SBAR Guada Allen, RN, BSN, CMSRN Staff Educator SLMV

1. Hand – Off Communication SBAR Guada Allen, RN, BSN, CMSRN Staff Educator SLMV

2. What is hand-off communication? • Interactive process of passing patient specific information from one caregiver to another • PURPOSE: • Ensure continuity and safety of the patient’s care • Provide accurate information about a patient’s care, treatment, and services, current condition and any recent or anticipated changes • Provides an opportunity to ask and respond to questions JCAHO, 2007

3. Why is it important? • Poor communication and patient hand-off is a common source of sentinel events • 70% of sentinel events in 2005 were caused by poor communication • ½ of those events occurred during patient hand-off • 2008 National Patient Safety Goals • Requires hospitals to implement a standardized approach to communication during patient hand-off Agency for Healthcare Research and Quality, 2009

4. Examples of patient hand-off • Nurse to Nurse – Shift Change • Nurse to Ancillary Staff • Nurse to Physician • Interdepartmental • Facility to Facility • Transferring On-Call Responsibility • Reporting Critical Results

5. Barriers to communication • Not listening • Giving advice • Expressing approval or disapproval • Defending • Requesting an explanation – Why? • Belittling feelings • Changing the subject Rural Connection, 2007

6. Strategies to improve communication • Use clear, concise words • Use language that the listener understands • Choose the right environment • Select the right time • Understand the other person’s stress level • Participate in active listening Rural Connection, 2007

7. Standardized approach to hand-off communication Discussion: • Think about a time you participated or observed a good hand-off. • What types of information did you receive? • Think about a time that you participated or observed a poor hand-off • What types of information did you NOT receive?

8. SBAR for hand-off commumication • S – Situation • B – Background • A – Assessment • R - Recommendation

9. Sbar 1. S=Situation -Introduction, Patient Problem, Assessment (Vital Signs), Stated Concern related to assessment. 2. B=Background -Pertinent information related to the situation: admit date, surgical day, current meds, lab results, other clinical information.

10. Sbar 3. A=Assessment -What is the nurse’s assessment of the situation?: I think the problem is __________. I’m not sure what the problem is, but the patient is deteriorating. 4. R=Recommendation -I suggest or request that you: transfer the patient, come see the patient, talk to the patient… -Do you want any tests like (CXR, ABG, EKG…)

11. Prior to calling: • Assess • Prepare data • Discuss • Know whom to call • Know admitting diagnosis • Read (read the progress note) • Have list of allergies, medications and lab/test results • Know code status

12. Rural Connection, 2007

13. Telephone & Verbal orders • Verbal communication of orders should be limited to urgent situation • They must: • Be used infrequently • Be reduced immediately to writing and signed by the individual receiving the orders • Be documented in the patient’s medical record and be reviewed and countersigned by the prescriber as soon as possible

14. Telephone & Verbal orders • Create a culture in which it is acceptable and strongly encouraged for staff to question the prescribers • Questions should be resolved prior to preparation, dispensing or administration of medication

15. Telephone & Verbal Orders • Elements that should be included: • Name of patient • Age and weight, when appropriate • Date and time of the order • Drug name • Dosage • Exact strength or concentration • Dose, frequency and route • Purpose or indication • Specific instructions for use • Name of prescriber • Signature of recipient

16. Telephone & Verbal Orders Must always be READ BACK!

17. Do NOT use abbreviations! • Do not use abbreviations • – Q.O.D./ QOD/ q.o.d./ qod • – Q.D./ QD/ qd/ q.d. • – Trailing zero (X.0 mg) • – Lack of leading zero (.X mg) • – MS, MSO4, MgSO4 • -IU, U

18. Examples • Dosage parameter used must be written. Example: Prednisone 6mg po daily x 10 days • Orders must specify the medication dose for liquid drugs. Do not order it by volume. Example: Tylenol 150mg NOT 5ml

19. Read the following scenario and then fill in the SBAR as you would tell it to the physician. Mrs. Vastin is an 80 year old women admitted to the hospital yesterday with a diagnosis of abdominal pain. She is on a clear liquid diet. She was stable until approximately 2 hours ago when she started to complain of increased abdominal pain. Dr Rispy was called at that time and ordered Morphine 2mg IV every 2 hours as needed. Morphine 2mg relieved her pain and she was doing better. A hour later, the nursing assistant went into the room to do vital signs and called you immediately. Her vitals were Temp 101.8 BP 80/62 HR 122 RR 25 and her level of consciousness was decreased. She has not had any labs since this am and has a capped IV. S B A R SBAR SCENERIONurse communicating with Physician

20. SBAR SCENERIONurse communicating with Physician • S • B • A • R Dr. Rispy this is Julie RN I have a 80 year old female Pt who has decreased responsiveness. Her systolic blood Pressure has dropped 20points and her LOC is decreased.. She was admitted yesterday with abdominal pain. She was stable until 2 hours ago when she started to complain of more pain which you gave a morphine order for. That relieved her pain and she seemed to be doing fine until just a few minutes ago. Current vitals 80/62 122 25 temp 101.8 Decreased level of consciousness I am concerned about this patient may have an Infection and that she may get shocky. Would you like me to do a stat CBC, blood cultures and start fluids? When should I call you again if necessary?

21. Read the following scenario and then fill in the SBAR to communicate with another nurse. Shift Report: Patient Mr. Celli, in Rm 56 was admitted 3days ago for pneumonia by Dr Lava. Today the patient’s breathing treatments have been switched to every 4 hours due to increase difficulty in breathing. He seems comfortable after getting the breathing treatments. His lungs are decreased at the bases with crackles on the right. He is wearing oxygen at 4 Liters which was just increased. His pulse oximetry is at 91%. Bp 120/68 R 24 (per breathing treatment) P 100 Temp 100. Just recently paged the Dr Lava and received an order for a stat chest x-ray and CBC and Tylenol prn The chest x-ray and CBC are getting done now and Mr. Celli just received a breathing treatment and 2 Tylenol. You should page Dr Lava with results. S B A R SBAR SCENERIO RN communicating to another RN

22. SBAR SCENERIO RN communicating to another RN Admitted for pneumonia. Respiratory status decreasing. • S • B • A • R History of lung cancer. Increase in oxygen need. Respiratory treatments q4hours. Physician aware. Vitals 120/68, R 24 (pre treatment), Temp 100. Decreased lung sounds, 4l O2 @ 91 %, decrease in lung sounds & crackles in bases. X-ray & labs being done Tylenol given. Watch pt closely and call MD with results of chest x-ray. Continue 4 hour breathing treatments.

23. Let’s Practice • It is 3:00am and Patient Suzie Q is complaining of pain and is in need of additional analgesics. Nurse Ratchet called Dr. Moody to inform him of the patient complaints. He replied by saying, “Go ahead and increase her morphine to 4mg.” • What would you do? • What additional information would you request? • Would you question the prescriber? • How would you document the order in the patient record?

24. References • Agency of Healthcare Research and Quality. (2009). Available at: http://www.innovations.ahrq.gov/content.aspx?id=2313 • Joint Commission (2007). Available at : http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/08_hap_npsgs.htm • Rural Connection. (2007). Nurses as Teachers. Boise, Idaho.