Structured patient handovers

National Guideline Centre (UK)

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National Guideline Centre (UK). Emergency and acute medical care in over 16s: service delivery and organisation. London: National Institute for Health and Care Excellence (NICE); 2018 Mar. (NICE Guideline, No. 94.)

Emergency and acute medical care in over 16s: service delivery and organisation.

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Chapter 32Structured patient handovers

32. Structured patient handovers

32.1. Introduction

Handover is the system by which the responsibility for immediate and ongoing care is transferred between healthcare professions. Changing work patterns mean that establishing standards for handover “should be a priority”.¹⁰²

Although the process of handing over between shifts has been embedded in nursing practice for many years, the changing patterns of work in the hospital setting mean that there may be different medical teams looking after groups of patients across a 24 hour period. The medical and nursing professions both recognise the importance of effective handover between shifts and between health care professionals;

“Incomplete or delayed information can compromise safety, quality and the patient’s experience of health care.”⁷⁸

The Royal College of Nursing dedicate a section of The Principles of Nursing Practice¹⁰¹ to communication and reporting stating;

“Evidence suggests that communication improves when nursing handover involves the patient and is carried out using a structured reporting format.”⁷⁰^,¹¹⁶

The World Health Organisation goes as far as to recommend the use of SBAR (Situation, Background, Assessment, Recommendation) as a tool to standardise handover communications.¹²⁵ It is recognised in the literature that one system does not fit all settings and that local adaptations may be needed.

Despite the evidence and apparent agreement that handovers are improved by following a structure, the Royal College of Physicians make further recommendations which suggest that there are still improvements to be made and that this is not yet standard practice in all areas.

“Improvement and standardisation of handover are vital keys to improvement in efficiency, patient safety, and patient experience. There is a need to define common core principles for handover, which can be adapted locally. For example, a standardised proforma for written handover is essential, preferably in conjunction with face-to-face verbal handover. Furthermore, in the current technological climate, where possible, electronic handover processes should be encouraged.”¹⁰²

Although the evidence to date points to the value of structured patient handover, there may be cost implications for services if there is a need for change in shift pattern and an overlap required to allow time for handover. It is therefore important to investigate the most appropriate form of handover for best patient outcomes and the impact this may have on services.

32.2. Review question: Do structured patient handovers between healthcare professionals improve outcomes?

For full details see review protocol in Appendix A.

Table 1

PICO characteristics of review question.

32.3. Clinical evidence

Six studies were included in the review; 1 non-randomised controlled study and 5 before-after studies²⁰^,³⁴^,⁴²^,⁴⁶^,⁵⁸^,¹²⁷ and these are summarised in Table 2 below. Evidence from these studies is summarised in the GRADE clinical evidence profile/clinical evidence summary below. See also the study selection flow chart in Appendix B, study evidence tables in Appendix D, forest plots in Appendix C, GRADE tables in Appendix F and excluded studies list in Appendix G.

Table 2

Summary of studies included in the review.

Table 3

Clinical evidence summary: Intensive Care Unit.

Table 4

Clinical evidence summary: Neurological Care Unit.

Table 5

Clinical evidence summary: Emergency Department.

Table 6

Clinical evidence summary: Internal Medicine.

32.4. Economic evidence

Published literature

One economic evaluation was identified with the relevant comparison and has been included in this review.¹²⁶ This study is summarised in the economic evidence profile below (Table 7) and the economic evidence tables in Appendix E.

Table 7

Economic evidence profile: Structured patient handover versus usual care.

The economic article selection protocol and flow chart for the whole guideline can found in the guideline’s Appendix 41A and Appendix 41B.

32.5. Evidence statements

Clinical

Intensive care unit

One study comprising 820 people evaluated the role of structured patient handover within the intensive care unit setting for improving outcomes in secondary care in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that structured patient handovers provide a benefit in reduced mortality, length of stay and improved staff satisfaction (overall, nurse satisfaction and attending physician). However, the evidence suggested there was no effect on readmission (very low quality for all outcomes) and a reduction in staff satisfaction by fellows.

