NSW Child Health Network Allied Health Education & Clinical Support Program Clinical Handover Report

NSW Child Health Network Allied Health Education & Clinical Support Program Clinical Handover Report Carmel Blayden (M Health Science), Allied Health Educator Western Child Health Network, Ward 11, Bloomfield Hospital, Locked Bag 6008, Forest Road, Orange NSW 2800 Carmel.Blayden@health.nsw.gov.au Sonia Hughes (Bachelor Applied Science Speech Pathology), Allied Health Educator Northern Child Health Network, 64 Pulteney Street, Taree, NSW 2429 Sonia.Hughes@hnehealth.nsw.gov.au Jennifer Nicol (M Health Admin), Allied Health Educator Greater Eastern and Southern Child Health Network, Sydney Children s Hospital, High Street, Randwick NSW 2031 Jennifer.nicol@sesiahs.health.nsw.gov.au Susan Sims (M App Science), Allied Health Educator Greater Eastern and Southern Child Health Network, Sydney Children s Hospital, High Street, Randwick NSW 2031 Susan.sims@sesiahs.health.nsw.gov.au Abstract Introduction Effective clinical handover has been identified by allied health practitioner focus groups as an area of clinical practice requiring the identification and implementation of consistent, reliable processes across referral sites. Recent data indicates the importance of accurate handover, along with the need for formalised tools of handover, to ensure client safety and quality control. However, much of the current documented evidence concerns medical and nursing practice, with little published information regarding handover for allied health professionals, especially those working in rural/ remote locations. Method The NSW Child Health Network Allied Health Educators facilitated 19 focus group discussions within the 3 NSW tertiary paediatric hospitals and 16 regional and rural centres. Participating allied health practitioners identified key components of consistent, reliable and appropriate clinical handover relevant to varying allied health clinical settings. Results Interviews were transcribed and themed into the following categories: Current handover systems (including ISBAR), expectations, incidents and solutions. Clinicians indicated that ISBAR is used broadly across acute wards, mostly by medical/ nursing staff resulting in improvements to ward/inpatient handover. However, ISBAR is not a regularly utilised model of facilitating handover between allied health professionals. Participants identified a minimum data set required to support timely handover between allied health professionals and indicated that some centres have their own intake/discharge forms, however, even then essential criteria

is sometimes omitted. Poor handover was reported as a contributing factor in a number of incidents although these tended to be seen as not requiring documentation in the Incident Information Management System (IIMS) within health facilities. There was general consensus that handover processes need to be planned and timely, supported by a standardised format that can be tailored to meet the needs of the individual service/client. Conclusion Participants expressed strong ideas regarding handover between tertiary and local facilities, reporting that current handover practices need streamlining in order to minimise frustration for families and health professionals, and the more serious possibility of critical incidents for patients. Participants identified the development of professional relationships and the role of health data systems as key areas crucial to effective handover. Respectful relationships between professional disciplines, as well as between clinicians and families were identified as critical factors in effective clinical handover as high quality professional relationships enable the breaking down of barriers between facilities and promote improved communication. Effective clinical handover would also be improved if health data systems that facilitate communication between sites allowed all clinicians to access relevant patient information in a timely manner from a common reliable database. Allied Health Education & Clinical Support Program Clinical Handover Report Introduction Effective clinical handover has been identified by allied health practitioner focus groups as an area of clinical practice requiring the identification and implementation of consistent, reliable processes across referral sites. Recent data indicates the importance of accurate handover, along with the need for formalised tools of handover, to ensure client safety and quality control. However, much of the current documented evidence concerns medical and nursing practice, with little published information regarding handover for allied health professionals, especially those working in rural/ remote locations[1, 2]. Handover has been defined as the transfer of clinical responsibility for some or all parts of care for a patient to another person or professional group on a temporary or permanent basis[3]. Allied health professionals are involved in handover at two levels. Firstly, the multidisciplinary team handover, which is often a summary of intervention, and generally does not allow for provision of detailed discipline specific information. The second level involves discipline specific handover, where information is provided between individual allied health professionals at the referring and receiving sites [1]. Several studies have identified ineffective communication as an issue effecting handover of patient information between hospital and local primary care providers[4]. Studies have highlighted the usefulness of checklists and memory aids such as ISBAR to guide handover[5-7]. ISBAR (Introduction, Situation, Background,

