am going to start with a handover from an ED SHO to the ED registrar/consultant:
This 80 year old has been admitted with bilateral wheeze. BG of COPD, lives with wife and is struggling with ADLs, high WCC, CRP . I have given him nebs, steroids and antibiotics. His ABG shows chronic type 2 resp failure with normal pH. His EWS is 0 and I think he is safe to transfer to a medical ward where he can be clerked.
Tips:
The reg/consultant in ED is interested in these things:
1. Whether this patient can be transferred to a medical ward to be clerked ( and thus empty a bed where a patient waiting in the corridor/back of an ambulance/waiting room can come and be assessed) or does this patient need to be seen by the medical registrar/ITU team ( if warranted).
- The ABG, EWS and a brief handover clarifies that he is safe for transfer.
2. Whether the management in ED has been given ( nebs, streoids, antibiotics for infective exacerbation of COPD)
3. Whether the investigations have been done ( ie ABG, CXR, bloods)
What the reg/consultant in ED is NOT interested in:
1. Background of osteoarthritis - is this an acute issue? No! Hence please do not mention such conditions.
2. The whole description of his FBC, U and E's, LFTs - keep it simple and to the point. Mention the relevant positive investigations.
3. His medication list - The ED senior has agreed with you that this patient needs admission. Do not waste your time going through the 20 medications the patient is on.
This is what the ED registrar/ consultant needs to decide:
1. Whether this patient can go home?
2. Whether this patient needs to be assessed by the relevant specialty urgently?
3. Whether this patient is safe for transfer to the specialty ward?
My tips:
1. The ED team is extremely busy. Keep it relevant and try to think like the registrar/consultant
2. Use a SBAR format of presenting your case:
S - Situation This 80 year old has been admitted with bilateral wheeze.
B- Back ground BG of COPD, lives with wife and is struggling with ADLs.
A - Assesment High WCC, CRP . I have given him nebs, steroids and antibiotics. His ABG shows chronic type 2 resp failure with normal pH. His EWS is 0
R - Your plan and I think he is safe to transfer to a medical ward where he can be clerked.
3. Of course, escalate when concerned or when you are not sure. But always follow the aforementioned format.
4. Start doing the same with the new FY1 who has just started in ED - ask him/her to give you a SBAR. This will make your thinking process change and you will be able to improve your leadership skills this way.
Ward handover
There are different types of handovers:
HANDOVER FROM ED NURSE TO AMU NURSE:This is when the patient is transferred from the emergency department to the acute medical unit
The SBAR as above PLUS
1. Social issues: whether the patient lives alone and is struggling ( the nursing staff can then start involving therapists, ie PT/OT as soon as the patient is medically fit to delay discharges)
2. Any safeguarding concerns
3. Any outstanding jobs
4. Any sores, wounds, etc ( so that tissue viability team can be involved and the nursing team can get special air mattresses and change the position of the patient on a regular basis if (s)he is bed bound)
PLUS
The local protocols of the trust - The nurses usually have a few nursing documents to fill in themselves when they take over care of a patient and it varies from trust to trust so the aforementioned list is not 100% accurate.
HANDOVER FROM SHO CLERKING PATIENT TO THE POST TAKE TEAM DURING MEDICAL HANDOVER
In some trusts, every patient admitted overnight is discussed in the morning AMU doctors handover. It is led by the night registrar and is attended by the medical consultant. Again, this is not always the case in other trusts but I find this quite useful as things which may be missed by the clerking team can be urgently done by the post take team.
Case presentation:
He is an 80 year old gentleman, known COPD and chronic retainer, who was admitted with shortness of breath. His ABG was not acidotic and I have treated him for an infective exacerbation of COPD given that he was very wheezy on arrival, CXR was normal and he had a CRP of 70 and a WCC on 15.0 with oral doxycycline, steroids and nebs. He is struggling at home and will need OT/PT. His flu swab was negative.
