Clinical Handover of Immediate Post-Operative Patients: a Literature Review

Volume 31 Issue 2 Article 4

6-1-2018

Clinical handover of immediate post-operative patients: A literature review

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Recommended Citation Clarke, Samantha; Clark-Burg, Karen G.; and Pavlos, Elaine (2018) "Clinical handover of immediate post- operative patients: A literature review," Journal of Perioperative Nursing: Vol. 31 : Iss. 2 , Article 4. Available at: https://doi.org/10.26550/2209-1092.1029 https://www.journal.acorn.org.au/jpn/vol31/iss2/4

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Authors Samantha Clarke Clinical handover of immediate M App Sc, BN, RN The University of Notre Dame, Australia post-operative patients: Conflicts of interest: None to report. Associate Professor Karen Clark-Burg A literature review PhD, MBA (Executive), BN, Dip Bus, RN The University of Notre Dame, Australia Abstract Conflicts of interest: Manuscript reviewer for ACORN. The transfer of professional responsibility for some or all aspects of patient care, within and between professional groups on a Professor Elaine Pavlos MN, MBA, RM, GAICD. temporary or permanent basis, is termed clinical handover. The University of Notre Dame, Australia Communication during clinical handover is considered a Conflicts of interest: None to report. challenging patient safety problem. A key principle of transfer Corresponding author of professional responsibility for patient care is the minimum amount of information or content that must be contained and Samantha Clarke The University of Notre Dame, Australia transferred in any particular type of clinical handover. E: [email protected] Aim: The purpose of this literature review was to establish the scope of the literature about clinical handover from the operating room to Post Anaesthesia Care Unit (PACU) published in the last ten years and identify relevant key sources, theories, concepts and ideas. Method: The literature included in this review is divided into policy framework, practice, theoretical and primary research literature. Findings: This literature review demonstrates that either clinicians perceive clinical handover as informal, unstructured and inconsistent or transfer of information in handover as incomplete or unclearly expressed. Anaesthetists and PACU nurses differed in expectations of content and timing of information transfer. Conclusion: There is a need to develop training and educational strategies to improve clinical handover practice, particularly in a way that encourages collaboration. Keywords: clinical handover, post-operative, literature review, observational studies, interventional studies. Background Australian Commission on Safety and Quality in Health Care (ACSQHC) is The World Health Organization the lead technical agency for conduct (WHO)1 recognised communication and governance of the WHO ‘High 5s during patient care handover as project’ in Australia4. one of five challenging patient safety problems. This led to the Clinical handover has been defined launch of the ‘High 5s project’ in in National Safety and Quality Health standardising efforts for patient Service (NSQHS) Standards5 as ‘the safety1-3. The WHO4 stated in an transfer of professional responsibility interim report that ‘five standard and accountability for some or all operating procedures were drafted; aspects of care for a patient, or group however, due to resource constraints, of patients, to another person or only two were fully developed professional group on a temporary and implemented’ which were or permanent basis’(p.5). A standard namely ‘medication reconciliation’ key principle is the minimum amount and ‘correct site surgery’(p.9). The of information to be transferred

