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Handover practices of nurses transferring trauma patients from intensive

care units to the ward: A multimethod observational study

Article in Australian Critical Care · May 2020

DOI: 10.1016/j.aucc.2020.03.004

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Australian Critical Care

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Research paper

Handover practices of nurses transferring trauma patients from

intensive care units to the ward: A multimethod observational study
Madeleine Powell, RN a, *
Duncan Brown, RN a
Chelsea Davis, RN a
James Walsham, MB ChB, MRCP FCICM a, d
Pauline Calleja, RN, PhD a, b, c
Sue Nielsen, RN a
Prof. Marion Mitchell, RN, PhD a, b, c
a
Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
b
Menzies Health Institute Queensland, Griffith University, Australia
c
School of Nursing and Midwifery, Griffith University, Brisbane, Queensland, Australia
d
School of Medicine, The University of Queensland, Brisbane, Queensland, Australia

article information a b s t r a c t

Article history: Poor-quality patient handover leads to adverse patient outcomes. Consequently, handover has been
Received 10 September 2019 identified as a national and international priority for preventing patient harm. Risks are exacerbated
Received in revised form during transfers of trauma intensive care unit (ICU) patients to a ward because of the complexity of their
4 March 2020
injuries coupled with a de-escalation in care and monitoring. This study assessed current handover
Accepted 18 March 2020
practices for ICU trauma patients, identifying barriers and facilitators to best practice handover.
A multimethod design was used, including naturalistic observations of clinical handover of trauma
Keywords:
patients transferred to a ward and semistructured interviews with both the ICU and ward nurses caring
Clinical handover
Communication
for the trauma patient. The study was conducted at an Australian metropolitan public adult teaching
Discharge hospital ICU. Purposive maximal sampling of patient handover opportunities was sought. Recruitment
Transfer continued until data saturation was reached using thematic analysis.
Intensive care Ten ICU and ward nurses were recruited, with 10 observations of handover and 20 interviews con-
Nursing ducted. Observations of the handovers identified multiple issues, including deficits and discrepancies in
Patient safety the information communicated that could impact patient safety, variable handover processes, and poor
Trauma patient and family involvement. Interviews elicited two major themes around the handover: practices
Patient/family centered care
and processes. Nurses identified that interruptions, time, and workload pressures presented barriers to
handover, whilst teamwork, using a structured and systematic approach, preparation time for handover,
and communication before transfer facilitated effective handover and transfer. Nurses suggested a
structured tool to aid handover.
This study identified clinically significant deficits and discrepancies in the information communicated
to the ward nurses. Nurses identified that interruptions, time, and workload pressures presented barriers
to effective handover. Teamwork where preparation and the handover event are prioritised over other
activities is needed. A minimum data set for handover in conjunction with patients and family members
is recommended.
© 2020 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction

* Corresponding author. Princess Alexandra Hospital, Ward 3A ICU, Building 1, Despite the recognition that clinical handover is critical to
199 Ipswich Road, Woolloongabba, Brisbane, QLD, 4102, Australia. providing quality patient care,1 poor-quality handover continues to
E-mail address: madeleinecpowell@gmail.com (M. Powell).

https://doi.org/10.1016/j.aucc.2020.03.004
1036-7314/© 2020 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

Please cite this article as: Powell M et al., Handover practices of nurses transferring trauma patients from intensive care units to the ward: A
multimethod observational study, Australian Critical Care, https://doi.org/10.1016/j.aucc.2020.03.004
2 M. Powell et al. / Australian Critical Care xxx (xxxx) xxx

