A13: Patient Care Planning for Handover

Jon Deakin, Mike Sugimoto, and Leon Baranowski
Reviewed: March 1, 2021

Introduction

Patient handover often presents as the most critical time in a patient's care journey.  At these events, the responsibility for overall patient management and care planning rests with the holder of the highest license level, or most qualified attendant, at the scene.  This individual is generally referred to as the most responsible paramedic (MRP), or if an MRP is not on scene, an EMR or FR. 

The MRP or EMR/FR is responsible for the development of an appropriate care plan for the patient based upon findings from appropriate investigations and assessments.  Where possible, care plans should be developed in collaboration with those who may be receiving handover of the patient.  Considerations should include the care required and the scope of practice of the receiving paramedic or EMR.  This guideline is intended to provide clarity and advice to paramedics and EMRs/FRs where handover of care may occur. 

Essentials

• All patients require deliberately created care plans.  A care plan may be as simple as conveying to the hospital with ongoing monitoring, but can also be considerably more complex. 
• When considering whether a patient can be handed over to other paramedics or EMRs, the MRP or EMR must consider:
  • The current or future need for interventions.
  • The projected clinical course of the patient.
  • The ability of other providers to provide the care required following delegation.
• Implementation of the care plan is a collaborative process between the MRP or EMR/FR and other paramedics and/or EMRs/FRs at the scene.  Delegation of care may only take place with the consent and agreement of the paramedic or EMR assuming care of the patient.  The MRP or EMR/FR must provide a complete handover to the receiving paramedic or EMR, discuss ongoing care requirements, and clinical pathway when appropriate.  Crews are not obligated to assume care of a patient if they are uncomfortable with the required care or when the care exceeds their scope of practice.
• The MRP or EMR/FR must document their assessment and decisions in the electronic patient care record (or similar), including information regarding the developed care plan.  This information must be handed over to the crew accepting the delegated care plan, and the MRP or EMR/FR must ensure the crew understands all relevant elements of the clinical scenario.

General

In general, the MRP may elect to handover care to another paramedic or EMR crew on the basis of three interdependent elements:

1. Current or future need for interventions.  
   • Ongoing therapies that are limited by scope of practice may not be delegated.
   • Single-dose therapies, such as analgesia for musculoskeletal injuries, or anticholinergic therapy for bronchospasm, that successfully address the patient’s needs may be handed over once they have been completely administered, and the MRP is satisfied they are unlikely to produce adverse effects.  The MRP must ensure that a reasonable time period has passed following administration of any medication to observe for adverse effects.
   • The MRP remains responsible for the implementation of the care plan for non-therapeutic reasons, including interpersonal dynamics with patients, a perceived need for advocacy, a complex clinical presentation, or a need to conduct ongoing patient assessment.
   • Regardless of the patient’s current clinical status, the MRP should not handover care of patients where the provisionally diagnosed condition would generally benefit from their ongoing attendance.
2. Projected clinical course
   • Handover should not occur for patients whose clinical condition or associated risks can be reasonably expected to deteriorate at scene or during conveyance.
   • The MRP must not handover patients who can be reasonably expected to require their ongoing attendance during their conveyance time.  In this case, “conveyance time” can be defined as the total time between departure from the scene and the transfer of care to hospital staff.
   • The MRP must consider the ability of the other paramedic or EMR crew to utilize established clinical pathways when indicated.  Patients who meet the criteria for entry into a specific clinical pathway may require and benefit from the MRP attendance to safely bypass facilities.
3. Identification of providers able to provide appropriate care.
   • The MRP must not handover a patient to a paramedic or EMR who is uncomfortable with the patient's presentation or condition, or who is not able to provide the required care, monitoring, advocacy, or who cannot communicate the pertinent clinical findings to the receiving facility. 
   • Prior to handing over care, the MRP must be satisfied the receiving paramedic or EMR understands the clinical scenario, the elements of the patient’s care plan, and has the ability to manage the patient appropriately.
   • Paramedic or EMR crews uncomfortable with receiving handover of the patient must inform the MRP.  Resolution of this discomfort is left to the discretion of the MRP and paramedic or EMR crews, however, this resolution must not delay or impact patient care.
   • Under no circumstances will the MRP attempt to coerce or intimidate a paramedic or EMR crew into accepting a patient.

When concerns arise involving patient care, crews are encouraged to submit a PSLS so that the event can be reviewed and appropriate measures can be taken to mitigate any further events.