Miscommunication and Handover in the ED

Eavesdropping

Image courtesy of Jeroen van Oostrom / FreeDigitalPhotos.net

Image courtesy of Jeroen van Oostrom / FreeDigitalPhotos.net

On my last set of night shifts I was reviewing a patient on our observation ward when I overheard the following nursing handover:

“Mrs Jones is waiting for ophthalmology to close her eyelid wound. She had a fit and was found at the top of the stairs.”

Now.

This was frustrating for me.

Why?

Because while Mrs Jones might have been waiting for ophthalmology to review and close a wound on her eyelid, the reason she was on the observation ward was actually because she was found at the bottom of the stairs following her fit, not at the top, implying an altogether more sinister potential mechanism of injury. She had also had a CT brain, a fact omitted from the handover. The purpose of her admission was for neurological observation following a head injury; the eyelid wound was a by-product of the trauma itself and had the need for a review by ophthalmology been the sole reason for her continued presence in the hospital she would probably not have needed to be admitted to the observation ward.

Of course, the situation above is fictional, combined from a number of real-life clinical scenarios. But something similar happened recently, and not for the first time, and it made me wonder; why, when I’ve spent five minutes writing a legible, succinct history in the notes, is misinformation being passed on?

Chinese Whispers

Image courtesy of David Castillo Dominici / FreeDigitalPhotos.net

Chinese Whispers is a children’s game (called Telephone in the US) in which children pass on what they think they’ve heard in a message whispered by another child. The receiver has a single opportunity to hear the message and then has to pass it on. Usually the message becomes more and more corrupted until by the end of the line or circle it is unrecognisable from its original form. The name of the game is archaic and may be considered offensive but the concept resonates deeply enough for the phrase “Chinese whispers” to have been adopted into common parlance in the UK.

The game is essentially about the quality of communication.

OK, it isn’t packaged as such and I imagine the opportunities to break down, feedback and reflect on the task afterwards are not often seized at birthday parties, but there is a message we can take from it into our clinical practice. Misinformation is easy to pass on and near impossible to correct.

The difference, of course, between Chinese Whispers and clinical handovers is that we take every opportunity to hear the information being shared and we are all trained in communication so we do a great job of paying attention when our colleagues try to share clinical information and we always check what we have understood is the right information.

Except we don’t. And let’s face it – we should.

Photo courtesy of jamingray (Flickr)

Photo courtesy of jamingray (Flickr)

Why are we so bad at this?

I’m a pretty nosey person, to be honest. I think it makes me good at my job – I am quite good at overhearing conversations which have led to me getting involved in the care of patients in the ED who actually really needed it (without my being invited to do so). I like to know what is going on and I think that’s a skill which becomes more important the more senior I become. But until now I’ve been lazy with my handovers, I’ll admit.

Yes, I always seek out the nurse looking after the patient I’ve seen and explain my assessment and plan to them. But I’m not as thorough or structured as I ought to be. And recently I’ve confused the medical SHO on call by asking her to “have a look at a patient” (rather than stating that I wanted to refer the patient to her).

There are lots of reasons we are bad at passing on clinical information. We think we’re good at it. We are rushed. We have lots of patients waiting and a million things to do. And we forget that communication is a two-way process, which means there is responsibility for both parties.

There is additional risk in the ED. As doctors we rarely have co-ordinated team handovers (due to shift work and unpredictability of our workload). We often have multiple single-patient handover events; from a paramedic crew on arrival, between doctors going off shift, from the nurse looking after the patient when we go to start a clinical assessment and then back to the nurse once we have formulated a plan, to our seniors or colleagues when cases aren’t straightforward, to our specialty colleagues when we make a referral. The same patient’s story is told multiple times to different people and so it’s easy to see how information can be misinterpreted.

But handover is important – really important – so much so that the National Patient Safety Agency (NPSA) says, in the BMA’s Safe Handover, Safe Patients document:

Handover of care is one of the most perilous procedures in medicine, and when carried out improperly can be a major contributory factor to subsequent error and harm to patients.

So what can we do to make things better?

Better Sharing

There are lots of things we can do, change and think about in order to share information in a more effective and efficient way, whether face-to-face or over the telephone.

Communication - 5S

Summary first

Start with a succinct summary of the patient’s main problem: “this 46-year-old man needs further assessment following a collapse on exertion as I think he has critical aortic stenosis.” This will often win you the admission battle before you begin and ensures the main message is clearly communicated making use of the primacy effect.

Speed 

This is my main challenge – the most common feedback I hear about teaching and presentation sessions is that I speak ridiculously quickly (if you don’t believe me, check this out and believe me when I say that I slowed down a lot for this). Make sure the receiver is ready before you start and consciously speak slowly and clearly. Pause frequently and listen out for active listening noises to signal that the receiver is ready for more information. Put aside the time pressures of the ED and remember that this is one of the most important things you will do.

Structure

Using a recognised structure (and signposting to it) helps aid the retention of information. This might be SBAR (situation, background, assessment, recommendations) or ABC (airway, breathing, circulation) according to the nature of the handover you are giving. This recently published (and open access!) JAMA study describes how introducing a standardised handover reduced errors among paediatric inpatients.

Simplicity

Cut out unnecessary information. We get better at doing this in our consultations; our medical notes are not a complete transcription of our interactions with patients but should contain more detail than the verbal exchanges we have. If you are talking to me as your senior for advice on a patient, you do not need to regurgitate the entire consultation. Neither should you read verbatim the history you have just written in the patient’s notes. Either one of these things will cause me to switch off entirely and disengage from you as you try to overload me with unnecessary information. Stick to the important positives and negatives.