Neurointensive care unit

One study comprising 261 people evaluated the role of structured patient handover within the neurointensive care unit setting for improving outcomes in secondary care in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that structured patient handovers have no effect on ICU readmission and avoidable adverse events defined as rapid response team call at 6 months (very low quality for both outcomes).

Emergency department

Two studies comprising 1415 people evaluated the role of structured patient handover within the emergency department setting for improving outcomes in secondary care in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that structured patient handovers have no effect on staff satisfaction (1 study, very low quality) or avoidable adverse events defined as medications not administered as prescribed (1 study, very low quality).

Internal medicine

Two studies comprising 3991 people evaluated the role of structured patient handover within the internal medicine setting for improving outcomes in secondary care in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that structured patient handovers may provide a benefit in reduced avoidable adverse events defined as critical data omissions, near misses, adverse events and handoffs related errors (1 study, very low quality).

Economic

One cost-utility analysis found that structured handover was cost effective compared to usual care for patients discharged from hospital to the community (ICER: £180 per QALY gained). This analysis was assessed as partially applicable with potentially serious limitations.

32.6. Recommendations and link to evidence

Recommendations	19. Use structured handovers during transitions of care^a and follow the recommendations on transferring patients in the NICE guideline on acutely ill patients in hospital.
Research recommendations	-
Relative values of different outcomes	Mortality, avoidable adverse events (including prescribing errors, errors of omission, cardiopulmonary resuscitation, unplanned admission to intensive care, delayed or missed investigations and delayed or missed treatment), patient and/or carer satisfaction, length of stay and quality of life were considered critical outcomes by the guideline committee. Staff satisfaction was considered an important outcome by the committee.
Trade-off between benefits and harms	Six studies were considered in the clinical review. The committee noted the variation in interventions and heterogeneity in how the intervention was delivered (that is, some were structured electronic forms while other studies just documented a handover process). Therefore, the results for each study were presented by setting and not meta-analysed. Mixed medical and Surgical ICU The evidence suggested that structured patient handovers may provide a benefit in reduced mortality, length of stay, improved senior clinical staff satisfaction and nurse satisfaction. The evidence suggested there was no effect on readmission and a reduced staff satisfaction for fellows. The group discussed the decreased staff satisfaction of junior doctors (compared to senior doctors and nurses) with a structured handover but suggested that this may be due to the imbalanced amount of time placed on junior doctors in the handover process. Overall, the evidence suggested a benefit of structured patient handover in the intensive care unit setting. There was no evidence for quality of life or patient and/or carer satisfaction. Neurological care unit The evidence suggested that structured patient handovers have no effect on readmission and avoidable adverse events defined as a rapid response team. The committee noted that this evidence was from 1 small study reporting for 1 unit and both outcomes were very low quality. There was no evidence for mortality, quality of life, patient and/or carer satisfaction, staff satisfaction or length of stay. Emergency department The evidence suggested that structured patient handovers have no effect on staff satisfaction or avoidable adverse events defined as medications not administered as prescribed. There was no evidence for mortality, quality of life, patient and/or carer satisfaction or length of stay. Internal Medicine The evidence suggested that structured patient handovers may provide a benefit in reduced avoidable adverse events defined as critical data omissions, near misses, adverse events and handoffs-related errors. The committee discussed the reductions in avoidable adverse events with the structured handover and suggested this may be due to the multi-factorial nature of the intervention. In this case it was a verbal (face-to-face) handover with an electronic sign-off sheet compared to no structured handover. There was no evidence for mortality, quality of life, patient and/or carer satisfaction, staff satisfaction or length of stay. Overall, the committee considered that structured handovers were associated with improvement in patient outcomes and staff satisfaction and should be part of current patient care. They discussed the evidence with regards to their own clinical experience and decided to support a strong recommendation for structured handovers for an AME population. They noted that while structured handovers could become a ‘tick box’ process and could lead to reduced communication both between healthcare professionals and with patients, when conducted properly a formal structure for exchanging information would improve outcomes. The committee discussed the best type of structured handover but the evidence was not strong enough to make a recommendation on a particular handover model.
