SBAR Hilary M. Kile, RN BS March, 2010

1. Hand – Off Communication SBAR Hilary M. Kile, RN BS March, 2010

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. Situation • Patient name • Age • Physician • Diagnosis • Surgery(s) • IMMEDIATE CONCERNS/RISKS related to this patient * • Anticipated changes in patient condition • Any pending treatments or tests *

10. Background Brief pertinent medical history Code status Advance directive status Allergies (allergy band or NKA sticker on?) Mental health concerns (suicide risk?) * IVs/central lines Treatments Catheters-tubes-drains (labeled by type) Pending/CRITICAL tests/labs * Expected length of stay

11. Assessment Vital signs RESPIRATORY: O2 amount/mode (weaning process?) NEUROLOGICAL: (mental status, GCS, seizures) CIRCULATION SKIN: (incisions, wounds, injuries, skin care) GI/GU: (I/O, last BM, nutrition, weight) MUSCULOSKELETAL PSYCHOSOCIAL/communication: (suicide risk) * Pain level (where? new? best treatment?) Activity needs/mobility/FALL RISK * Infections/isolation status *

12. Recommendations • Cultural and communication needs • Pending orders • Immunizations • Smoking cessation documented • Age specific needs-thermoregulation, sensory • Patient preferences/involvement in care * • Goals for this patient* • Medications (IV/oral) & Medication Transfer Form

13. Rural Connection, 2007

14. SBAR Example Scenario Scenario: A nurse wants to report a change in patient condition to the Physical Therapist who is scheduled to work with the patient later in the day. Situation: “Tom, this is Lisa on Orthopedic Unit. You’re scheduled to do PT with Mr. Jones, in room 5, this afternoon at 1400. I wanted to give you an update on his condition as it might change your plans for today’s therapy session.” Background: “Mr. Jones had his hip surgery two days ago and has only been out of bed once since his surgery was completed. He has been complaining of intense pain in that area. This morning, his incision is reddened and there is an increase in the amount of drainage. Infectious Disease has been consulted.”

15. SBAR Example Scenario • Assessment: “I’m thinking that Mr. Jones has a surgical site infection. I have received his labs this morning and he does have an elevated WBC.” • Recommendation: “Tom, I would like to recommend that you either postpone your time with Mr. Jones or make this first session a very brief one.”

16. 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

17. 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

18. 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

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

20. 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

21. Examples • Dosage parameter used must be written. Example: Prednisone 6mg po daily x 10 days (2mg/kg/day) weight = 3.0kg • Orders must specify the medication dose for liquid drugs. Do not order it by volume. Example: Tylenol 150mg NOT 5ml

22. 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 the 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?

23. 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.