pose a threat to patient safety.2,3 Communication failures have been 3.2. Setting
identified as a major contributing factor in 70% of adverse events in
health care, with 50% of these failures occurring during handovers.4e6 The study was conducted at an Australian metropolitan public
Poor-quality handover leads to adverse patient outcomes, such as adult teaching hospital, accredited as a level 1 trauma centre, with
delays in and incorrect diagnosis and treatment, medication errors, comprehensive critical care services. The hospital admits patients
discrepancies in patient data, and increased hospital length of stay requiring all major specialties, including medical and surgical pa-
(LOS).4,6,7 Consequently, handover has been identified as a national8 tients, except obstetrics and gynaecology and burns. The 30-bed ICU
and international9 priority for preventing patient harm. admits approximately 2300 patients per year, 300 of whom are
Clinical handover is defined as ‘the transfer of professional re- trauma patients.
sponsibility and accountability for some or all aspects of care for a
patient, or group of patients, to another person or professional
group on a temporary or permanent basis’.8(p.5) Simply put, hand- 3.3. Sample and recruitment
over is a human-to-human interaction involving the sending,
receiving, and processing of information. However, during hand- The study included two participant groups; ICU nurses
over, numerous inputs are processed and received, involving the transferring trauma patients to a ward and the ward nurses
interactions of multiple personal and organisational factors.7 accepting the trauma patient into their care. The nurse
The Australian Commission of Quality and Safety in Health Care researcher (NeR) screened all ICU patients on weekdays. In-
(ACSQHC) identified transitions of care for patients with complex clusion criteria were as follows: trauma patients aged
18
healthcare needs, such as intensive care unit (ICU) patients, as high- years who consented together with their ICU nurse and the
risk events.10 Of particular concern are transfers of complex ICU ward nurse. Purposive maximal sampling was used to ensure
patients to a ward because this transition marks de-escalation in that a representative sample of nurses (with a diverse range of
care and monitoring.3 These changes in environment and care can years of experience), and trauma patients typically admitted to
also lead to patients and family experiencing stress, fear, and anx- this ICU (short- and long-stay patients and age variations) were
iety, known as ‘relocation stress’.11,12 recruited.23 Sample size was determined by data saturation and
Between-ward handovers are challenged by infrequent face-to- not set a priori.
face communication between an ICU nurse and ward nurse and a
potential lack of clinical expertise by the receiving ward nurse.13 4. Data collection
Handover of ICU patients during transfer is further complicated
by the challenges of interspecialty communication and 4.1. Demographic data
collaboration,11 clinicians lacking adequate handover training and
expertise,4 increased acuity of patients, and the amount and Demographic data of the transferred patients were collected.
complexity of information to be communicated.3,14 Patient safety Demographic characteristics included age, gender, number of
risks are intensified in trauma ICU patients who often have multiple injured body systems, and a complete list of trauma injuries. Acute
specialist teams providing patient care. For these trauma patients, Physiology and Chronic Health Evaluation (APACHE) II and III
the information and communication for continuity of care is scores, Injury Severity Score, ICU length of stay, and the accepting
especially important and the opportunity for error, omission, and ward were recorded.
reduced quality of ongoing care occurs.15
Improved handover quality and effectiveness have been achieved
by using systematic and standardised handover methods, including 4.2. Observations and data collection tool
using tools, checklist and communication mnemonics, such as
Identity, Situation, Background, Assessment, Recommendation Data from clinical nursing handovers of trauma patients were
(ISBAR).4,10,15e19 Such tools can improve reliability of information collected using naturalistic observations of the transfer process
transferred by reducing reliance on memory, as well as improving and handover delivery. Before accompanying the ICU nurse and
provider satisfaction.20,21 Online forms, checklist, and computerised patient to the ward, the NeR (an experienced ICU registered nurse)
technologies have also been used to guide clinicians to provide read the patient medical record to familiarise herself with the
relevant and critical information.4 Whilst standardising handover patient's condition, injuries, and medical course. Handover was
delivery has proved effective, the importance of tailoring handover observed discretely but sufficiently nearby to be able to hear and
interventions to the specific context is emphasised.2e4,20,22 Further see interactions and communication. The handover process was
research on methods to improve handover of complex ICU patients, defined as starting from the moment the ICU nurse first addressed
such as trauma patients, can provide insight into ways of improving the ward nurse/s to the moment the ICU nurse left the ward area.
communication and patient safety.20,22 Two of the recruited ICU nurses called the ward nurses to provide
a phone handover before transfer; for both of these instances, the
2. Aim research nurse observed and collected data separately for both the
phone handover and bedside handover, ensuring to distinguish
The aims of this study were to assess current handover between information communicated via phone and in person. A
practices and both the ward nurses’ and ICU nurses’ perceptions of structured data collection tool, modelled on the ISBAR handover
handover delivery and transfer process for ICU trauma patients. process,6 was designed by a group of experts. The tool included
handover processes, such as time and location, and an extensive
3. Method list of data points expected in an exemplary ICU handover whilst
also allowing for unstructured field notes (see supplemental ma-
3.1. Study design terial A). The NeR recorded whether each data point from the list
was handed over. Data points were recorded as yes, no, or not
A multimethod design with observations of handover practices applicable. Further field notes were recorded to capture infor-
was adopted to provide a comprehensive understanding of mation communicated on the patient's diagnosis, treatments, and
handover. medical and social history.

