Transitions in care

• Transitions in care involve the transfer of professional responsibility and accountability for some or all aspects of care for a patient or group of patients to another healthcare professional on a temporary or permanent basis¹.
  • Transitions can take place within or between departments
• A transition in care is a vulnerable point on their journey through the healthcare system.
  • It is the point at which the majority (70%) of errors in healthcare occur²
  • Poor or incomplete communication of information can delay care, cause confusion or, occasionally, lead to disastrous consequences^3,4
• MRTs are aware of facility policies on transitions in care and ensure compliance.

• The goal of communication during a transition is to provide timely, accurate information about a patient’s care plan, treatment, current condition and any recent or anticipated changes⁵.
  • The information shared between providers helps update patient care, identifies safety concerns and facilitates continuity of care²
• There is a need for efficient, reliable information shared in both directions.
• Effective communication includes transfer of information within the organization, between staff and service providers, with the patient and family, and to other services outside the organization, such as primary care providers⁶.

What to communicate

• MRTs ensure important information is addressed during transitions in care, including, but not limited to:
  • Patient identifiers
  • An explanation of the planned procedure/treatment
  • Current patient status
  • Relevant health record accompanying patient (e.g., has patient/family requested “do not resuscitate” status)
  • Patient isolation status
  • Information about procedures performed
  • How patient managed procedure/treatment
  • Any problems/concerns while patient was in MRT’s care
  • Issues other healthcare professionals should be aware of post procedure/treatment
  • Serious or unexpected findings (please see related guideline: Communication of serious or unexpected findings)
  • Patient risk factors (if any)
• The information transferred depends on the clinical circumstances and the nature of the interaction with the patient⁷.
• The transition process should include opportunities to discuss the meaning of the information, seek clarification and ask questions.

How to communicate

• Information about the patient is relayed in a manner that ensures a clear and full understanding between healthcare professionals in the handover^7,8:
  • An appropriate amount of time is allowed
  • Interruptions and distractions are limited
  • The talk back rule is employed to ensure that the information has been understood

Patient/Family involvement

• If appropriate, the patient or family may take part in the exchange of information during a transition (see related guideline Patient and family-centered care in practice).
  • This forms part of patient centered care
  • Patient/family may be able to provide essential information during transfer of care

• Mechanisms and tools to review key patient safety issues, identify errors and limit patient harm (e.g., safety checklist) are helpful in providing a consistent structure to the information exchanged at transition.
  • Written tools help to minimize the reliance on memory
• Examples of mechanisms to ensure accurate transfer of information may include:
  • Forms and checklists⁶
  • Communication algorithms such as mnemonics (e.g., SBAR, ANTICipate, SIGNOUT, DRAW, IPASS the BATON)⁷
  • Five Ps (Patient, Plan, Purpose, Problems, Precautions)⁵
  • Multidisciplinary notes
  • Verbal reports
  • Patient whiteboards
  • Electronic tools