In 2004, the European working time directive was implemented among junior physicians, reducing the number of hours worked by trainees. With this came the introduction of shift systems and a loss of continuity of care, with patients being looked after by more than one team of physicians over the course of any given day. Consequently, handover of clinical information between such teams has become more frequent, and the need for robust handover mechanisms more important (British Medical Association [BMA]).
Handover may be defined as “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” (BMA). Accurate handover is integral to the safety of patients, allowing health-care professionals to communicate outstanding tasks and avoiding vital aspects of patient care being missed. Omitted patient information in handover can lead to suboptimal care,1 and poor communication between physicians can have devastating consequences for patients.2
It is apparent that written information to support verbal handover significantly increases retention of information, with printed handover sheets best avoiding data loss.3 The Royal College of Surgeons (RCS) has produced guidelines on safe handover practice,4 in which a minimum dataset is recommended for inclusion when handing over patients to incoming surgical teams, and studies have indicated better adherence to these guidelines when preprinted handover proformas are used.5,6 However, handover practice among surgical teams varies widely, and sadly, a large proportion of hospitals do not use such proformas.7–9 We found our district general hospital to be one such place in which preprinted handover sheets were not used. The aim of this audit was to objectively assess adherence to RCS guidelines and to investigate and reform our own practice. This is the first report in the literature on general surgical handover practice and the possible impact of introducing structured handover.
Within our surgical department, handover occurs twice daily. During these sessions, patients admitted throughout the previous shift are handed over to the incoming team of surgical physicians, usually with the aid of a “handover sheet” passed between teams and containing information to prompt discussion and aid in keeping track of new admissions. However, before this study, no standardized handover template was readily available or widely used within the department, and the composition of information sheets varied widely between individual surgical physicians.
All surgical handover sessions were attended for a 1-week period, and copies of handover sheets were taken. These were analyzed against RCS guidelines on the essential dataset for safe handover practice. A standardized handover sheet (Fig. 1), developed in accordance with these guidelines and designed to encourage impartation of this minimum dataset, was then circulated among members of the surgical department and made readily available on wards. After a 6-week period, a postintervention audit was conducted using the same methods.
Data analysis was carried out using SPSS statistical software version 20.0. Data were entered and coded numerically. Analysis was done using frequency, percentages, and comparison of means using independent samples t test with equal variances not assumed. P < 0.05 was considered statistically significant with 95% confidence intervals (not containing 0).
During the preintervention audit, 64 patients were handed over during a 1-week period. Patient details were written on plain sheets of paper in all handover sessions, but a wide variety of formats were used. After the introduction of a standardized proforma, 53 patients were handed over during a 1-week postintervention audit period, during which there was 86.8% compliance with the proforma. Although not formerly assessed, staff attitudes were generally positive toward the newly introduced proforma, and a number commented on the greater ease with which they were able to follow information written on handover sheets.
The proforma aimed to encourage the use of computer-generated patient identifier labels to improve the handover of patient demographics as defined by the inclusion of date of birth and hospital number, in addition to patient name. Before its introduction, labels were used for 52% (33) of patients, compared with 73.6% (39) afterward. There was improvement in the handover of patient demographics, although this unfortunately did not reach statistical significance.
Striking differences were seen in the quality of information handed over preintervention and postintervention (Table 1). There was a large increase in the proportion of patients for whom a location was documented, with ward and bed documented in 56% of cases preintervention and 87% of cases postintervention (P < 0.0001; 95% CI, 0.460–0.151). The results of significant or pending investigations were statistically significantly better recorded, and outstanding tasks were documented in 89% (47) of cases after the introduction of the proforma, compared with only 45% (30) in the initial audit period (P = 0.004; 95% CI, 0.439–0.089). In addition, documentation of blood results significantly improved with the use of the proforma (P < 0.0001; 95% CI, 0.523–0.226). Most notably, however, the proportion of patients for whom the occurrence of a senior review was documented increased from 28% (18) to 85% (45) (P < 0.0001; 95% CI, 0.717–0.419) (Figs. 2 and 3). There was no difference in the duration of the handover before (25 minutes) or after the intervention (27 minutes).
