Document Control Title Author Directorate Surgery Date Version Issued 0.1 Oct 2009 0.2 Nov 2009 1.0 Nov 2009 1.1 Feb 2010 2.0 Feb 2010 2.1 Aug 2011 2.2 Oct 2011 Handover of Care (Maternity) Guidelines Status Draft Revision Final Revision Final Revision Revision Author s job title Lead Clinical Midwife Department Ladywell Unit Draft Guidelines developed Comment / Changes / Approval Approved by November Guidelines Group Ratified and published on Tarkanet 3.0 June 2013 Final 3.1 Jul Revision 2013 4.0 June Final 2016 Main Contact Lead Clinical Midwife Ladywell Unit North Devon District Hospital Raleigh Park Barnstaple, EX31 4JB Lead Director Director of Nursing Superseded Documents N/A Issue Date Review Date June 2016 June 2019 Consulted with the following stakeholders: (list all) Midwives Obstetricians and Gynaecologists Senior Management in Senior Midwives Risk Co-ordinators Amended to include the recommendations made by the CNST Assessor. Approved at February Guidelines Group and Maternity Services Patient Safety Forum Revised for new template Minor amendments by Corporate Governance to document control report, version control, headers and footers and formatting for document map navigation. Revised and approved by Guideline Group on 12.06.13 Replacement of Appendix 1 with revised SBAR sticker and removal of red text. Revised and approved by Guideline Group on 05.09.2016 Tel: Direct Dial 01271 322605 Review Cycle Three years Handover of Care (Maternity) Guidelines V4.0 05Sep16 Page 1 of 13
Ward Co-ordinators Approval and Review Process Lead Clinician for Women & Children Directorate General Manager in Guideline Group Local Archive Reference G:/ Team/ Local Path /Policies and Guidelines/ Filename Handover of Care (onsite) guidelines v3.1 16Jul13.doc Policy categories for Trust s internal website Tags for Trust s internal website (Bob) (Bob) Handover of Care (Maternity) Guidelines V4.0 05Sep16 Page 2 of 13
CONTENTS Document Control... 1 1. Introduction... 3 2. Purpose... 3 3. Definitions... 4 Clinicians... 4 Individual Patient Notes... 4 SBAR Situation, Background, Assessment and Recommendation... 4 4. Responsibilities... 4 5. Handover of Care... 5 Communication and documentation between professional groups;... 5 Communication and documentation for handover of care at the change of every shift;... 5 Communication and documentation for handover of care between clinical areas;... 7 Communication and documentation when escalation of concerns warrants review or assessment of a woman, fetus or baby in your care;... 8 6. Education & Training... 9 7. Consultation, Approval, Review and Archiving Processes... 10 8. Monitoring Compliance with and the Effectiveness of the Guideline... 10 9. Associated Documentation... 10 Appendix 1 SBAR Situation, Background, Assessment and Recommendation... 11 Appendix 2 Audit Methodology for Handover of Care (Onsite) Guidelines... 12 Appendix 3 Audit Criterion for Handover of Care (Onsite) Guidelines... 13 1. Introduction 1.1. Effective communication is the foundation of good clinical care. A successful multidisciplinary team will seek to promote optimum care for women and their babies by ensuring efficient team working through structured, clear communication (NHSLA, 2011). This document sets out Northern Devon Healthcare NHS Trust s (NDHNT) system for handover of care. It provides a robust framework to ensure a consistent approach within maternity services and across the whole organization. 2. Purpose 2.1. The purpose of this document is to ensure all staff are aware of the required communication and documentation; between professional groups for handover of care at the change of every shift for handover of care between clinical areas when escalation of concerns warrants review or assessment of a woman, fetus or baby in your care 2.2. The process is monitored for compliance and subsequent action plans are implemented to address any gaps in documentation or the process involved. Handover of Care (Maternity) Guidelines V4.0 05Sep16 Page 3 of 13