Please cite this article as: Powell M et al., Handover practices of nurses transferring trauma patients from intensive care units to the ward: A
multimethod observational study, Australian Critical Care, https://doi.org/10.1016/j.aucc.2020.03.004
 M. Powell et al. / Australian Critical Care xxx (xxxx) xxx 3

4.3. Interview 6. Ethical considerations

To understand nurses’ perception of the handover practice, Informed consent was received from all participants. All data
semistructured interviews were conducted with the ICU and ward from patient records were collected in a deidentified form, with any
nurses caring for the trauma patient. Immediately after handover, potentially identifiable data stored separately to study data. Ethical
the NeR conducted the interview with the ICU nurse and approxi- approval was received from the study site and university Human
mately 1 hour after handover with the ward nurse e allowing the Research Ethics Committee, EC00167.
ward nurse time to admit and fully assess the patient. Interviews
were informal, face-to-face, and audio taped, with field notes taken. 7. Results
Semistructured questions, prompts, and probing questions were
used (see supplemental material B). Nurses were also asked Ten patients and their respective ICU and ward nurses were
descriptive demographic questions including their age, years recruited with 10 observations of handover and 20 interviews
working as a nurse, and years worked in their respective units. conducted from November 2017 to January 2018. No one declined
participation. The median age of the trauma patients was 33.0 years
5. Data analysis (IQR ¼ 50.8); they had a mean of three injured body systems
affected (standard deviation ¼ 1) and a median ICU LOS of 5.7 days
5.1. Demographic data (IQR ¼ 9.9) (Table 1). ICU and ward nurses were predominantly
female. ICU nurses had worked considerably longer and in their
To assess for normality of distribution, continuous demographic respective specialties than did the ward nurses (Table 2).
data were graphed using box plots and quantileequantile plots, and
descriptive statistics were calculated and compared.24 Continuous
8. Observations
demographic data were summarised using standard deviation and
mean (for normal distribution) and median and interquartile range
The median length of handover was 15 min (IQR ¼ 6 min). Most
(IQR) (for non-normal distribution) were calculated, and categori-
handovers occurred at the bedside, and nine of the ten nurses
cal data were reported as frequencies.
commenced handover by introducing the patient to the ward nurse
receiving handover; however, no patients or families were asked if
5.2. Observations
they had questions or concerns at any time during the handover.
Ward nurses and equipment were frequently not prepared and
Field notes and handover data were compared with the patient's
ready for patient transfers. ICU nurses used differing methods of
medical notes to assess for accuracy, relevance, and comprehen-
handover delivery (Table 3).
siveness. Missed or inaccurate information was identified and
recorded. Further analysis was conducted for specific data points
(for example, if the patient was alert and orientated/mental status, 8.1. Handover information
heart rate, blood pressure, oxygen saturations, temperature, urine
output) to assess whether missed data were ‘abnormal’ (for Although patient vital signs (blood pressure, respiratory status,
example, Glasgow Coma Scale [GCS] <15/confused, heart rate <60 heart rate, temperature) were frequently handed over correctly, no
beats per minute or >100 beats per minute, systolic blood handover included every vital sign for the patient. There were
pressure < 90 mmHg, oxygen saturations < 92%, seven observations when temperature was omitted during hand-
temperature > 37  C, urine output <30 ml/h). Handover was over; five of these patients were febrile (temperature >37.5  C).
assessed against the Australian Commission on Safety and Quality Other vital signs not communicated included a patient's respiratory
in Health Care (ACSQHC) standards to determine whether the function when the patient had high oxygen requirements (40%
recommended components of handover had been conducted (for fraction of inspired oxygen and 40 L of flow) with episodes of
example: ISBAR).1
Table 1
5.3. Interview Participant characteristics (n ¼ 30).

