‘The ABC of Handover’: impact on shift handover in the emergency department
- 1Emergency Department, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
- 2Centre for Patient Safety and Service Quality, Department of Surgery and Cancer, Imperial College, London, UK
- Correspondence to Dr Maisse Farhan, Emergency Department, First Floor QEQM, St Mary's Hospital, Praed Street, London W2 1NY, UK;
Contributors All authors designed the study. MF collected and analysed the data. RB and MW reviewed the data analysis. MF wrote the manuscript. All authors contributed to its revision.
- Accepted 20 November 2011
- Published Online First 28 December 2011
Introduction A study was undertaken to test the impact of a new tool for shift handover, ‘The ABC of Handover’, in the emergency department (ED). The impact on shift handover following implementation of this structured tool, the effect on clinical and organisational aspects of the subsequent shift and the opinions of users of this new tool are reported.
Methods A prospective observational before and after study was performed to explore the effect of implementing ‘The ABC of Handover’ on clinical and organisational practice using a questionnaire.
Results 41 handovers were observed before implementation of ‘The ABC of Handover’ and 42 were observed after. The new tool was successfully implemented and resulted in a change of practice which led to a significant increase in the operational issues mentioned at handover from a mean of 34% to a mean of 86% of essential items with the ABC method. Over the study period, middle-grade staff demonstrated improved situational awareness as they adopted proactive management of operational issues such as staffing or equipment shortages. All participants reported that ‘The ABC of Handover’ improved handover regardless of the seniority of the doctor giving it, and found the ABC method easy to learn.
Conclusions Successful implementation of ‘The ABC of Handover’ led to a change of practice in the ED. Improving handover resulted in better organisation of the shift and heightened awareness of potential patient safety issues. The ABC method provides a framework for organising the shift and preparing for events in the subsequent shift.
Transferring the management of patients and the department is a time of increased risk to patient safety, and studies have highlighted the importance of standardising the method with which handover takes place.1–4 However, there are no unified recommendations for best practice of handover in the emergency department (ED). ‘The ABC of Handover’ described in our previous study5 provides a standardised and validated tool for shift handover which is evaluated in this study.
Formal training and structure of handover is not widely available in healthcare,6 and handover has been reported in a survey of UK doctors to be of good quality only in a minority of cases.7 The responsibility of shift handover traditionally lies with the senior doctor and nurse in charge of the shift. Effective shift handover is complex,8 but is vital for the smooth, efficient and safe transition between shifts in the ED. Many factors affect the ability of one middle-grade staff member to hand over such a complex environment, such as environmental factors (location/completing demands), team factors and lack of standardisation of the handover method.6 Knowledge of the environment and status of the department at the beginning of a shift will allow ED middle-grade staff members to anticipate problems and respond appropriately. This anticipation, information gathering and communication together with team working are the basis of non-technical skills key to patient safety.
The new method described by ‘The ABC of Handover’ provides a mnemonic familiar to emergency medicine that summarises essential information necessary for managing the subsequent shift. This study assesses the effect of ‘The ABC of Handover’ on organisational and clinical aspects of the ED shift. It has been widely recognised that handover constitutes a vulnerable time for transfer of information to ensure continuity of care. Improving the process of handover will therefore serve to enhance the communication process and increase the reliability of information transfer.
St Mary's ED is in a London teaching hospital with an annual rate of new attendances of 80 000 with a separate paediatric ED. This study was based in the adult ED, geographically set in a similar layout to most UK ED departments with ‘Resuscitation’, ‘Majors’ and ‘Minors’ areas and a 12-bed Clinical Decisions Unit (CDU) adjacent to the ED. There are three daily consultant-led ward rounds at 08:00, midday and 16:00. The middle-grade member of staff assigned the overall responsibility for the department leads a ward round at 22:00. Doctors' handover occurs at the 8:00, 16:00 and 22:00 ward rounds and nurses have a separate handover that follows the nursing shift pattern. The consultant leads the board/ward rounds and frequently delivers teaching and directs the clinical management of patients discussed, and supervises handover between middle grades.
The rota is compliant with the European Working Time Directive (EWTD) and takes into account recommendations by the Royal College of Physicians on handover,9 with an overlapping hour dedicated to clinical handover at shift change-over times.
