Clinical Handover UHL Policy

Policy for Clinical Handover
Approved By: Policy and Guideline Committee

Date Approved: 17 August 2018
Trust Reference: B18/2013
Version: 3
Supersedes: V2 – April 2016
Author / John Jameson, Deputy Medical Director,
Originator(s): Julia Ball, Assistant Chief Nurse
Name of Responsible John Jameson, Deputy Medical Director,

Committee/Individual: Julia Ball, Assistant Chief Nurse
Latest Review Date 17 August 2018

Next Review Date: August 2021
Policy for Clinical Handover 1|Page

V3 Approved by Policy and Guideline Committee on 17 August 2018, Trust Ref: B18/2013 Next Review: August 2021
NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents
CONTENTS
Section Page
1 Introduction and overview 2
2 Policy Scope 3
3 Definitions 3
4 Roles and Responsibilities 4
5 Policy Statements, Standards, Procedures, Processes and Associated 5
Documents
6 Education and Training 7
7 Process for Monitoring Compliance 7
8 Equality Impact Assessment 7
9 Supporting reference, evidence base and related policies 8
10 Process for Version Control, Document Archiving and Review 8
Appendices Page
Policy Monitoring Table 9
Revisions
V1 Approved 15 March 2013
V2 Review of Version 1 March 2016

• Inclusion of the Alliance.
• Requirements of content of medical and nursing handover combined.
KEY WORDS
Medical Handover, Nursing Handover.

1 INTRODUCTION AND OVERVIEW
1.1 Continuity of information is vital to the safety of our patients. Effective

handover needs to occur when shifts of staff change and patients move
between areas within the hospitals or transfer between specialties.
1.2 All staff looking after an individual patient need to share relevant information
about that patient.
1.3 Handing the care of a patient over to another multi-disciplinary team requires
good communication and co-ordination. Good handover requires work by all
those involved with responsibility for direct patient care. It also requires that
clinical departments organise their services to facilitate effective handover.
1.4 There needs to be an embedded cultural awareness that handover is an

essential and important aspect of clinical practice. Time and resource need to
be dedicated to ensure that good handover is part of everyday clinical practice
within UHL.
1.5 The fundamental objective of handover is to share relevant information to

ensure that patients receive safe, efficient, high quality and responsive care.
Clear lines of responsibility need to be identified for each patient. How handover
is achieved and what is handed over needs to be clearly understood and
shared by each specialty and monitored by each CMG.
2 POLICY SCOPE
2.1 This policy relates to all medical, nursing, and allied health professionals within
UHL, including Bank and Agency staff, Locums and students.
2.2 This policy relates to all patients within UHL, including the Alliance.
3 DEFINITION OF HANDOVER
3.1 Handover is the transfer of responsibility and accountability for some or all
aspects of care for a patient, or group of patients, to another person or
team/discipline on a temporary or permanent basis.
3.2 It is the transfer of all relevant information about an individual patient.
3.3 Effective handover is required when a patient moves between any area of the
hospital to another (e.g. from a ward to endoscopy, from theatre to a ward, from
ITU to a ward)
3.4 The term handover applies to transfer of care both within UHL and also from UHL
to other health care partners such as community hospitals or care homes
3.5 Clinical handover provides a good opportunity to ensure all patients, or family and
carers are involved and informed in care, treatment decisions and be able to
respond to the following:
1. What is the matter with me?
2. What is going to happen today?
3. What is needed to get me home?
4. When am I going home?
4 ROLES AND RESPONSIBILITIES
4.1 Responsibilities within the Organisation
4.1.1 Chief Executive
Has the ultimate responsibility for the quality of care provided to patients within
University Hospitals of Leicester. They have overall responsibility for
implementation of this policy.
4.1.2 Executive Lead - Medical Director/ Chief Nurse
The Medical Director and Chief Nurse are jointly responsible for ensuring that
when clinical handover takes place, it is done appropriately and in accordance with
this policy. This includes ensuring there are appropriate systems in place to
identify and train people to undertake clinical handover by overseeing the
implementation and compliance with this Policy. The Medical Director and Chief
Nurse are also responsible for ensuring there are appropriate systems in place for
reporting compliance with this policy to the Board.
4.1.3 CMG Clinical Directors have a responsibility to ensure that:
• high-quality handover occurs between clinical teams for each patient in

