Standardised handover

protocol: increasing safety

awareness
This Future Hospital Programme case study details how
Dr Shirine Boardman from Grantham and District
Hospital, United Lincolnshire Hospitals NHS Trust (ULH)
seized the opportunity to use the morning handover
meeting to increase safety awareness among staff and
encourage a ‘harm free’ culture. It also provided an
opportunity to enhance the learning and training of
junior medical staff, by highlighting relevant guidelines.

Authors: Dr Shirine Boardman, consultant in acute medicine, Grantham and

District Hospital

Key words: clinical effectiveness, patient safety, handover, mentoring

Improving patient safety

Key recommendations

 Enhance efficiency of the morning post-take ward rounds on the acute

medical unit (AMU) by incorporating both medical and nursing priorities.

 Make safety awareness part of the daily routine for medical staff and
encourage a ‘harm free’ culture where safety-related situations can be
reported and dealt with urgently, if needed.

 Likewise, incorporate learning from recent clinical incidents are, where

relevant, into the routine.

 Bear in mind the overnight teams will be tired from their shifts, as such
chair brief and relevant handover meetings every morning (30 minutes
maximum)

 To enhance the learning and training of junior medical staff, use the
meeting to highlight relevant guidelines including discharge criteria.

The challenge
 Increasing demand on adult acute medical unit (AMU).
 Care and handover discussions focused on medical rather than holistic needs of patients.
 Need for more accurate and timely reporting of patient safety issues and a continued push to
support an honest, open and supportive reporting culture.
 Need to ensure that learning from clinical incidents is remembered and applied in practice
whenever applicable.

Local context
Grantham is a small, rural district general hospital which provides urgent and emergency care for a
population of about 125,000. The hospital has about 100 medical acute beds and a ward for both
emergency and elective orthopaedics. The accident and emergency (A&E) department sees about
30,000 patients each year and local GPs work in A&E alongside the department’s clinical staff.

This AMU has 28 beds and a medical take of about 15 patients in 24 hours. It serves as both an
Emergency Assessment Unit and a short stay ward.

Our solution
 Enhance the efficiency of the morning medical handover by introducing a standardised
protocol for morning handover.
 Involve nursing team in handover discussions.
 Encourage immediate reporting of safety incidents.
 Promote learning and training of junior staff by supporting an open reporting culture in which
juniors and supervisors reflect upon their practice.

By incorporating safety awareness and reporting into our morning handover meetings, we have found a
simple and effective way for staff to think about safety as part of their daily routine.

Standardised handover protocol: increasing safety awareness © Royal College of Physicians 2017 2
Improving patient safety
The Francis Inquiry was clear in its vision to have safety culture deeply embedded in medical teams and
that training should be provided for new doctors. It is also an opportunity to ensure that learning from a
clinical incident can be recollected/highlighted if relevant to patients being handed over.

Make safety awareness part of the daily routine for medical staff and
encourage a ‘harm free’ culture where safety-related situations can be
reported and dealt with urgently, if needed.
Dr Shirine Boardman, Grantham and District Hospital

We have found the handover session also complements junior doctors’ training. In daily discussions
about patients and procedures that have taken place, the handover sessions provide a valuable
opportunity to keep trainees informed of guidelines. For example, if there has been an update to a
guideline that the junior doctor might not be aware of or not implemented at night, you can quickly
educate them.

The sessions also allow consultants to put in reminders about clinical practice and it has proven to be a
brilliant training opportunity where whole medical and nursing teams can be informed about a wide
range of important information, from board strategies (eg sepsis 6 audit findings which need
improvement) to a norovirus outbreak (and preventative strategies being put in place). I particularly like
having the opportunity to highlight a ‘lesson of the day/week’.

Staffing
Staff mix involves:
 three consultants (usually involving two consultants at any one time who also provide cover
for the critical care unit jointly with anaesthetists)
 two registrars (one of whom may be on nights or on call or leave etc)
 one acute care common stem trainee
 one Trust doctor
 one foundation year 1 and one foundation year 2 (ie total of 4 junior doctors – some of whom
might be on call/nights or on leave).

There are three handovers daily at 9am, 5pm and 9pm, the main handover being at 9am.

Methods
We introduced a standardised protocol for morning handover involving the following stages:

1. A member of the AMU medical team is designated as scribe and is assigned to document
patients’ needs and the tasks being handed over on the handover form, based on the template
recommended by the RCP. Usefully, the document includes a record of the names and grades of
those present.

2. During handover the night team present all of the new admissions to the AMU clinical team.
They describe any concerns they have about patients who are particularly unwell or who have
complex needs.

3. The night team reflect on potential safety issues during the night, with a particular focus on
patients whose condition is deteriorating and unexpected deaths. This allows for safety matters
to be identified on a daily basis and immediate action taken where necessary.