Before this study the routine practice for handover and board rounds in the department was to conduct a brief overview of all the patients in the ‘Resuscitation’ and ‘Majors’ areas and CDU. The majority of cases were briefly discussed and decisions were made accordingly, with the consultant delivering teaching. For some patients, further review took place after the ward round or handover. Patients in the CDU were usually reviewed several times a day either by the consultant or the middle-grade staff member in charge of the shift. There was no other structure or routine format for handing over operational or organisational issues except on an ad hoc basis when the consultant would request this information from the nurse in charge. The amount of information exchanged at handover was dependent on the clinicians present.
This is a prospective observation study of a series of handovers and associated events before and after the implementation of ‘The ABC of Handover’ tool.
Observations were carried out over a 13-week period to record the quality of 41 handovers before the tool was implemented and a 12-week period observing 42 handovers after implementation. No formal power calculation was carried out as it was difficult to determine what would be considered a significant improvement in handover in this area that lacks evidence-based interventions. All doctors were aware of the observations occurring but were not informed at any stage of the items on the checklist used to judge the quality score of handovers. A preformatted measurement tool, the Handover Quality Score, was used to score handovers which included 20 items deemed necessary for shift handover.
Data were collected on the following aspects before and after implementation of the ABC tool.
Content of handover
This reflected compliance with the ABC of Handover tool. One researcher (MF) observed a series of handovers and recorded their content using a Handover Quality Score checklist. All observations were carried out using a preformatted checklist which was derived from ‘best practice’ interviews reported in the accompanying paper.5 Following each handover, information regarding that shift was collected to compare events that had occurred during the previous shift with the amount of information that was passed at handover. This was to determine whether any items missing from the ‘best practice’ were correctly not mentioned (because there was nothing to discuss) or whether they were relevant to the shift but were missed out at handover.
Sources of information for each shift included the following:
– Hourly attendance audits for each shift from the IT system ‘Symphony’
– Staff rotas and sickness reports
– Manual check of equipment in the department after every handover
– Information collected from the nurses' daily log of the shift
– Information from the nurses' daily communication book
– Review of deaths from the electronic patient database
– Review of critical incidents reported by ‘Datix’
– Daily ‘breach’ report for each shift (patients staying in the ED >4 h)
In addition, a verbal enquiry at the end of every handover was made to the nurse in charge to establish whether any other significant event had occurred.
Impact on the organisation of the next shift
This reflected the response of the middle-grade staff to potential operational problems—that is, whether middle-grade staff used the information handed over to manage proactively operational issues arising—for example, whether any special adjustments were made in response to issues handed over (staffing shortages/equipment failures) or if any redistribution of doctors occurred following handover of overcrowding or long waits.
Impact on clinical care and patient safety
This reflected changes in clinical practice due to the ABC tool. Events in the subsequent shift were reviewed to identify exemplary new practices or adverse events that followed handover.
User opinions of the ABC tool
A survey was undertaken of 24 middle-grade staff, senior nurses and foundation year doctors to elicit their opinions of ‘The ABC of Handover’ relating to the use of the tool and its effect on their clinical practice. Examples of questions included the frequency with which they use the ABC tool; whether any items should be added to or removed from it; and whether they had previously used a structured method for handover. In addition, participants were asked to rate their opinion of the quality of handover before the use of ‘The ABC of Handover’ and after its implementation on a scale of 1–10.
The process of implementation of ‘The ABC of Handover’ is outlined in our first study5 and continued for 4 weeks until it became common practice in the department at every handover. The ABC method takes approximately 3–5 min to complete.
The content of each handover was recorded and items mentioned at handover were compared with those gleaned from independent sources (outlined above). An independent t test was used on the percentage of relevant items handed over to test for differences before and after the introduction of the new handover tool. Where possible a series of χ2 tests were used to test each aspect of the handover tool. Not all items met the necessary criteria to conduct this test owing to low frequencies in some cells. A repeated measure t test was used to test for differences in user opinions of handover before and after the introduction of the ABC tool.
The average shift intensity before and after implementation of ‘The ABC of Handover’ was unchanged. This was measured by a daily log of average patient attendances on the electronic patient tracking software ‘Symphony’. There was an increase of only 0.1 patient/h in the second phase of the study, equivalent to one additional patient per shift.
