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Patient Safety Tip of the Week

June 7, 2022

SBAR to the Rescue!

 

 

Handoffs are among the most common transactions in transitions at all levels of the healthcare system and are also among the processes most prone to error. We know that breakdowns in communication are contributing factors in roughly 70% of all Sentinel Events in Joint Commission’s Sentinel Event database and many of those breakdowns occur during handoffs. The use of structured communications formats has been very helpful in improving handoffs.

 

Our February 14, 2012 Patient Safety Tip of the Week “Handoffs – More Than Battle of the Mnemonics” and our multiple columns on handoffs (listed below) discussed multiple formats for handoff communications. Some are tailored to the type of handoff. For example, I-PASS has now been widely adopted for physician-to-physician handoffs. Our April 9, 2019 “Handoffs for Every Occasion” discussed formats for a variety of other situational handoffs.

 

But there is one structured communication tool that has stood the test of time and can be utilized in multiple scenarios – SBAR. The SBAR mnemonic stands for:

 

SBAR is particularly useful for facilitating communication across professions. For instance, after an RCA showed that a nurse was reluctant (probably for a variety of reasons) to ask a physician to physically come see a patient, we noted that SBAR could have been very helpful:

                                   

That communication is succinct, conveys an appropriate amount of urgency, and is actionable.

 

Murphy and colleagues (Murphy 2022) recently described a quality improvement project to improve communication in one of their ICU’s. In this ICU, there was no standardized communication method used by nurses and advanced practice providers (APP’s). They noted that communication practices differed greatly between the 2 groups, and the nursing and APP staff members had reported communication between the 2 groups multiple times per shift. This often resulted in incomplete, inaccurate, or delayed information when clinical concerns were reported or escalated.

 

So, they selected SBAR as an appropriate standardized communication tool. Both groups (nursing and APP’s) received education on use of the tool. In addition to a Power Point presentation, other tools were used to reinforce use of SBAR. These included laminated signs near computers and desks, “badge buddies” (mini-versions of the laminated signs), and educational flyers placed in strategic areas.

 

A total of 200 nurses and 24 APP’s were involved in the project. Surveys before and after the intervention were completed and analyzed. For the APP’s, 62% were using the SBAR tool in clinical practice before and 82% after the intervention, but this did not reach statistical significance. For the nurses, 66% were using the SBAR tool in clinical practice before and 95% after the intervention (p<0.001). Scores on the communication survey subscales of Collaboration, General Perceptions, and Open Communication all improved after the intervention.

 

Success factors included several informal clinical champions and involvement of nursing leadership, Interestingly, the APP’s role-played clinical scenarios with nurses and provided feedback and encouragement.

 

After implementation of the SBAR tool, the nurses and APP’s reported a significant increase in their confidence in the accuracy and completeness of data being reported. Though improving teamwork was not a specific goal of this project, both groups also expressed enjoyment in working together, probably also the result of enhanced communication and collaboration between the 2 groups.

 

Use of the SBAR tool also seemed to spread to communications across other professions. Nurses and APP’s were observed using the SBAR tool with physicians, and respiratory therapists requested SBAR education for their team.

 

Most physicians appreciate receiving information in a concise, structured format that includes an assessment and recommendations. A few, however, may think such communication may be too assertive. Assertiveness is often a double-edged sword in team situations. Dominating a team can become dangerous but appropriate assertiveness is important. Communication obviously takes place between and among numerous individuals in settings such as the OR. Not being afraid to buck the authority gradient or hierarchy is critical and assertive communication is a key component of good teamwork. One example of escalating assertive communication is the CUSS tool:

    C   I’m concerned and need clarification”

    U   I am uncomfortable and don’t understand”

    S    I’m seriously worried here”

    S    Stop”

 

We highly recommend the SBAR format for inter-professional communications. Use of such a format is helpful not only in hospital venues, but also in outpatient venues. Every organization should do an inventory of the communication formats being used across professions in multiple settings. If no structured one is being used, SBAR is a good option.

 

 

Read about many other handoff issues (in both healthcare and other industries) in some of our previous columns:

 

May 15, 2007              Communication, Hearback and Other Lessons from Aviation

May 22, 2007              More on TeamSTEPPS

August 28, 2007         Lessons Learned from Transportation Accidents

December 11, 2007     Communication…Communication…Communication

February 26, 2008       Nightmares….The Hospital at Night

September 30, 2008     Hot Topic: Handoffs

November 18, 2008     Ticket to Ride: Checklist, Form, or Decision Scorecard?

December 2008            Another Good Paper on Handoffs”.

June 30, 2009               iSoBAR: Australian Clinical Handoffs/Handovers

April 25, 2009             Interruptions, Distractions, Inattention…Oops!

April 13, 2010             Update on Handoffs

July 12, 2011              Psst! Pass it on…How a kid’s game can mold good handoffs

July 19, 2011              Communication Across Professions

November 2011           Restricted Housestaff Work Hours and Patient Handoffs

December 2011            AORN Perioperative Handoff Toolkit

February 14, 2012       Handoffs – More Than Battle of the Mnemonics

March 2012                 More on Perioperative Handoffs

June 2012                    I-PASS Results and Resources Now Available

August 2012               New Joint Commission Tools for Improving Handoffs

August 2012                Review of Postoperative Handoffs

January 29, 2013         A Flurry of Activity on Handoffs

December 10, 2013     Better Handoffs, Better Results

February 11, 2014       Another Perioperative Handoff Tool: SWITCH

March 2014                  The “Reverse” Perioperative Handoff: ICU to OR

September 9, 2014      The Handback

December 2014            I-PASS Passes the Test

January 6, 2015            Yet Another Handoff: The Intraoperative Handoff

March 2017                 Adding Structure to Multidisciplinary Rounds

August 22, 2017         OR to ICU Handoff Success

October 2017              Joint Commission Sentinel Event Alert on Handoffs

October 30, 2018        Interhospital Transfers

April 9, 2019               Handoffs for Every Occasion

November 2019          I-PASS Delivers Again

August 2020               New Twist on Resident Work Hours and Patient Safety

September 29, 2020    ISHAPED for Nursing Handoffs

May 25, 2021              Yes, Radiologists Have Handoffs, Too

February 2022             Communication Failures and Malpractice

 

 

References:

 

 

Murphy M, Engel JR, McGugan L, et al. Implementing a Standardized Communication Tool in an Intensive Care Unit. Crit Care Nurse 2022; 42 (3): 56-64

https://aacnjournals.org/ccnonline/article/42/3/56/31762/Implementing-a-Standardized-Communication-Tool-in

 

 

 

 

 

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