Trade-off between net effects and costs	A single study conducting a cost-utility analysis was included. The intervention included an online database with handover tools, shared staff experience of handovers and online staff training. As well as the online resource, the intervention required staff time to undertake classroom education in patient handovers. The study showed structured patient handovers between the hospital and community are cost-effective at £180 per QALY, significantly under the £20,000 threshold. Quality of life was not measured in a trial. Instead quality of life scores were estimated by categorising adverse events into groups and assigning the groups to an indicative state. However, the committee felt that the intervention would have low costs and for this reason, it would only need to have a small benefit to be cost-effective. There was evidence for this in the analysis, with the study showing the intervention only needing to be 1.6% effective at reducing preventable adverse events to be cost-effective. The transition between hospital and community would most likely involve more intensive handovers than those within a hospital. Therefore, the cost-effectiveness results might be extrapolated to other areas of patient handover, such as between staff members or shifts, wards and different hospitals. There was no evidence around the type of structured patient handover, for example, electronic, paper or verbal. It seems unlikely that there would be a large difference in the cost-effectiveness of the different structures. However, there was evidence in the clinical review of change in resource use for structured patient handover. One study outlined a change in shift patterns, increasing the shift duration of junior doctors to undertake structured handovers and adding further costs to the intervention. There was also evidence that structured handovers reduced the length of stay for patients in the ICU, freeing up resources and decreasing costs as a result of the intervention. The committee concluded that there may be an increase in staff time associated with structured handover but this would potentially be offset by reduced length of stay and clinical errors avoided.
Quality of evidence	Clinical evidence For all comparisons the clinical evidence was considered to be very low quality due to the study type (observational or before and after), risk of bias (outcome reporting) and imprecision. In particular, the subgroup noted the composite outcomes reported as adverse effects and how these were reported poorly by most studies. Economic evidence The included economic study was deemed partially applicable because resource use and costs were from the Netherlands. It was also assessed to have potentially serious limitations because the effectiveness of the intervention was elicited from experts, rather than being based on a trial.
Other considerations	The committee noted that electronic systems for patient handovers could provide benefits in terms of documenting and identifying trends, in data analysis and audit, sharing information between different members of the multidisciplinary team, and in preserving patient confidentiality. Important contextual modifiers may include training, shift length and the quality of electronic systems. The Professional Record Standards body⁴⁸ has published clinical standards for electronic systems for patient handovers to ensure consistency and interoperability. The committee highlighted that structured handover of care between transferring and receiving teams is well established within NHS current practice and is reinforced by related NICE guidance (CG50)¹⁵ and the Acute Care RCP Toolkit.¹⁰² Currently, structured handover practice takes place through a range of methods including updated written lists, electronic and verbal face-to-face and this varies between departments and hospitals. However, standardisation across trusts is not common and would be difficult to implement. It is also important to understand that the ability to deliver a structured handover does not come naturally and training is vital to ensure that the benefits are realised. Handover is not just a simple matter of imparting information. It is about providing the required information in a format that is useful and beneficial to patient care. One key issue in the training is to ensure staff understand the importance of a good handover in delivering good patient care. Electronic systems would entail some training, resources to obtain and modify or develop the system and a change in the nature of the shift. The committee noted that it is important to provide a structured handover between primary and secondary care as this is a point of escalation and that this may require different emphasis and amount of information. Therefore, there was scope for further research in this area covering the bridge between secondary and primary care.

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Appendices

Appendix A. Review protocol

Table 8Review protocol: Do structured patient handovers between healthcare professionals improve outcomes?