Improvements in all aspects of handover were shown with the introduction of a standardized handover proforma. Although it was not directly demonstrated that the use of this proforma improved patient care, this is inferred from the plethora of evidence supporting the importance of good handover.6,10–12 Among the surgical teams in our department, handover sheets are the method used to identify newly admitted patients and to keep track of tasks performed. Arguably, better documentation on handover sheets therefore leads to greater efficiency and prevents essential details of patient care being missed.
The main limitation of this study was that handover sheets were considered the only method of communication between surgical teams. In reality, it was witnessed that more detail was used in verbal handover, and occasionally, incoming teams wrote additional information in personal notes during such discussions. Additionally, although physicians in the handover sessions were not directly informed of the audit, our purpose was apparent and could be argued to have affected handover practice. However, from our experience of handover sessions before the audit, we did not note any obvious changes in behaviour or practice. An objective measurement of the acceptability of the proforma in the form of a questionnaire would have also strengthened the argument for its use.
Junior physicians within the hospital receive limited training in effective handover practice, and few were aware of the RCS guidelines before this study. However, it is these physicians who are primarily responsible for keeping handover lists and relaying essential information to incoming surgical teams. Furthermore, there is currently no formal hospital handover policy in this health board.
Unfortunately, it is not in our hospital alone that junior physicians feel underprepared for effective handover,10 nor are we the only hospital in which handover guidance is not provided to surgical physicians.8 We propose that surgical trainees would benefit from formal training, particularly in the foundation years, and there is clearly scope for development of a concise and easily accessible policy for safe and effective handover within the surgical department. This would, among other things, encourage continued use of a handover proforma.
Studies have suggested that electronic handover applications may further improve handover practice13,14 and may even reduce length of hospital stay.11 Although this would not currently be practical within our department, we recommend it be considered for the near future. Not only might this improve handover of clinical information but it would prevent the problems caused by lost handover sheets and would allow handover information to be accessed by more than one member of the team.
The use of a structured, computer-generated handover proforma significantly improved compliance with RCS guidelines within the surgical department of our hospital, and we recommend its continued use among on-call surgical teams. This is the first report in the literature specifically investigating general surgical handover practice and adds to the current evidence base on the importance of well-structured, formal handover practice.
1. Arora V, Johnson J, Lovinger D, et al. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care
2. DoH. An Organization with Memory. In: Department of H, editor. London 2000.
3. Bhabra G, Mackeith S, Monteiro P, et al. An experimental comparison of handover
methods. Ann R Coll Surg Engl
4. RCS. Safe Handover
: Guidance from the working time directive working party. 2007.
5. Ahmed J, Mehmood S, Rehman S, et al. Impact of a structured template and staff training on compliance and quality of clinical handover
. Int J Surg
6. Ferran NA, Metcalfe AJ, O'Doherty D. Standardised proformas improve patient handover
of trauma handover
practice. Patient Saf Surg
7. Tokode M, Barthelmes L, O'Riordan B. Near-misses and missed opportunities: poor patient handover
in general surgery
. Bull Royal Coll Surg Eng
8. Kennedy R, Kelly S, Grant S, et al. Northern Ireland General Surgery Handover
Study: Surgical trainees' assessment of current practice. Surgeon
9. Shafiq-ur R, Mehmood S, Ahmed J, et al. Surgical handover
in an era of reduced working hours: an audit
of current practice. J Coll Physicians Surg Pak
10. Cleland JA, Ross S, Miller SC, et al. "There is a chain of Chinese whispers …": Empirical data support the call to formally teach handover
to prequalification doctors. Qual Saf Health Care
11. Ryan S, O'Riordan JM, Tierney S, et al. Impact of a new electronic handover
system in surgery
. Int J Surg
12. Nagpal K, Abboudi M, Manchanda C, et al. Improving postoperative handover
: A prospective observational study. Am J Surg
13. Raptis DA, Fernandes C, Chua W, et al. Electronic software significantly improves quality of handover
in a London teaching hospital. Health Informatics J
14. Payne CE, Stein JM, Leong T, et al. Avoiding handover
fumbles: a controlled trial of a structured handover
tool versus traditional handover
methods. BMJ Qual Saf