Assessment and Recommendation) is mandated for use in NSW Health as a standardised communication tool, which can be adapted to suit a variety of clinical handover situations with the support of documentation in healthcare records. A Western Australia Country Health Service (WACHS) project explored the allied health professional s role in handover and found that, due to the varying nature of the situations in which handover occurs and the number of different professionals involved, it was difficult to prescribe one definitive allied health handover practice. The content areas most frequently reported as being essential for allied health handover include clear and extensive contact details for the client, contact details of the handover clinician and clear information on the expectations of the receiving clinician such as timing, frequency of therapy, protocols and equipment requirements[1]. This level of detail is not captured using the ISBAR framework. Within NSW, allied health professionals working in smaller hospital or community settings often refer to, or receive referrals from one of the three tertiary children s hospitals, Sydney Children s Hospital Randwick (SCH), The Children s Hospital Westmead (CHW) and John Hunter Hospital (JHH).The NSW Child Health Network (CHN) Allied Health Education and Clinical Support Program (AHECSP) identified the need to consider strategies to facilitate allied health handover between and within tertiary and non-tertiary health facilities in NSW to ensure that children receive the best available care as close to home as possible. Methods In 2013, the CHN Allied Health Educators facilitated focus group discussions to identify key components of appropriate handover that met the needs of allied health professionals and could be applied to varying allied health clinical settings. Participants were recruited from existing networks of allied health professionals working with children across NSW. Qualitative data was collected from interviews conducted using 8 consistent questions as a reproducible framework for each discussion (Table 1). A total of 19 focus groups were conducted across the state at the 3 tertiary children facilities (SCH, CHW and JHH) and 16 regional/rural centres within NSW. Both face to face and teleconferenced focus groups of between 30-60 minutes were held with 2-15 participants in each group. The total number of allied health professional participants was 65. Table 1: Focus group questions How are current handover to/from services conducted? What are your expectations of handover? Is handover important (include reasons)? Do you record incidents that occur due to poor handover? How are incidents recorded? Do you know who to refer to at tertiary hospital or rural/regional hospitals? What solutions would facilitate handover?

What is your knowledge of ISBAR? What is your attitude to handover? Results Interviews were transcribed and themed into the following categories: Current handover systems (including ISBAR), Expectations, Incidents and Solutions. Current handover systems Focus group participants agreed that handover was a very important part of client care, setting the scene for future intervention and providing parents with confidence in facilitating transition of services seamlessly from one service to another. Various modalities were identified within the current handover system including handover forms, written reports, phone calls, fax and/or email. The choice of modality was largely determined by the needs of the patient and family, and influenced by the existing preferred referral systems of individual health services. Participants reported many inconsistencies between the quality of handover received and given, as well as frustrations when there was an absence of adequate clinical handover. Challenges varied depending on whether the handover was from an individual clinician or multi-disciplinary team, with referrals from individual clinicians being communicated in a more timely fashion. It was identified that reports from multi-disciplinary teams were often slow to arrive when dependent on the completion of a multi-disciplinary report by team leaders and/or medical officers at referring sites. Clinical handover was reported to work best when individual professional relationships between referring and receiving sites were strong, or when families were willing and able to inform the process by providing information regarding current treatment, attendance at clinics and/or reviews. However, it was identified that those multi-disciplinary teams with designated case managers or coordinators being responsible for referrals were better able to facilitate effective handover. Issues such as time spent locating appropriate therapists to whom to refer patients, maintaining contact lists and keeping up to date with changes to service referral criteria were identified as both time consuming and challenging. Many participants reported limited knowledge or confidence using ISBAR, particularly within the primary care setting. Clinicians indicated that ISBAR is used broadly across acute wards, mostly by medical and nursing staff resulting in improvements to inpatient handover. However, ISBAR is not a familiar model of facilitating handover of inpatients or outpatients between allied health professionals. Two way communication between referring and receiving clinicians was consistently identified as the key to effective clinical handover. Expectations Participants identified a minimum data set required to support timely handover between allied health professionals (Table 2). Some centres have their own intake/discharge forms but consensus was that essential criteria were sometimes omitted.

