Transcript SBAR for CAUTI - 1000 Lives Plus

28th September 2010
SBAR – improving communication
Presenter: Julie Parry
What can go wrong ?
• handover:
Patient with poor appetite referred to dietetic service by medical
staff on 16/1/07 (documented in medical notes). Patient not
actually referred to dietician until 25/1/07 (onward) = 9 day
delay in treatment + assessment of patient.
Communication breakdown between ward… and…
• transfer:
on transfer 24-8-06. On 29-8-06 seen on… No feeding
regime present. Assumed by… to be self caring with Bolus Peg
feeding – not the case patient had not been trained to be self
caring had been fed with pump on ward… bolus feeding
insufficient amount and inappropriate storage of feed, not
flushing Peg sufficient and taking oral diet and fluids when
should be nil by mouth as per medical notes from ward.
This document extracted from Quarterly Data Summary Issue 12 (May 2009).
See www.npsa.nhs.uk/nrls/patient-safety-data/quarterly-data-reports for the complete report.
Catheter inserted by Staff Nurse …….there was no
return of urine - however balloon was inflated.
Noted blood in urine bag. Doctor informed.
….patient distressed, rolling around in agony. Blood
coming from urethra - blood in urine bag. Attempt at
bladder washout - unsuccessful. Catheter removed
by doctor and noted to be a female catheter…
Communication Issues Leading
Factor in Root Causes
Collation of sentinel event-related data reported to The Joint Commission (1995-2005). Available
http://www.jointcommission.org/SentinelEvents/Statistics/
4
Recognising and responding appropriately
to early signs of deterioration in
hospitalised patients - NPSA November
2007
There are problems on call when you don’t know patients. The
nurse will say ‘their blood pressure just dropped.....’ they
should be able to give the clinical context so you can work out
how serious this is...’ (junior doctor)
• Patient presented to A& E in urine
retention, had female catheter fitted
yesterday by his district nurse, patient
states that she said she had no male
catheters and did he mind having a
female one.
NPSA – November 2007
• Nurses need to be more assertive
» (focus groups)
• Nurses may struggle to communicate in a manner that
would convince the doctors of the urgency
» (ethnographic analysis)
• Information is lost at handovers
» (interviews)
• Difficult for nurses to communicate the perceived urgency
to medical staff
» (literature review)
SBAR TOOL
• S – Situation: What is happening at the present
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time?
B – Background: What are the circumstances
leading up to this situation?
A – Assessment: What do I think the problem is?
R – Recommendation: What should we do to
correct the problem?
Why SBAR?
• The SBAR technique provides
– a framework for communication between members of
the health care team about a patient's condition.
– an easy-to-remember, concrete mechanism useful for
framing any conversation, especially critical ones,
requiring a clinician’s immediate attention and action.
– It allows for an easy and focused way to set
expectations for what will be communicated and how
between members of the team, which is essential for
developing teamwork and fostering a culture of patient
safety.
Process
• SBAR can be used in any clinical speciality it has
been commonly used in conjunction with an Early
Warning Score and has been included in Alert
training courses
• A number of organisations are using this as a
structure for reporting to the senior management
team
Learning points
It is essential that
• SBAR template reflects local needs
• an education programme is in place before
SBAR is tested
• all parties involved in the process have been
involved in the training
Handovers
• The transfer of information (along with authority and
responsibility) during transitions in care across the
continuum for the purpose of ensuring the continuity and
safety of the patient’s care.
Type of handovers
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Rescuing patients
On call responsibilities
Critical reports (laboratory and imaging )
External patient transfers (home, nursing homes)
Other transitions in care ( inter-ward , radiology, physiotherapy)
Patient hand-overs
– Level of care (cross coverage)
• Nursing shift change
• Medical staff transferring care
– Theatre to Intensive care
Research
12 Simulated Patients
5 consecutive handover cycles – 3 different styles

Verbal handover resulted in loss of all data

Note taking style resulted in loss of 31%

Form with verbal handover resulted in
minimal loss
Pothier, D, Monteiro, P, Mooktiar, M, Shaw, A “Pilot study to show the loss of important
data in nursing handover”. British Journal of Nursing, 2005, vol14, No. 20.
Implementation Suggestions
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Assess all points where hand over's occur
Concurrently monitor process at all points
Conduct gap analysis
Identify champions, medical staff, nurses,
leadership
Implementation Suggestions
• Select a consistent approach to hand over's
• Develop a policy and procedure? Test the
change
• Educate staff
• Implement the policy? Test the change and
spread
• Monitor & report findings
Why Consistency is Needed
• Complicating factors inhibit consistency
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Differences in styles of communication
Cultural background
Hierarchy of decision making
Level of respect between medical staff and nurses
Level of empowerment
Consistency in Communication
• Focuses on the patient and individual needs
• Increases the odds of consistent quality of care to the
patient
• Requires all staff to become more intentional and
disciplined in their interaction with each other
Standardised Communication
• Focuses on the patient not the people
• Standardised format allows all parties to have
common expectations:
– What is going to be communicated
– How the communication is structured
– Required elements
Assertive Communication is:
• Being organised in thought and communication
• Not expecting perfection while looking for
clarification/common understanding
• Owned by the entire team – not just a “subordinate”
skill set
• It must be valued by the receiver to be successful
Assertion Is Not
• Aggressive/hostile,
• Confrontational,
• Ambiguous, or
• Ridiculing
Why is Assertion So Hard?
• Hierarchy of decision making
• Lack of common mental model
• Don’t want to look “stupid”
• Not sure I’m right
• Culture
I - SBAR
I – introduction
S - ituation (the current issue)
B - ackground (brief, related to the point)
A - ssessment (what you found/think)
R – ecommendation/request (what you
want next)
Introduction
• State your name and unit
• I am calling about
(patient name)
Situation
• Patient age
• Gender
• Pre-op diagnosis
• Procedure
•Patient stable/unstable
Background
• Pertinent medical history
• Allergies
• Sensory Impairment
•Medication given
• Blood given – units available
• Musculoskeletal restrictions
Assessment
• Observations
• Isolation required
• Skin
• Risk factors
• Issues I am concerned
about
Recommendation/Request
• Specific care required
immediately or soon
• Priority areas
⁻ Pain control
⁻ IV pump
⁻ Family communication
Helpful tools for SBAR
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Forms/Templates
Check lists
Prompt cards
Note pads
Stickers on/next to phones
Thank you for listening
Any questions