Content of handover reflecting compliance with the ABC tool
Figure 1 shows the percentage of relevant information mentioned at handover before and after the implementation of ‘The ABC of Handover’. The two stages of the study are separated by the vertical line representing the implementation of the ABC tool. The results show an increase in the percentage of relevant items handed over from an average of 34% before the introduction of the ABC method to an average of 86% using the ABC method (t79=15.65, p<0.001). Figure 2 shows the mean and 95% CIs for the two study phases.
Following the introduction of the ABC method we observed an improvement in most areas of handover identified as necessary, with a mean increase of 58% for all items and a median improvement of 65%. The results are shown in table 1. Figure 2 shows the percentage of handovers that included items deemed essential for handover before and after the introduction of the ABC method.
The most obvious improvements were evident in the transmission of information regarding operational issues (such as waiting times in areas of the department, bed status issues, staff sickness, portering issues and equipment failures), with a mean improvement of 74% and a median of 80%. Operational issues were the main focus of the ABC tool. Handover about specific patients (clinical information) was already at a high level before the introduction of the ABC method (figure 3).
Impact of handover on the organisation of the next shift
Table 2 summarises the observed impact on the organisation of the next shift of information not handed over when relevant. We also report on examples of good practice observed using the ABC method for handover.
Effect on clinical care and patient safety
Table 3 summarises the observed impact on clinical care and patient safety of missing information on the shift in the pre-implementation stages and examples of good practice observed using the ABC method for handover.
User opinions of the ABC tool
Middle-grade staff were the main users of ‘The ABC of Handover’, and senior nurses and CT1/foundation doctors helped to triangulate the information. Questionnaires and further results are available from the authors. Twenty-one (83%) questionnaires were returned by nine middle-grade staff members, five nurses and six Foundation year 2 trainee doctors. Three respondents returned incomplete questionnaires. Eighteen participants, regardless of the level of seniority, agreed that the ABC method significantly improved handover (t17=9.07, p<0.001) and 19 believed it improved the handover given by locums. This is important as it demonstrates that the ABC method standardises handover and can be readily used by unfamiliar locum doctors. The majority of participants agreed with statements that were specific to improvements to the management of the shift achieved by the ABC method. All participants who ‘managed’ a shift confirmed they used the ABC method in the absence of consultants (out of hours). Of the 14 senior nurses and middle grades who completed the survey, 13 (93%) stated they had not previously used a structured method for handover, although one participant (7%) had witnessed another mnemonic method being used in a military setting.
Five participants (25%) indicated that giving handover with the ABC method made them nervous and two (10%) indicated they felt they were being tested. However, 19 (95%) agreed it should continue to be used in the department, and all 15 participants who completed the relevant sections of the questionnaire stated they would like to use ‘The ABC of Handover’ in other hospitals (the remainder stated it was not applicable to them). The majority of nurses who completed the questionnaire (4/5, 80%) stated they would like to see ‘The ABC of Handover’ adapted for nurses' handover.
The opinions of 18 participants (90%) on the quality of handover practice in general before and after implementation of ‘The ABC of Handover’ are represented by a visual analogue score of 1–10 (figure 4). All participants believed that the quality of handover in general had improved using the ABC tool. The mean score given for handover before the ABC method was 5.0 compared with a mean score of 8.8 for handover with the ABC tool, giving a mean improvement of 3.8 (range 1–7). Participants added comments such as ‘The ABC of Handover focuses my mind on the job ahead’ and ‘Giving a good handover tells me how well I managed the shift’.
‘The ABC of Handover’ has been shown to standardise communication and improve the proportion of necessary items handed over. There was a global and dramatic improvement, especially in the handover of operational issues, which was the main focus of the ABC tool. As well as an increase in the amount of information transferred at handover, we observed a change in attitudes of the middle-grade staff where proactive management of problems was apparent. This was an added benefit of raising awareness of operational issues where the middle-grade staff began to organise the department following the identification of potential issues and arrange for alternative solutions in anticipation. Although we did not expect this finding, it fits with other work on non-technical skills in the ED.10
Benefits to patient safety were also apparent, although direct causality is difficult to establish in a qualitative study. It is widely accepted that improving processes in healthcare that are recognised to pose a risk to patient safety will inevitably improve patient safety. At handover, accurate and comprehensive transfer of information is essential to ensure safe transfer of responsibility of the department from the outgoing to the oncoming teams, and ‘The ABC of Handover’ has been showed to improve and standardise the passage of information. Therefore, although causality cannot be proved in this setting, improving a step in the process directly implicated in patient safety is a recognised means of improving the resilience of that communication process and increasing the reliability of information transfer.
