11Resource: interprofessional ward round handovers
Fiona Geddes, Edward Stewart-Wynne and Phillip Della
In this chapter we present the training materials for interprofessional ward round handovers developed from the research reported in chapter 10. These resources draw on the work of Porteous et al. (2009) and Eggins and Slade (2012, 2016, chapter 7). The communication strategies can be easily adapted for handover training programs with both novice and experienced health practitioners. All the examples are taken from recordings of patients and past students in a student training ward, and nurses and doctors in a general medical ward of a hospital in Australia. The names of patients and clinicians have all been changed to protect their identities. These scripts are provided to give users some comparative examples of more and less effective communication at each stage.
11.1Better bedside communication
Drawing on Eggins and Slade’s research (chapters 6 and 7), we suggest that to achieve effective clinical communication in bedside handovers and ward rounds the whole team needs to consider:
1.Interactional dimension: how you talk
–You need to establish a relationship with the patient and participate actively in the team.
–You need to include the patient and your colleagues in the handover or ward round process.
–You should use CARE as an interactional tool – explained below.
2.Informational dimension: what you say
–You need to communicate clearly and concisely relevant clinical information that accurately portrays the patient’s situation.
–You need to make sure you know and understand everything you believe you need to about the patient.
–You need to organize clinical information in a logical sequence
–You should use CARE & iSoBAR as informational tools
11.1.1For better bedside communication
–Include the patient in the process as much as they’re willing and able to be involved.
–Interact with one another to check you all understand what you need to do to ensure continuity of care.
–Organize and present your information so it’s clear, complete and respects the patient’s active involvement in their own care.
11.2Informational structures: i-S-o-B-A-R
Just as iSoBAR provides a standard structure to help organize clinical information in handovers, it can also be used as a quality improvement tool to help you participate more fully in ward rounds. The use of iSoBAR for handover and ward rounds is intended to comply with the Australian clinical handover standard (ACSQHC 2012b). The iSoBAR protocol provides you with a reference for deciding what type of clinical information should be included and when it should be discussed. Table 11.1 below summarizes the iSoBAR stages.
The iSoBAR ward round checklist that we present below is based on the Western Sussex Hospitals Ward Round Considerative Checklist for Complete Patient Review, developed by Dr Gordon Caldwell and colleagues (Herring, Caldwell & Jackson 2011) and modified with the authors’ permission. Application of the Considerative Checklist has been found to
–improve reliability
–flatten the medical hierarchy
| iSoBAR in brief | |
| identify: | Introduce or identify patient, self and team. |
| Situation: | Provide working diagnosis and specific clinical problems/concerns |
| Observation: | Check, update & discuss recent vital signs |
| Background: | Update & discuss relevant medical & support information |
| Agree to a Plan (Actions): | Outline plan for assessment, treatment & discharge |
| Readback: | Confirm shared understanding Clarify tasks, timing & responsibility |
–improve communication
–provide a drill
–ensure active safety checking
The following iSoBAR framework provides a guide you can use when preparing for and conducting ward rounds. We suggest that team members perform standardized roles. All team members who have had responsibility for the patient should be actively involved in the ward round. We suggest you nominate two medical students to act in these roles:
- Leader: this team member is responsible for presenting the round and ensuring the accuracy of associated documentation with the consultant on completion of the round.
- Quality controller/ clerk: this team member is responsible for completing the checklist and using it to prompt discussions if required during the round. They may also be responsible for completing associated documentation although this role can be split between two students.
11.3Preparation
Before going to the patient’s bedside, think about how the round should be organized and who needs to be present. Familiarize yourself with the most current information. Consider and complete the following sections of checklist:
11.3.1Time management
Determine which patients will be involved in the rounds.
–Take into consideration the patient status (new or review) and their acuity (high, medium, low).
–Be aware of time availability and demands (e.g. the need for a patient to go for tests, staff breaks or attendance required at meetings).
11.3.2Team composition
Ensure all required members of the team are present:
–Ensure each team member is aware of their responsibilities in the round.
–Discuss if and how patients, family or carers are to be involved in the round.
11.3.3Organization
Check for updated or new results:
–Integrate relevant information from notes and charts.
–Discuss with the team any critical, sensitive or confidential information, e.g. ‘not for resuscitation’ decision, micro/ infection alerts.
–Ensure hand hygiene procedures are completed.
