NR 527 Week 2 Handover Write-Up for a Transfer Example

Handover Write-Up: Mrs. B.'s Second Transfer to the Emergency Department, Written for the Physician Who Will Read It in the Next Ten Minutes, With What We Need Sent Back

Student Name

College of Nursing, Chamberlain University

NR 527: Communication and Collaboration for Advanced Nursing Practice

Instructor Name

Month Day, Year

Handover Write-Up: Mrs. B.'s Second Transfer to the Emergency Department, Written for the Physician Who Will Read It in the Next Ten Minutes, With What We Need Sent Back

Who This Is Written For

This handover was written by the facility's own nurse practitioner, based at a skilled nursing home of 120 beds, for the emergency physician who would see Mrs. B. on her second transfer in three weeks. It is written for a reader who has never met her, is caring for several other patients, and will look at the first page for less than a minute before deciding what to do first. It follows the SBAR order of situation, background, assessment and recommendation, so that writer and reader expect the same sequence (Haig et al., 2006), and it adds a final section on what the facility needs sent back. The information is organized so that the most useful facts appear first and nothing the physician needs requires a phone call to find. Identifying details are changed; the resident is a composite.

The Handover as Sent

Situation. Mrs. B., 86, is being sent at 1510 for new fever of 38.6 C, heart rate 112, blood pressure 98/60 (her usual is 130s/70s) and a marked change in alertness since noon. She is drowsy but rousable and not following commands she usually follows. Oxygen saturation 94% on room air. We are concerned about sepsis, most likely urinary, given a recent urinary infection.

Background. Moderate Alzheimer dementia. Baseline: at her best she recognizes staff, answers yes or no questions, walks 20 feet with a walker and one staff member, feeds herself with setup and is continent by day with prompting. Atrial fibrillation on apixaban 2.5 mg twice daily; last dose 0800 today. Three weeks ago she was seen in your department after a fall with a negative head CT and was started on cephalexin for a urinary infection, which she completed five days ago. Allergies: sulfa (rash). Other medications on the attached list, with last doses marked.

Goals of care. Her signed POLST, attached, says do not resuscitate and limited additional interventions: hospital transfer and intravenous antibiotics and fluids are acceptable; intensive care and intubation are not. Her son, her named health care agent, agreed to this transfer by phone at 1450 and can be reached at the number on the form.

Assessment. Our concern is sepsis from a urinary source, with delirium on top of dementia. We collected a urine specimen before transfer; it is in the bag with her paperwork.

Recommendation and request. We ask for evaluation and treatment for sepsis consistent with her POLST. If she is admitted, please tell us. If she returns to us, please see the final section.

The handover also names what it does not know. Her last urine output and whether she has vomited were not observed by the day staff, and the handover says so rather than leaving the physician to assume they were normal.

What We Need Sent Back

This section was new, added after the first transfer, when Mrs. B. returned at 0145 with a one-line note and a new antibiotic that nobody at the facility knew about. It asks for four items if she returns: the diagnosis; any new or changed medications, with the time of the next dose; results that are still pending and who will follow them; and anything we should watch for overnight. It names a person to call, the facility nurse practitioner on weekdays until 1700 and the house supervisor after hours, with a direct number rather than the main switchboard. It also states that the facility's night nurse cannot see the hospital record, so anything not written on paper or said by phone will not reach the bedside.

Why It Is Built This Way

Each choice in the handover answers a known failure. Canadian researchers who audited several hundred nursing home transfers found that the details most often absent were activities of daily living, mobility and advance directives, each absent in roughly half of transfers (Cwinn et al., 2009). The baseline section addresses the first two by describing what Mrs. B. can do on a good day in terms an emergency physician can compare with what they see. The goals-of-care section addresses the third by putting the POLST's content on the first page, not only as an attachment.

The return section addresses a problem that interviews with staff from both settings found runs both ways, with paperwork missing on the trip out and on the trip back (Terrell & Miller, 2006). A handover that asks for nothing back invites nothing back.

Length was a deliberate choice as well. An earlier draft ran to four pages, including her full problem list and every medication change over the past year. It was cut to two because a longer handover would push the baseline, the goals of care and the return request off the first page, and an emergency physician with a waiting room will read the first page and skim the rest. Detail that the admitting team might need later, such as her past hospitalizations, travels in the attached medication list and the facility's discharge summary, not in the handover itself. The test for every sentence was whether the physician would act differently in the first hour for having read it.

What Happened

The emergency physician called the facility at 1720 to confirm the son's wishes before starting antibiotics and fluids. Mrs. B. was admitted to a medical unit with urosepsis. The hospital's admitting team said the baseline description helped them judge that her confusion was new, and they used it to set a goal for her discharge. When she returned to the facility five days later, a two-page summary came with her, covering all four requested items. One transfer does not prove the handover works. It does show that a document built for its receiver, with an explicit request for a reply, can be used as intended.

What I Would Change Next Time

Two changes are planned. First, the handover will state the time of the last bowel movement and fluid intake, which the admitting team asked about. Second, the return request will be printed on a separate colored sheet placed on top of the packet, so that it is less likely to be scanned with the rest of the paperwork before anyone reads it.

References

Cwinn, M. A., Forster, A. J., Cwinn, A. A., Hebert, G., Calder, L., & Stiell, I. G. (2009). Prevalence of information gaps for seniors transferred from nursing homes to the emergency department. CJEM, 11(5), 462-472. https://doi.org/10.1017/S1481803500011660

Haig, K. M., Sutton, S., & Whittington, J. (2006). SBAR: A shared mental model for improving communication between clinicians. Joint Commission Journal on Quality and Patient Safety, 32(3), 167-175. https://doi.org/10.1016/S1553-7250(06)32022-3

Terrell, K. M., & Miller, D. K. (2006). Challenges in transitional care between nursing homes and emergency departments. Journal of the American Medical Directors Association, 7(8), 499-505. https://doi.org/10.1016/j.jamda.2006.03.004