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UWHC,

Policies,Clinical,UWHC Clinical,Department Specific,Emergency Department

Emergency Department Hand Off Communication Guidelines (7.0)

Emergency Department Hand Off Communication Guidelines (7.0) - Policies, Clinical, UWHC Clinical, Department Specific, Emergency Department

7.0

POLICY & PROCEDURE





Effective Date:
April 14, 2015

 Administrative Manual
 Nursing Manual
 Other Emergency
Department_______________

Policy # 7.0

Original
x Revision


Page 1
of 2

Emergency Department Hand Off
Communication Guidelines

I. Purpose
A. To provide guidelines for the consistent and accurate communication of patient information from one
caregiver to another when there is a transfer of patient care.
B. To increase patient safety and provide patient reassurance

II. Policy
Communication of patient data will correspond to the SBAR acronym, a hand-off tool, per UWHC Administrative
policy 8.88. The SBAR acronym is: Situation, Background, Assessment, and Recommendation. UWHC has
adopted this framework of information to be communicated in any handoff of patient care. Handoffs should occur
at the bedside, unless patient condition (e.g.: violence, psychosis) does not allow for this.

S Situation: Patient (who is involved), physician, problem or diagnosis
B Background: Review of systems, labs, meds, allergies, code status, isolation, fall precaution,
communication barriers
A Assessment: Purpose (why are we doing what we are doing), current condition, catheters,
drains, lines, dressings, tubes
R Recommendations: Plan (what is to happen, where, when, how). Precautions (potential issues or
concerns). To do list for accepting party. Anticipated changes in condition
or treatment.

III. Procedure:
A. Hand-off communication will generally be done verbally between two healthcare providers to allow
opportunity for adequate exchange of patient information or may be done electronically with the
opportunity for verbal communication for clarification or questions.
B. A Bedside Safety Check will be included with Bedside hand-offs at change of shift in the ED. The
Bedside Safety Check allows for a brief visual scanning of the environment by the two caregivers (the
nurse that is handing off and the nurse that is receiving the patient).
C. The Bedside Safety Check includes but may not be limited to:
a. Quick visual scan of the patient
b. Vital signs and other assessment parameters, such as neuro checks if applicable to the patient
c. Oxygen device status
d. Pain status
e. Vascular access device sites
f. IV infusions and pump rates, including high-alert medications
g. Other tubes and lines: Line reconciliation—appropriate solution and device, if applicable
h. Introductions to patient/family
i. Presence of needed supplies











POLICY & PROCEDURE





Effective Date:
April 14, 2015

 Administrative Manual
 Nursing Manual
 Other Emergency
Department_______________

Policy # 7.0

Original
x Revision


Page 2
of 2

Emergency Department Hand Off
Communication Guidelines






D. Hand-off communication will occur at the following times:

Situation Communication Required
Documentation
ED transfer of nursing care
-End of shift report
-Relief for lunch/ breaks
-Change in patient
assignment
Verbal report
Transfer to another healthcare facility Verbal telephone report ED Transfer form and AVS
from Healthlink
Transfer to correctional facility Verbal telephone report ED Transfer form and AVS
from Healthlink
Transfer to surgery Verbal report to RN Pre-op checklist
Arrival by ambulance/ Med Flight Radio/ verbal report
Transfer to long term care facility Phone report ED Transfer form and AVS
from Healthlink
Admission to Inpatient ICU and IMC Verbal/ phone report to ICUs using
SBAR format

Admission to General Care beds, Inpatient
Unit
All written handoff reports will
provide the inpatient receiving
nurse an ED telephone number to
call with any questions

SBAR Handoff TRANSFER
NOTE TEMPLATE in
Discharge Navigator in
Healthlink
Off unit diagnostic testing procedures (x-ray,
CT, MRI, or Ultrasound) and/or treatment
areas such as Dialysis.
Verbal report to x-ray technologist
emergency technicians and nursing
assistants prior to transport by RN

Critical test results Lab telephones result to the ED MD
IV. UWHC Cross Reference

8.88 Hand-Off Communication
14.31 Guideline for Off-Unit Patient Hand-Off Communication
14.33 Nurse to Nurse Change of Shift Hand-Off

V. Reviewed By:
Clinical Nurse Specialist, Emergency Department
Clinical Nurse Manager, Emergency Department
Nurse Council, Emergency Department
Clinical Ops, Emergency Department





POLICY & PROCEDURE





Effective Date:
April 14, 2015

 Administrative Manual
 Nursing Manual
 Other Emergency
Department_______________

Policy # 7.0

Original
x Revision


Page 3
of 2

Emergency Department Hand Off
Communication Guidelines




SIGNED BY

Jeff Pothof, MD Tami Morin, RN, MS
Vice Chair of Quality and Operations Director
Department of Emergency Medicine Emergency Services