Michelle Rudd

Managing competing organizational priorities in clinical handover across organizational boundaries

Objectives Handover across care boundaries poses additional challenges due to the different professional, organizational and cultural backgrounds of the participants involved. This paper provides a qualitative account of how practitioners in emergency care attempt to align their different individual and organizational priorities and backgrounds when handing over patients across care boundaries (ambulance service to emergency department (ED), and ED to acute medicine). Methods A total of 270 clinical handovers were observed in three emergency care pathways involving five participating NHS organizations (two ambulance services and three hospitals). Half-day process mapping sessions were conducted for each pathway. Semi-structured interviews were carried out with 39 participants and analysed thematically. Results The management of patient flow and the fulfilment of time-related performance targets can create conflicting priorities for practitioners during handover. Practitioners involved in handover manage such competing organizational priorities through additional coordination effort and dynamic trade-offs. Practitioners perceive greater collaboration across departments and organizations, and mutual awareness of each other’s goals and constraints as possible ways towards more sustainable improvement. Conclusion Sustainable improvement in handover across boundaries in emergency care might require commitment by leaders from all parts of the local health economy to work as partners to establish a culture of integrated, patient-centred care.

EMERGENCY CARE HANDOVER (ECHO STUDY) ACROSS CARE BOUNDARIES–THE NEED FOR JOINT DECISION-MAKING AND CONSIDERATION OF PSYCHOSOCIAL HISTORY

Background Inadequate handover in emergency care is a threat to patient safety. Handover across care boundaries poses particular problems due to different professional, organisational and cultural backgrounds. While there have been many suggestions for standardisation of handover content, relatively little is known about the verbal behaviours that shape handover conversations. This paper explores both what is communicated (content) and how this is communicated (verbal behaviours) during different types of handover conversations across care boundaries in emergency care. Methods Three types of interorganisational (ambulance service to emergency department (ED) in ‘resuscitation’ and ‘majors’ areas) and interdepartmental handover conversations (referrals to acute medicine) were audio recorded in three National Health Service EDs. Handover conversations were segmented into utterances. Frequency counts for content and language forms were derived for each type of handover using Discourse Analysis. Verbal behaviours were identified using Conversation Analysis. Results 203 handover conversations were analysed. Handover conversations involving ambulance services were predominantly descriptive (60%–65% of utterances), unidirectional and focused on patient presentation (75%–80%). Referrals entailed more collaborative talk focused on the decision to admit and immediate care needs. Across all types of handover, only 1.5%–5% of handover conversation content related to the patients social and psychological needs. Conclusions Handover may entail both descriptive talk aimed at information transfer and collaborative talk aimed at joint decision-making. Standardisation of handover needs to accommodate collaborative aspects and should incorporate communication of information relevant to the patients social and psychological needs to establish appropriate care arrangements at the earliest opportunity.