11.4Guidance on following the steps in the iSoBAR protocol 11.4.1I is for Identify
The nature of introductions can differ with the medical context and the team’s familiarity with the patient. Australian national standard 5 (patient identification) requires patients to be identified using three approved identifiers when providing or handing over care. Approved identifiers are name, date of birth, gender, address, hospital ID. The Identify stage includes two components:
Identify: Correct identification is critical for patients who are unable to actively engage in their own care (e.g. unconscious, highly medicated, cognitively impaired, hearing impaired, ESL patients, very young or old patients). Ensure all identification information on documents, charts and the patient’s wristband correspond and are confirmed verbally where practicable.
Introduce: Introduce yourself (name, role), your patient (name, age/DOB, gender, address, hospital ID, bed, admission date) and the team. If the team has a longer term engagement with the patient, introductions and identification checks can be abridged but not omitted. Any new participants should be acknowledged.
☒ In Bed 6 we’ve got Tom ...
☑ ‘Morning Mr Harris. I’m Sally, the medical student responsible for your care, so I’m going to be discussing your progress with the team today. You’ve met Sue, our OT and Tim, our pharmacist … and of course Helen has been looking after you since you arrived on the ward yesterday. So, Mr Harris in Bed G24, is 78 years old, he was admitted 10 days ago and has just transferred across to us from Ward X. Mr Harris your birth date is June 1935, is that right? Can I just have a quick look at your wristband Mr Harris? [Checks band] Thanks, that’s fine.
☑ Doctor: So hi Mr Harris, how are you today?
Patient: Not too bad thank you.
Doctor: Good, well it’s me again Mr Harris, Sally. We have the team together to discuss your progress. Today Sarah the physiotherapist is going to give us an update on your mobility as Grace is away. Ok? [Mr Harris nods] Mr Harris is now on day 15 of his admission and five days post-op from his cholecystectomy surgery. He is 78 lives in Broome with his wife Maureen, who is here with us today, and he is looking forward to going home shortly. Isn’t that right Mr Harris?
11.4.2S is for Situation
The focus for the situation heading is on describing the patient’s current presentation. You should include the principal and any secondary diagnosis, the patient’s stability and any specific issues or problems. A brief description of the onset of the condition may be relevant for new patients. It is important to have a clear understanding of the patient’s current condition so the team can recognize and respond to any clinical deterioration across the patient’s journey.
☑ In G23 we have Rita who is a 62-year-old lady from Melbourne. She was admitted 08/09, 5 days ago, while on a holiday here with an infected exacerbation of COPD. Rita’s condition is stable but she’s recently been complaining of lower back pain which appears to be musculoskeletal in origin and related to her coughing …
11.4.3O is for Observations
To provide the team with the best opportunity to monitor and assess the patient’s ongoing condition you should present the most recent, relevant clinical information. Australian national standard 9 recognizes the essential role that the timely measurement and correct interpretation of physiological observations plays in detecting a patient’s deteriorating condition. At this stage in the round it is recommended that you work through the seven-point safety check with the patient, explained below. This is also a good opportunity to seek input from the team and patient.
Review vital signs: Be aware and take note of the time the observations were taken and any trends or changes. Include temperature, pulse, respiration rate, blood pressure, oxygen saturation levels and rate of flow. Try to include an interpretation of the patient’s vital signs rather than just listing numbers.
Check and update relevant charts: Include in the discussion any relevant information from the observations, fall, medication, weight and fluid charts.
Seven-point safety check: Conducting the safety check gives you an important opportunity to ask your patient about their condition and to discuss any concerns with both the patient and the team. The seven areas you should cover are:
1.Pain or discomfort
2.Eating and drinking
3.Urine and catheter status
4.Diarrhea or constipation
5.Cannulae and IV lines
6.Venous thromboembolism (VTE) prophylaxis
7.Skin, mouth and eye care.
☒ Her stats are fine.
☑ Nurse: Mrs Green’s becoming febrile, I just took her temperature and she’s up to 37.2. She is also hypertensive with a blood pressure of 140/90 and a heart rate of 91. Mrs Green is saturating at 90% on 3 liters via nasal prongs. [Looking at patient] You’ve also been reporting light headedness and nauseousness... (Mrs Green nods & puts her hand to her tummy)... and you vomited about an hour ago. She’s currently very fatigued and hasn’t felt like any food today. Iris has an IVC in her left wrist which has been bothering her, hasn’t it Iris? ...
Patient: Yes, it’s not so good
Nurse: I will fix that up soon Iris... and you said overall your pain was about 6?