4. As soon as the night staff have concluded their report, they leave so they do not impact on
required rest period.

Standardised handover protocol: increasing safety awareness © Royal College of Physicians 2017 3
Improving patient safety
5. The day team hear from the senior nursing staff regarding any patients they have concerns
about or operational matters. Bed state and patients requiring urgent medication to take home
are sometimes highlighted, which facilitates efficient discharge from the AMU. Relevant audit
action or poor performance indicators, such as compliance with care bundles, infection control
priorities, recurrent prescribing mishaps, etc, are also sometimes highlighted. A senior sister
attends each handover in order to impart the information collected by the nursing team and
share any important social concerns they might have learned from the patients and families.

6. The consultant chairing the handover then reviews the medical staffing available for the day
and allocates junior doctors appropriately to maximise an efficient ward round

Barriers and levers

 There was a tendency to get into too much detail about a patient or get carried away when
discussing a safety incident.
 Junior doctors were not keen on a protracted handover.

There was a concerted attempt to keep the case presentations short and focused. A standardised
systematic handover was devised, which allowed the night team to leave after medical handover and
this was followed by the nursing report and the discussion around admission unit practicalities of the
day, which were of greater importance to the day team.

Outcomes
Patients are provided with more holistic care thanks to enhanced involvement of the nursing team. The
more detailed 9 am handover incorporates patient and nursing feedback on significant patient
circumstances, priorities or concerns, so that the subsequent morning post-take ward round allows a
more holistic care plan, which incorporates the patient’s perspective.

Additionally, necessary imaging/bloods for decision making, which have not been ordered by the night
staff, can be identified and ordered after handover. This improves efficiency as results return earlier,
facilitating decisions around discharges. It also allows treatment changes, which includes escalation of
care and discussions about diagnosis with patients/relatives.

‘By incorporating safety awareness and reporting into our morning

handover meetings, we have found a simple and effective way for staff to
think about safety as part of their daily routine.’
Dr Shirine Boardman, Grantham and District Hospital

An evaluation of the handover showed that junior doctors felt that there is improved reporting of
patient safety incidents. They also feel supported to report safety incidents were more confident in
presenting at handover and they describe improved communication between medical and nursing team
members.

In Grantham’s 2014/15 AMU Friends and Family test, 89% of patients would recommend the unit, whilst
the score for emergency care across the Trust was just 81%. On a recent survey done on patient
experience at our AMU using a validated questionnaire, the patient experience scores were higher in
almost all domains compared with published national results for AMU. To read how applying a validated
national survey to can help identify ward-specific areas that need improving upon from a patient’s
valuable point of view, read our story: A mechanism for measuring and improving patient experience on
an acute medical unit on the RCP website.

Patient feedback
The best care and understanding possible.

Standardised handover protocol: increasing safety awareness © Royal College of Physicians 2017 4
Improving patient safety
An excellent service throughout. Caring, efficient and friendly staff with a great sense of humour
who clearly enjoyed working together. If I need to visit a hospital again, I hope it will be
Grantham.

Benefits
There has been a reduction in hospital readmission rate for patients on CSII therapy and on CGMs.
This also has meant, in many instances, that patients have not had to take time off from their working
day or take the CYPD out of school to manage their diabetes. CSII therapy has resulted in reduced time
spent in hospital care even in patients with poor compliance who were repeatedly admitted with
diabetic ketoacidosis. We aim to audit this in the coming years.

What’s next?
The handover was formally evaluated by a team at the University of Lincoln. In the feedback from the
junior doctors involved, we found there was a real desire to keep the meeting short.

The feedback from the junior doctors clearly asked for the meetings to be kept concise. At the
beginning, there had been a tendency for the meeting to run over time if there were a number of
important things to discuss. This inevitably made it very difficult for the overnight team to concentrate
after a long shift.

Now, we take great care to start the meeting at 9am sharp, it is properly chaired and we remind teams
to be clear and concise in their summaries. As such the amount of information shared in the meeting is
limited to the most important points and after 30 minutes (the maximum length of time for each
handover) we welcome anyone with further things to discuss to meet with the relevant people.

Supporting materials
If you would like to see a copy of the EAU handover form at Grantham and District Hospital, please
contact the Future Hospital Programme: futurehospital@rcplondon.ac.uk

This case study is not an endorsement of any individual or organisation. The material within is
promotional only and we do not necessarily reflect the views of the author and the organisation they
represent.

Future Hospital Programme

Royal College of Physicians

11 St Andrews Place
Regent’s Park
London NW1 4LE
Tel: +44 (0)20 3075 1585
Email: futurehospital@rcplondon.ac.uk
www.rcplondon.ac.uk

Standardised handover protocol: increasing safety awareness © Royal College of Physicians 2017 5