Having a structured approach to documentation and handovers is beneficial to ensure that you can plan what you're going to say, ensure that you get your points across, and feel confident that you've not missed out any crucial information. At the sharp end, a good handover can ensure that your patient gets the care they need to save their life. There are plenty of tools and acronyms out there that provide this structure, but how do you know which tool is best?
Short answer- trial and error. It may also depend on the situation and how much detail you need to provide in any given moment. But mostly, you're going to be trying out a few different ones to find the one that works best for you. Below, I've included 4 used in practice with examples of what a handover might look like for each.
RSVP
RSVP isn't hugely well know, as it's mostly been usurped by SBAR. However, I quite like it as it still gets across all the information you need fairly succinctly for a deteriorating patient. Before you make the call, you'll want to assess the patient yourself, know the reason for admission, and read the most recent notes to have a sense of what might be going on.
R- Reason, Why are you calling? About whom? What are your concerns?
S- Story- a short but relevant history including past medical and surgical history, resus status and summary of current admission
V- Vitals- ensure you have a full set of observations prior to making the call. Talk through your A-E assessment.
P- Plan- what do you want to happen as a result? What are you going to do and what would you like someone else to do?
My name is Christie, I'm a nurse calling from Ward 5. I am calling about Patient X in bed 17. The patient is deteriorating. They are complaining of pain in their back and have a NEWS score of 6 for high heart rate, high temparature and low blood pressure. I need your advice please.
Patient X was admitted on 02 December for a urinary tract infection. They have a past medical history of type 1 diabetes, and postural hypotension. They are for resuscitation, and are being treated with oral nitrofurantoin for the UTI and IV fluids for low blood pressure.
Their airway is clear (A) They have a respiratory rate of 16 (B) and are saturating at 98% on room air (B). Their blood pressure is 92/109 (C) and pulse is 140 (C). They have IV fluids running (C) and have passed 20mL of urine in the last 6 hours with a catheter in situ. They are alert (D), GCS 15 (D) with a blood glucose of 6.4mmol/L (D). Their temperature is 38.1 deg (E). Their NEWS score has gone from 1 to 6 in the last 4 hours.
Could you please come and review the patient as soon as possible. I am concerned that this is urosepsis, so I am going to get peripheral blood cultures and a lactate level, start high flow oxygen, and monitor urine output via their catheter. They are already on IV fluids. They will need IV antibiotics prescribing once you have reviewed. Do you agree with this plan? Are there any other tests or checks you would like in the meantime?
In this scenario, you have clearly laid out who the patient is, what you're concerned about, what you already know about them, and what you are going to do or would like someone else to do. There's very little information other than what is covered above that another clinician might want to establish how to prioritise this patient, except maybe what the last set of observations showed (for example, we know that Patient X has postural hypotension, so what was their previous BP? Is 92 systolic normal for them? Were they laying down when the BP was taken?).
ATMIST
ATMIST is not a tool I've personally used, but from what I've seen it's mainly used out of hospital by paramedics or in A&E. It's cited as a very brief tool, which should take only 45 seconds to complete to give bare bones information to others w=so that they know what resources to prepare to treat the patient.
A- Age. Basic demographics- age and sex
T- Time. ETA to hospital and time of incident.
M- Mechanism of Injury. Gross mechanism and details of any other relevant factors associated with major injuries.
I- Injuries. Seen or suspected.
S- Signs. Vital signs and whether patient has improved or deteriorated since first seen.
T- Treatment. Anything given and to what effect?
Female patient, approximately 30 years old.
Driver in pedestrian vs car collision at 1830. ETA to ED is 15 minutes.
Car hit pedestrian at 30 miles per hour, driver not wearing a seatbelt and was ejected through windshield.
Obvious deformaties to right arm and right leg, query fractured pelvis. Bleeding profusely from head injury. Query rib fractures on right side.
Blood pressure 100 systolic, heart rate 125, respiratory rate 20, oxygen saturations 99% on 5L via non-rebreathe mask, temperature 36.5, GCS 13- eyes 3, verbal 5, motor 5. Sats have improved with oxygen, 82% on room air when we arrived on scene.
TXA given, no effect on head bleed. On 5L oxygen, IV fluids running, morphine given to good effect.
I like this one because you don't need to worry about niceties. You're purely trying to get life saving information across so that whoever you're handing over to has the best chance of caring for the patient. If you've ever seen or heard a paramedic handover a major trauma patient, you know how efficient they are so you can definitely see why this would only take 45 seconds. Plus, the staff in ED are prepared to information to be rattled off like this which helps a lot.