HANDOVER FROM MEDICAL TEAM TO THE MDT
In every medical ward, there is a MDT which includes:
1. Discharge coordinators
2. Nurse in charge
3. Physiotherapists
4. Occupational therapists
5. Doctors
The purpose of the MDT is to:
1. Identify patients who are medically fit and need therapists input
2. Ask why patients need to stay in hospital
3. If the discharge coordinator can expedite anything to ensure the patient is discharged early.
Why is this a big deal?
1. This prevents patients for staying in for a long time and avoid deconditioning of elderly patients and avoid hospital acquired infections.
2. Everyone working on the ward knows what is going on with the patients.
3. The nurses do not have to go through each and every patients notes to find out what the plan from the consultant ward round is.
4. It builds communication and leadership skills for doctors - they ensure that they know the answers to these important questions: Why does the patient need to stay in hospital? What can we do to expedite his/her discharge ? What social issues need to be addressed.
An example:
This 80 year old gentleman was admitted for management of infective exacerbation of COPD. His OBS are stable and he is not requiring oxygen and we have switched his regular nebs to PRN. However his wife is struggling. He has osteoarthritis and there is no tenderness but he does struggle to mobilize independently. I think he could go home tomorrow if he does not require any PRN nebs in the next 24 hours and if our physiotherapists could assess him. I will prepare his discharge paperwork today for potential discharge tomorrow and I can authorize it tomorrow morning if he does not require any nebs. His target saturations are 88 to 92% and I have set these targets on our electronic system. The respiratory nurses have already seen him.
What is important here?
1. The patient needs a 24 hour neb free period
2. But the patient is approaching medically fit and the PT team can start assessing him.
3. The PT team know his social situation and the background of osteoarthritis- hence will know that his poor mobility is NOT secondary to an acute pathology ( like a fracture) UNLESS they assess him and find that he cannot weight bear at all, etc.
4. The discharge coordinators can ensure that if he is fit the following day, all the discharge paperwork is ready early.
5. Ensuring the nursing staff know his target saturations to avoid over saturating him.
What is not important?
1. His ABG - the MDT is not interested in this.
2. His detailed blood results , ECG, CXR findings.
CASE 2 - AN UNWELL PATIENT:
A 60 year old gentleman has been admitted to ED with shortness of breath, cough productive of yellow sputum. He has low oxygen saturations, ABG shows Type 2 respiratory failure with pH of 7.32 and lactate of 3.0.His WCC, CRP are raised and his chest x ray is hyper-inflated.
Background: COPD ( no spirometry available) , still smokes.
Medications: 2 inhalers.
Has never been admitted to hospital before.
Social : Lives with wife but otherwise independent.
On examination: Bilateral wheeze , heart sounds normal, abdomen soft non tender, legs and calves: soft, non tender, no clinical evidence of DVT, no oedema. Neurology: Grossly normal, AMTS: 8/10
ECG: normal
Management in ED:
Salbutamol nebs
Ipratropium nebs
IV hydrocortisone
IV tazocin
IV fluids
EWS in ED: 10
BP: 80/50 (3)
SO2: 85% on Air initially, now 88% on 28% (2)
HR: 120/min (2)
Temperature: 38.9 (1)
RR: 22/min (2)
HANDOVER TO THE ITU TEAM AND MEDICAL REGISTRAR ON CALL FROM ED:
Hello, I am one of the ED SHOs and I have just seen a 60 year old gentleman with known COPD , on inhalers, never admitted to hospital. On arrival he was very wheezy with an AMTS of 8/10.
His ABG on admission shows acute respiratory acidosis with a pH of 7.32, lactate of 3.0, p02 of 9.0, PCO2 of 8.7, bicarbonate 26.
I have given him nebulizers, IV tazocin, IV hydrocortisone .
I have set his target saturations to 88 to 92%. His WCC, CRP are raised and his chest x ray is hyper-inflated.