Table 2: Required Data Client name (aliases) Client date of birth Full name of carers Best contact details for client including phone number/s ATSI status Current social situation (including who is providing care or AVOs) Background (growth information) Medical history including current diagnosis (copy of operation report post op) Intervention to date (including Assessment information) Current treatment status Recommendations (priorities/goals especially for complex cases). Expectations regarding follow-up appointments (and responsibility for organising these) Consent to refer Date of discharge Level of priority/urgency Contact details of treating therapist and others on the team Other professionals/agencies involved name, designation, contact Red flag information Incidents Poor handover was seen as a major contributor to a number of incidents although these tended not to be documented in the Incident Information Management System (IIMS) within health facilities. Apart from specific cases resulting in rehospitalisation and regression of function, the majority of incidents reported were in relation to service inefficiency resulting in increased time spent following up required information, delay in service commencement and inappropriate choice of intervention. In some cases these issues resulted in families disengaging from the health system. Concern was expressed regarding some incidents when referral/handover was never received. These cases usually involved referral from non-allied health clinicians, the orthopaedic surgeon recommended physiotherapy to the parents, but the parents did not recognise the importance and were not empowered to pursue the referral. The child therefore did not receive important follow-up.

Solutions It was recognised that the needs of different health services vary in complexity and that no single solution would appear to address all needs. There was general consensus that handover processes need to be planned and timely, supported by a standardised format that can be tailored to meet the needs of the individual service/client. Difficulties should be addressed on a case by case basis and all allied health professionals should strive towards improving systems and communication. Discussion The issue of effective, timely clinical handover between allied health professionals is complex due to the number of different professionals involved and the lack of an identified single solution. Participants in this study identified five overarching features which may inform progress towards a more effective handover system in the future. These features include: 1. Collaborative relationships Collaborative relationships were identified as being essential to effective clinical handover. Participants indicated that this could be achieved by encouraging the strengthening of networks across health facilities through regular formal and informal contact. In part, this contact could be promoted through continuing access to the clinical educational secondment program offered by the AHECSP 2-3 times/ year. In addition, relationships could be enhanced by the development of a directory of services for allied health practitioners across NSW, including clear information regarding services and resources available at all sites. These initiatives would foster the open communication between clinicians, especially regarding agreement on treatment expectations, which is critical to the achievement of optimal patient outcomes. As one clinician explained, weekly therapy may not be feasible due to service constraints or the family s social situation and it is unfair to set the intervention up to fail before it begins. It was identified that it is important for clinicians at tertiary sites to have an awareness and appreciation of available staffing and environmental resources in non-metropolitan health facilities so that therapy expectations are appropriately and collaboratively agreed on between therapists, the patient and their family. 2. Shared care Participants reported the need to educate medical practitioners regarding programs such as Team around the Child. This should include adoption of processes to empower parents as they often have the information regarding their child s needs and upcoming appointments. The Personal Health Record (Blue Book) was identified as a readily accessible, currently available handover tool, which could be promoted as one means of communication between health professionals. Clinicians also identified the need to develop a more strategic, consistent interface between existing e-health systems currently in use. A case management model involving a case coordinator for multi-disciplinary services was presented as a successful option for improving handover for children

