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Level 2 of 6Must-remember

Clinical handover and communication

Assess, manage and stay safe — enough on its own

The card — assess, manage, caution

Assessment— look, ask, measure

  • Know what you are transferring: clinical handover is the transfer of professional responsibility and accountability for some or all aspects of the care of a patient or group of patients, temporarily or permanently — information and responsibility must BOTH move and both parties must agree that they have.
  • Identify which handover this is: shift-to-shift of a whole caseload, telephone referral asking for an opinion or acceptance, intra-hospital transfer between levels of care, inter-hospital transfer (patient unmonitored for a period), discharge to primary or community care, or formal transition of a young person with chronic disease from paediatric to adult services — where written confirmation that handover has occurred is the accepted standard.
  • Take the history you will hand over: onset and duration; relevant past history; allergies; anticoagulants, insulin, steroids, immunosuppressants and traditional preparations; what has been given and when; and the trend of the observations, not the whole clerking.
  • Measure and transmit numbers, not adjectives: an aggregate score with an agreed threshold is a more reliable carrier of concern than saying he does not look right.
  • NEWS2 cut-offs (adults ≥16 years, not pregnant): 0 routine; 1-4 low risk; 3 in any single parameter is low-to-medium risk prompting review even if the aggregate is low; 5-6 medium risk, the key threshold for urgent review; ≥7 high risk — hand over the score AND its direction of travel.
  • Glasgow Coma Scale: hand over the three components separately — eye (4), verbal (5), motor (6) — because the total conceals the trend, and a fall of ≥2 points between assessments is significant whatever the absolute value.
  • qSOFA: respiratory rate ≥22/min, systolic blood pressure ≤100 mmHg, altered mentation; ≥2 of 3 in suspected infection indicates higher risk of poor outcome, but it is insufficiently sensitive to exclude sepsis.
  • Children are scored against age bands, never adult thresholds: indicative normal heart rate is under 1 year 110-160/min, 1-2 years 100-150, 2-5 years 95-140, 5-12 years 80-120, over 12 years 60-100 — a heart rate of 150/min is unremarkable in an infant and pre-terminal in a 12-year-old, and bradycardia in a child is a pre-arrest sign.
  • Hand over the trend, not the snapshot: a creatinine of 180 micromol/L rising from 90 over 24 hours and one falling from 300 demand opposite responses, so give the previous value and the interval.
  • Recognise a failing handover in real time: a qualitative summary (stable, nothing much to do) with no numbers, times or trend; a working diagnosis with no differential and no statement of what has not been excluded; tasks in the passive voice with no named owner; pending investigations with no time sent and nobody named to review; ceiling-of-care decisions alluded to but not attributed to a person, a time or a family conversation; no read-back and no questions invited; and acceleration towards the end of the list.
  • Red-flag patients at high risk of handover failure: the patient who was unstable and is now stable (they are supported, and the support may fail); the unresolved diagnosis nobody wishes to own; the patient whose next step depends on a result not yet returned; the patient waiting for a procedure delivered elsewhere; the patient on an anticoagulant, insulin, steroid, immunosuppressant or opioid infusion; the ceiling-of-care decision made but not written and timed; the patient handed over last, by telephone or during departmental overload; and any child whose weight was estimated rather than measured.
  • Test whether the message actually arrived: read-back at the point of handover is the most immediate and informative test available — a read-back that omits the escalation threshold, or alters a dose or route, is a positive result and must be corrected before the conversation ends, and reluctance to read back is itself abnormal.
  • Assess the receiver as well as the patient: get the name and role of the person you are speaking to and write it down, and for a telephone conversation record the time, the name and grade, what was said and what was agreed.
  • Assess the patient's ability to correct you: patients who are deaf or hard of hearing (around 55% of people over 60, fewer than 1% of whom sign), visually impaired, aphasic after stroke, cognitively impaired or not sharing a language with the team cannot correct an inaccurate handover, which removes the informal error-checking other patients provide.
  • Consider the mimics before calling it a communication problem: documentation failure (never written, illegible, copy-and-pasted), referral failure (urgency not conveyed), prescribing or administration error (wrong drug, dose, route, concentration, decimal place or patient), diagnostic error (wrong conclusion from adequate data), patient-clinician communication failure (detected by teach-back), discharge communication failure (presents days to weeks later) and failure of escalation (the information was transmitted, but hierarchy blocked action).
  • Absence of documentation is evidence, not merely absence of evidence: practically and medico-legally, a decision existing only in one clinician's memory has not been made.