Journal of Perioperative Nursing Volume 31 Number 2 Winter 2018 acorn.org.au 29 in any clinical handover that is qualitative and quantitative methods Inclusion and exclusion criteria inherently involved with the transfer will enable exploration of the whole Literature that met all three of the of responsibility. This is termed the story. Qualitative methods will enable following criteria was included in this ‘minimum data set’ and defined as an understanding of clinicians’ review: ‘the minimum set of information and needs, perceptions and behaviours, content that must be contained and in contrast to quantifying various • published in the last ten years transferred in a particular type of objective outcome measures related • relevant to the perioperative clinical handover’5. to clinical handover that is specific to setting this type of research inquiry. Clinical handover takes place at • incorporated the transition point many transition points between Methods of care from the operating room to professional interfaces within the the PACU. perioperative setting and in the This literature review of practice broader context of heath service standards, theoretical frameworks Literature that met all three of the delivery6. Transfer of patients and primary research literature following criteria was excluded from from the operating room to the published in the last ten years is this review: focused on clinical handover practice PACU involves inter-professional • transition point of care from the from the operating room to the PACU communication. At this transitional operating room directly to intensive of post-operative patients. Search point in care, when emerging from care unit or coronary care unit (not strategy for the literature, conducted anaesthesia, patients are clinically via the PACU) at high risk due to altered level of in March 2017, used key terms and consciousness and compromised combinations with Boolean operators • grey literature (unpublished airway7,8. and word truncations according to literature without peer review) database requirements to source • all information was available in the all possible keyword terms. Search Purpose published literature report for data terms included: post-operative, The purpose of this literature review extraction. recovery, Post Anaesthesia Care was to establish the scope of the Unit, handover, handoff, information There were 15 observational studies published literature available on transfer, communication, structured and 12 interventional (standardising) clinical handover from the operating communication, checklist, standards, studies included in this review. room to the PACU and identify education, training, safety, quality, The data that was extracted from relevant key sources, theories, quality improvement, adverse each primary research study was concepts, and ideas to understand events, omission and error. Search included into a table format with and ascertain the current knowledge terms were entered for each of the headings of lead investigator, base of this subject area. the following databases: Cochrane year of publication, country of A guiding research framework to Database of Systematic Reviews, origin, setting, sample size, research improve clinical handover practice Cumulative Index to Nursing & design, methods, aims, intervention proposed by Jeffcott and others9 Allied Health Literature, MEDLINE, (if included), instrumentation, identifies information transfer, EBSCO host research database, outcome measures, key findings and responsibility and accountability Ovid Technologies Incorporated, implications for practice. within systems as the three elements Joanna Briggs Institute and PubMed. of clinical handover. Measuring Additional studies and literature Results these elements together with were obtained from reference The literature included in this review policy, practice and evaluation will lists of retrieved papers. Other are divided into policy framework identify multi-dimensional gaps and information sources were hand literature (n = 3), practice literature underpin research to improve clinical searched and included: Policy and (n = 3), theoretical literature handover. Therefore, the elements of Practice Standards, WHO website (n = 2) and primary research information transfer, responsibility and their Institutional Repository for literature (n =27). and/or accountability within systems Information Sharing (IRIS) database. were posed a priori in structuring Policy framework literature and organising the research literature The ACSQHC developed the NSQHS 9 to date. Jeffcott et al. emphasised, Standard 6: Clinical handover5 with due to the complexities of handover, the intention of ensuring ‘timely,

30 Journal of Perioperative Nursing Volume 31 Number 2 Winter 2018 acorn.org.au relevant and structured clinical The Australian College of active participation and use of handover that supports safe patient Perioperative Nurses (ACORN) 14 opinion leaders15,16. care’(p.7). Key criteria were outlined in provides statements, criteria and three core or developmental areas rationale for both the anaesthetic Discussion to achieve this national clinical nurse and PACU nurse roles which Improving the measurement of handover standard and for purposes directly relate to clinical handover. clinical handover, with the elements of health service organisation Nursing role statements of clinical of information transfer, responsibility accreditation which are as follows: handover cover the systematic and/or accountability within systems structure of clinical handover 1. governance and leadership posed a priori in structuring and using evidence-based handover for effective clinical handover organising, was found in the research communication tools when actively 9 systems literature to date . This is similar to engaged in the comprehensive findings of a qualitative observational 2. documented and structured exchange of information and in study which reported that the three clinical handover processes the reallocation of the nurses’ objectives of clinical handover in responsibility. 3. mechanisms to include patient the PACU were knowledge transfer and carer in clinical handover Theoretical literature and about the surgical patient, transition processes. perspectives of responsibility, and provision of an ‘audit point’17. Training of clinical workforce Multiple interfaces between is identified as a key task in professionals, managers and Information transfer implementation strategies in using administrators with differing focuses The handover of post-operative policy, procedure and/or protocols and priorities within complex health patients has been qualitatively surrounding clinical handover. delivery systems makes quality described as informal, unstructured, Furthermore, policy surrounding improvement interventions to and inconsistent17,18, which is clinical handover are suggestive change clinical practice challenging similar to incomplete information of including mandatory education and require well-informed theory- or information omissions and training sessions for the 15 based strategies . Theories about consistently reported in quantitative clinical workforce. Resources have complexity of changing practice observational studies18–23. been provided by the ACSQHC are comprehensively covered by Alternatively, in a separate study with that guide implementation to 16 Grol and Wensing . Impact theories differing outcome measurements, support structured processes and describe how a specific intervention Randmaa et al.24 described improvement in clinical handover10,11. will facilitate desired change and information was expressed unclearly Practice literature are directed at the ecological level by the sender and less than half of individual professional, social of the verbally given information In a statement of the handover setting, organisational, political and was remembered by the receiver responsibilities of the anaesthetist, economic context. Theories about in observed handovers. Critical the Australian and New Zealand social interaction and context are incidents have also been associated College of Anaesthetists (ANSCA)12 impact theories that encompass with poor communication25,26. Professional standard 53 clearly theory of communication, social Incomplete handover has been outlines the responsibility and learning theory, social network associated with source, transmission accountability of the anaesthetist and influence theory, theories and receiver failures in information during and after completion of teamwork, professionalism transfer and communication of anaesthesia12. Within this and leadership that overlap in in the post-operative setting18. professional standard direct implementation of clinical practice Furthermore, inherent professional statements are made regarding changes. To date, there is no and organisational tensions have effective communication between theoretical framework published on been described in the process of health professionals in sharing the process and learning of clinical safely handing over a patient in the care. A background paper to this handover in the perioperative setting. PACU17,21,25–30. professional standard discusses Furthermore, in the assessment clinical handover delivery as divided of learning, a needs assessment is In observational studies, a large into four stages: prepare, organise, required with consideration given to variation between instrumentation environmental awareness and use of duration and space of educational and outcomes measurements communication tools13. activity, group composition exists between studies reviewed. (particularly inter-professional), The countries of origin may

