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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 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”
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”
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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