Clinical handover for older people in hospital

Clinical handover

Clinical handover is the ‘procedure’ we use in hospitals for transferring “professional responsibility and accountability, in writing and face to face, 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

It has been recognised as a high risk area for patient safety and a priority for all clinicians.

It can occur:

shift-to-shift
ward-to-ward
between clinical staff
between disciplines, and
between treating teams.

Good clinical handover includes considering if:

environmental factors are impacting or might impact the patient¹
a patient needs significant care or immediate attention¹
a patient is deteriorating or might deteriorate (see Standard 9)¹
occupational health and safety issues need to be addressed¹

The process is enhanced when:

it follows a standard format
uses a checklist
contains a minimum dataset¹

As clinicians, it is our responsibility to understand and follow the documented and standardised clinical handover processes in use at our health services.

Many Victorian health services are moving towards involving patients and their families in bedside handover wherever possible and appropriate, such as during shift-to-shift and ward-to-ward handovers within daylight hours. This provides the opportunity to invite patients and their families to take small evidence-based actions to keep well during their stay in hospital.

Handing over involves communicating the actions needed to address the person’s presenting problem and the actions needed to prevent additional problems occurring. This includes incorporating strategies outlined in the topics to prevent functional decline.

ISBAR/ISOBAR

Victorian health services are using the ISBAR or ISOBAR¹ tools as a means to implement standardised clinical handovers. Each of the components of these tools contains essential elements to guide clinicians in the process of face-to-face and written handover^2,3

I – Identification of patient

Should include three patient identifiers such as name, date of birth and medical record number
Current clinical status
Advance care planning
Person centred care requirements
Prospect of discharge or transfer

S - Situation and status, including risk of delirium, pressure injuries, falls, continence and medication issues and so on

O – Observation, including latest risk assessments, examinations etc

Latest observations and when they were taken (NSQHS Standard 9 recognising patient deterioration)
Presenting problem
Background problems
Current issues
Evaluation (examination findings, investigation findings, current diagnosis)
Management to-date and an assessment as to whether the management is working

B – Background and history

A – Assessment and actions, including risk assessments and successful management strategies such as providing water with meals to alleviate swallowing difficulties

Understanding of what problems are being treated or clear communication that the diagnosis in unknown
Tasks to be completed
Abnormal or pending results (includes recommendations and an agreed plan and who to call if there is a problem)
A plan for communication to the senior in charge
Clear accountability for actions

R – Responsibility and risk management, including documenting and recording all successful/unsuccessful prevention strategies

Responsibility and task acceptance from the incoming team. Ideally includes signing or accepting handover sheets
Read back of critical information by the incoming team
Where risks are identified for a patient ensure clinical risk management plans are included in handover.

1. 'Safety and Quality Improvement Guide Standard 6: Clinical Handover (October 2012)', (Sydney: ACSQHC, 2012).

2. Clinical Communique [electronic resource]: Department of Forensic Medicine Monash University Victorian Institute of Forensic Medicine, 2 (2015).

3. Australian Commission on Safety and Quality in Health Care, 'The Ossie Guide to Clinical Handover Improvement', (Sydney: ACSQHC, 2010).