Journal of Perioperative Nursing Volume 31 Number 2 Winter 2018 acorn.org.au 31 have impacted on some of this content, structure, procedure or responsibility and/or accountability variation with differences in clinical guidelines24,29–31. Minimum standards of each professional interface12,14. governance and professional for content of clinical handover of Communication tools have organisations, as studies have verbal (ISOBAR mnemonic) and non- incorporated recommendation/ originated from the United States verbal information (ten-point safety responsibility/referral as part of a of America26, Canada21, Australia25,28, checklist) have been proposed25,28. mnemonic structure22,24. However, United Kingdom and Europe17–20,22,27,29,30, Despite differences in methodological worthy of exploration is clinicians’ Netherlands31, Germany23 and approaches, consensus was reached understanding of their responsibility Sweden24. that standardisation of information and accountability for clinical transfer improves patient safety17–31. Nonetheless, anaesthetists and PACU handover from differing professional Standardisation is proposed to nurses differed in expectations of interfaces in assessing the current assist with informal, unstructured content and timing of information knowledge base. and inconsistent transfer of transfer17,21,27. An element of familiarity information18,22,25,26,29–31 and aids in with and the briefness of handover Systems memory18,24,30. has been described in several Lack of knowledge has been qualitative studies, with the sender Standardising the content alone identified as associated with often using terms such as ‘my usual’ does not suffice to complete communication breakdowns and or ‘routine’, and ‘happy’ with the information transfer. The importance failures30,32. Developed communication completed handover process17,25,27,28. of assessment, planning and tools such as information transfer decision making with structuring The safe process of Connect, Observe, assessment tool for surgery or the communication tools, such as Listen and Delegate (acronym mnemonic-based SBAR provide mnemonics like SBAR (situation, COLD) in transition of care from quantifiable objective feedback background, assessment, the operating room to the PACU to clinicians and organisations in recommendation), should also occurs either simultaneously or targeting behaviours for improvement be considered in the process of 19 sequentially25,28. PACU nurses have and training . When developing communication25,28,29. It is considered identified the need to connect training interventions, Manser and essential that the PACU nurse has 29 and receive clinical information others recommended attention be complete information from previous simultaneously as concerning. These given to patient assessments and transitions of care, particularly as nurses agreed it was necessary to acknowledgement stages rather than PACU nurses are considered the only stabilise the surgical patient before just focusing on complete information ‘bridge’ in transferring information 29 commencing clinical handover and transfer . Importantly, as Siddiqui et from the operating room to the next 21 that a clear sequence of clinical al. highlighted, the communication point of transition in care17. handover is required in content process is taught informally in 28 professional practice in Canada. delivery . Although receiving Accountability and/or information and transferring responsibility The situation is similar in Australia, equipment simultaneously is less as highlighted in a recent survey Earlier observational studies have preferred than doing these things of health professionals that was consistently cited ambiguity, failure sequentially, it was alarming that not setting specific, sampled from to make plans and delegating the most observed occurrence public health services in four states responsibility as associated with in the published studies was the or territories in Australia (n = 707, error in clinical handover17,20,25–27,30. simultaneous occurrence which response rate 14 per cent)32. Nurses From Canadian origins, Siddiqui contributes to reduced attention, (60 per cent), doctors (22 per cent) and others21 proposed possible disjointed focus, diminished listening and allied health (18 per cent) causes of inconsistent transfer ability and thus a negative effect on made up the health professionals. of patient information between the memory of the receiver17,18,22,25,28,30,31. Respondents acknowledged the value professional interfaces is the lack of communication skills (99 per cent) The evidence base in support of of guidelines from professional and considered handover training standardising the process of clinical organisations about required content should be included in undergraduate handover gained momentum with or conduct. Practice standards within (53 per cent) and postgraduate the realisation that there was wide Australia, for both anaesthetists and (36 per cent) university courses32. variability in practice and with perioperative nurses clearly outline clinicians identifying lack of standard Participants reported receiving no handover training and that more

