06:50AM: You are heading towards the tail end of your night shift, swamped with traumas, resuscitations, and overall high volumes of patients. You look forward to heading back to the warm embrace of your bed. However, before you can leave, you run your list again with your supervising physician and realize that there are still a few patients that will likely need to be handed over to the morning shift physician. The incoming physician walks in right on cue, and your staff physician instructs you to directly hand over your patients whilst he goes to speak with a consultant. You nervously look through your list, having not had much experience with handovers in the Emergency Department, and practice your delivery in your head.
Handovers are well-known to be a potential source of miscommunication that can ultimately lead to medical errors and adverse patient outcomes. Learning to effectively hand over patients is an important skill for both junior residents and medical students who are expected to attend and, on occasion, hand over patients directly to the incoming ED physician. Here are some tips for effectively handing over patients in the ED:
Be familiar with the local hospital/physician group policy on handovers
Make sure you are aware of the handover policy in your Emergency Department. Some EDs require handover of all patients that have not been admitted to a hospital service, including patients awaiting consultation, whilst others only require handover of patients that are still actively being investigated under the care of the emergency physician. No matter what type of handover practices your ED institutes, it is always important to highlight the most potentially sick patients, regardless of their admission status. The patients who are still in the Emergency Department are the ED physician’s responsibility and it is imperative that we are aware of the concerning patients at all times. Even though a consulting service has accepted a patient, you still have shared responsibility with any patient still present in your department. Additionally, services may require your aid in procedures or resuscitations and thus it is imperative that you know about these high risk patients. For the purposes of this blog post, handovers will only refer to the patients whose workup is still incomplete and disposition is still unclear, as these patients will require the most amount of attention for the incoming physician.
Hand over in a safe and quiet area with minimal interruptions/distractions
The CMPA published a Good Practices guide on how to safely hand over in a clinical setting. One of the most important aspects of a safe handover is the environment. Imagine trying to hear about someone’s day when you have three other people talking to you about something entirely different. The information you retain will likely be distorted and miscommunicated. It is crucial to find a protected environment to carry out handovers, where there are minimal interruptions and everyone is focused on the speaker. Additionally, the environment should be a safe setting where, regardless of the level of training, everyone feels emotionally and mentally comfortable to hand over effectively.
Utilize a consistent approach to delivering handovers
Handovers can be very similar to presenting a patient to your staff physician. Have a consistent and structured approach so that the physician receiving handover can easily understand and follow the thought process. Handover should be presented in a format that is universal and easy to understand. Strongly consider using a validated tool like SBAR (situation, background, assessment, recommendations) to format your handovers to ensure no important information is neglected.
|Situation||Describe the specific situation about a particular patient, including name, age, patient location, vital signs, and chief complaint.|
|Background||Communicate the patient’s background, including relevant past medical history, current medications, allergies, laboratory results, progress during the ED stay, and other relevant information collected from the patient’s charts.|
|Assessment||Deliver your critical assessment of the situation, working differential diagnosis, clinical impression, and detailed expression of concerns.|
|Recommendations||Detail the current workup/management plan, making suggestions and being specific about disposition decisions.|
Provide a clear diagnostic and dispositional algorithm for patients still undergoing workup
Plan 2-3 steps ahead for each patient that needs to be handed over from both a diagnostic and disposition perspective. Have a plan for the appropriate services to consult if the workup is positive, as well as whether the patient can be discharged home if the workup is negative. Make sure to always consider the patient’s disposition during handovers. The 82 year old lady who fell and hit her head should not be sent home even if the CT head is negative if she cannot ambulate safely in the ED. At the same time, be sure to acknowledge any diagnostic uncertainty during handover and avoid anchoring biases based on workup results alone (note: anchoring bias is the tendency for an individual to depend too heavily on an initial piece of information when making decisions, and fail to adjust this initial impression in light of later information). The teenager with RLQ pain may still require serial abdominal exams if the ultrasound is negative or inconclusive to decide whether further workup is necessary or if he can be sent home. Make sure to include these recommendations during the handover process so that the receiving physician has a clear guideline on how to continue management of your patients and avoid any miscommunication errors.
Tie up any loose ends for the incoming physician
Everyone knows that paperwork, scripts, and other logistical documents can be tedious and takes time away from clinical care. Make sure to relieve the incoming physician of this burden by getting those things done for your patients ahead of time, including prescriptions, outpatient referrals/investigations, and forms for home supports. You know your patients better than the receiving physician and will be better able to fill out such paperwork. Additionally, these gestures are always appreciated by the incoming physician and help preserve a collegial environment within the physician group.
Take a moment to practice writing out your own handovers using the SBAR format for patients 1-4 below and compare them to the examples provided!
Patient 1: 76 year old male
Chief Complaint: Dyspnea
History: 1 week history of dyspnea and cough with purulent green sputum production, decreasing energy levels, and worsening fatigue. Lives alone with no social supports and has significantly reduced oral intake.
Past Medical History: Recurrent pneumonias requiring admission (most recent 4 months ago), COPD, coronary artery disease
Medications: Puffers, aspirin, bisoprolol, ramipril, rosuvastatin
Exam: SpO2 91% on 2L O2, BP 110/72, HR 95, Temp 36.7. CVS normal S1/S2. RESP crackles over left lower lung base.
Labs: WBC 15.0, remainder normal. Electrolytes normal, creatinine 150 (baseline 90).
Plan: IV 1L bolus, blood cultures x2, start IV Ceftriaxone and Azithromycin. Discussed case with Internal Medicine — will see and possibly admit, but currently in the process of AM handover and rounds. To clinically monitor patient in ED in the meantime in case of deterioration.