Management— do this, in order

  • Use one fixed framework in the same order every time — ISBAR: Identify, Situation, Background, Assessment, Recommendation, then read-back; standardised prompts force concise, focused information at the correct level of detail and measurably increase patient safety.
  • I — Identify: your name and role, the patient's full name, age, sex, location and one unique identifier, and the name and role of the person you are speaking to, written down — for example, I am the physician looking after Mr A, 62, male, registration 44821, may I take your name.
  • S — Situation: the problem, now, in one sentence, with your level of concern stated explicitly — he has a potassium of 7.1 mmol/L with broad QRS complexes, I am worried he is going to arrest.
  • B — Background: onset and duration, relevant history, allergies, anticoagulants, insulin, steroids, immunosuppressants and traditional preparations, what has been given and when, and the trend of observations — for example anuric for 12 hours, blood pressure 96/60 on arrival and 104/64 now.
  • A — Assessment: your interpretation, the differential not yet excluded and what you do not know — hyperkalaemia with acute kidney injury, probably pre-renal, I cannot exclude sepsis, the lactate is 3.2 mmol/L.
  • R — Recommendation: precisely what you want, from whom, by when (I need him reviewed within 15 minutes), the ceiling of care, and the escalation trigger as an explicit conditional — if the systolic falls below 90 mmHg or he becomes drowsy, do X.
  • Close every loop: the receiver repeats the plan, doses and triggers in their own words and the sender confirms aloud — so, calcium given, hourly ECG and potassium, escalate if the QRS widens — correct.
  • Present the caseload in order of acuity, not by bed number, because handovers get interrupted and the patients presented first are those that survive interruption.
  • Transmit six items for every patient: physiological state with the score and its trend; working diagnosis and what has NOT been excluded; outstanding tasks with a named owner and a clock time; pending results with the time sent and who will review them; ceiling of care and resuscitation status with who decided it and when; and an escalation trigger written as a conditional.
  • Resolve rather than transmit anything completable in the time available: an unread ECG is not a handover item but unfinished work.
  • Give every verbal or telephone drug order as drug, dose, route, time, read back in full, confirmed aloud, and transcribed into the chart at the first opportunity.
  • Adrenaline for anaphylaxis (1 mg/mL, 1 in 1000): adult 500 micrograms (0.5 mL) IM into the anterolateral thigh, repeat after 5 min if needed; under 6 years 150 micrograms (0.15 mL) IM; 6-12 years 300 micrograms (0.3 mL) IM; over 12 years 500 micrograms (0.5 mL) IM — read back adrenaline 500 micrograms, that is 0.5 mL of 1 in 1000, intramuscular, thigh, now.Doctor / Nurse
  • Adrenaline for cardiac arrest (100 micrograms/mL, 1 in 10 000): adult 1 mg (10 mL) IV every 3-5 min; child 10 micrograms/kg IV every 3-5 min — read back the concentration, never the ratio alone.Doctor / Nurse
  • Calcium gluconate 10% for hyperkalaemia with ECG change: adult 10 mL IV over 5-10 min, repeated until the ECG normalises; child 0.5 mL/kg IV (maximum 20 mL) over 5-10 min — the read-back must state the salt (gluconate versus chloride), the volume and the duration.Doctor / Nurse
  • Glucose for hypoglycaemia: adult 100 mL of 20% glucose IV or 50 mL of 50% glucose IV, recheck at 10 min; child 2 mL/kg of 10% glucose IV, repeat as needed, recheck at 10 min — 50% glucose must not be given to a child peripherally, and the read-back states the concentration and the volume in millilitres separately.Doctor / Nurse
  • Insulin and potassium orders: never abbreviate units as U or IU, and say six units — six, units; for potassium chloride state concentration, total dose, diluent volume and infusion duration, never give it undiluted, and repeat all four elements (in children with the mmol/kg stated).Doctor / Nurse
  • For any weight-based paediatric order the read-back must include weight in kilograms, the mg/kg dose, the total milligrams, the volume in millilitres and the route — a tenfold error in a mg/kg calculation is the classic paediatric drug death; where a child has not been weighed transmit the estimate, the method and the fact that it IS an estimate, using weight (kg) = (age in years + 4) x 2 for ages 1-10 years, and never let two different weights circulate simultaneously.Doctor / Nurse
  • When a concern is not acted upon, escalate the FORM of the message, not its volume: probe, alert, challenge, emergency (PACE) or I am Concerned, I am Uncomfortable, this is a Safety issue (CUS) — and under the two-challenge rule, if a concern has been stated twice without acknowledgement you are expected, not merely permitted, to take the matter further.

