Clinical Strategies to Improve Patient Outcomes

1. Clinical Strategies to Improve Patient Outcomes Strategies to Improve Communication With Physicians

2. Objectives • Describe physician-nurse communication patterns • Discuss how SBAR can improve communication • Introduce new tools to assist agencies with physician communication

3. Physician-Nurse Communication • Emergent Care – Acute Care Hospitalization link • More than one physician • Teamwork • Collaborative relationship

4. Physician-Nurse Communication • Sign the Plan of Care • Coordination of Services • Verbal Orders • Multidisciplinary Team Member

5. Physician-Nurse Communication • Different Styles Nurses are trained to be narrative and descriptive Physicians are trained to be problem solvers “ what do you want me to do” – “ just give me the headlines” • Human factors: gender, national culture, hierarchy/ power distance, prior relationship • Perceptions of patient’s need • Paradigm shift

6. What Do Physicians Want To Know? • Accurate concise information • All pertinent information available • The patient was assessed • Possible solution or recommendation

7. Communication Barriers • Telephone tag • Unfamiliar with home care • Incomplete information • Failure to return telephone calls • Interruption to daily routine

8. Physician Communication Establish…… • Best method • Standing orders • Relationship & trust

9. SBAR • Situation • Background • Assessment • Recommendation * Institute Healthcare Improvement www.ihi.org

10. Why SBAR? • SBAR is similar to the SOAP model • Provides answers to physicians’ three main questions • What is the problem? • What do you need me to do? • When do I have to respond? • Standardized approach that promotes efficient transfer of • key information between physicians, nurses and other • members of the team • SBAR helps create an environment that allows clinicians • to express their concerns

11. S: Situation • Identify yourself, home health agency • Whether you are in the home • Describe the patient situation • When the problem started • Severity

12. B: Background • Patient’s admission to the agency • Current list of medications, including allergies • Recent medication changes • Laboratory values • Recent ER visits or hospitalizations • Date of Birth

13. A: Assessment • Clinicians current assessment of the situation • I think the problem is: ____________

14. R: Recommendation • Recommend what action the clinician wants from the physician • Describe what you are able to do • Let physician know you will call back with the patient’s response • Request an extra skilled visit

15. SBAR Exercise • Mr. Nelson is 71 year old male with HTN and COPD. Patient c/o being tired and weak the last 2 days. After the nurse assesses patient she determines that has had syncope s/s with sudden movements, for the last day or two after starting “that new medication.”

16. SBAR Exercise, continued • BP 102/60(R), 106/62(L), 98/52(L standing) P 72 bpm, & R 24. Previous VS were 164/82(R), 158/80 (L), P 74 bpm, R 22. Nurse discovers that the patient’s “new medication” was filled at a different pharmacy, and was really the same antihypertensive he was already taking.

17. SBAR Exercise, continued Situation: Dr. Smith, this is Nancy Nurse from ABC Home Care. I am calling about Mr. James Nelson your 71 year old patient that is now having s/s syncope.

18. SBAR Exercise, continued Background: ABC Home Health has been seeing for the last 3 weeks for exacerbation of HTN. His previous vital signs were 164/82(R), 158/80 (L), P 74, R 22.Mr. Nelson has been complaining of lightheadedness, weakness and syncope with sudden movement. VS today were: BP 102/60(R), 106/62(L), 98/52(L standing) P 72, & R 24.Nurse discovered patient was taking a double dose of his antihypertensive, XXXX 1 tablet, XX mg, twice a day for the last 4 days by accident.

19. SBAR Exercise, continued Assessment: Patient accidentally had a refill of the same antihypertensive filled at another pharmacy. He is hypotensive from the medication error. Recommendation: I would like to hold his antihypertensive medication until tomorrow and schedule two extra skilled nursing visits starting tomorrow to recheck his blood pressure and for medication teaching. Can I have parameters when to restart the medication?

20. If SBAR does not work? “CUS” program: I’m Concerned… I’m Uncomfortable … This is unSafe…..

21. * Assertion • Model to guide andimprove assertion inthe interest of patient safety

22. Why is Assertion So Hard ? • Hierarchy / power distance • Lack of common mental model • Don’t want to look stupid • Not sure I’m right • Other?

23. Physician Communication Toolkit • The Physician Role in Reducing Hospitalizations • Physician letter • Guidelines for physician contacts • SBAR documentation form • SBAR fax statement to the physician Available for download at http://providers.ipro.org/index/homehealth_downloads

24. Contact Information Sara Butterfield , RN, BSN, CPHQ, CCM Project Director Phone: 518-426-3300 ext. 104 Email: sbutterfield@nyqio.sdps.org Christine Stegel RN, MS, CPHQ Performance Improvement Coordinator Phone: 518-426-3300 ext. 113 Email: cstegel@nyqio.sdps.org