Clinical Handover and Escalation Policy Template

Standardises clinical handover communication between shifts and escalation pathways for deteriorating residents, using structured tools such as ISBAR.

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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.

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