Clinical case study

I reinforce to Elsie the best thing she can do to get back to her garden, is to try and keep doing all the usual things she would at home whilst she’s in hospital. Like drinking and eating regularly, getting up to go to the toilet and taking short walks with her daughter or one of the nurses around the ward.
Arriving on the ward
When I meet Elsie on the ward, I read in her notes that she is an 85 year old lady who presented to ED via ambulance following a fall. She has fractured her left shoulder in two places and has just had surgery. She has a history of osteoarthritis, had a mild stroke some years ago, has mild congestive cardiac failure, a mild cognitive impairment and wears glasses for myopia and hearing aids. Elsie lives alone, drives to see her husband in a nursing home every day and has been independent with all her activities of daily living. This is not the picture I see when I look her. She is quite a thin lady, who is drowsy after her anaesthetic and looks quite dishevelled in her hospital gown. Elsie looks quite frail. She’s been in hospital for two days and her notes say that she could have been on the ground for over 8 hours before a neighbour found her.
Orientating Elsie to the ward
I introduce myself and tell her that I’ll be the nurse looking after her today. I ask her if she can tell me where she is and she says she knows she’s in hospital but doesn’t know what day it is or how long she’s been here. The last thing she remembers is being in her garden. I explain that she had fallen over and that she has fractured her shoulder in two places. I tell her that her surgery went well and that she’s now in ward 2B. I tell her that I’ll help her settle in and then we will run through a few tests to make sure we give her the right care while she’s here.
Elsie denies that she’s in any pain, but I notice she is wincing when I help her move around in bed. I also note that there is no record of her having used her bowels since she presented in ED two days ago.
I know Elsie has had a little bit to eat and drink in recovery and I’m keen that she keeps her fluid up so we can keep her hydrated. I help her to sit up and put her glasses on the tray table within her reach. She has a few sips of water and we complete the menu for her lunch together. I place a request to have her meal delivered on a red tray, which lets all staff know that she needs assistance with her meal when it arrives. I ask her if she’d like me to give her daughter a call to let her know that she has arrived on the ward. Elsie thinks this would be a good idea and requests that I ask her daughter to bring in her hearing aids. In the meantime, we decide that I’ll speak directly into her right ear, as she says that makes it easier for her to hear me.
I explain that she’ll need to keep drinking and eat well. I also explain that once she’s a little more alert in a few minutes, we’ll get her up and walk to the bathroom together.
Elsie seems reluctant to get up to go to the toilet, so I explain to her that it is one of the most important things to do in order to keep up her strength. Even a few short walks to the toilet can help her to stay mobile and helps prevent problems like developing pressure sores from staying in the one position for too long.
In the bathroom, the small amount of urine she passes is very dark in colour. I show her how to sit on the commode safely and I explain that this is a sign of dehydration so we’ll need to keep her fluids up.
I explain to Elsie that even a few short walks to the toilet can help her to stay mobile and helps prevent other problems like developing pressure sores from staying in the one position for too long.
Working with the team, Elsie and her family
She is clearly in pain when she is getting back into her gown, so I ask the registrar to review her medication and she recommends some pain relief. The doctor also notes that Elsie is at high risk of developing delirium from both unmanaged pain and dehydration. She completes a frailty, pain and cognitive screen so that we can decide how to manage her symptoms and have a baseline on these areas to monitor throughout Elsie’s stay. I also commence a bowel chart.
With Elsie’s permission I call the GP to get more of a picture of her usual cognitive and physical function. When her daughter arrives, the doctor and I both speak to her to gather further information. We encourage her to let us know if she notices any changes in Elsie’s level of alertness during her stay in hospital.
I note that as Elsie is particularly at risk of falling and that her balance is compromised by only using one arm. I place her call bell within reach of her right arm and show her how to use it. She’s a bit drowsy so I’ll need to assess her ability to use the bell and repeat the instruction again.
I let her know that we that I’ll be checking in on her regularly to monitor her pain and provide medication if necessary, help her with getting comfortable, see if she needs to go to the toilet and help with anything else. I remind her to take regular sips of water to avoid a dry mouth and explain the importance of this to her daughter too and provide the daughter with reassurance as I can see she is worried.
Handing over Elsie’s care
When my shift is about to finish I make sure my notes are up to date. I introduce Elsie to my colleague and we complete handover at Elsie’s bedside. I let Elsie know that I’ll explain to my colleague what has brought her into hospital and the types of measures we have put in place to ensure she stays as well as possible whilst she’s here. I run through the post-surgery precautions, wound care, pain relief, the bowel chart and falls prevention interventions and explain to my teammate that Elsie needs prompting to keep up her fluids and assistance with eating. I also explain that Elsie’s daughter will be bringing in her hearing aids a bit later. Elsie adds that her appetite hasn’t been good for the last few months and says she thinks she’s lost some weight. We make a note of this and my colleague says she’ll make a referral to the dietitian.
Second day on the ward
Elsie looks much brighter today but says she’s worried she might not make it home to her garden. When I ask her why it is worrying her, she says her husband John also had a fall about four months ago and did very poorly after he got home from hospital. She says he is now in a nursing home. She shows me a photo of herself and John, in their garden, taken about two weeks before he had the fall. I see a well-groomed lady, with a bright smile and I can tell she has a spring in her step. I empathise that this must have been so hard for them both and then ask her to tell me about John. She starts smiling and says “he’d be saying to me ‘chin up Else!’”. I say he must be a lovely man and she laughs and nods saying “‘not a bad looker either’”. We both have a giggle.
I reinforce to Elsie the best thing she can do to get back to her garden, and her usual routine, is to try and keep doing all the usual things she would at home whilst she’s in hospital. Like drinking and eating regularly, getting up to go to the toilet and taking short walks with her daughter or one of the nurses around the ward. I also emphasise that getting dressed and sitting out of bed for her meals is really important, as is asking for pain relief. I ask her to make sure she and her daughter keep a note of her questions for when the doctor, nurse or pharmacist came to see her. I tell her that we’ll be organising a physiotherapist, occupational therapist and possibly a social worker to come and see her over the next few days so we can all work with her to get her back home. I also encourage her to talk to her daughter about who she would like to make decisions for her if there comes a time in the future when she no longer can. She says that she’s been thinking about this since John went into the nursing home. I tell Elsie it’s not surprising and it’s likely her daughter is too.

Reviewed 17 July 2024

Clinical handover for older people in hospital

On this page