Summary (again)

When you have finished, repeat your initial summary sentence. This will reinforce the primacy/recency effect and signal that you have finished your side of the exchange.

Better Listening

We also have a responsibility to be better listeners and take ownership of the flow of information we receive. There are also several things we can do to improve our performance here.

Handover 5S2

Sit Up

By this I mean we need to focus on the incoming information and become active listeners. This might mean you need to ask other people to stop talking (for an ambulance handover in resus), put away your phone, move to a different area of the department or ask the other person to wait while you finish assessing an ECG or requesting a chest x-ray so you can give them your full attention. Interruptions are rife in the ED and impede our ability to process information, potentially contributing to medical error. Interruptions are very much part of the ED but we need to protect against them when important information is being exchanged (for this reason, night shift to morning shift handover at St Emlyn’s now occurs in the ED seminar room away from the shop floor).

Shut Up

This is another tricky one for me: do not interrupt the giver of information. In doctor/patient consultations we are notoriously bad at this with one study finding that only 23% of patients completed their opening statement (there’s more info on this here). It’s incredibly tempting to interrupt someone who is committing the crimes mentioned in “Simplicity” above – especially in a busy ED with 3hr wait to be seen and a queue of other people waiting for a piece of your time – but try to resist! Focus on what is being shared. This will also prevent you asking clarification questions the information giver has already answered; if someone has ever done that to you, you know how frustrating and demoralising that feels.

Sure Up

When the information giver has finished talking, now is the time to ask questions to clarify anything you didn’t quite understand or to obtain information not originally shared. Be polite though :-)

Sum Up

When the conversation is finished, you can check you have an accurate shared understanding by using SBAR to make your own summary of the clinical scenario and next steps. This provides a final safeguard against anything which might have been misunderstood, allowing the information giver to ensure you are on the same page.

Supplement

Lastly, READ THE NOTES - the ambulance sheet (PRF), the triage notes, the nursing notes, the medical notes, the GP referral letter… We know that patients retain information better if we give them written reinforcement – Cochrane tells us so! And we think we are better than patients – but we aren’t. Read the ED notes or medical clerking to consolidate the information you have received.

And what now?

This is simple stuff, right? At the end of the day we are fallible, busy human beings who try our best to do the right thing by our patients and to keep them safe. Handover is an area we are making mistakes we can avoid – ones which can have potentially serious consequences. Let’s take responsibility for communicating with our colleagues in more effective and accurate ways; it’s time well spent.

At St Emlyn’s, we (Simon!) are trying to include frequent high-fidelity simulation with opportunities to watch a video of our own efforts. A recent simulation in our resus area showed me just how bad I can be at listening to a handover – especially if it isn’t delivered in a structured way. Having me (as the senior doctor/registrar) join a junior doctor part-way through a sim scenario wasn’t planned but actually reflected real life in the ED better and brought out extra human factors issues I hadn’t been aware of. I would definitely encourage you to make handover of information (paramedic to nurse, nurse to nurse, nurse to doctor, junior to senior… lots of options here) part of your sim practice. It’s something we can all do better.

Nat

 

 

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  1. I love this – not least because I speak in 50mbps data transfer and am listening to two conversations during sign out. But also, framing the giver of a handoff as delivering DC instructions w responsibility to check playback, and the receiver of handoff as the listener of an HPI (who should not interrupt the “pt.”) is hugely useful towards getting those behaviors adopted. Great stuff.

  2. I love this. Not least b/c I speak at 50mbps and am listening to 2 other convos during sign out. But mostly b/c framing it as person giving handoff is giving DC instructions and is responsible for checking if message received, and person receiving is listening to the story of HPI and shouldn’t interrupt the speaker, makes the likelihood of buy-in and actually doing something different much more likely.

  3. Nice post Nat – Chinese whispers are dangerous

    Implicit is the thought in the back of our mind that someone will actually READ our notes – as you know, this doesn’t happen – primary care physicians letters aren’t read, ED notes aren’t read, previous notes are ignored.

    Some advocate this as a reason to have eHealth records – an electronic record that is accessible to all across primary/secondary/tertiary care

    I had the privilege of working in a brand spanking new hospital in regional NSW in 2011 – moved from the tired old base hospital a few km down the road to a purpose built, all new kit multimillion dollar institution.

    One of the advancements was electronic notes

    But here’ s the rub – the ED used different system to the ICU – which used a different system to the Theatre – which used a difference system to the wards!

    So…we had the same issue of chinese whispers – errors in transcription as patients moved form one set of eHealth records to another.

    Even within the ICU, where we had one set of PC-based notes, it was not uncommon to see that people didn;t read the previous day’s notes – because of the need to use multiple mouse clicks to swap between previous days and current notes views…

    Best handover?

    I make everyone STFU in the resus bay and hear the ambos handover before the patient is transfered to bed

    When referring, I try to lead the medical or surgical reg to the bedside and do an end-of-bed handover, with the patient and relatives.

    Good post

  4. If you think about ED shift signout as a procedure – It certainly is a high risk one. This is well documented in medical – legal proceedings. Up until now, there has been little written on how to safely and effectively perform this procedure. Thanks. The video/sim examples of the very good and very bad sound like a great idea

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