Patient: It was 6 but now I would say about 8.
Doctor: So your pain is getting worse? … [Explores the situation further]
11.4.4B is for Background
The focus of the patient’s background is on updating the team and patient on both pre and post admission history. With new patients, you may need to put a greater emphasis on preadmission medical history and on providing their general social and behavioral situation. With patients being reviewed, the focus might include post admission details such as recent clinical developments, results and medication information. As a patient is approaching discharge, consideration of social issues (such as independent or supported living arrangements) are likely to become more pertinent. The background section supports discussion of any micro alerts, allergies and medications history (NHQHS Standard 4 Medication Safety). In summary:
Review relevant preadmission information: Past medical history, medications (make reference to drug charts as required), alerts such as drug allergy, food allergy and micro alerts, mental health and social issues.
Update post admission information: Recent investigations and results, patient mobility issues and progress, medication changes.
Differentiate between past and recent information: Discussions of medications and tests are generally the areas least understood by patients. This is often because the clinical information is simply listed rather than explained or contextualized. To help distinguish between past and more recent background information try to use clear context and time signposts (e.g. ‘His past medical history includes .., Since being admitted ..., His most recent CT scan shows ..., Changes to her medications include ... Results back today ...’ ). Try to be aware and sensitive to how your comments about a patient’s background may be interpreted.
☒ Nurse: His background includes excessive alcohol use, multiple presentations for alcohol intoxication, psychosis, he has a past history of intravenous drug use and his main issue is his homelessness. His de facto is also homeless as well. Social Work are diligently working on the home situation to find some accommodation for him. He has burnt his bridges at a number of places so that is going to prove challenging.
☑ Nurse: Regarding John’s past medical history, he has had some serious issues with alcohol and intravenous drug usage and has been hospitalized previously with psychosis. Both John and his de facto partner are currently homeless... Social Work are following up about accommodation options but beds are pretty tight at present so it is proving challenging.
☑ Nurse: On Mrs Kelly’s background ... she’s legally blind, but you can see a little with your glasses on, can’t you Mrs Kelly?
Patient: Yes, but I take them off to sleep and then I can’t find them. That’s how I had my fall at home.
Nurse: We’ll definitely keep an eye on that Mrs Kelly.
Patient: [Mrs Kelly laughs] Two eyes please. [laughter]
Nurse: We do have a falls chart for Mrs Kelly. She has a past history of RHD, eczema, hyperthyroidism, hypertension and veracious veins. Mrs Kelly is also allergic to pethidine with nausea symptoms. Mrs Kelly lives independently in a retirement village and today she has already been seen by the continence nurse and physio ...You mentioned earlier today you were having some problems with fecal incontinence as well as with your water works [Mrs Kelly nods] … but it wasn’t in the patient notes and it wasn’t in her history. We’ve updated that now … and also arranged for some pads to be sent down.
11.4.5A is for Agree to a Plan (Actions)
The focus of this section is on the formulation of a care plan and discussion of all actions required by the team including: ongoing assessment, treatment and discharge preparations. It is crucial at this stage that you seek team input.
Assessment: Conduct an examination if required. (This can be done earlier when the observations and the seven-point safety check are being discussed. Anticipate risk factors (based on background and any new information provided), assess the patient’s readiness for discharge and provide an estimated date for discharge (EDD) if appropriate.
Allocation and timing of tasks: tests required, consultations required, procedures to be performed, medication changes. Ensure the timing of tasks is clearly understood.
☑ Medical student: Cyril has already agreed with our plan for him to have another chest x-ray. That will happen at 2 pm. An ECG has been ordered and we’re going to have to chase up the colonoscopy report and echo. Cyril will also be seen by the anesthetist later this morning and he still requires a physio consult as well, is that right, Helen?
Physio: Yes, I’ve organized for Cyril to have a stair assessment. He did 2 laps around the ward and he was quite alright, but we do need to keep encouraging him with his mobilization...You need to try not to use too much zimmer frame, Cyril.
Medical student: And so we are possibly looking at discharge later this week … Thursday or Friday.
☑ Medical student: With regard to the plan for Mr Day, the results of your angiogram showed a calcified artery block so that’s why we’ve arranged another angioplastic review on Thursday afternoon. Sue [Nurse], did you want to have some input here?
Nurse: Yes ... Mr Day is on hourly obs now and needs to have rest in bed until 1.40. I’ve got down here that you will need to be fasted up to breakfast on Thursday... so you can only have a couple of sips of water... but I will double check that, it seems a long time.
