Critical Care Medicine — Transition to Discipline

TTD4 Transferring clinical information between health care providers at handover

Key Features:
- This EPA focuses on the communication required for safe handover within the critical care patient team or as the patient leaves the unit to another health care setting.
- It includes the timely written documentation of the events while in the ICU (including appropriate record-keeping, daily events), as well as verbal handover when going off duty and at the end of call shifts.

Assessment plan:
Direct observation and/or review of documentation (chart, handover paperwork, transfer/discharge note) by supervisor and/or physician receiving handover
Use Form 1. Form collects information on:
- Observation (select all that apply): single patient handover; entire unit handover
Collect 3 observations of achievement
- At least 2 entire unit handovers
- At least 3 different observers

Form

F1: Observation

Milestones

• ME 4.1. Establish plans for ongoing care, including follow-up on investigations and response to treatment

• COL 3.2. Describe specific information required for safe and effective handover during transitions in care

• COM 5.1. Organize information systematically within an electronic or written medical record

• COM 5.1. Maintain accurate and up-to-date problem lists

• COM 5.1. Document information about patients and their medical conditions in a manner that enhances intra- and interprofessional care

• COL 3.2. Summarize patient issues, including plans to deal with ongoing concerns

• COL 3.2. Provide anticipatory guidance for issues that are likely to arise

• COL 1.3. Communicate clearly and directly to promote understanding in the health care team

Context Variables

• Observation (select all that apply) (multiple-choice)
  • entire unit handover
  • single patient handover

Requirements

• Collect 3 observations of achievement (minimum 3)
• At least 2 entire unit handovers (minimum 2)
  • Only counts when Observation (select all that apply) is entire unit handover
• At least 3 different observers (minimum 3)
  • Counted once per distinct Assessor