their CMG
• procedures are in place for handover between all groups of clinical staff
within each department
• ensuring that each Consultant, Ward Sister and Allied Health Professional
has satisfactory handover procedures in place for their patients and
wards
• the implementation of Handover Guidance is audited in all their clinical

areas
This responsibility can be delegated to Heads of Service.
4.1.4 Consultant, Ward Sister, Team Leaders and Head of Therapy Services
They have a responsibility for defining safe handover procedures in their clinical
area and for monitoring these processes on a regular basis.
They are responsible for ensuring awareness of the importance of handover

amongst their teams and for providing support and education as necessary.
4.1.5 All Clinical Staff
Handover is the responsibility of the clinical team looking after a particular patient
and there is a responsibility for individual doctors, nurses and allied health
professionals to handover accurate and timely information to colleagues.
All clinical staff should be aware of who is involved in handover, when, where,
how and what are the handover arrangements within their area.
4.1.6 Hospital at Night (H@N) co-ordinators
The H@N co-ordinators are responsible for ensuring that the H@N handover
process runs smoothly in line with the policy (Appendix 1) and that all junior
doctors are in attendance. It is also their responsibility to ensure that the H@N
handover attendance spreadsheet is completed and submitted.
5 POLICY STATEMENTS, STANDARDS*, PROCESSES*, PROCEDURES* AND

ASSOCIATED DOCUMENTS
5.1 Where relevant, handover should be a multi-disciplinary team activity thereby

reducing repetition within professional silos.
5.2 Where relevant, handover should be a teaching and learning opportunity for staff
involved.
5.3 Individual clinical areas will have their own requirements for handover dictated by
the complexity of the clinical work, the numbers of patients involved, their
geographical distribution and their working patterns. It is therefore not possible to
be prescriptive about handover arrangements but all areas should have pre-
determined arrangements detailing how handover will occur (see section 6.5).
5.4 Hospital at Night handover:
5.4.1 All staff involved in H@N care must attend and comply with the requirements
of the H@N handover process. This ensures all clinical staff available for work
receive handover of all sick patients or patients requiring clinical
intervention/review out of hours. This process also facilitates opportunity for
registering onto the workload allocation system and receiving a hand held device
for the allocation of Clinical jobs.
5.4.2 The process for H@N handover is documented in Appendix 1. Appendix 2

documents the current meeting time venues for each site.
5.4.3 Attendance at the H@N handover meetings is mandatory and is monitored by use
of the H@N attendance spreadsheet that the co-ordinator fills in for each shift.
5.5 Specialty policy document
5.5.1 Each specialty will have an identified process that details the following for each
type of handover.
5.5.2 Who participates in handover
For effective handover senior input is essential with clear leadership during this
process. Handover will be led by a suitably senior clinician who is responsible for
the process. Multidisciplinary handover is to be encouraged when practical;
however, the information requirements for medical, nursing and other allied health
professionals are different and should be taken into account ensuring that all
relevant information is shared between multidisciplinary groups. The need for
multidisciplinary involvement should not be allowed to result in a handover which
becomes unwieldy and inefficient.
5.5.3 When handover occurs
The time of handover should be clearly identified within each area and sufficient
time should be allowed for handover. Different staff groups should be aware of
handover time for colleagues and respect the need for others to focus on the
process. Unnecessary interruptions should be avoided except for urgent matters.
5.5.4 Where handover occurs
Ideally handover should occur in a consistent place so that staff become familiar
with this and time is not wasted looking for the venue. It should be free from
distractions but within reasonable distance of the clinical area. Ideally there
should be access to a networked PC to allow clarification of results if necessary.
Nursing handover should also include a bedside handover. There may be some
clinical areas where it is either impractical or unnecessary to have a face to face
handover. CMGs should be clear where non face to face handover is occurring
and have assurance that safe practice is being followed
5.5.5 How handover is be conducted
This will vary depending on the area but should follow a pre-determined format.
Ad hoc handover often results in important information being omitted. The senior
clinician/nurse/therapist present will provide supervision and clear leadership
should be established. Information presented should be relevant and succinct.
It is recommended that the SBAR approach is followed for presenting information

in a structured format (Appendix 3).
5.5.6 What information is to be relayed
Minimum dataset for patients handed over:

• demographics
• responsible consultant
• working diagnosis
• EWS/stability of the patient/if a review is needed, when and by whom
• management plan including fluid balance and nutritional requirements
• outstanding tests