3. Definitions Clinicians 3.1. For the purpose of this guideline clinicians will refer to Midwives, Maternity care assistants, Obstetricians, Anaesthetists, Paediatricians and all other allied healthcare professionals. Individual Patient Notes 3.2. Individual Patient notes are defined as the Perinatal Institute Notes for Antenatal, Intrapartum (Birth), Postnatal and Baby Care. It will also include the Antenatal inpatient notes used within NDDH. 3.3. The Perinatal Institute notes must be used at all times by all healthcare professionals for the purpose of documentation for all women booked for care at North Devon. SBAR Situation, Background, Assessment and Recommendation 3.4. SBAR is an easy to remember mechanism that you can use to frame conversations, especially critical ones requiring immediate attention and action. It enables you to clarify what information should be communicated between members of the team, and how. It can also help you to develop teamwork and foster a culture of patient safety. The tool consists of standardised prompt questions within four sections, to ensure that staff are sharing concise and focused information. It allows staff to communicate assertively and effectively, reducing the need for repetition (Institute of Innovation 2009). 3.5. At the Lady well unit, SBAR communication tools are provided in the form of telephone communication sheets and escalation or handover stickers to apply to patient notes. 4. Responsibilities 4.1. It is the responsibility of all clinicians involved in the care of women and their babies to ensure their; Documentation is written on the correct paperwork, in a contemporaneous manner and in accordance with guidance from their professional bodies. This includes comprehensive assessment, a clearly written plan and a record of actions taken/follow-up of this plan. All care provided should be recorded on approved documentation (see section 3 Definitions) and filed appropriately in the hospital records Communication is respectful, factual, comprehensive and includes a clear plan of care that the women understands and consents to 4.2. The standards and requirements for documentation apply to all of these groups without exception. Handover of Care (Maternity) Guidelines V4.0 05Sep16 Page 4 of 13
5. Handover of Care Communication and documentation between professional groups; 5.1. Whenever assessment and planning is undertaken by any clinician involved in a woman s care and care is shared between or transferred to a different professional groups the following must be completed; all relevant areas of the Individual Patients notes, a clearly written MANAGEMENT PLAN with timeline, any appropriate additional documentation which may include any of the following: - referral forms, - Prescription Charts (including name and number inside each chart and ALL known Allergies recorded on the front of each chart) - Venous Thromboembolism risk assessment form - Risk assessment Booklet - Maternal and neonatal observations and checks. 5.2. Examples of care in these scenarios will include; Obstetric review in Antenatal clinic, Obstetric review during labour, Obstetric review during admission to Bassett ward. 5.3. Both the clinician completing the review and the clinician accepting the care should clearly document the date and time responsibility changed hands and there should be clearly legible names and signatures evident in the documentation. Communication and documentation for handover of care at the change of every shift; 5.4. The clinician on duty must ensure that a clearly communicated and documented handover of care, with a clear plan, is completed for all women and/or babies (as appropriate) and the individual patient notes are completed accurately and contemporaneously. 5.5. This will include: for Obstetricians on call; all women who are inpatient on Delivery Suite and Bassett ward, including any telephone communication or anticipated admissions or transfers, for Obstetricians with allocated clinical duties; all women who are booked at that session; be it antenatal clinic, Caesarean section theatre list or Day Assessment Unit, including any telephone communication or anticipated admissions or transfers, Handover of Care (Maternity) Guidelines V4.0 05Sep16 Page 5 of 13
for Midwives on duty; all women who have been allocated during that shift including any telephone communication or anticipated admissions or transfers 5.6. Documentation of handover of care should be recorded on; the appropriate handover of care sheet, (e.g. Bassett handover sheet, Obstetricians handover sheet) the appropriate SBAR sticker in the individual patient notes, signed by both clinicians with time and date of handover 5.7. Handover of care must include communication of; assessment, diagnosis and management plan which is clearly documented in the individual patient notes for all women, assessment, diagnosis and management plan which is clearly documented in the individual patient notes for all babies, 5.8. any appropriate additional documentation which may include any of the following: - referral forms, - Prescription Charts - Venous Thromboembolism risk assessment form - Risk assessment Booklet - Maternal and neonatal observations and checks. 5.9. Documentation of care should be checked by the responsible clinician prior to handover to ensure that; a recorded signature has been entered in the appropriate place, all entries are timed and dated, all additional documentation that may be appropriate to each individual patient is completed. This may include any of the following: - Fluid Charts - Modified Early Obstetric Warning Score - Prescription Charts - Cardiotocograph recordings - Neonatal Early warning Score Handover of Care (Maternity) Guidelines V4.0 05Sep16 Page 6 of 13