Review question	Structured patient handovers
Guideline condition and its definition	Acute medical emergencies.
Objectives	To see if structured means are better than unstructured for relaying patient information and to assess the best method for conducting handover for example, verbal, paper-based or electronic.
Review population	Adults and young people (16 years and over) with a suspected or confirmed AME (in all contexts not just secondary care).
	Adults.
	Line of therapy not an inclusion criterion.
Interventions and comparators: generic/class; specific/drug (All interventions will be compared with each other, unless otherwise stated)	Structured (planned framework as defined by the study) between healthcare professionals between shifts in acute settings; this will include (i) set times of the day, (ii) using a structured template or proforma for the handover (iii) recording the information in written or electronic form. Paper-based handover; using paper to conduct the structured handover. Verbal patient handover; verbally conducting the structured handover. Electronic-based handover; using electronic means to conduct the structured handover. Normal handover; routine unstructured handover.
Outcomes	- Mortality (Dichotomous) CRITICAL - Avoidable adverse events (prescribing errors [errors of omission or commission] cardiopulmonary resuscitation, unplanned admission to intensive care, delayed or missed investigations, delayed or missed treatments) (Dichotomous) CRITICAL - Quality of life (Continuous) CRITICAL - Patient/carer satisfaction (Continuous) CRITICAL - Length of stay (Continuous) CRITICAL - Staff satisfaction (Continuous) IMPORTANT
Study design	Systematic reviews (SRs) of RCTs, RCTs, observational studies only to be included if no relevant SRs or RCTs are identified.
Unit of randomisation	Patient Setting
Crossover study	Permitted
Minimum duration of study	Not defined
Other exclusions	Major trauma Structured reporting around major incidents (not applicable to individual) standardised criteria for admission and discharge covered by other questions.
Sensitivity/other analysis	If studies have pre-specified in their protocols that results for any of these subgroup populations will be analysed separately, then they will be included in the subgroup analysis.
Subgroup analyses if there is heterogeneity	- Frail elderly (Frail elderly; Not frail elderly); Population may differ - Critical care patients (Critical care patients; Not critical care patients) Population may differ - Speciality/profession (Inter-professional handover; Profession-specific handover); May differ but may be crossover
Search criteria	Databases: Medline, Embase, the Cochrane Library Date limits for search: 2005 Language: English

Appendix B. Clinical article selection

Figure 1Flow chart of clinical article selection for the review of patient handover

Appendix C. Forest plots

C.1. Intensive Care Unit

Figure 2Mortality

Figure 3Readmission within 48 hours

Figure 4ICU length of stay

Figure 5Staff satisfaction

C.2. Neuroscience Unit

Figure 6ICU Readmission

Figure 7Rapid response team call

C.3. Emergency Department

Figure 8Staff satisfaction

Figure 9Avoidable adverse events (medications administered as prescribed)

C.4. Internal Medicine

Figure 10Critical omissions

Figure 11Near misses

Figure 12Adverse effects

Figure 13Avoidable adverse events (handoffs related errors)

Appendix D. Clinical evidence tables

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Appendix E. Economic evidence tables

Download PDF (420K)

Appendix F. GRADE tables

Table 9Clinical evidence profile: Intensive care unit

Quality assessment							No of patients		Effect		Quality	Importance
No of studies	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Structured	Unstructured	Relative (95% CI)	Absolute	Quality	Importance
Mortality
1	observational studies	serious¹	no serious inconsistency	no serious indirectness	very serious²	none	26/389 (6.7%)	8.5%	RR 0.71 (0.43 to 1.17)	26 fewer per 1000 (from 48 fewer to 14 more)	⨁◯◯◯ VERY LOW	CRITICAL
Re-admission <48hours
1	observational studies	serious¹	no serious inconsistency	no serious indirectness	very serious²	none	21/431 (4.9%)	3.6%	RR 1.35 (0.7 to 2.63)	13 more per 1000 (from 11 fewer to 59 more)	⨁◯◯◯ VERY LOW	CRITICAL
Length of Stay (Better indicated by lower values)
1	observational studies	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	431	389	-	MD 2.78 lower (4.68 to 0.88 lower)	⨁◯◯◯ VERY LOW	IMPORTANT
Staff satisfaction
1	observational studies	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	34/57 (59.6%)	18.2%	RR 3.09 (1.7 to 5.61)	380 more per 1000 (from 127 more to 839 more)	⨁◯◯◯ VERY LOW	IMPORTANT
Staff satisfaction - Attending Physician
1	observational studies	serious¹	no serious inconsistency	no serious indirectness	serious²	none	6/11 (54.5%)	18.2%	RR 3 (0.77 to 11.74)	364 more per 1000 (from 42 fewer to 1000 more)	⨁◯◯◯ VERY LOW	IMPORTANT
Staff satisfaction – Fellows
1	observational studies	serious¹	no serious inconsistency	no serious indirectness	very serious²	none	6/16 (37.5%)	43.8%	RR 0.86 (0.37 to 1.99)	61 fewer per 1000 (from 276 fewer to 434 more)	⨁◯◯◯ VERY LOW	IMPORTANT
Staff satisfaction – Nurses
1	observational studies	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	22/30 (73.3%)	6.7%	RR 11 (2.83 to 42.7)	670 more per 1000 (from 123 more to 1000 more)	⨁◯◯◯ VERY LOW	IMPORTANT