• DNACPR status
• ceiling of care/End of Life status
• Infection Prevention status
• Risk Factors (e.g. Waterlow score, MUST score, VTE, Falls assessment,
dementia screen if applicable)
• Other factors (e.g. DoLS, safeguarding)
• Medication issues
• Any information specific to that particular patient (e.g. pain control issues,
communication needs of the patient)
• Estimated Date of Discharge
• Handover information is to be recorded electronically using the UHL
approved platform, currently Nerve Centre
5.5.7 Responsibilities of and communication with stakeholders
On discharge from UHL, all patients will have a Discharge Summary to the
General Practitioner which will detail the care received whilst in hospital and will
handover the responsibility for care to the Primary Care team.
For patients transferred to another Hospital, details of care required will be

included in the Discharge/Transfer letter.
For patients discharged to the care of the District Nursing team, details of care
will be included in a District Nurse letter.
For patients discharged to a Care Home - a copy of the Discharge Summary

should be provided and, where applicable, a copy of the District Nurse letter.
The above documents should be recorded on the UHL approved platform,

currently ICE.
6. EDUCATION AND TRAINING REQUIREMENTS
6.1 Clinical Handover is an integral part of being a health care professional. Guidance
is available from relevant colleges – see Section 10.
6.2 Use of electronic handover (Nerve Centre) is included in the induction of all new
clinical staff.
7 PROCESS FOR MONITORING COMPLIANCE
7.1 See Monitoring Compliance Table of Key Performance Indicators.
8 EQUALITY IMPACT ASSESSMENT
8.1 The Trust recognises the diversity of the local community it serves. Our aim
therefore is to provide a safe environment free from discrimination and treat all

individuals fairly with dignity and appropriately according to their needs.
8.2 As part of its development, this policy and its impact on equality have been
reviewed and no detriment was identified.
9. SUPPORTING REFERENCES, EVIDENCE BASE AND RELATED POLICIES
9.1 Royal College of Physicians. 2011. Acute Care Toolkit 1. Handover May 2011
9.2 British Medical Association (2004) Safe Handover: Safe Patients. Guidance on
Clinical Handover for Clinicians and Managers. BMA, London.
10. PROCESS FOR VERSION CONTROL, DOCUMENT ARCHIVING AND REVIEW
10.1 This document will be uploaded onto SharePoint and available for access by
Staff through INsite. It will be stored and archived through this system.

POLICY MONITORING TABLE
The top row of the table provides information and descriptors and is to be removed in the final version of the document
Reporting
Element to be monitored Lead Tool Frequency
arrangements
H@N Handover attendance H@N Lead Sign sheets Annually ACACB
Handover takes place in each clinical area Heads of Service and Matrons Observational Audits Annually CMG Boards
Appendix 1
Handover Meeting Schedule

For use at ALL H@N handover meetings
1. Please text / call all members of team 15 minutes prior to meeting start time
and encourage them to attend early to prepare and complete handover sheets
2. Handover meetings to start at time specified: Projector to be on, NerveCentre

loaded and displayed on screen
a. AM: 09:00 (Bank Holidays / weekends)
b. PM: 21:30 (every day)
3. Record attendance of all doctors as they arrive on the handover spreadsheet.

a. If attending late, note this on separate audit sheet
b. Also name on whiteboard in red pen
c. Late attendees should not delay start time of meeting
SITUATION i.e. who is on Shift, staffing levels etc.

4. Meeting to be led by Co-ordinator to ensure each section is adequately
covered
a. Clinical aspects to be led by Incoming Med SpR
5. At start time, each team member to introduce themselves {role, grade, wards
covered (for those finishing shift only)}
a. Introductions in this order:

i. Coordinator
ii. Med SpR Incoming
iii. Med SpR Outgoing
iv. Incoming SHO’s / FY1’s
v. Outgoing SHO’s / FY1’s
Policy for Clinical Handover 10 | P a g e

BACKGROUND i.e. what state is the hospital in currently?
6. Any sickness / shortages on rota for shift starting?
a. Circle option on whiteboard and record details on audit form
7. NerveCentre review
a. Document number of outstanding jobs on whiteboard for each ward
area
i. This would preferably be done prior to meeting starting to give
team idea of job intensity in each area
8. AMU review
a. Document number of admissions awaiting clerking on whiteboard for
each of the AMU areas
i. This highlights potential need for ward team to provide assistance
to AMU
ACTIONS i.e. where will each team member be working?