Characteristic Participants
Recordings were transcribed verbatim. Transcribed interviews
and field notes were read several times, and meaning units iden- Patient characteristics (n ¼ 10)
Gender
tified, condensed, and coded. Each code was given a unique number
- Male 7
to enable returning to the original transcription as necessary. Pat- - Female 3
terns between codes were sought, and codes with the same Age in years - median (IQR) 33.0 (50.8)
meaning grouped together into themes and subthemes.23 The data Number of systems affected - mean (SD) 3 (1)
were analysed after each interview to assess for inductive thematic Injury Severity Score - mean (SD) 15.4 (9.9)
APACHE II - median (IQR) 14.4 (38.3)
saturation, defined as when no new codes and themes were iden- APACHE III - median (IQR) 46.1 (38.3)
tified within the data from the final interview.25 ICU LOS in days - median (IQR) 5.7 (9.9)
Common themes between the ward nurses and ICU nurses were Hospital LOS in days - median (IQR) 17.0 (23.0)
developed, with no major differences, albeit with different per- Specialty warda
- Surgical 8
spectives between groups, so themes were combined. Study in-
- Medical 2
vestigators (M.P. and M.M.) developed the themes and subthemes,
and all authors agreed on the final themes against the original data, Key: IQR ¼ interquartile range; SD ¼ standard deviation; APACHE ¼ Acute
Physiology and Chronic Health Evaluation; LOS ¼ length of stay; ICU ¼ intensive
ensuring integrity and trustworthiness. In addition to open-ended care unit.
questions, both ICU and ward nurses were asked to rate and self- a
Surgical wards included neurosurgery high dependency unit, orthopaedic,
rate the handover on a scale of 1e10 (see supplemental material), colorectal/hepatology/gastroenterology, cardiothoracic surgery, upper gastrointes-
and these scores were compared to assess for correlation between tinal/breast, and endocrine; medical wards included cardiology (permanent nurse
pool) and general medical.
the ICU nurses’ and ward nurses’ perceptions of handover quality.

Please cite this article as: Powell M et al., Handover practices of nurses transferring trauma patients from intensive care units to the ward: A
multimethod observational study, Australian Critical Care, https://doi.org/10.1016/j.aucc.2020.03.004
4 M. Powell et al. / Australian Critical Care xxx (xxxx) xxx

Table 2 Table 4
Nurse characteristics (n ¼ 20). Frequency of information communicated during handover (n ¼ 10).