32 Journal of Perioperative Nursing Volume 31 Number 2 Winter 2018 acorn.org.au training was required (27 per cent), Despite the noted differences in inconsistent in the reality of whereas other participants reported standardising techniques used practice receiving handover training though in interventional studies, studies • national standards for clinical also identifying that more training reported that standardising the handover in Australia were was required (38 per cent). Survey content, structure and/or process published in 2012 respondents perceived the most improved information transfer, effective training methods were teamwork and satisfaction, whereas • consensus was reached across workshops (71 per cent), followed a reduction in patient length of stay all studies that standardisation by online and print resources (47 and task errors was also a significant of information transfer improves 33–37,43,44 per cent). Furthermore, in an open- finding in reviewed studies . patient safety ended question of suggestions to The use of communication tools improves structure and/or content • anaesthetists and PACU nurses improve clinical handover, education differed in expectations of content was one of four themes that of information transfer between 36–40,43 and timing of information transfer. emerged alongside mode of delivery, professionals . Compliance standardisation and contextual with using communication tools is Findings with implications for issues. improved with training session/s or education include: an education program37,39–42. Barriers Standardising clinical handover to improvement of clinical handover • lack of knowledge has been were identified as lack of knowledge associated with communication It is worth noting the clear and the impact of time and shift work breakdown and failure differentiation between reviewed implications on undertaking training interventional studies and what • needs assessment is required of session/s41. Based on this review each study was standardising in the knowledge base in clinical of interventional standardising handover process the process of clinical handover. studies, it is concluded that limited The noted differences between research attention has been given • development of training standardisation included: to the development of education interventions requires attention • standardising protocol of clinical and training strategies to improve to patient assessment and handover33–36 clinical handover practice in the PACU acknowledgement phases setting. Furthermore, the theoretical • the communication process is • mnemonic communication tools basis of learning the process of in the transfer of content and taught informally at undergraduate clinical handover has received little and postgraduate level in each structure of information such as exploration as a way to improve professional interface situation, background, assessment, clinical handover practice in the 37–41 recommendation (SBAR) and perioperative setting and, perhaps, • education and workplace training SBAR progressions including more broadly. Arguably, clinical needs to be targeted at individual, introduction (I) as ISBAR42 and handover involves multiple processes professional and organisational Questions (Q) as ISBARQ43. An and professional interfaces that factors associated with American study used a mnemonic require consideration when guiding communication breakdown. communication tool of illness the development of education Findings with implications for severity (I), patient summary (P), and training strategies for clinical research include: action list (A), situation awareness handover improvement. (S) and synthesis by receiver (S) • workplace training and education as I-PASS36, which was different to Implications in clinical handover is a unique another American study that used This review identified a number and separate process that warrants key content items44 of findings that have implications research attention aside from the process of clinical handover itself • an education or training for perioperative nursing practice, component was included education and research. These • no published theoretical framework in some but not all studies findings are summarised in Table 1. exists for the process and learning when standardising content Findings with implications for of clinical handover and structure of information practice include: • few studies have focused on transfer34,37,39–42. • clinicians perceive that handover clinical handover training and is informal, unstructured and education of anaesthetists and perioperative nurses.

Journal of Perioperative Nursing Volume 31 Number 2 Winter 2018 acorn.org.au 33 Conclusion 6. World Health Organization. Transitions of 19. Nagpal K, Vats A, Ahmed K, Vincent C. An care: Technical series on safer primary care evaluation of information transfer through This literature review has [Internet]. Geneva: WHO; 2016 [cited 2017 the continuum of surgical care. Ann Surg presented that communication of March 30]. Available from: www.who.int/iris/ 2010b;252(2):402–407. handle/10665/252272. patient handover is considered a 20. Nagpal K, Abboudi M, Fischler L, Schmidt 1 7. Scott B. Airway management in post T, Vats A, Manchanda C et al. Evaluation of challenging safety problem . National anaesthetic care. J Perioper Pract post-operative handover using a tool to standards for clinical handover 2012;22(4):135–138. assess information transfer and teamwork. provide best practice criteria at 8. 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On behalf of the ACORN board and members, we congratulate our very own Tracey Nicholls, Member Director 2016–2018, on winning the 2018 South Australia Nursing and Midwifery Excellence Award. The award was announced at the 18th Annual Nursing and Midwifery Excellence Awards Gala Ceremony on Friday 11 May 2018. Tracey’s nursing career spans over 40 years and more than half of these years have been in the operating room. She has presented at national and international events and, as immediate past president of the Otorhinolaryngology Head and Neck Nurses Group (OHNNG), has run many education sessions, study days and 12 national conferences as well as organising and assisting in surgical dissection/instructional courses. Tracey has established a large personal and professional network with leaders of and members from many national and international nursing organisations. She serves on the SAPNA committee, South Australian committee for Australian College of Nurse Practitioners and is a member of the Coalition of National Nursing and Midwifery Organisations board. Tracey and Flinders Medical Centre Nursing Director, Annette Boonen, at the 18th Annual Nursing and Midwifery Excellence Awards Gala Ceremony

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