Pharmacist: We also need to withhold Mr Day’s clexae but we still need to give his aspirin and clopidogrel.
Medical student: OK, so Mr Day, you’re not quite ready for discharge as we need to wait for the angioplastic review on Thursday, but things are moving forward. Have you got any questions for us about that?
11.4.6R is for Readback
The focus of the readback phase of the round is to ensure that the patient and all team members finish the interaction with a shared understanding of all the information discussed. It is the point at which everyone has the opportunity to clarify the plan of action determined and check the distribution of responsibilities. Providing a simple explanation of the information can help ensure all participants in the ward round, especially the patient, understand why decisions are being made and actions taken. At this point it is also important that all student actions are confirmed with the senior supervising staff.
Readback also highlights the requirement that accurate details of the ward round be recorded in documentation for future reference. Compliance with hospital protocols, legibility and clarity of the written record are important.
You should complete the following steps in your readback:
1.Clarify responsibility: make sure what, why, who and when are made clear
a.What actions and tasks need to be performed (What)
b.Why the actions are required (Why)
c.Who has responsibility for each action (Who)
d.When the actions need to be completed (When)
2.Confirm the nursing plan with the supervising nurse
3.Check documentation is up to date: patient notes completed and signed.
a.Ensure hospital procedures are complied with in terms of providing date, time, clinician information (name, clinical level, contact) and signature.
b.Ensure the supervising consultant confirms and signs the medical records.
4.Sum up for the patient: before leaving the patient’s bedside provide a clear summary and reasons for their ongoing treatment.
5.Offer your patient the opportunity to ask any questions.
☑ Medical student: OK ... so just to quickly recap ... today Mr Tully you’re starting on some new medications, diuretics and Slow K. You’re also now on metoprolol for your heartbeat as well. Sue (Nurse) is going to organize for you to have 3 liters of cold Go Lightly at 12 o’clock to prepare for your endoscopy early tomorrow. Both your endoscopy and colonoscopy will be tomorrow. After the colonoscopy you will be having a 24-hour urine copper collection. Currently for nursing we need to complete a fluid balance chart, a stool chart, BD BSL, daily weight and daily girth as well. We’ll be waiting on all the test results before we see if you’re going anywhere. Ok... do you have any questions or need me to go over any of that, Mr Tully?
Patient: [Mr Tully smiles and shakes his head] No ... it’ll be a big day tomorrow.
Medical student: Yes it will ... OK well thanks, Mr Tully, we’ll see you a bit later then. Bye.
As shown in this final transcript all members of the clinical team should feel confident to contribute to the clinical discussion. Being appropriately assertive is an important communication skill to develop.
☑ Medical student: so to sum up the plan for Larry – or does anyone have anything to add?
Physiotherapy student: Um I just wanted to say that from a physio point of view Larry is very independent, he’s walking on his own, ah managing his own airway, so from our point of view when he’s medically stable he can be discharged.
Medical student: Fantastic. Nursing?==No.==Pharmacy … anything? yep, brilliant. [looks around to each member of the group as mentioned] OK so to recap, the plan at the moment is to continue with the medications as charted, encourage Larry to get up and walk around, when he can, so he’s not lying in bed. Um, ID consult later today, and the transesophageal echo later today. [addresses patient as she gestures to her own heart] it basically just gives us a picture of your heart so we can see if the infection’s made it into your heart or not.
Patient: Yeah … But at this stage we don’t think it has.
Medical student: That’s right, Larry … At this stage we don’t – we’re not quite sure until we get that image. Yep. Um we’ll be reviewing your chest x-ray from yesterday with the medical consultant. [addresses Lloyd] That’s the plan. Are you happy with that?
Patient: Yep.
Medical Student: Any questions? [looks at patient and around the group]
Patient: No, just carry on.
Medical student: Alright. OK, thanks, Larry.
11.5Summary of resources
In chapter 10 we presented two single-page resources that were developed and tested in the training ward intervention. Fig. 10.1 (page 210), a ward round checklist, and Fig. 10.2 (page 212), a guide to using iSoBAR, could be easily adapted to other training contexts.
Finally, Fig. 11.2 below provides a useful visual summary of the relationship between the interactional and informational dimensions and the CARE and iSoBAR communication protocols discussed in chapters 6 and 10. (See also discussion of the integrated iCARE3 model in chapter 15.)