Communication and documentation for handover of care between clinical areas; 5.10. The clinician who is responsible for arranging transfer of care must ensure that a clearly communicated and documented handover of care, with a clear plan, is completed for all women and/or babies (as appropriate) and the individual patient notes are completed accurately and contemporaneously. 5.11. This will include: Obstetricians arranging transfer to an external maternity unit, internal speciality for example Intensive Care Unit or ward to ward within maternity for example transfer to Delivery Suite for increased monitoring of the deteriorating patient, Midwives arranging transfer of women into the hospital from the community, out to an external maternity unit, across to an internal speciality for example Intensive Care Unit or ward to ward within maternity. 5.12. Documentation of transfer of care should be recorded on; the appropriate handover document; this may be a letter if transferring externally or within the individual patient notes if internally, the appropriate SBAR sticker in the individual patient notes, signed by both clinicians with time and date of handover 5.13. Handover of care must include communication of; reason for transfer, assessment, diagnosis and management plan which is clearly documented in the individual patient notes for all women, reason for transfer, assessment, diagnosis and management plan which is clearly documented in the individual patient notes for all babies, 5.14. any appropriate additional documentation which may include any of the following: - referral forms, - Prescription Charts - Venous Thromboembolism risk assessment form - Risk assessment Booklet - Maternal and neonatal observations and checks. 5.15. Documentation of care should be checked by the responsible clinician prior to handover to ensure that; a recorded signature has been entered in the appropriate place, all entries are timed and dated, Handover of Care (Maternity) Guidelines V4.0 05Sep16 Page 7 of 13
all additional documentation that may be appropriate to each individual patient is completed. This may include any of the following: - Fluid Charts - Modified Early Obstetric Warning Score - Prescription Charts - Cardiotocograph recordings - Neonatal Early warning Score 5.16. Copies of all documentation relating to the care episode should be sent with external transfers. Communication and documentation when escalation of concerns warrants review or assessment of a woman, fetus or baby in your care; 5.17. The clinician who is escalating their concerns must ensure that a clearly communicated and documented escalation of concerns, with a clear plan, is completed and the individual patient notes are completed accurately and contemporaneously. 5.18. This will include: any member of the multi-disciplinary team who seeks peer, senior, experiential or alternative professional review of a woman, fetus or baby about which they have concerns. 5.19. Documentation of escalation of concerns should be recorded on; the appropriate SBAR sticker in the individual patient notes any additional communication should be documented thoroughly and contemporaneously on additional stickers. Repeat as necessary. In other words, keep adding stickers each time you make a new call, even if it is for the same issue. 5.20. Escalation of concerns must include communication of; reason for the request to review in addition to - assessment findings and how they vary from the previous findings and/or normal ranges, - a current working diagnosis - and a timeline in which the review is required, Handover of Care (Maternity) Guidelines V4.0 05Sep16 Page 8 of 13