Characteristic ICU participants Ward participants Component Frequency

(n ¼ 10) (n ¼ 10)
Identity
Gender - Computer used for digital hospital 10/10
- Male 1 2 - Patient introduced to accepting area staff 9/10
- Female 9 8 - Patients identity verified 1/10
Years working as a 16.0 (19.9) 2.5 (2.5) - Date of birth 1/10
nurse - median (IQR) Situation
Years working in specialty 7.0 (14.4) 2.0 (2.6) - Primary diagnosis 10/10
ward/ICU - median (IQR) - Procedures/surgery 9/10
Background
Key: IQR ¼ interquartile range.
- Allergies 5/10
- Alerts/risks discusseda 2/3
Assessment
desaturation that day. The interview with this patient's ward nurse - Patient observations discussed/reviewed 10/10
- Medication reviewed in Medication Administration Recorda 7/9
revealed that shortly after the transfer, the patient desaturated (79%
Sign-off
peripheral oxygen saturation) and required an urgent medical re- - Accepting staff asked if they had any questions 5/10
view and related interventions. - Patient/carer asked if they had any questions or concerns 0/10
ICU nurses handed over primary diagnosis, mode of injury, and - Sign-off within electronic medical record 2/10
Patient vital signs
mobility (10/10) consistently. However, during one handover two of
- Alert and orientated/mental status 7/10
the patient's injuries were omitted; minimally displaced sacral - Temperature 3/10
fracture and resolved bilateral pneumothoraces. Components least - Oxygen saturations/respiratory function 8/10
frequently communicated included the patient's identity and date - Heart rate 8/10
of birth (1/10) (Table 4). - Blood pressure 9/10
- Urine output 9/10
Site-specific policies for handover, based on national
Trauma-specific patient information
standards,8 mandate a number of components to be handed over Situation
during unit-to-unit handovers. None of the handovers included all - Mode of injury 10/10
these mandatory components, and primary diagnosis was the only - Injuries 9/10
component accurately and completely communicated in every - Surgical procedures/treatments/interventions 9/10
Assessment
observation (Table 4). - Regular or pro re nata analgesia 7/10
- Activity þ mobility 10/10
8.2. Interviews - Limb power 5/10
- Plaster/castsa 0/1
- External fixationa 0/1
Ward and ICU nurses were asked nine and 10 questions, - Vascular/circular observationsa 0/4
respectively (Supplemental material B). The median duration of - Wounds 8/10
interviews was 5 min (IQR ¼ 1.5 min). Both the ward and ICU nurses - Dressing regime 8/10
- Sutures þ removal datesa 3/6
were asked to rate and self-rate, respectively, the provision of in-
- Pressure area/skin condition 7/10
formation during handover. Nurses agreed upon handover ratings, - Hand splintsa 2/2
within 1 point of each other, in 8 of 10 handovers (Table 5). - Foot drop splintsa 3/4
- Collara 2/3
Table 3 - Drainsa 3/4
Handover processes and frequency of communicated information (n ¼ 10). Other key patient observations
- Fluid balance 3/10
Characteristic Frequency - Blood glucose level 2/10
- Pain 8/10
Handover location
- Last bowel movement 7/10
- Bedside 8/10
- Bowel sounds 5/10
- Bedside and phone 2/10
- Intravenous access 7/10
Staff present for handover
a
- Ward nurse and ICU nurse 6/10 Please note: Denominator represents the number of patients for whom that
- Ward nurse, ICU nurse, in-charge nurse 3/10 information was applicable.
- Ward nurse, ICU and student nurse 1/10
Handover preparation Inductive thematic analysis of the interviews identified two
- Ward staff ready for handover 5/10 major themes when nurses were asked about the recent handover,
- All equipment ready for transfer 2/10
practices and processes, with two and three subthemes,
- Bed/mattress ready for transfer 7/10
- Infusion pumps ready for transfer 2/8 respectively.
- Oxygen humidification system ready for transfer 2/4
- Computer available for transfer 10/10 8.2.1. Practices
Structure used for handover delivery
- Systems approach 5/10
The Practices theme incorporated responses that centred on the
- ISBAR 3/10 comprehensiveness of the handover which varied in both their
- No identifiable method 2/10 completeness and accuracy together with the disruptions that
Sign-off impacted on the handover as perceived by the ICU and ward nurses.
- Accepting staff asked if they had any questions 5/10
This theme had two subthemes: completeness and interruptions.
- Patient/carer asked if they had any questions or concerns 0/10
- Sign-off within EMR 2/10
i) Completeness
Key: ICU ¼ intensive care unit; ISBAR ¼ Identity, Situation, Background, Assessment,
Recommendations; EMR ¼ electronic medical record.
*Frequencies are out of the total number of participants for whom the information In the nurse interviews, there were mixed reports on the
applied. perceived completeness of the handover desired and received by

Please cite this article as: Powell M et al., Handover practices of nurses transferring trauma patients from intensive care units to the ward: A
multimethod observational study, Australian Critical Care, https://doi.org/10.1016/j.aucc.2020.03.004
 M. Powell et al. / Australian Critical Care xxx (xxxx) xxx 5

Table 5
Ward nurses’ and ICU nurses’ perceptions of handover (n ¼ 20).

