Sharing incorrect or omitting information can have harmful or life-threatening consequences for patients and residents in our care. Therefore, clinical handover and communication of critical information can be a high-risk process in healthcare.
Clinical handover falls under Standard 6: Communicating for Safety Standard in the National Safety and Quality Health Care standards (NSQHS).
The way we communicate can be affected by a range of factors, such as:
- The situation: what and why are we needing to communicate? Is it a shift handover? Is it urgent or non-urgent? Are there any distractions or potential disruptions? Do you have time to plan what you want to say? It’s ok to write what you want to communicate first, provided it is not a time critical conversation.
- The method: is it face to face? is it verbally over the phone? Is it written in a page or email?
- The location: is it at the bedside? Is it at a meeting? Is it in the staff/handover room?
- The participants: is it nurse/midwife to nurse/midwife? Is it to other members of the multidisciplinary team? Is the patient and their family involved?
To ensure all healthcare professionals are communicating effectively, the ISBAR communication tool was developed. ISBAR stands for:
- Identify
- Situation
- Background
- Assessment
- Response/Recommendations
ISBAR was originally used by several industries outside of healthcare, such as maritime and airline sectors. Healthcare adapted the SBAR tool to be more patient centred by adding the Identify component.
ISBAR is a versatile and effective tool which can be used in a variety of situations, such as bedside handover, internal or external transfers (e.g. from nursing home to hospital, from ward to theatre) communicating with other members of the multidisciplinary team, and upon discharge/transfer to another health facility.
Using ISBAR for verbal/written communication (e.g. phone call, email or referral)
Identify: yourself and your role, and the patient/resident using the three patient identifiers (name, date of birth (DOB) and UR number). Refrain from referring to the patient by their location “the patient in bed 5”.
Situation: what is going on, what is your reason for calling this person? Has there been a change in their condition? Do you need a medication order for pain or vomiting? Has there been an incident e.g. fall, refusal of care?
Background: what has been happening with the patient/resident during your shift? What is their current diagnosis and plan of care?
Assessment: provide details of observations, procedures, treatment thus far, what do you feel needs to be done or changed? Remember, you can use subjective or objective data to communicate your assessment findings. The patient/resident’s vital signs and other observations may be normal, but their behaviour or appearance seems different compared to your previous assessment.
Response/recommendations: how urgent do you require a response from this person? Set a deadline for when you would like your request acknowledged (e.g. “could you please reinsert her IV cannula prior to her next dose of IV antibiotics at 1800hrs?”). If any of the patient’s vital signs fall into MET criteria, or their condition is critical/life threatening, follow local procedures for escalation and initiating a MET call or Code Blue or calling 000 for an ambulance.
Semi urgent example
Hi Dr Roberts, it’s Anna calling from Ward 4 looking after Jane Citizen in bed 8. She is admitted with pneumonia on a background of Type 2 diabetes. Her BGL before lunch is 20.5mmol/L. She reports feeling a little dizzy and nauseated, and she looks quite pale. All her other observations are within normal parameters. She has had her morning NovoRapid dose of 6u and is not due any more insulin until 2000hrs. Would you be able to review her before lunch? Please contact me as soon as possible on 1234.
Non-urgent example
Hi Social Work department its Brooke calling from Ward A, I’m the nurse looking after Fred Harris. He has reported to me today stating he is experiencing financial difficulties at present, and would like to speak to someone from SW to see what assistance is available to him. He lives alone and is currently unemployed. We anticipate he will be discharged early next week once he is medically stable. Please call me on 1234.
Using ISBAR for clinical handover (e.g. change of shift, prior to ward/external transfer)
Identify: introduce and identify the patient using the three patient identifiers (name, DOB and UR number) – these identifiers can be checked with the patient/resident if they are cognitively intact, or using their wristband if the patient is cognitively impaired or has limited verbal communication.
Situation: what is the patient or resident’s current diagnosis and medical history? What are the latest pathology and radiology results? Are there any alerts for this person identified as a result of your assessments e.g. falls risk, wandering behaviours, advanced care directives, allergies or adverse drug reactions, infectious risks? Provide any relevant documentation to the receiving nurse for them to visualise, such as a documented Advanced Care Directive.
Background: what has been happening with the patient/resident during your shift? Are there any abnormal findings or observations to report, and what have been your actions as a result of these findings (e.g. MET call initiated, doctor review, altered MET criteria)? What procedures or activities have occurred?
Assessment: provide details of the plan of care – any procedures, treatment thus far, outstanding tasks or interventions, discharge planning.
Response: has the person you are handing over to understood? Is there anything that requires clarification or follow up (e.g. what time was their procedure scheduled for? Could you follow up on the order from pharmacy?). Allow the staff member who is receiving handover to review the charts before moving on to the next patient.
Example of good bedside hand over
“Nurse A, this is (checks wristband) Mary Day, UR number 123456 DOB 1/1/1935. She has been admitted to us with a L fractured NOF post mechanical fall at home. She has a history of AF on Warfarin, OA and dementia. She is a high falls risk and has a documented allergy to Morphine which causes hallucinations. She has a documented advanced care directive – NFR. Her pain has been well controlled with the femoral nerve block from this morning, and regular analgesia as per the medication chart. Her vital signs have been within normal limits throughout the shift. Mary is currently fasting for theatre this evening, consent has not been done yet – the treating team are awaiting her MPOA to come in and meet with the team. She has a 12/24 bag of N/Saline running. She will need an IDC inserted and a theatre pack completed prior to going to OT. Did you have any questions in regards to Mary’s care?”
Example of bad bedside handover
“Hey how was your weekend? Check out this thing I saw on Facebook earlier. Oh, this is bed 5, you looked after her yesterday didn’t you? No change, she’s stable. Think she’s fasting for theatre, but I could be wrong, maybe I’m getting confused with bed 6”
If the patient is cognitively intact and it is appropriate to do so, allow them the opportunity to have an input into their handover, such as clarifying their medical history, or allowing them to ask questions about things they may not understand or know about. This allows the patient to feel included and informed, and to understand the rationale for aspects of their care. If family members or other visitors are present at the time of the bedside handover, ensure the patient consents to them being present during the handover.