Examples of areas where considerable improvements were seen include handing over information concerning waiting times (which increased from 3% to 95% after implementation). This led to reallocation of staff and subsequently avoided delays despite shortages and a high patient intensity. The reporting of staffing issues increased from 11% to 97%. Multiple reports of patient delays occurred during shifts when handover did not include this item, whereas delays to only one patient were reported in the period of data collection following the introduction of the ABC tool. Notable differences were also observed in handing over faulty equipment (in 100% of occurrences), which were never mentioned before the ABC tool was implemented.
A change of culture occurred as well as improvement in handover once the ABC tool was implemented, with middle-grade staff members providing solutions for problems and following them up with updates on subsequent handovers reporting any return to normal function—for example, booking agency staff to replace absence; arranging for all phlebotomy to be done by alternative means when the assistant was absent; and when the ‘shute’ system (air tube transportation system for pathology samples) was faulty it was handed over and a report was given that porters had been asked to collect samples every 30 min to convey them to the pathology department. These changes reflect awareness of the problems and show that middle-grade staff developed a more global sense of management of the shift. This was not in the original aims of the study but was observed to follow as the next step when staff became more aware of operational issues. Thus, they began to anticipate problems and adjust practice accordingly.
It is also interesting to note that some middle-grade staff reported that receiving handover with the ABC method at the start of their shift acted to focus their mind on the job ahead, and they felt that giving a good handover was a measure of how well they had handled a shift.
‘The ABC of Handover’ tool can potentially be adapted to suit other areas of practice in the hospital than the ED, wherever shift handover involves operational as well as clinical aspects. This may be done with specific knowledge of the shift and department variables that may be necessary for handover.
One of the aims of this study was to test the impact of the ABC method on clinical practice. It is somewhat difficult to link clinical events to handover as there are multiple factors that enforce good clinical practice (such as teaching and education, departmental guidelines and supervision). Measuring clinical performance by simply counting the number of incidents reported would not provide an accurate reflection of the effect of handover as many other factors influence the number of incidents reported. In contrast, good practice is not reported formally. Although we looked at incident reports occurring during the study period, it is not possible to associate any reduction in patient harm by improving handover. Another potential limitation is that observations may have resulted in the Hawthorne effect as participants were aware that the study on handover was being conducted. However, any observed behaviour change was likely to be a positive one, resulting in an improvement in handover in both stages of the study. Despite this, we were able to demonstrate improvements after the ABC tool was implemented. Furthermore, a possible source of bias may have arisen from the observer not being blinded, as it was not possible to provide blinding. Attempts were made to reduce any subjectivity where, in the initial stages of the study, 10% of handovers were observed by two independent researchers using a preformatted scoring tool. Results from this showed a 90% match in the score of all handovers observed. It is also worth adding that this research was carried out in our own department where the intervention was evaluated by the researcher and therefore may be open to bias in favour of a positive outcome.
Successful implementation of ‘The ABC of Handover’ resulted in a change of practice in the ED. We have shown that the ABC method improved the overall content of handover, especially with respect to operational issues. We have also shown that it led to a change in culture to one of anticipation and proactive management of potential issues on a shift, and achieved clinical improvements. The ABC structure provides a reminder of how to prepare for handover and consequently provides a framework for highlighting and solving problems during the shift. The ABC method standardises handover in a comprehensive and easy to remember mnemonic. This is suitable for any senior doctor leading the shift and is applicable to nursing handover as well as other areas of the hospital. Controlled evaluation of implementation in a range of different settings would provide much stronger evidence of effectiveness.
The authors thank the emergency department at St Mary's Hospital for facilitating this research.
Funding MF received funding from London Deanery to conduct research in clinical safety in collaboration with the Clinical Safety Research Unit. The Clinical Safety Research Unit is affiliated with the Centre for Patient Safety and Service Quality at Imperial College London which is funded by the National Institute of Health Research http://www.cpssq.org/index.htm
Competing interests None.
Ethical approval This was deemed unnecessary by the local research and ethics committee.
Provenance and peer review Not commissioned; externally peer reviewed.