1: All non-randomised studies automatically downgraded due to selection bias. Studies may be further downgraded by 1 increment if other factors suggest additional high risk of bias, or 2 increments if other factors suggest additional very high risk of bias.
2: Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.

Table 10Clinical evidence profile: Neurology Unit

Quality assessment							No of patients		Effect		Quality	Importance
No of studies	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Structured	Unstructured	Relative (95% CI)	Absolute	Quality	Importance
ICU Readmission
1	observational studies	serious¹	no serious inconsistency	no serious indirectness	very serious²	none	5/131 (3.8%)	3.1%	RR 1.24 (0.34 to 4.52)	7 more per 1000 (from 20 fewer to 109 more)	⨁◯◯◯ VERY LOW	CRITICAL
Rapid Response Team Call at 6 Months
1	observational studies	serious¹	no serious inconsistency	no serious indirectness	very serious²	none	4/131 (3.1%)	1.5%	RR 1.98 (0.37 to 10.65)	15 more per 1000 (from 9 fewer to 145 more)	⨁◯◯◯ VERY LOW	CRITICAL

1: All non-randomised studies automatically downgraded due to selection bias. Studies may be further downgraded by 1 increment if other factors suggest additional high risk of bias, or 2 increments if other factors suggest additional very high risk of bias.
2: Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.

Table 11Clinical evidence profile: Emergency Department

Quality assessment							No of patients		Effect		Quality	Importance
No of studies	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Electronic	Routine	Relative (95% CI)	Absolute	Quality	Importance
Staff satisfaction (Better indicated by higher values)
1	observational studies	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	1058	78	-	MD 0.17 higher (0.33 lower to 0.67 higher)	⨁◯◯◯ VERY LOW	IMPORTANT
Avoidable adverse events (medications administered as prescribed)
1	observational studies	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	149/151 (98.7%)	97.7%	RR 1.01 (0.98 to 1.04)	10 more per 1000 (from 20 fewer to 39 more)	⨁◯◯◯ VERY LOW	CRITICAL

1: All non-randomised studies automatically downgraded due to selection bias. Studies may be further downgraded by 1 increment if other factors suggest additional high risk of bias, or 2 increments if other factors suggest additional very high risk of bias

Table 12Clinical evidence profile: Internal Medicine

Quality assessment							No of patients		Effect		Quality	Importance
No of studies	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Electronic	Routine	Relative (95% CI)	Absolute	Quality	Importance
Critical data omissions
1	observational studies	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	0/19 (0%)	79.3%	Peto OR 0.04 (0.01 to 0.14)	660 fewer per 1000 (from 444 fewer to 756 fewer)	⨁◯◯◯ VERY LOW	CRITICAL
Near Misses
1	observational studies	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	0/19 (0%)	23.1%	Peto OR 0.18 (0.04 to 0.8)	180 fewer per 1000 (from 37 fewer to 219 fewer)	⨁◯◯◯ VERY LOW	CRITICAL
Adverse events
1	observational studies	serious¹	no serious inconsistency	no serious indirectness	very serious²	none	0/19 (0%)	10.3%	Peto OR 0.21 (0.02 to 1.78)	79 fewer per 1000 (from 101 fewer to 67 more)	⨁◯◯◯ VERY LOW	CRITICAL
Avoidable adverse events (handoffs related errors)
1	observational studies	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	5/1970 (0.25%)	2.70%	RR 0.09 (0.04 to 0.23)	25 fewer per 1000 (from 21 fewer to 26 fewer)	⨁◯◯◯ VERY LOW	CRITICAL

1: All non-randomised studies automatically downgraded due to selection bias. Studies may be further downgraded by 1 increment if other factors suggest additional high risk of bias, or 2 increments if other factors suggest additional very high risk of bias.
2: Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.