9. Record which wards each team member will be primarily responsible for on
whiteboard
a. Remember to state, “If one ward area (including AMU) is very busy cross
covering / help will be provided by all other team members as required”
b. “You may be asked to perform jobs on other wards dependant on
complexity of task and grade of doctor.”
RESPONSE i.e. which patients need attention?

10. Outgoing staff invited to discuss “sick” patients with oncoming staff
a. Recurrent calls / attendances for review during on call period (>3)

b. EWS >3
c. Clinical concern
d. Difficult consultation
e. Undecided / difficult management plan (DNAR / escalation decisions)
11. Any other patients / jobs to be discussed with assistance of NerveCentre on

projector
12. Ensure that handover spreadsheet is complete and submitted only once– this
is the responsibility of the co-ordinator.
Appendix 2

Appendix 3


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Policy for Clinical Handover

Approved By: Policy and Guideline Committee

Name of Responsible John Jameson, Deputy Medical Director,

Latest Review Date 17 August 2018

Policy for Clinical Handover 1|Page

V1 Approved 15 March 2013

V2 Review of Version 1 March 2016

Medical Handover, Nursing Handover.

Policy for Clinical Handover 2|Page

1.1 Continuity of information is vital to the safety of our patients. Effective

1.4 There needs to be an embedded cultural awareness that handover is an

1.5 The fundamental objective of handover is to share relevant information to

3.2 It is the transfer of all relevant information about an individual patient.

4 ROLES AND RESPONSIBILITIES

4.1 Responsibilities within the Organisation

4.1.1 Chief Executive

4.1.2 Executive Lead - Medical Director/ Chief Nurse

4.1.3 CMG Clinical Directors have a responsibility to ensure that:

• high-quality handover occurs between clinical teams for each patient in

• the implementation of Handover Guidance is audited in all their clinical

This responsibility can be delegated to Heads of Service.

They are responsible for ensuring awareness of the importance of handover

4.1.6 Hospital at Night (H@N) co-ordinators

5 POLICY STATEMENTS, STANDARDS*, PROCESSES*, PROCEDURES* AND

5.1 Where relevant, handover should be a multi-disciplinary team activity thereby

5.4 Hospital at Night handover:

5.4.2 The process for H@N handover is documented in Appendix 1. Appendix 2

5.5 Specialty policy document

5.5.2 Who participates in handover

5.5.3 When handover occurs

5.5.4 Where handover occurs

5.5.5 How handover is be conducted

It is recommended that the SBAR approach is followed for presenting information

5.5.6 What information is to be relayed

Minimum dataset for patients handed over:

Policy for Clinical Handover 6|Page

5.5.7 Responsibilities of and communication with stakeholders

For patients transferred to another Hospital, details of care required will be

For patients discharged to a Care Home - a copy of the Discharge Summary

The above documents should be recorded on the UHL approved platform,

6. EDUCATION AND TRAINING REQUIREMENTS

7 PROCESS FOR MONITORING COMPLIANCE

7.1 See Monitoring Compliance Table of Key Performance Indicators.

8 EQUALITY IMPACT ASSESSMENT

Policy for Clinical Handover 7|Page

9. SUPPORTING REFERENCES, EVIDENCE BASE AND RELATED POLICIES

10. PROCESS FOR VERSION CONTROL, DOCUMENT ARCHIVING AND REVIEW

Policy for Clinical Handover 8|Page

H@N Handover attendance H@N Lead Sign sheets Annually ACACB

Handover Meeting Schedule

2. Handover meetings to start at time specified: Projector to be on, NerveCentre

3. Record attendance of all doctors as they arrive on the handover spreadsheet.

SITUATION i.e. who is on Shift, staffing levels etc.

a. Clinical aspects to be led by Incoming Med SpR

a. Introductions in this order:

Policy for Clinical Handover 10 | P a g e

ACTIONS i.e. where will each team member be working?

RESPONSE i.e. which patients need attention?

a. Recurrent calls / attendances for review during on call period (>3)

11. Any other patients / jobs to be discussed with assistance of NerveCentre on

5 POLICY STATEMENTS, STANDARDS, PROCESSES, PROCEDURES* AND