Participant Provision of information rating Organisedb Missed or incorrect information

ICU, range (1e10)a Ward, range (1e10)a ICU nurse Ward nurse ICU nurse Ward nurse

1 8 8 Organised Unorganised No No
2 10 9 Unorganised Organised No No
3 9 10 Unorganised Unorganised No Incorrect
4 9 5 Unorganised Unorganised Incorrect, missed Missed
5 9 8 Unorganised Unorganised Missed No
6 6 5 Unorganised Organised Missed No
7 8 8 Organised Unorganised Missed Missed
8 9 10 Organised Organised No No
9 9 9 Organised Unorganised No No
10 7 10 Organised Unorganised No Missed

***Was there any missed information from the verbal handover or charted information?.
a
1 ¼ lots of information missing; 10 ¼ exceptional e concise, comprehensive handover with all important aspects of care provided.
b
“How organised and ready did you feel to receive this patient?” or “Was the ward organised and ready to receive this patient? (i.e., appropriate equipment ready, staff
ready for handover)”.

the ward nurses. This was perceived to be affected by the level of “The doctor just asking me questions, I lost my place … and had to start
nurses' experience with ICU patients. Some ward nurses stated that again” (ICU8).
the handover was complete and concise, with the ICU nurse pri- There were other instances where nurses commented that there
oritising and communicating only relevant information in a logical were environmental disruptions that impacted their handover,
sequence; for example,“ … everything she gave me was relevant and such as the following: “Having lots of people around, background
straight to the point, relevant and factual” (Wd2). Conversely, other noise of people talking, constantly, from nursing staff, lots of noises and
ward nurses identified that there was omitted information that conversation and stuff, behind me (made it difficult)” (Wd2).
impacted on care delivery and patient safety. Several instances of The second main theme centred on the processes of handover.
absent and inaccurate information were identified by ward nurses,
for example, one stated: “His oxygen saturations are very low … 79% 8.2.2. Processes
on 40% (high flow oxygen) … I had to call the doctors to review the The processes of handover theme included how the complexity
patient …” (Wd4). Another ward nurse explained that a medical of the illness of the patient being transferred had a major impact on
review was required after transfer to review blood test results that the handover activity. Patient acuity formed one of the three sub-
had not been handed over: “I would have liked to know that his themes along with the workload of both nurse groups, which
haemoglobin level was in the 70s. (His) electrolytes were out (low), so impacted the process of handover. Difficulties with administrative
I've been busy replacing those. They (Doctors) came in and reviewed sign-off associated with unfamiliarity with each other's electronic
him and made changes” (Wd7). medical record (EMR) system comprised the third subtheme that
Although ward nurses identified the need for more information, affected handover processes.
paradoxically, ICU nurses perceived that the ward nurses did not
wish for a detailed handover. One ICU nurse stated that “They (ward i) Patient acuity
nurses) weren't even interested in blood results” (ICU9). Although
from separate handovers, this contradicts the ward nurse's Nurses were asked if they perceived handover for trauma pa-
comment mentioned earlier (Wd7). Whilst ICU nurses said that it tients to be more difficult than handover for other patients. Whilst
was essential to give a detailed handover of the patient's condition they agreed that trauma patients were complex and require
owing to the complexity and acuity of their condition, they detailed handovers, they reported that each patient situation was
perceived that the ward nurse did not always share this view. An unique, and the complexity of handover was related to the patient's
ICU nurse said, “… they kept changing the subject. That's why I think ICU LOS, the number of treating teams, the patient's comorbidities,
they wanted a more basic handover. I feel they didn't want to hear my and illness complications. A ward nurse stated, “It depends on the
handover. You could see the look on their face, like “why is she talking acuity of the patient more so than if they are trauma or non-trauma. If
about pulses?” (ICU2). they are more acute there are more things to go over and more at-
Both ICU and ward nurses stated that their level of experience tachments make transfer harder” (Wd7). One ICU nurse stated that
with the transfer of ICU patients impacted their confidence to LOS was significant, stating: “You can have patients that are non-
deliver a comprehensive handover. A ward nurse stated that she trauma and they are here (in ICU) for a long time and so many
found it difficult to understand all aspects of the handover and things have happened. I think it's more the longevity of it that makes it
attributed that to her inexperience. She said“It takes a while if you difficult to handover” (ICU8).
don't know what you're doing … and it makes it confusing, and Along with patient acuity, workload was perceived to influence
sometimes I get confused because I am a new grad” (Wd4). the process of handover.
Interruptions were identified and perceived detrimental to the
practice of handover. ii) Workload

ii) Interruptions Nurses reported that other patients' needs and time pressures
impacted the ICU patient transfer process and overall handover
The nurses stated that interruptions during handover impacted quality. Ward nurses reported difficulty with prioritising ICU
their ability to concentrate on the handover information. For transfers within their already changeable schedule. One nurse
example, an ICU nurse said that their handover was impacted by stated that they were “… unorganised because this morning we had