Patient 1 SBAR:
|Situation||76 year old male with dyspnea + cough|
|Background||1 week history of productive purulent cough and shortness of breath. Past Medical History of COPD, CAD, and recurrent pneumonias requiring hospitalization in the past. |
CXR shows LLL pneumonia.
Evidence of acute kidney injury on bloodwork.
|Assessment||1. Community Acquired Pneumonia |
2. Acute Kidney Injury – likely pre-renal
|Recommendation||IV Abx: Ceftriaxone and Azithromycin started |
IV fluids: 1L normal saline given, ongoing maintenance fluids
Disposition: Internal Medicine will see and likely admit, but may take time as in the middle of AM Handovers/Rounds
Clinically assess patient in 1-2 hours and ensure hemodynamically stable. If clinical deterioration, consider:
1. More IV fluids
2. Broadening antibiotic spectrum — i.e. Pip-Tazo/Vancomycin
3. Infusion of vasopressors + ICU consult
Patient 2: 82 year old female
Chief Complaint: Fall
History: Mechanical fall from ground level at home; struck her head and left shoulder. Witnessed by partner. No LOC or seizure activity. Aside from ongoing headache no other complaints. Lives at home with partner, no supports, otherwise very independent.
Past Medical History: COPD, CAD, dementia, rheumatoid arthritis, and colon cancer. However, she has good follow-up and care from her specialists.
Exam: Trauma survey reveals no significant injuries. X-rays of injured areas were all negative.
Plan: Going for CT of her head and C-spine.
Patient 2: SBAR
|Situation||82 year old female with fall + head injury|
|Backround||Mechanical fall, head injury with no LOC.|
Clinical exam reveals no significant injuries.
Past Medical History of COPD, CAD, dementia, rheumatoid arthritis, cancer.
From retirement home, regular supports.
X-rays of injured areas negative.
|Assessment||1. Mechanical Fall|
2. Head Injury
|Recommendation||CT Head + C-spine: done and report pending |
Disposition: pending based on CT reports
Follow up on CT head and C-spine results:
1. If CT reports clinically significant findings: admit to appropriate service
2. If imaging negative for significant injury: clinically reassess and have pt ambulate in ED
3. If able to ambulate well: home with increased supports
4. If unable to ambulate safely: consider admission to hospitalist for physiotherapy/rehabilitation
Patient 3: 18 year old male
Chief Complaint: Abdo pain
History: RLQ pain x 3 hours with associated nausea/vomiting. No urinary symptoms, stools normal. No fevers/chills, normal appetite. No testicular pain. Otherwise healthy and on no medications.
Exam: RLQ tenderness with no peritonitis, secondary appendicitis signs, or testicular findings.
Labs: Slight WBC elevation at 13.0.
Plan: Abdominal and testicular ultrasound. Toradol for pain relief.
Patient 3: SBAR
|Situation||18 year old male with RLQ pain|
|Background||RLQ Pain x 3 hours, associated N/V, otherwise healthy.|
Abdo exam: (+) RLQ tenderness, no secondary appendicitis signs, no peritonitis, no testicular findings.
Labs: slight WBC elevation at 13.0, otherwise unremarkable.
|Assessment||1. RLQ Pain NYD|
|Recommendation||Pending abdo and testicular ultrasound to R/O appendicitis and testicular torsion |
Given 10mg Toradol IM for pain control
Disposition: pending based on ultrasound report
Follow up on ultrasound report:
1. If positive: consult appropriate services
2. If negative: clinically reassess patient
a) If pain subsided and serial abdominal exams benign: consider disposition home
b) If ultrasound negative but clinically concerning abdominal exam: consider CT abdomen for further work-up
Patient 4: 45 year old male
Chief complaint: chest pain
History: 1 hour history of crushing retrosternal chest pain radiating to his left shoulder whilst shovelling snow. The pain subsided after he stopped shovelling and since his arrival to the ED he has been pain free. No PE or cardiac risk factors. PERC negative.
Exam: Respiratory, cardiovascular, and abdominal exam were all normal
Labs: His CXR and ECG are unremarkable, as is his blood work including two troponin levels.
Plan: A third set of bloodwork for troponin has been drawn because the chest pain was clinically concerning and is still pending.
Patient 4: SBAR
|Situation||45 year old male with chest pain|
|Background||Chest pain x 1 hour after shovelling snow, retrosternal & exertional. |
PERC negative, CXR nil acute, ECG NSR.
Troponin negative x 2 (3 hours apart).
|Assessment||1. Chest Pain NYD, ?Angina|
|Recommendations||Third troponin pending (just drawn) |
HEART score: 3
Disposition: to reassess after third troponin resulted
Follow up on third troponin:
1. If positive: admit to IM or cardiology for further ?ACS workup
2. If negative but stuttering chest pain in ED: admit to hospitalist/IM for unstable angina
3. If negative and no further chest pain: consider discharge home with urgent stress test + cardiology follow-up (forms filled and faxed) as well as prescription for daily ASA (Rx given)
This post was edited by Megan Chu and Julia Heighton.
Reviewing with the Staff
Handovers in any specialty is an extremely important experience. In the hustle and bustle of the Emergency Department, there are many barriers to making sure that handovers are effective and protected. Without proper handover protocols and techniques, there is potential for medical errors and compromise to patient safety. All Emergency Medicine physicians and their leaders must create an environment with standardized protocols that should be adhered to in order to allow proper handovers to occur. Using tools such as SBAR as well as having dedicated handover time with minimal interruptions will enhance the effectiveness of the experience. No matter the level of training, this process must be followed and upheld, to minimize patient risk. This article has excellent pearls on the handover process and I strongly encourage all readers to review it thoroughly so that they can incorporate it into practice.