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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 Commissions 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 ICUs. In this ICU, there was
no standardized communication method used by nurses and advanced practice providers
(APPs). 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 APPs) 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 APPs were involved in the project. Surveys before and after
the intervention were completed and analyzed. For the APPs, 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 APPs
role-played clinical scenarios with nurses and provided feedback and encouragement.
After implementation of the SBAR tool, the
nurses and APPs 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 APPs
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 Im concerned and
need clarification
U I am uncomfortable
and dont understand
S Im 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 kids 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
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