Pushing the envelope: clinical handover from the aged-care home to the emergency department

The residential aged-care sector is often overlooked when patient safety issues are considered. This is exemplified by the paucity of literature about clinical handover between aged-care homes (ACHs) and hospitals.1-3 Residents of ACHs are elderly, usually frail, and almost always have complex care needs. They often need to go to hospital — usually at short notice to an emergency department (ED), but also for planned admissions or to attend outpatient appointments. The transfer of ACH residents between ACHs and the acute sector involves a number of clinical handovers (between ACH staff, and between ambulance officers [AOs] and hospital staff) and a number of communication modalities (face-to-face, via telephone, by documents and — occasionally, but probably increasingly — electronically). The multiplicity of factors generates a high risk of communication failure and unsafe clinical handover, which can have a direct impact on the continuity of care and health outcomes for this population.3,4

As part of the Aged Care General Practitioner Panels Initiative (ACGPPI),5 we developed an “Aged care home transfer-to-hospital envelope” (the Envelope) (Box 1) in response to frequent anecdotal reports from ACH and ED staff about the poor quality of transfer and discharge information (clinical handover) accompanying residents both to and from hospital. We identified several reasons why clinical handover was frequently so poor between these health care settings.6 Firstly, there is limited understanding of the range of constraints affecting the provision of care in each setting. Secondly, there are workforce issues that have a direct impact on both reasons for transfer to hospital and the provision of clinical handover. These include limited access to timely and regular medical care, the skills mix of the residential aged-care workforce, and frequent turnover of staff in both ACH and ED settings (recruitment and retention issues as well as shift-to-shift and staff rotation issues). Thirdly, ACH staff frequently reported that clinical and other handover information they had provided did not reach the ED but disappeared into a so-called “black hole”. In addition, we commonly had the impression, from discussions with both ACH and ED staff, that clinical handover was not really recognised as necessary. There was a sense that, once the resident/patient was “sent off”, the responsibility for care was discharged and that “they” (ED or ACH staff, respectively) would take over effective care (without awareness of the need to provide handover information).

Clinical handover is required both when a resident is transferred to hospital and when he or she is discharged to the ACH. The Envelope was designed specifically to support clinical handover when a resident is transferred to hospital. An envelope is a familiar communication tool. As well as its traditional function of containing documents for transfer from one place to another, the back of the Envelope features a checklist of key clinical and other handover information needed when a resident is transferred from an ACH to an ED.

We set out to evaluate the use and usefulness of the Envelope as a tool to support safe clinical handover from the ACH to the ED, and to raise awareness of the need for clinical handover between these settings. Throughout the trial, we sought feedback on the layout, design and content of the Envelope and on factors that would support ongoing and national use of the Envelope.

In the trial, our focus was on the ED, as the most common destination for transfer. Clinical handover at discharge from hospital to the ACH is a separate process requiring further study.

Our results clearly show that the Envelope was used in the large majority of transfers of ACH residents to EDs. It was reported as easy to use, useful and highly valued by all parties involved in clinical handover from the ACH to the ED. There was a high level of support for its ongoing use.

The checklist of clinical and other handover information was particularly valued. It was developed and refined through a process of extensive consultation with all stakeholders, both before and during the trial, so we are confident that all key handover information is included.

An envelope is a low-cost, familiar, age-old communication tool and the instructions on the Envelope we designed and refined are simple and clear. The Envelope can function as a stand-alone tool, requiring minimal support and training for its implementation and use. The key challenges for ongoing and wider use of the Envelope are about supply and distribution (Box 4).

Our results suggest that using the Envelope improved clinical handover. This is supported by the consistent finding that ACH staff, AOs and ED staff believed that clinical handover was better when the Envelope was used. Given the established links between the quality of clinical handover, continuity of care and patient outcomes, it is likely that the Envelope is an effective means of improving the safety and quality of clinical handover and, therefore, of patient care.

We note the discrepancy in background data on the number of resident transfers to hospital recorded from each data source (ACHs, EDs and Ambulance Victoria). However, in our view, this does not affect the main outcomes of the trial.

Previously we had observed widely variable awareness of the need for clinical handover between ACHs and hospitals. This was the case among some staff in both ACH and ED settings and consequently informed one of the key objectives of the trial, which was to raise awareness of the need for clinical handover in this situation. The finding that all interviewees in the trial (ACH, ambulance and ED staff) believed that using the Envelope raised this awareness indicates that this objective was met.

Further work is needed in the area of provision of safe clinical handover in the reciprocal scenario — that is, when a patient is discharged from hospital to an ACH.

1 Envelope (revised version after trial) — front and back view

3 Features of the Envelope identified as useful by staff of aged-care homes