His observations are:BP: 80/50 (3)
SO2: 85% on Air initially, now 88% on 28% (2)
HR: 120/min (2)
Temperature: 38.9 (1)
RR: 22/min (2)
Which makes an EWS of 10.
I have moved him to the resuscitation bay for close monitoring.
I feel he may need NIV if his repeat ABG in an hours time is not improving. Can you please review him?
I have already informed my ED registrar who is in agreement
What is important in this:
1. The situation:
He is acidotic, in type 2 respiratory failure. Appropriate treatment has been given but he is at risk of deterioration.
2. Background:
He has COPD and has never been admitted to hospital before. He still smokes and is independent.
3. Assessment:On arrival he was very wheezy with an AMTS of 8/10.
His ABG on admission shows acute respiratory acidosis with a pH of 7.32, lactate of 3.0, p02 of 9.0, PCO2 of 8.7, bicarbonate 26.
I have given him nebulizers, IV tazocin, IV hydrocortisone .
I have set his target saturations to 88 to 92%. His WCC, CRP are raised and his chest x ray is hyper-inflated.
His observations are:BP: 80/50 (3)
SO2: 85% on Air initially, now 88% on 28% (2)
HR: 120/min (2)
Temperature: 38.9 (1)
RR: 22/min (2)
Which makes an EWS of 10.
4. Recommendation ( plan):
I have moved him to the resuscitation bay for close monitoring.
I feel he may need NIV if his repeat ABG in an hours time is not improving. Can you please review him?
I have already informed my ED registrar who is in agreement
This will give the ITU team and medical registrar an idea of how unwell the patient is.
This is what they both want to know:
1. How unwell is the patient?
2. If they are seeing another sick patient, do they need to delegate the responsibility of that patient to their colleague/ SHO or can they come in 20 minutes?
3. Whether the patient is for full escalation?
Their background helps in making this decision
They may recommend things like: doing a flu swab, giving IV boluses, catheterizing the patient. Such patients are reviewed urgently , however this depends on the workload of the ITU team and medical registrar.
My tips:
1. Introduce yourself. This is very important. You could be a medical student, a FY1 or a consultant - the person on the other line does not know.
2. Mention the important points. The above handover can be given in a minute or 2. The ITU/ medical registrar will be jotting down all of these points.
3. Have all the relevant investigations to hand. The ABG , bloods, OBS are very important. It is best to sit at a computer with everything open infront of you.
4. Keep a paper with you and jot down any advice they give. It is very easy to forget things especially in a high turn over area like ED.
5. Remember to keep an eye on such unwell patients EVEN if they have been seen by the relevant specialties. Ie, if there is a CRASH call on a medical ward and the medical registrar/ITU registrar cannot come to re- review the patient after they have been, you may have to do that ABG yourself - it takes 10 seconds to do and 1 minute to run on the machine (which even the ED resus nurses can do for you).
Overall, handovers are very important in the NHS. They vary from trust to trust. Some places have an electronic handover system but in my opinion, nothing beats a face to face handover. This way, the person handing over learns what is important to the team (s)he is handing over to, improves communication skills and improves overall management of the patient.
With time and experience, we get better at this. As doctors, we should do this on a regular basis.
In my opinion, this is what helps better management of a patient from the front door.
1. A quick SBAR, ABCDE assessment from the paramedics to the ED team
2. A SBAR from the ED to medical team
3. A SBAR from the medical clerking team to the post take team
4. A "huddle/MDT meeting' between the ward team and MDT focusing on these points:
- Why is the patient still in?
- How long will (s)he stay in?
- What does (s)he need as an inpatient
- Can we expedite any of these?
This way, we can ensure that the patient is managed appropriately from the front door to the discharge lounge.
As doctors, we can ensure that this can happen. It does not matter if we are foundation trainees, non trainee SHOs, registrars or consultants. Any of us can ensure that we implement this. You will see a significant difference in patient care and can avoid prolonged admissions this way.
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