Clinical Handover and Escalation Policy Template
Ensure safe, structured communication between clinical staff at every shift change and a clear escalation pathway when a resident's condition deteriorates.
Overview
Unsafe clinical handover is a recognised leading cause of preventable adverse events in residential aged care. Aged Care Quality Standard 3 (Clinical Care) requires providers to demonstrate that clinical information is communicated accurately and that staff can recognise and respond to deterioration. This policy template embeds the ISBAR (Identify, Situation, Background, Assessment, Recommendation) framework into daily handover practice and defines a tiered escalation pathway.
What This Policy Covers
- Structured ISBAR handover process for end-of-shift and cross-facility transfers
- Minimum information requirements for each handover
- Escalation criteria for deteriorating residents (using Early Warning Signs)
- Chain of escalation: carer → RN → GP → hospital transfer
- 24/7 Registered Nurse responsibilities in handover and escalation
- Documentation of handover in the care record
- Family/carer notification triggers
- After-hours escalation protocols
Compliance Alignment
- Aged Care Quality Standard 3 – Clinical Care
- Aged Care Quality Standard 8 – Organisational Governance
- Aged Care Act 1997 – Quality of Care Principles 2014
- Australian Commission on Safety and Quality in Health Care – ISBAR guidelines
- Mandatory 24/7 Registered Nurse presence requirements (from Oct 2023)
Why This Policy Matters
The ACQSC identifies poor clinical communication as a root cause in a significant proportion of serious incidents investigated under the SIRS. A documented, practiced handover policy demonstrates Standard 3 compliance and reduces clinical risk. Facilities without a formal handover policy frequently receive Requirement for Improvement notices during accreditation.