any appropriate additional documentation which may include any of the following: - assessment forms - Maternal and neonatal observations and checks. 5.21. An example is please review A who has PET symptoms; she has raised BP, proteinurea and oedema, this is changed from this morning when she had a normal BP and no proteinurea. I am worried she has PET. Please can you come within half an hour, if you are unavailable please tell me so that I can seek your colleague or senior within that time. 5.22. Documentation of care should be checked by the responsible clinician to ensure that; all additional documentation that may be appropriate to each individual patient is completed. This may include any of the following: - Fluid Charts - Modified Early Obstetric Warning Score - Prescription Charts - Cardiotocograph recordings - Neonatal Early warning Score a recorded signature has been entered in the appropriate place, all entries are timed and dated, NB THIS CHECK AND COMPLETING OUTSTANDING DOCUMENTATION SHOULD NOT DELAY THE CALL TO ESCALATE CONCERNS. 6. Education & Training 6.1. It is the responsibility of each clinician to ensure they are completing their communication and documentation in accordance with the guidance of their professional body and their NDHNT contractual requirements. Any breach in these responsibilities will be managed through appropriate HR processes. 6.2. Annual education updates are provided by the Trust through e-learning and classroom sessions in addition to Trust induction for new members of staff. Any member of staff requiring additional training should be directed to Workforce development, the Practice Development Midwife, their line manager or professional lead/supervisor (as appropriate). Handover of Care (Maternity) Guidelines V4.0 05Sep16 Page 9 of 13
7. Consultation, Approval, Review and Archiving Processes 7.1. Consultation with stakeholders completed as per the Terms of Reference for Guideline group. Please refer to the Document Control Report. Final approval by the Guideline group with review triennially. All versions of these guidelines will be archived in electronic format by the author within the Team policy archive. Any revisions to the final document will be recorded on the Document Control Report. To obtain a copy of the archived guidelines, contact should be made with the Team. 8. Monitoring Compliance with and the Effectiveness of the Guideline 8.1. Monitoring of implementation, effectiveness and compliance with the Handover of Care guidelines is the responsibility of the senior maternity management team. The maternity services audit programme and methodology of process, reporting and escalation is described in Appendix 2 using the audit criterion in Appendix 3. 9. Associated Documentation Maternal Transfer Guidelines Admission to an Emergency Department Guidelines Handover of Care (Maternity) Guidelines V4.0 05Sep16 Page 10 of 13
Appendix 1 SBAR Situation, Background, Assessment and Recommendation Handover of Care (Maternity) Guidelines V4.0 05Sep16 Page 11 of 13
Appendix 2 Audit Methodology for Handover of Care (Onsite) Guidelines NDHT Obstetrics, Gynaecology and Midwifery Guideline: Handover of Care Guidelines CNST Ref: Standard: 4 Criterion: 8 Monitoring arrangements Clinical Audit N Monitoring Y 3 Yearly Audit Lead for Monitoring Compliance Name: Job role: Post Holder Bassett Ward Manager Method Sample All health records of women who have been transferred to HDU/ICU 1% or 10 sets, whichever is the greater, of all health records of all women who have delivered Audit tool An audit tool will be developed using the standard statements set out below. [may just include first column of Criterion statements table in guidance document] Data collection process Process for collating and reporting data The tool will be piloted prior to use. Patient notes will be audited by a clinically qualified member of staff. The information will be recorded using the audit tool. Data will entered and analysed using appropriate software to show compliance levels. Frequency of monitoring/audit 3 yearly audit Process for reviewing results and ensuring improvements in performance occur At the end of the audit, the Manager of Bassett ward will report results to Patient Safety Forum. Where monitoring identifies deficiencies an action plan will be agreed. Actions will be implemented under the authority of Senior Midwife/Risk Lead Women s Inpatient Services. Implementation of actions will be monitored by MSPSF Handover of Care (Maternity) Guidelines V4.0 05Sep16 Page 12 of 13
Target Ref Handover of Care (Maternity) Guidelines Appendix 3 Audit Criterion for Handover of Care (Onsite) Guidelines Criterion statements for audit tool Criterion statements Exception s Indicator/Location of information National guidance Reference Trust guideline reference Where is the information against which compliance can be audited recorded? E.g. Postnatal notes E.g. Stork screen Page no/ Field Which national guidance does this demonstrate compliance with e.g. NICE CG13 p22 On which page of the Trust guideline is the relevant statement? 1 Was the handover of care correct for each staff group on transfer to HDU/ICU? 2 Was the handover of care correctly recorded when handing a woman over from labour ward to postnatal ward? Handover of Care (Maternity) Guidelines V4.0 05Sep16 Page 13 of 13