Background A new electronic whiteboard multi-professional handover (e-handover) was introduced to the in-patient unit. Handover is an excellent opportunity to share information, but is a potential source for errors, if not utilised correctly. There was no standard operating procedure (SOP) for the new e-handover, one was developed to ensure accuracy, a consistent approach and that addressed patients‘ specific palliative care needs.
Methods The e-handover was audited by two independent doctors against standards developed by The Academy of Medical Colleges, local nursing guidelines and against palliative care outcome measures. A multi-professional group of palliative care specialists including doctors, nurses, and allied health professionals then developed a SOP. The handover was then re-audited following its institution with staff training.
Results In March 2017, 16 patients‘ notes and e-handover summaries were audited. One hundred percent of patients had an accurate primary diagnosis on their handover, although documented in a variety of different places. Thirty three percent had a documented preferred place of death (PPD), 56% had documented escalation status (ES), 50% had phase of illness (PoI) and 0% had modified Australian Karnofsky performance status (AKPS) documented on the e-handover. Sixty-nine percent of handovers were easy to read and 55% used trust approved acronyms. Following the SOP introduction, the second audit was performed in September 2017. One hundred percent had the primary diagnosis documented and all in the correct place. PPD was documented in 100% of patients. One hundred percent of patients had a documented ES, AKPS and PoI; however this was not always documented in the patients‘ notes. Ninety-two percent were easy to read and 92% used trust approved acronyms.
Conclusion Introduction of a SOP has improved documentation of diagnosis, escalation status, AKPS and PoI on the e-handover and enhanced ease of reading. Improvement is still required in documentation in patients‘ notes.
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