Clinical handover of patients arriving by ambulance to a hospital emergency department: A qualitative study

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Abstract

Aim

The aims of this study were to (1) explore the clinical handover processes between ambulance and ED personnel of patients arriving by ambulance at one hospital and (2) identify factors that impact on the information transfer to ascertain strategies for improvement.

Methods

A focused ethnographic approach was used that included participant observation, conversational interviews and examination of handover tools. Participants included ambulance paramedics, nurses and medical practitioners from an ambulance service and regional hospital located in South East Queensland, Australia. Grounded theory methods of constant comparative data analyses were used to generate categories of findings.

Findings

Two types of clinical handover were identified: (1) for non-critical patients and (2) for critical patients. Quality of handover appears to be dependent on the personnel’s expectations, prior experience, workload and working relationships. Lack of active listening and access to written information were identified issues.

Conclusion

Clinical handover between two organisations with different cultures and backgrounds may be improved through shared training programmes involving the use of guidelines, tools such as a whiteboard and a structured communication model such as MIST. Future participatory research to evaluate new handover strategies is recommended.

Introduction

Miscommunication during clinical handover is acknowledged as a contributing factor to adverse events (Australian Commission on Safety and Quality in Health Care, 2008, Australian Medical Association, 2006) and has subsequently been targeted to improve patient safety in the general hospital setting (Arora et al., 2008, Catchpole et al., 2007, Chaboyer et al., 2008) and in the emergency department (ED) (Evans et al., 2010, Owen et al., 2009, Yong et al., 2008). EDs are chaotic and complex environments which can result in inaccurate or lost information during the handover process (Owen et al., 2009). For these reasons it is imperative that clear, consistent and concise communication between health care providers within the ED is undertaken to minimise the risk of an adverse event occurring.

The majority of research on clinical handover has focused on shift changes of doctors and nurses and between hospital departments or facilities (Bomba and Prakash, 2005, Catchpole et al., 2007, Chaboyer et al., 2008). As a consequence of serious adverse events occurring through poor communication in the hospital setting, tools have been developed to promote a shared mental model between clinicians by transferring information in a predetermined format. Examples of tools include SBAR (Situation, Background, Assessment, and Recommendation) (Woodhall et al., 2008); ISBAR (Introduction, Situation, Background, Assessment and Recommendation/discussion) (Aldrich et al., 2009) and MIST (Mechanism of injury/illness, Injury or illness, Signs and Treatment) (Hodgetts and Turner, 2006). These tools are reportedly useful for improving the quality of information received and are ascribed to be adapted to fit the clinical context. The extent to which these tools are utilised in the clinical handover of patients arriving by ambulance to EDs is unknown.

The few studies on handover from the ambulance service to ED suggest that the nature, content and quality of information passed between the ambulance service and hospitals vary, and appears to be based on the handover method, language used, education levels and experience (Jenkin et al., 2007, Owen et al., 2009, Yong et al., 2008). For example, lack of active listening from ED personnel (Jenkin et al., 2007, Owen et al., 2009) and a perceived expectation to repeat verbal handover (Jenkin et al., 2007, Yong et al., 2008) reportedly impact on the quality of handover. In contrast ambulance personnel preferred to give only one handover because repetition may result in lost or changed information at each handover (Owen et al., 2009).

Findings from a recent review suggested that gaps in communication may occur due to different terminology used and diverse priorities of ambulance, medical and nursing personnel (Bost et al., 2010). Whilst previous research has identified issues that can affect the quality of patient information transferred during clinical handover in the ED, there is a lack of research surrounding the processes, handover content and factors that impact on the quality of information passed between the ambulance and hospital organisations.

The aims of this study were to: (1) explore the clinical handover processes between ambulance and ED personnel of patients arriving by ambulance to the ED; and (2) identify factors that impact on the transfer of information in order to ascertain strategies for its improvement.

Section snippets

Method

A focused ethnographic approach was utilised to explore the processes and identify the factors which impact the quality of handover from ambulance to ED personnel. Ethnographies are appropriate to understand how individuals and groups work in a particular culture. Focussed ethnography is a hyphenated form of ethnography often called a microethnography because it focuses in on particular behaviours in particular settings rather than portraying a whole cultural system (de Laine, 1997).

Findings

A total of 38 handovers were observed and 20 conversational interviews (with one or two participants at a time) were conducted. Table 2 summarises the number and designation of the participants observed and interviewed as well as the settings in which the clinical handovers were observed. Four categories emerged during data analysis: (1) handover process; (2) handover content; (3) handover tools; and (4) factors compromising handover.

Discussion

This study demonstrated the complexity of clinical handover from the ambulance service to the ED. Type of information and timing from the giver to the receiver appear to be dependent on the patient’s reason for attendance, the individual staff member’s expectations, education, prior experience and the busyness of the ED. Some of the findings of this study were similar to previous studies.

In our study, repetition of handover was discussed by the paramedics in both types of clinical handover –

Limitations

There were several limitations to this study. We used an observational method and interviews to collect data at only one site. Consequently the findings may not be generalisable to other EDs. Overt observation during data collection may have subtly changed participants’ behaviour during clinical handover (i.e. Hawthorne effect) although the researcher took active measures to be integrated into the field. Observer bias where the results may be influenced by prior experience of the situation

Conclusion

Clinical handover is an important process that either assists or deters safe transitions for the patient through the health care system. Patients arriving by ambulance to the ED bring together two organisations that need to find common elements to ensure the patients begin their hospital journey with health care professionals’ knowledge of the “full story”. Interprofessional education may be one strategy to assist in the development of strong communication and teamwork skills that will enhance

Funding source

This study was funded by Queensland Health Nursing and Midwifery Research Grant, 2008. The funding was applicable to novice nurse researchers working within any Queensland Health facility. Queensland Health did not influence the topic, department or the direction of the findings.

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