Appendix G. Excluded clinical studies

Table 13Studies excluded from the clinical review

Reference	Reason for exclusion
Abraham 2012²	Incorrect comparison (paper based versus paper based handover tools)
Abraham 2014⁴	No useable outcomes
Abraham 2014³	Systematic review (incorrect PICO)
Ah-kye 2015⁵	Incorrect population (trauma patients)
Ahmed 2012⁶	Incorrect population and study design (before and after study; acute surgical admissions)
Anderson 2015⁷	Systematic review (incorrect PICO)
Anon 2015⁴⁹	Systematic review (incorrect PICO)
AORN 2016¹	Evidence appraisal of a RCT Salzwedel 2013- the study has been excluded due to incorrect population (post-anaesthesia patients)
Arora 2009⁸	Systematic review (incorrect PICO)
Barnes 2011⁹	No relevant outcomes
Berkenstadt 2008¹⁰	No relevant outcomes
Blaz 2012¹¹	Systematic review (no references included)
Bost 2010¹²	Incorrect study design (qualitative)
Brown 2015¹³	No relevant outcomes
Bump 2012¹⁴	Incorrect comparison (does not compare handover types (standard sign out versus additional training.)
Christie 2009¹⁶	Narrative review
Chu 2009¹⁷	Incorrect study design (survey)
Cohen 2010¹⁸	Systematic review (no relevant outcomes)
Collins 2011¹⁹	Systematic review (incorrect PICO)
Cornell 2014²¹	No relevant outcomes
Craig 2012²²	No relevant outcomes
Curtis 2013²³	No relevant outcomes
Dawson 2013²⁴	Systematic review (incorrect PICO)
Dhillon 2011²⁵	Incorrect population (surgical patients)
Dixon 2015A²⁶	Incorrect population (surgical patients)
Donnelly 2012²⁸	Incorrect population (not AME); no relevant outcomes
Donnelly 2014²⁷	Incorrect population (not AME)
Dowding 2001²⁹	No useable outcomes
Downey 2013³⁰	Incorrect population (trauma patients)
DRACHZAHAVY 2015³¹	No useable outcomes
DuBosh 2014³²	No useable outcomes
Dufault 2010³³	Systematic review (incorrect PICO)
Evans 2014³⁵	Incorrect study design (narrative review)
Field 2011³⁶	Incorrect setting (nursing homes)
Flanagan 2009³⁷	Incorrect study design (survey)
Flemming 2013³⁸	Systematic review (incorrect PICO)
Foster 2012³⁹	Systematic review (incorrect PICO)
Gakhar 2010⁴⁰	No relevant outcomes
Gardiner 2015⁴¹	Systematic review (incorrect PICO)
Govier2012A⁴³	Incorrect study design (audit)
GRAAN 2016⁴⁴	No useable outcomes.
Halm 2013⁴⁷	Systematic review (incorrect PICO)
Hesselink 2012⁵⁰	Incorrect population (patient discharge from hospital to primary care)
Hill 2015⁵¹	Incorrect intervention (inter-hospital transfer)
Iedema 2012⁵²	Incorrect study design (survey)
Jensen 2013⁵³	Systematic review (incorrect PICO)
Johnson 2016⁵⁴	Comparator not defined
Kaufmnan 2013⁵⁵	Incorrect population (mainly children and neonates)
Keebler 2016⁵⁶	Systematic review (references screened)
Keenan 2006⁵⁷	Description of handover tool only.
Kessler 2013⁵⁹	Incorrect study design (narrative review)
Kitson 2014⁶⁰	Incorrect study design (narrative review)
Kochendorfer 2010⁶¹	Incorrect intervention (electronic rounding report)
KUHN 2016⁶²	Surgical patients – patients admitted to neurosurgical service
Lamond 2000⁶³	Looking at the information content of handover, not comparing types of handover.
Lee 1996⁶⁴	Pre-1995 study
Li 2013⁶⁵	Systematic review (incorrect PICO)
Malekzadeh 2013⁶⁶	No useable outcomes
Manser 2011⁶⁸	Incorrect study design (narrative review)
Manser 2013⁶⁷	Incorrect study design (narrative review)
