Clinical Handover in the Paediatric Unit CHBH varied according to staff skills, personal preference for Handover style, previous experience, and activity on the Unit on the day. Clinical Handover generally took place in a room away from the patients, often started late and involved an amount of informal conversation. There was evidence from errors and inefficiencies linked to poor communication between nursing shifts that the current process for Handover was inefficient and unsafe.

A new clinical handover procedure was trialled and implemented following research, stakeholder involvement and education. The new procedure encompassed Bedside clinical handover, involvement of the Junior Medical Officer, safety checks of patient identification and equipment, checking of documentation and involvement of parents. Evaluation of the procedure utilizing audits, Parent satisfaction questionnaire, and a review of Medication errors has shown significant improvements to the Clinical care of patients in the Unit.

Within 6 months, develop a patient focused, standardised Clinical Handover procedure for the Paediatric Unit that would improve the safety of Clinical care, improve communication with Parents and improve the efficiency of the Unit overall.

Inadequate Clinical handover encompassed efficiency and patient safety issues and was evidenced by:

1. Oncoming staff seeking further information following Handover.
2. Handover frequently starting late and running over time.
3. Medication errors - drugs not signed for.
4. Patients without correct identification.
5. Emergency equipment not routinely checked.
6. Parents not aware of patient's plan of care.
7. Missed tests and procedures.
8. Parents complaints that "buzzers" and reception enquiries were not attended in a timely manner while Handover was occurring.

Diagnostic Phase

1. By participating in the Clinical Handover procedure the Nurse unit Manager was able to identify that the Procedure vary greatly between individuals depending on the preference and experience of the nurse giving the information and the amount of activity occurring at the time. The NUM observed that no specific criteria were used and that topics considered important to communicate by one nurse were often not considered as important by another eg the condition of the IV cannula site. During busy periods information was decreased to a minimum.
2. The NUM undertook to specifically observe the ward whilst handover was occurring and concluded that there was a problem with insufficient staff coverage of the ward and reception.
3. Routine Nursing Care Audits showed that important safety equipment such as Oxygen and Suction that should be checked at change of shift was not functioning to 100% and that all patients did not have an Identification band in place and allergy status recorded.
4. Frequent parent enquiries to the NUM and reception demonstrated that Parents were not fully aware of their child's care plan.
5. An IIMS report identified that some Medication errors may have been avoided with improved checking and communication during change of shift.

Root causes identified could were summarised as:

1. Lack of an agreed standardised policy for Clinical Handover including mandatory discussion points and safety checks.
2. Lack of involvement of relevant people including the Multidisciplinary team, the patient and carer.
3. The environment where Clinical handover taking place being away from patients.

Alternative methods of Clinical handover were investigated. A comprehensive study by St Vincent's Health (Stolp and King) was reviewed as well as a system for attending Bedside checks by at Royal Children's Hospital in Melbourne (Iliffe p31). A method combining the two procedures - bedside Clinical Handover with Bedside checks was presented to the staff to trial. Additionally, consultation with the Paediatricians identified their support for the attendance of the Junior Medical Officer at the 1400hrs Clinical Handover round. The specific Bedside checks were altered to reflect the needs of the Paediatric Unit:

• IV fluids correct.
• IV cannula site free from signs of infection.
• Medication chart complete.
• Correct patient identification in place.
• Patient allergies recorded, oxygen and suction equipment functioning.
• Handover at the bedside.
• Nebulizer mask renewed.

Opposition by staff to the proposed trial focused around the potential of Bedside Clinical Handover to impinge on the patient's privacy as well as the time Handover would take if Bedside checks were combined with the Handover.

Evidence from the St Vincent's research that patients do not have privacy concerns as a result of Bedside Clinical Handover was presented to staff during in-services and a folder outlining the St Vincent's project was left for staff to access, however this remained a difficult issue throughout the trial. The NUM agreed that Oxygen and Suction Checks could be left until the completion of Clinical Handover.

The new Clinical Handover procedure commenced on the agreed date.

The new Clinical handover procedure has been in place for 9 months, outcomes achieved have been:

1. There was an 83% reduction in Medication errors comparing the 6 months prior to the new procedure to the 6 months following the procedure.
2. Audit of 27 patients Bedside Checklists encompassing 92 days of care identified that the checklist had been complete on 100% of patient days, there was 100% compliance with full completion of the checklist with the exception of 86% compliance with two staff signatures.
3. Parent satisfaction with the new procedure was measured with a survey of 14 parents who had participated in the procedure. On the whole parents rated the value of participation as 9.6 out of 10 and rated the ability of the procedure to contribute to the Quality of care received by their child as 9.6 out of 10. One parent stated they were concerned regarding confidentiality by supported the practice because of the overall benefit.
4. After 3 months, audits identified that Oxygen and Suction equipment was not being routinely checked following the Clinical Handover so the procedure was changed to include the checking occurring at the time of Handover.
5. The Junior Medical officer routinely attends and participates in the 1400hr Clinical Handover.

It is widely acknowledged that the root cause of many errors occurring in the Health Care system can be linked to poor communication between staff and with patients and carers. Clinical Handover, occurring as frequently as 5 times a day is an important opportunity to enhance communication and patient safety. The new Bedside Clinical handover procedure on the Paediatric Unit combined three different ideas to provide a solution for poor communication in our Department. Future successful projects involving Clinical Handover should be tailored to the individual needs of the patients and the Department involved and ideally involve the patients and carer.

1. Stolp, M.J. & King, E. 2004, Patient Handover Project, St Vincent's Health Service.
2. Iliffe, J. 2005, Handing over to Safety, Australian Nursing Journal, Vol. 12 No 9, p31.