Passing the baton: Getting to grips with after-hours handovers

I love the Olympics, especially the gymnastics, swimming and athletics – and magically every 4 years, for a period of 2 weeks, I’m an avid fan. One event that captivates everyone is the 4 × 100 m relay. It is fast, exciting and truly a team effort. The importance of the last point is most evident in this event – and individual brilliance even at the Usain Bolt level isn’t enough without the whole team pulling their weight and working together effectively. The riskiest part of the race is the points at which successive runners ‘pass the baton’. Many an accomplished team has lost the race because of mishaps when handing over this seemingly innocuous piece of equipment.

In between the 4-yearly fortnight of sporting indulgence, I return to my role as a psychiatrist. And it struck me that these stages of the race in which the baton is skilfully passed, while ensuring smooth continuity of pace, are similar to our work in psychiatry. Working in a busy public hospital, or liaising with another service, you will often need to pass the baton to a colleague or another team member on a regular daily basis. On busy wards, it is necessary to hand over to nursing staff, and when on call, inform your colleagues, juniors and seniors about patients, either those presenting in the emergency department (ED) or those receiving ongoing care.

Patient safety research suggests that miscommunication, particularly around times of transition of care, can contribute to medical error (Merten et al., 2017). Structured handover forms one element of the Australian national safety and quality health service standard on communicating for safety (Australian Commission on Safety and Quality in Health Care (ACSQHC), 2017). In the United States, the ability to give or receive handover is now considered a ‘core’ entrustable professional activity for graduated medical students commencing residency (Obeso et al., 2017). It is therefore important to acknowledge these points of vulnerability in our systems of care and in our personal practice.

To aid in this regard, I have outlined some considerations for improving handover – especially after-hours. The advice is focused on the role of junior doctors and registrars (and adopted their perspective) as they are the ones usually at the centre of most medical handovers, but the principles also hold more broadly for all clinicians.

• 1. Start at the very beginning

It is a logical place to start. First, make sure you introduce yourself with your full name and role, the full name of the patient you wish to discuss, their age and MRN. Take your time conveying this information and be prepared to repeat yourself (for example, if calling late at night). As a rule of thumb, it is best to wait for a verbal confirmation from the recipient before wading into your presentation. Note, if you are in your first year of training, or doing your first ever after-hours shift as a registrar, it might be useful to mention this at the outset. Try if possible to find a quiet spot to call from: this can be fairly challenging if calling from a busy ED.

• 2. Use a consistent structure

There are many structured handover tools that can be used, with evidence that the use of structured handover tools improves information transfer at handover (Merten et al., 2017). The ISBAR tool, for example, is well known, and its simplicity and familiarity make it convenient to use in an after-hours conversation with a consultant (see Table 1). It is helpful to have a copy on your phone to remind you of the mnemonic and there is also a free app available. If you are yet to complete your notes, make sure you write down any important points you want to discuss with the consultant, and have your documentation in front of you to help answer any queries. The ‘S’ in ISBAR should remind you to succinctly identify the current reason for calling, and this is often a good time to flag the urgency of your call, for example, ‘I am calling to discuss a possible mental health admission for Joe Smith following a presentation to the ED by ambulance after a significant overdose of prescribed medication, who is now medically stable after ED management’ versus ‘I am calling to seek urgent advice in regards to the management of Margaret Smith, a 48 year old women presenting with acute agitation associated with a relapse of psychosis who has a history of neuroleptic malignant syndrome, and remains highly agitated in the ED despite the administration of two doses of diazepam’.

Table 1.

ISBAR.

I	Introduction	An introduction of yourself and the patient
S	Situation	A succinct description of the current problem
B	Background	The background to this patient’s presenting problem
A	Assessment	Current mental state examination, risk assessment, vital signs and any other relevant findings on physical examination
R	Request, Recommendation, Read-back	The opportunity to provide recommendations about further management, request advice and confirm what has been heard.

In terms of ‘Background’, an abbreviated standardised psychiatric history is appropriate at this point beginning with some further details of the presentation. Mention both relevant positive features and negative features in all sections, and ensure you list current medications, dosages and allergies (if known). In the history of presenting illness, include any interventions already completed or underway in the ED, and include the drug and alcohol or medical history. This may seem obvious but it is remarkably easy to omit when fatigued, exceptionally busy or if you are focussed on a significant suicide attempt and a complex psychosocial situation. If you have been able to speak with family or carers, include this crucial collateral in your presentation.

The ‘Assessment’ should include a detailed mental state examination (great examination practice), risk assessment, current vital signs and any relevant positive/negative findings on physical examination (for example, signs of alcohol withdrawal).

The ‘R’ of ISBAR can include your recommendations and/or your requests. As a first-year registrar, your recommendations about further management may be tentative, but this is a valuable opportunity to consider what immediate steps might be appropriate to take. A more senior trainee will be able to consistently recommend proposed management at this point, noting there are some situations that challenge even the most experienced clinician. Share your uncertainty with the consultant at those times – you can then work together to develop a safe management plan. The ‘R’ also stands for read-back – i.e. make sure you have understood the management plan for the patient by re-stating it succinctly to the consultant. It is generally helpful to confirm Mental Health Act status, observations, medication dosages and any further investigations at this point. Don’t be perturbed by the consultant asking you questions: they too are trying to ensure they have understood the situation clearly.

• 3. Practice

Like learning any new skill, you will need to practice your handover presentations to become more confident – and competent. This is not time wasted: apart from contributing to patient safety, you are learning skills that will be helpful in your Objective Structured Clinical Examination (OSCE). There are opportunities to do this in hours, such as when liaising with nursing staff about patient transfers, or to community teams in discharge planning. Your colleagues and consultants will appreciate your succinct yet sufficiently detailed handovers (especially in after midnight discussions).

• 4. Seek feedback

Perhaps not at 4:00 a.m., but getting feedback about your handovers can be a useful learning opportunity. Presenting new patients in team meetings, for example, could be an opportunity to practice your structured handovers, with subsequent feedback and discussion with your consultant in supervision. There are examples in the literature of handover assessment tools that you and your supervisor could use to assist with structured feedback (Moore et al., 2017). As a first-year trainee, understanding what consultants want to know in a handover, and why, can help unpick the importance of elements of a psychiatric history and mental state examination, and why we focus on those features.

• 5. Start a revolution

Not literally, but given the systemic implementation of handover has been associated with a reduction in medical error (Stamer et al., 2014), are there opportunities to improve handover more broadly in your service? You might end up exploring factors beyond structured handover which can influence communication in teams within hospitals. If so, perhaps you can be a champion for change in your team or service and start a quality improvement project.

It is only just over a year until the next Summer Olympics. Thankfully none of us have to train for the 4 × 100 relay, but instead can look forward to 2 weeks of inspiring spectating. However, all of us (consultants too) can work at improving our own baton-passing skills and make a modest – but important – contribution to patient safety where we work.