Mardis 2016⁶⁹	Systematic review (references screened)
Matic 2011⁷¹	Incorrect study design (narrative review)
Moller 2013⁷³	Incorrect population (surgical patients)
Moseley 2012⁷⁴	Incorrect population (neurology inpatients)
MCQUILLAN 2014⁷²	Incorrect population- Paediatric patients
Mueller 2016⁷⁵	Incorrect population (paediatric patients)
Nakagawa 2016⁷⁶	Study abstract
Nakhleh 2006⁷⁷	Incorrect population (surgical patients)
O’Byrne 2008⁷⁹	Incorrect study design (narrative review)
Ong 2011⁸⁰	Systematic review (incorrect PICO)
Palmer 2014⁸²	Incorrect intervention (checklist to encourage the completion of outstanding tasks before shift change on Friday evening)
Patel 2014⁸³	Comparator not defined
Patterson 2010⁸⁵	Incorrect study design (narrative review)
Patterson 2012⁸⁴	Incorrect study design (narrative review)
Payne 2012⁸⁶	Incorrect study design (before and after study); no useable outcomes
Petrovic 2012⁸⁷	Comparator not defined
Phillips 2009⁸⁸	Incorrect study design (observations and interviews). No comparison group stated.
Pincavage 2013⁸⁹	Incorrect population (primary care setting)
Poore 2012⁹⁰	Incorrect population (surgical patients)
Pothier 2005⁹¹	No relevant outcomes
Pucher 2015⁹²	Incorrect population (surgical patients)
Raduma-Tomas 2011⁹³	Systematic review (incorrect PICO)
RAITEN 2015⁹⁴	Review -scanned for relevant references
Raptis 2009⁹⁵	No useable outcomes
Reid 2005⁹⁶	Incorrect study design (audit)
Riesenberg 2009⁹⁹	Systematic review (incorrect PICO)
Riesenberg 2009⁹⁸	Systematic review (incorrect PICO)
Riesenberg 2010⁹⁷	Systematic review (incorrect PICO)
Robertson 2014¹⁰⁰	Systematic review (incorrect PICO)
Ryan 2011¹⁰³	No extractable outcomes (length of stay reported as median and interquartile range)
Salzwedel 2013¹⁰⁴	Incorrect population (post-anaesthesia patients)
Starmer 2014¹¹⁰	Incorrect population (paediatrics)
Segall 2012¹⁰⁶	Incorrect population (surgical patients)
SEGALL 2016¹⁰⁵	Inappropriate study design- surveys, interviews and focus groups
Siefferman 2012¹⁰⁷	Incorrect population (rehab patients)
Singer 2006¹⁰⁸	Incorrect study design (narrative review)
Staggers 2013¹⁰⁹	Systematic review (incorrect PICO)
Stephens 2015¹¹¹	Incorrect population (surgical patients)
Talbot 2007¹¹²	No useable outcomes
Thompson 2011¹¹³	No useable outcomes
Timko 2015¹¹⁵	Incorrect population (substance misuse)
Till 2014¹¹⁴	No relevant outcomes
USHER 2016¹¹⁷	Inappropriate intervention- transfer between hospitals (inter-hospital hand-offs)
Van Eaton 2005¹¹⁸	No relevant outcomes
Van Eaton 2010¹¹⁹	Incorrect population (more than 50% surgical patients, trauma and paediatrics)
Van Sluisveld 2015¹²⁰	Systematic review (incorrect PICO)
Vines 2014¹²¹	Systematic review (incorrect PICO)
Walton 2015¹²²	No relevant outcomes
Williamson 2015¹²³	Incorrect population (surgical patients); comparator not defined
Wood 2015¹²⁴	Systematic review (incorrect PICO)

Appendix H. Excluded economic studies

No economic studies were excluded.

Footnotes

a: NICE’s guideline on medicines optimisation includes recommendations on medicines-related communication systems when patients move from one care setting to another, medicines reconciliation, clinical decision support, and medicines-related models of organisational and cross-sector working.

Bookshelf ID: NBK564933

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