What is Clinical Handover?

Clinical handover is essential for integration and continuity of care provided to patients in hospitals, in outpatients or at the community level. At its most basic level, ‘integrated or continuity of healthcare’ consists of communication and coordination of care across different services and levels of care; transfer of patient-specific information from one healthcare provider to another and to the patient and their family.  It puts patients at the centre of both the design and delivery of care and meets their needs through apparently seamless, efficient and effective services.  

Effective integration of care between community (primary) and hospital care (secondary) services is particularly critical for a patient whose needs extend beyond the initial episode, and continuity of care is required by the next level of provider.  

Consequences of ineffective handover?

A review of evidence in high-income countries indicates that the consequences of ineffective handover and communication between providers and between providers and patients are numerous and substantial:

  • incorrect treatment due to a disconnect and poor communication between the range of providers in the community and hospitals, public and private health facilities
  • delays in medical diagnosis due to delayed diagnostic test communication and disconnected care provision between provider visits
  • adverse events including disability and death
  • increased length of stay due to inadequate inpatient shift-to-shift handover
  • increased re­admissions due to poor discharge procedures and continuity of care in the community, including adverse events and increased rate of acute crisis
  • inadequate patient-centred care with low self-management ability for patients
  • loss of confidence in healthcare provision and decreased service satisfaction due to medical errors and sub-optimal care, resulting in increased patient complaints and litigation 
  • inefficient healthcare with increased healthcare expenditure for both patient and the system due to inappropriate care or adverse events, increased healthcare seeking, acute crisis and admissions
  •  other impacts on health systems and patients.

Poor clinical handover particularly affects discharge follow-up which is required for long-term conditions and surgical cases. Once the patients have been discharged, if poorly managed and follow-up instructions are not adhered to, they can fall through the net leading to adverse conditions at home requiring readmission. Furthermore, where clinical notes are not available during outpatient visits, particularly where numerous providers are visited such as primary and secondary care outpatients or private and public providers, errors in diagnosis, prescribing and management are common. These scenarios lead to repeated acute clinical crisis, complications, worsened prognosis and patient outcomes and put unnecessary increased pressure on already scarce resources.

Levels and types of clinical handover

A seamless provision of quality care and integration and continuity of healthcare, begin with the crucial stage of information exchange about the patient’s current medical condition(s) and required care that is the essence of clinical handover.  

This information exchange should also include the patient and their family carers as they often need to care for the patient on a daily basis and regularly have to make complex decisions about self-care.  Clinical handover and subsequent continuity of care within healthcare systems can occur at several levels:

  1. from primary to secondary care or to other community or social services;
  2. from secondary to primary care including to other community or social services;
  3. from secondary to secondary care;
  4. within a hospital or care institution to various other medical or supportive services (e.g. a sub-speciality doctor, or physiotherapist or nurse specialist etc).

 Clinical handover processes diagram

Primary care flow chart

Definition of Primary and Secondary care

In our work, we are defining primary and secondary care as follows:

Primary care

Activity of a healthcare provider who acts as a first point of consultation for all patients. Generally, primary care practitioners are based in the community, as opposed to the hospital. Primary care practitioners refer cases they cannot manage or that require specialist attention to medical specialists in hospital or outpatient clinics for more complex or inpatient care. They can also refer patient to ancillary community social or medical services such as community midwives or nurses, social workers and so on. These can be called General Practitioners (GPs), Family Doctors or local doctors.

Hospital care (Secondary or Tertiary healthcare)

Hospitals usually provide inpatient and outpatient services delivered by medical specialists who generally do not have first contact with patients. Most hospital services are referred to as secondary care services and have more common specialised care based around major organ systems, such as cardiologists, urologists, orthopaedics, paediatrics, obstetrics and dermatologists.

A tertiary health centre provides more specialised consultative care, usually on referral from primary or secondary medical care personnel, by specialists working in a centre that has facilities for special investigation and treatment.  Examples include: specialist cancer care, endocrinology, burns care and plastic surgery, or sub-specialities such as podiatry sub-speciality of orthopaedics and neurosurgery (brain surgery). Many tertiary centres also provide secondary care in addition for their immediate catchment area population.

Where primary care is still developing or there is no integration between primary and specialist care services, such as many LMIC, patients may self-refer to secondary or tertiary care providers for most healthcare needs thus using them as primary care providers. This makes for a highly inefficient and expensive healthcare system with demotivated clinical staff who are either underworked and under-stimulated at the primary level or over-worked and frustrated at the secondary and tertiary care level.