Care handovers are letting down patients

Questions have been raised about the extent to which current handover practices across care boundaries in emergency care are supporting the communication of patients’ social and psychological needs. This is according to new research published in the Emergency Medicine Journal.

‘The aim is to make the journey for patients easier and to enable early intervention to prevent unnecessary deterioration of patients’ health and social care needs’

The backdrop is an ageing UK population, with the number of people aged 85 and over expected to increase by two-thirds over the next 20 years. An increasingly elderly population with complex health and social care needs confronts the NHS with new challenges.

Effective handover across care boundaries is an essential prerequisite for delivering high quality care to the country’s increasingly elderly population.

Meanwhile, concerns have been raised about the safety and quality of care that elderly patients receive. Notably, a Health Service Ombudsman report has highlighted poor quality care provided to elderly patients in acute care settings. 

Whole system approach

In 2012, a best practice guideline, Quality Care for Older People with Urgent and Emergency Care Needs (also known as The Silver Book), was published under leadership of the College of Emergency Medicine and the British Geriatrics Society. The Silver Book describes the urgent care needs of older people and it sets out the competencies required to effectively meet their needs. 

The guide points out that “implementation of improved care for older people requires a whole system approach” across health and social care, instead of current fragmented services. One way of achieving this is through models of integrated care.

The King’s Fund emphasises the benefits to patient experience and health outcomes when organisations and services overcome barriers and start working together. Some NHS trusts and councils already provide integrated care in the form of pilot schemes focusing on improved outcomes for patients.

The National Collaboration for Integrated Care and Support published in a framework in May setting out their commitment to establishing the integration of services. The aim is to make the journey for patients easier and to enable early intervention in order to prevent unnecessary deterioration of patients’ health and social care needs. 

Unplanned hospital admissions and emergency attendances can affect the patient’s ability to live independently in the community. A prerequisite for the seamless transition of patients across care boundaries is effective patient handover between organisations and departments.

Social and psychological needs

Research suggests social and psychological needs may not be communicated routinely during handover. The research, conducted by a team led by Warwick Medical School, investigated handover practices across care boundaries in three NHS accident and emergency departments, including handover from the ambulance services and referrals to hospital inpatient teams.

‘The research raises questions about the extent to which early consideration of psychosocial aspects is currently supported by the handover process’

The study found that, on average, as little as 2-5 per cent of handover communication content during ambulance service handover, and 1.5-2.8 per cent of handover communication content during referrals, was concerned with the patient’s social circumstances or psychological needs. 

The patient’s psychosocial history and needs were not discussed routinely during handover, but only following a small number of triggers. 

For patients admitted to hospital, there may be the opportunity to establish their needs by the inpatient team. However, the majority of patients will be discharged straight from the A&E.

Risks to patients

Without adequate consideration of the patient’s social and psychological needs, there might be risks for patient safety and it could negatively affect the quality of care delivered to patients. 

Ambulance crews often have important background information, which should be communicated during handover to the emergency department and subsequently to the inpatient teams, in order to involve appropriate services at the earliest possible opportunity. 

Integrated care teams might already know some patients and professionals could be contacted in order to discuss the patient’s health and social care needs. This would facilitate the discharge planning process and it could contribute to reducing delays and unnecessary re-attendances. 

Our research raises questions about the extent to which early consideration of psychosocial aspects is currently supported by the handover process in the emergency care pathway.

Bio-psychosocial model

Handover practice should move from a model based on physiological priorities towards a bio-psychosocial model of patient care.

‘Interdisciplinary working by professionals from different teams, specialties and organisations should be reflected in handover’

Efforts aimed at improving patient handover often include standardisation through approaches supported by mnemonics, such as “ATMIST” (age, time, mechanism, injury, signs, treatment) or “SBAR” (situation, background, assessment, recommendation). 

It is conceivable that consideration of the patient’s psychosocial history could be included as another element, a further “S”, for example. However, in order to achieve sustainable improvements in the provision of person-centred and high-quality care to elderly patients, a culture shift may be required. 

Healthcare professionals require training and the development of extended skills to approach and deliver care for elderly patients within a bio-psychosocial model. Interdisciplinary working and an appreciation of the contribution to patient outcomes by professionals from different teams, specialties and organisations will have to become ingrained in everyday practice. This should then be reflected in handover. 

These brief conversations are often the only opportunity for care providers from different organisations to exchange important background information relevant to the patient’s social and psychological needs.

Mark A. Sujan is associate professor of patient safety at Warwick Medical School, Warwick University. Matthew Cooke, Peter Spurgeon, Pete Chessum, Laurence Fitton, Michelle Rudd and Matthew Inada-Kim were also part of the project team. The research was funded by the National Institute for Health Research and Health Services and Delivery Research programme (project number 10/1007/26). Visit the programme website for more information. The views and opinions expressed in this article are those of the authors and do not necessarily reflect those of the HS&DR programme, the NIHR, the NHS or the Department of Health.