SBAR
Probably the most well known tool. Everyone (I mean everyone) in healthcare will have done, or attempted, an SBAR handover. In researching this, I foudn out that it was originally designed in the military to allow for consicse handovers.
S- Situation. Who are you, who is the patient, and why are you calling?
B- Background. Brief and relevant overview of the patient and their history.
A- Assessment. Relevant clinical findings- assessment, vital signs, general impression of the situation.
R- Recommendations. What would you like to happen? Clarify if any action is needed from you.
My name is Christie, I'm calling from ward A about Patient X in bed 2. I'm calling because the patient is complaining of severe abdominal pain.
Patient X was admitted 2 days ago with severe constipation. They have a learning disability, autism, and a history of constipation which has led to bowel obstruction in the past. They are being treated with enemas for the constipation but this has not yet had an effect.
They are indicating 10/10 pain through their communication board and look very uncomfortable. Observation are stable other than heart rate of 105 giving a NEWS score of 1. On examination, the abdomen feels soft and non-tender but the patient is in worsening pain when palpating the abdomen.
Could you please review the patient when possible. They have had paracetamol but it has not helped with the pain and I think they need something stronger. I am concerned that this could be the start of another bowel obstruction.
Never underestimate the power of clearly stating your worries or concerns when discussing your assessment or plan. Sometimes even just saying 'I don't know what's going on but I am worried' is enough- gut instinct exists for a reason. And it's totally okay to not know what's going on- you are calling to ask for advice or help after all! The only thing I would change from my example above is 'when possible'. It can be more helpful to give a timeframe so that you know when to escalate again. For example, you could ask when they may be able to review the patient and when you should call back- either timescale wise, or worsening wise.
HUMANS
This one was introduced to me more as a written documentation tool, but I found that combining it with an ABCDE assessment made for a really comprehensive handover when stepping down a patient from ICU to a ward. Plus, it's my favourite acronym of the lot.
H- Hygiene.
U- Urination, elimination and hydration.
M- Mobility.
A- Areas and wound care. Are their pressure areas intact and how are any wounds being taken care of?
N- Nutrition.
S- Social.
I'm handing over Patient X, a 55 year old male 4 days post bowel resection. He is maintaining his own airway on room air, NEWS score is 0. BP is 120/85, heart rate 72, respiratory rate 14, temparature is 36.1, GCS 15 and blood sugar is 7.4mmol/L. Not currently complaining of any pain (ABCDE). He is alert and oriented and all medications have been given this morning.
He is independent with self care including washing, dressing and oral hygiene, he will just need a bowl of water bringing to him. He has dentures which are currently in situ.
His urine output has been 50mL/hr, voiding into bottles independently. He last opened his bowels this morning, type 4. Not on a fluid balance chart and drinking normally, adequate oral intake so no IV fluids running.
He is independently mobile using a stick, had some input from physio after surgery to get him mobilising. Low risk for falls, he just needs to ensure he is wearing his glasses so he can see where he's going and ensure appropriate footwear.
All pressure areas are intact, no risk of pressure sore development per the Braden score. One surgical wound to midline abdomen, wound is intact, clean and dry, surgical glue in situ. Covered with Cosmopore dressing, last changed this morning. He has a 22 gauge cannula in his left ACF, inserted yesterday and dressing changed this morning.
He is eating a normal diet, no feeding tube in situ and no dietician input. He has complained of some nausea so has PRN metoclopramide prescribed.
His family have been visiting in the afternoons, and I have informed them he will be moving wards today. Plan is for discharge with a BD package of care to help him with meal preparation. Discharge planning in progress, expected discharge by the end of this week. No social issues noted.
As you can see, I started the example above with a very brief A-E assessment and summary of vital signs. This helps the receiving clinician to get a good overview of how stable the patient is.
In pressure areas and wound care, I like to also mention any invasive devices that break the skin barrier, like cannulas and drains. It's also useful to mention any troublesome symptoms, such as pain and nausea, and how these are being managed, and any other lines and tubes in the relevant sections, like NG tubes or catheters.
This format can be used for a verbal handover, or as I said above, used to structure written documentation. Your colleagues will appreciate the detail!
I hope that this has been a helpful overview of handover tools to cover a range of situations, from pre-hospital, to a deteriorating patient, to a stable patient. I'd love to hear if anyone knows of other tools not mentioned in this post?
Love always,
Christie x
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