Please cite this article as: Powell M et al., Handover practices of nurses transferring trauma patients from intensive care units to the ward: A
multimethod observational study, Australian Critical Care, https://doi.org/10.1016/j.aucc.2020.03.004
6 M. Powell et al. / Australian Critical Care xxx (xxxx) xxx

had a lot of (bed) swaps and changes. We had bed closures and at the including observational data and interviews with nurses from both
last minute I had to discharge one patient … to get the ICU patient” the ICU and the wards to gain an in-depth understanding of patient
(Wd4). Similarly, an ICU nurse described how new ICU admissions handover issues that are not evident in other studies.
effected the transfer process for them which flowed on to the ward The observational data highlighted that information, at times,
nurse's inability to be prepared to receive the patient as inadequate was inaccurate or omitted. This is problematic and has a deleterious
notice was given. She said, “We had to change discharge from 1pm to effect on the patient and continuity of care with patient safety
12:30pm due to having to take an admission to ICU ASAP (as soon as jeopardised. A number of the observed handovers had deficits in
possible). If they (ward nurse) had more time, they would have had both fundamental and clinically significant patient information that
time to get a nimbus and the correct bed” (ICU3). For both of the could have impacted patient safety if the ward nurses had not
aforementioned transfers (handover 3 and 4), phone handovers identified abnormalities and taken subsequent action. The ICU
were given before transfer, potentially indicating that workload nurses in this study had worked in the speciality for over three
limits ward nurses from acting on information provided in times as long as had the ward nurses in their current ward. To the
handover. ICU nurse, a patient transfer may have been commonplace, and yet
Nurses highlighted that workload also impacted communica- a number of key elements of handover were missed. The relatively
tion at the time of handover. One ward nurse expressed that they inexperienced ward nurses caring for a critically ill patient imme-
were ill-prepared and unable to concentrate on the handover “ … diately after ICU transfer were only invited to ask questions by the
because I had a patient coming at exactly the same time on an ICU nurse in only half of the transfers. The ACSQHC advocate face-
ambulance stretcher” (Wd5). The ICU nurse delivering handover also to-face handover as it provides the opportunity to clarify infor-
noted this stating, “I think the nurse was a bit distracted with two mation; therefore, when ICU nurses omit this process, it marks a
admissions coming in at once. (She) couldn't really 100% focus on what lost opportunity.6
I was saying because she did ask questions about stuff I had already Similarly, information not handed over has been reported
handed over” (ICU5). elsewhere,3,11,14,18,26 and interventions to improve communication
The processes of handover were impacted by the EMR systems and information transfer are needed. Specific handover tools,
at the site. checklists, and a systematic approach for trauma ICU patients were
improvement strategies suggested by nurses and are consistent
iii) Administrative sign-off with strategies from earlier studies.14,20,27 The use of a checklist for
complex ICU patients has been trailed in handover for transfers
At this site, the ICU and the ward areas use different, incom- from theatre to the ICU, and although there was an improvement in
patible EMR systems that do not link patient information. Both ICU handover practices, there was limited use of the checklist.28 A
and ward nurses expressed that they were unfamiliar with the comprehensive handover tool for ICU patient transfers to the ward
other's EMR and this affected their ability to efficiently access the where handover is between nurse and nurse may be more effective.
EMR systems to enable administrative sign-off at handover. An ICU When key stakeholders identify how improvements in practice can
nurse explained that “Some of the (ward) nurses still aren't aware be made, there is a greater likelihood that their engagement and
that ICU use Metavision and not iEMR and they find it difficult to understanding of the contextual factors will increase the success of
understand we don't use it [ieMR] for any of the medications or notes implementing new evidence-based ways of ICU to ward hand-
(and need to show them in another way)” (ICU3). over.6,29 Establishing an agreed-upon minimum data set for
Further to the themes outlined earlier, nurses made suggestions handover, and the structured approach with clinicians, could align
on aspects of handover they thought could be improved. They ICU and ward nurses’ expectations of handover and improve the
made two key suggestions. First, they suggested the use of a delivery of comprehensive patient information.26,27 Further
trauma-specific discharge summary and checklist which they said research is required in this area.
would assist with the delivery of complex information. For When clinicians perceive handover as a team priority, it is
example, one ward nurse stated, “… I like having a check list … more likely to be successful.18 Minimising the impact that in-
because … when there is a lot of information and (the patient) has had terruptions have on handover is fundamental to one's ability to
a complicated admission, (the ICU nurse) will leave and I've forgotten concentrate, and colleagues' support is vital to achieve this. Suc-
to ask something” (Wd10). This discharge summary/checklist could cessful methods to reduce interruptions and improve clinician
provide a systematic structure for handover that they thought attentiveness have been implemented in the ICU and include
would be of benefit to improve handover. This was exemplified by a establishing two distinct phases of handover: a set-up phase and
ward nurse's comment on the handover she experienced: “It was ‘hands-off’ phase for handover delivery.28 This method could be
really good because … she followed ‘head to toe’ (handover)” (Wd9). adapted to ward transfer handovers with similar benefits seen in
Second, both ward and ICU nurses identified that the receiving clinician attentiveness and alignment of ward and ICU nurse
ward nurse was often not prepared for the transfer and they sug- priorities.
gested that direct phone communication, before ICU discharge, Careful planning for the transfer is also needed to facilitate ward
could improve the transfer process. An ICU nurse explained, “… so readiness to receive the patient. Direct communication before
they can be prepared, like what infusion pumps do they need, do they transfer between the ICU nurse and the ward nurse was recom-
need Hi-flow (oxygen)?. and there should be a phone call prior be- mended in the present study to improve planning and preparation
tween nurses (direct-care nurses), rather than just between in- and facilitates a patient-centred approach. A number of ward
charges … about half an hour prior” (ICU9). nurses indicated during interviews that they had not been aware of
key details about the ICU transfer, and in one instance, the ward
9. Discussion nurse had not been informed about the transfer entirely. This in-
dicates a failing in the communication pathway, despite routine
This multimethod study sought to examine current patient practice of communication between the ICU and ward in-charge
handover practices from the ICU to the general ward for complex nurses. As suggested by interviewed nurses, direct communica-
trauma patients, from the perspective of what was observed to tion between bedside nurses could reduce missed information, as
occur and from the perspective of ICU and ward nurses. This is a long as the ward nurse has the adequate support to prepare for the
strength of this study as it draws together multiple data sources transfer.

