The document summarizes a study on handover processes between high acuity and low acuity care units. The study found poor agreement between units on the presence and relevance of information regarding anticipated changes to a patient's condition and warning signs. Sender units reported transmitting more overall information and anticipatory guidance than recipient units perceived receiving. The limited involvement of nursing staff in handovers may reduce the reliability of information transfer and contribute to adverse events. Further research is needed on improving common ground and information sharing between sender and recipient units.

1. Handover process in multidisciplinary health care:
information transfer and common ground
construction
Giulio Toccafondi, Riccardo Tartaglia, Stefano Guidi, Sara Albolino

2. Background
Handover can be defined as “The transfer of professional responsibility 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”
(Wong M. et al 2008 )
In health care systems patients’ transictions between diferrent care settings are
increasing in frequency. Usually more than one medical team is taking care of a
patient . The transfer of patient may pose threats to patient safety.
Poor communication during the exchange of medical information contributes to
handover incidents and inefficacy of care processes

3. According to the Joint Commission the lack of effective communication is
among the main root causes for the majority of sentinel events that occurred
from 2009 to 2011 in the United States
http://www.jointcommission.org/Sentinel_Event_Statistics/

4. Handover as Communication
The handover of medical information is a communication activity
which plays an important role in orienting care.
The 31% of the residents indicated something had happened while they were
on call that the handover had not prepared them for; and that
the only variable influencing doctors’ perception of preparedness for their
night on-call was the quality of the handover.
(Borowitz SM et al. 2008)
In order to make sense of patient handovers and improve them, we need to
analyze the relationships between the content conveyed and the social context
in which the communication occurs.

5. Handover as Cooperation
Patient handover, like all human communication, is a relational activity involving at least
two actors sharing a common ground
Common ground: pertinent knowledge, beliefs and
assumptions that are shared among the involved
parties, and support interdependent actions in
some joint activity
(Clark & Brennan, 1991)

6. Study Setting
Setting 1 - TERTIARY REFERRAL CENTER TEACHING HOSPITAL
Emergency Intensive Care High Dependency Unit
Unit ICU (10 beds) HDU (8 beds)
Setting 2 - SECONDARY REFERRAL CENTER TERRRITORIAL HOSPITAL
General Intensive Care Unit General Surgery ward
ICU (10 beds) (12 beds)
SENDER UNIT - High Acuity RECEIVING UNIT- Low Acuity
Data on 22 transictions of care collected by 1
hospital physician and 1 nurse in each unit
Handoffs at Handoffs at
internal shift
Handover internal shift
changes changes

7. Study Objective
• Focus - critical handover scenario: transfer from high acuity care to low acuity care
• Objective - observe the media and work patterns enabling handover process in
order to assess the level of concordance between critical care units on handover
content items
High Acuity Low Acuity
Handover Content Items
Diagnosis and present state of the patient
Recent changes in the conditions or treatment.
Anticipation in changes of conditions or treatment
Handoffs at Handoffs at
internal shift What to monitor along shifts (physicians and nurses)
internal shift
changes changes
Warning signs
Handover

8. Handover Probe
Type of media
Care continuity
Minimal set of information
about the patient health
status
Anticipatory guidance
Clinical information acquired
by health care providers of
the sender units based on
their recent experience with
the patient
Presence of content item
in discharge form Relavance and
reperebility

9. Handover Probes outcomes
Collection of data on in ‘blind copy’ in two units of each setting on the transitions of care.
•Presence of handover content item in discharge form
•Perceived relavance of content item
•Reperebility of content item in extended patient record
High Acuity Low Acuity
Handover Content Items Handover Content Items
Diagnosis and present state of the Diagnosis and present state of the
patient patient
Recent changes in the conditions or Recent changes in the conditions or
Level of
treatment. treatment.
concurrence
Anticipation in changes of conditions or Anticipation in changes of conditions or
treatment treatment
What to monitor along shifts (physicians What to monitor along shifts (physicians
and nurses) and nurses)
Warning signs Warning signs

10. Quantity and Relevance of content items
The sender unit reported the presence
of a significantly higher amount of
information in the DF than the recipient
unit (p<0.01).
The difference was only relative to the
amount of information about the
anticipatory guidance. (p<.0001)
The sender unit also reported the
presence of a significantly higher
amount of relevant information in the
DF than the recipient unit (p<0.05).

11. Accessibility of content items
Tha average accessibility of content in the medical documentation reported by
recipient unit was lower than that reported by the sender unit (p<.01).

12. Agreement among units
P<.01
P<.05
Poor agreement between the units about the presence in DF and the relevance of
items relative to predictable changes and warning signs.

13. Results in context
The outcomes of the probes were discussed in focus groups with the health
practitioners in order to contextualize the data, and understand the
characteristics of the common conceptual ground.
Focus groups revealed that:
•anticipatory guidance is
communicated implicitly;
•the medical staff is more
involved in the pre-handover
than the nursing staff;
•verbal and face-to-face
interactions are mainly used to
transmit information about
anticipatory guidance

14. Conclusions
Our study highlighted that the handover process is shaped more by the information
needs of the sender units than by those of the recipients.
The limited participation of the nursing staff to a common conceptual ground
reduces the reliability and possibility of correct interpretation of patient
handovers and may contribute to adverse events.
The handover practices used in the settings seems to be lacking in important
information connected to the anticipatory guides.
Further research should address the interaction among sender and receiving
units and the common ground construction. Focusing only on tools and media,
in fact, does not allow to understand all the possible breakouts in handover
processes.

15. Agreement among units
Present in DF Relevant
Content item Senders Recipients p-value * Senders Recipients p-value *
Diagnosisand present 100% 100% – 96% 91% 1
state of the patient
Recent changesin the 96% 76% 0.375 96% 67% 0.063
conditionsor treatment
Anticipation of changesin 91% 38% 0.006 86% 55% 0.109
condition or treatment
What to monitor along 96% 71% 0.125 82% 76% 1
shifts(physicians/ nurse)
Warningsigns 50% 10% 0.02 67% 33% 0.344
Poor agreement between the units about the presence in Df and the relevance of
items relative to predictable changes and warning signs.