Caution— what harms

  • Never assume a message has arrived: open-loop communication — sent and merely assumed received — is how misheard drug names, concentrations and decimal places kill silently, surfacing only at the bedside.
  • Never hand over the word stable for a patient who was unstable an hour ago: they are SUPPORTED, and the support may fail; a rising NEWS2 of 6 and a falling NEWS2 of 6 are different patients.
  • Never leave a task without a named owner and a clock time: chase the potassium, in the passive voice, is structurally identical to a task never mentioned and will not be done.
  • Never abbreviate units as U or IU on an insulin order, and never give potassium chloride undiluted or without stating concentration, total dose, diluent volume and duration.Doctor / Nurse
  • Never give 50% glucose to a child peripherally — in children use 2 mL/kg of 10% glucose IV and recheck at 10 min.Doctor / Nurse
  • Never state an adrenaline order as a ratio alone: say the concentration — 1 mg/mL (1 in 1000) 500 micrograms IM for anaphylaxis versus 100 micrograms/mL (1 in 10 000) 1 mg IV in arrest — because the two are given by different routes at different doses.Doctor / Nurse
  • Never let two different weights for one child circulate at the same time, and never accept a weight-based order without hearing weight, mg/kg, total mg, volume and route read back.Doctor / Nurse
  • Never hint: hinting and hoping is not communication, and I am worried about this patient is the most reliable transmitter of urgency in clinical language — urgency must be conveyed by direct spoken communication, because written or messaged urgency is regularly missed while spoken urgency is not.
  • Never hand over by bed number, and never let the handover accelerate towards the end of the list, or the patients discussed last receive a fraction of the time given to the first irrespective of how ill they are.
  • Never trust a normal result that nobody has seen: a normal result does not close a loop unless someone has looked at it, and a result with nobody named to review it is functionally equivalent to a test never sent.
  • Never inherit a label without re-examining it: diagnostic momentum, anchoring and premature closure turn probably gastritis, but I have not excluded cardiac pain into gastritis by the third telling — state uncertainty out loud, because a named uncertainty gets re-examined.
  • Never rely on copy-and-paste: identical text repeated verbatim across successive daily entries means obsolete statements are propagating and the record can no longer be relied on for current information.
  • Never alter a record: records are dated, signed with a printed name and kept secure, and a correction is made only by a signed, dated note alongside the original, which is left intact — concealment, not error, is what constitutes negligence.
  • Never use a family member or a child as an interpreter: relatives may censor sensitive material or substitute their own views and confidentiality cannot be assured, so use a trained professional interpreter where clinician and patient do not share a language fluently.
  • Never let the framework become ritual: a handover in which ISBAR headings are recited without content is no safer than one with no structure and may be less safe, because it creates the appearance of rigour.

Refer / escalate

Escalate immediately — by voice, using graded assertiveness and explicit safety language — whenever a concern has been raised twice without acknowledgement, whenever a patient meets a NEWS2 of 5-6 (urgent review) or ≥7, or 3 in any single parameter, whenever the GCS falls by ≥2 points, whenever a ceiling-of-care decision is undocumented, and whenever a receiving clinician declines a request you believe is clinically necessary, recording the request, the response, the time and the name.

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