Please cite this article as: Powell M et al., Handover practices of nurses transferring trauma patients from intensive care units to the ward: A
multimethod observational study, Australian Critical Care, https://doi.org/10.1016/j.aucc.2020.03.004
 M. Powell et al. / Australian Critical Care xxx (xxxx) xxx 7

Patient- and family-centred care is frequently identified as an Appendix A. Supplementary data

approach to care delivery that improves patient outcomes.30,31 It is
an expectation that both family and patients are involved in Supplementary data to this article can be found online at
handover, empowering them to take ownership of their health and https://doi.org/10.1016/j.aucc.2020.03.004.
include them as an active member of the healthcare team.32 A
unique finding from our study revealed a lack of patient-/family-
centred care with no family or patients asked of their concerns or References
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Please cite this article as: Powell M et al., Handover practices of nurses transferring trauma patients from intensive care units to the ward: A
multimethod observational study, Australian Critical Care, https://doi.org/10.1016/j.aucc.2020.03.004
8 M. Powell et al. / Australian Critical Care xxx (xxxx) xxx

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Please cite this article as: Powell M et al., Handover practices of nurses transferring trauma patients from intensive care units to the ward: A
multimethod observational study, Australian Critical Care, https://doi.org/10.1016/j.aucc.2020.03.004
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