with complex needs who require significant amounts of communication and negotiation, including those with acquired brain injury or cerebral palsy. Participants also recommended that shared care and clinical handover could be improved by linking local clinicians into case conferences with tertiary hospital clinicians using technology such as videoconferencing. 3. Common processes There was consensus that processes should be developed both locally and across the state to ensure timely and effective referral. Formalising systems across the state was identified as a possible solution and this may be as simple as ensuring data management systems communicate with each other and electronic notes were accessible state-wide. As a minimum, all handover should be clearly documented using a more consistent format. Common processes are facilitated when all health services have access to current allied health contacts and lists of clinics available at tertiary sites. Having good contacts makes the job much less stressful, particularly for rural clinicians managing a partial paediatric caseload on their own. Once you are able to make contact, people are helpful and handover works. 4. Local processes Strategies to improve internal systems and communication between staff at local facilities were identified as opportunities to improve effective handover. This includes local management of waiting lists to prioritise and be more responsive to patients being discharged from tertiary centres. Participants identified examples of services where referral to intake officers was an efficient and effective method of referral. These intake officers were seen as providing a vital role and of knowing their service intimately Someone needs to keep these local staff and service lists up to date and make them available to all clinicians. 5. Communication Communication is seen as an essential part of the solution and should ideally be on a one to one basis, this could be via email, telephone or videoconference. Participants identified that clinicians need to respond to messages left in a timely manner. Videoconferencing services or use of alternative technologies such as Skype and video cam were suggested to facilitate communication across the state. Conclusion Overall it was felt that the clinical handover process is extremely important in ensuring that clients receive optimal care. Unfortunately, time constraints, workloads and poor communication are just some of the factors that can impact negatively on effective handover despite its obvious importance. The importance of clinical handover is reinforced in NSW Health policy directives and education around ISBAR, however, despite the work that has been completed in NSW to look at handover and the standardised process for handover provided by ISBAR, this tool does not appear to be effectively meeting the needs of allied health professionals. This could be partly due to poor awareness of the broad use and

adaptability of ISBAR as well as lack of acknowledgment of its usefulness and/or clinician s confidence in its application. There are a number of published NSW Health guidelines for improving handover in relation to acute patients, mainly with a medical focus, but more evidence is needed on how handover differs for allied health practitioners, particularly those working with children in regional/rural areas. Participants expressed strong opinions regarding handover between tertiary and local facilities, reporting that current handover needs streamlining and is a source of frustration for patients, families and health professionals. Participants identified three key areas as being crucial to enabling effective handover: 1. The promotion of strong, respectful relationships between professionals from tertiary, rural and remote sites, as well as between clinicians and families. 2. The need to break down communication barriers between health care facilities. 3. Improvement of health data systems to allow clinicians from all local health districts access to a shared database with accurate, relevant patient information. This study was limited by its qualitative nature based on subjective common themes emerging from focus group discussions. The themes identified could be further studied more objectively by identifying and measuring key patient outcomes such as the reporting of critical incidents related to ineffective clinical handover in the IIMS database. References 1. Western Australia Country Health Service. Back to the Bush: Allied Health Clinical Handover Project. 2009 [cited 2014 July 15]. Available from: http://www.wacountry.health.wa.gov.au/fileadmin/sections/allied_health/ah_r_clinicalhandoverp roject.pdf. 2. Scott P, Ross P, Prytherch D. Evidence-based inpatient handovers: a literature review and research agenda. Clinical Governance: An International Journal. 2012;17(1):14-27. 3. Australian Commission on Safety and Quality in Health Care. Implementation Toolkit for Clinical Handover Improvement. 2011 [cited 2014 July 15]. Available from: http://www.safetyandquality.gov.au/wpcontent/uploads/2012/02/implementationtoolkitforclinicalhandoverimprovement.pdf. 4. Hesselink G, Schoonhoven RN, Barach P, Spijker MA, Gademan P, Kalkman C, et al. Improving Patient Handovers from Hospital to Primary Care. Annals of Internal Medicine. 2012;157. 5. Currie J. Improving the efficiency of patient handover. Emergency Nurse. 2002;10:24-7. 6. Yee K, Wong M, Turner P. Hand me an ISOBAR: a pilot study of an evidence based approach to improving shift to- shift clinical handover. Medical Journal of Australia, 190: 121 124. Medical Journal of Australia. 2009;190(11):S121-S4. 7. Australian Commission on Safety and Quality in Health Care. Ossie Guide to Clinical Handover Iimprovement. 2010 [cited 2014 January 2]. Available from: http://www.safetyandquality.gov.au/wp-content/uploads/2012/01/ossie.pdf