5 Background US Navy Nuclear Submarine Service S = Situation B = Background A = Assessment R = Resolution
6 Background Aviation – United Airlines We have a serious problem. Stop and listen to me! C = I am Concerned (with my patient’s condition) U = I am Uncomfortable (with my patient’s condition) S = The Safety (of the patient) is at risk
7 Background Healthcare –Hand-offs Clinician to physician Clinician to clinician Home Health Aide to clinician
8 Background Hand-offs –Definition The transfer of care from one provider to another provider A mechanism for transferring information, responsibility, and authority from one set of caregivers to another
9 Background Principles of error-free hand-offs –Communicate interactively – allow and promote questions –Communicate up-to-date information regarding care, treatment, services, condition –Limit interruptions to avoid losing or skewing information –Allow sufficient time to complete hand-off –Require a verification process – repeat-backs or read- backs –Ensure the receiver of the information has the opportunity to review relevant data, including previous care treatment services
11 Why do we need SBAR? Situation: poor communication errors Background: –Training on communication styles varies among clinicians –Hierarchy lack of assertiveness –Distractions missing information
12 Why do we need SBAR? Assessment: we need a new communication style that all healthcare professionals can use Recommendation: SBAR is a simple tool that has effectively improved communication in other settings and has been effectively applied to healthcare
13 Why do we need SBAR? Physician engagement SBAR provides answers to 3 important questions What is the problem? What do you need me to do? When do I have to respond?
14 Why SBAR? 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 Helps create an environment that allows clinicians to express their concerns
15 Why SBAR? Clinician to Clinician –Provides direction –Provides opportunity for improved care planning
16 Why SBAR? Home Health Aide to Clinician –Provides valuable patient information
17 SBAR Guidelines: Step 1 Have all the patient’s information available before you contact the physician. Name Medical record number Age Diagnosis Medication list Allergies Vital signs Lab results Advance Directive
18 SBAR Guidelines: Step 2 A physical assessment has been conducted Have I seen and assessed the patient myself before calling? Review the chart for appropriate physician to call. Complete a telehealth encounter (phone monitoring, telemonitoring or teletriage)
19 SBAR Guidelines: Step 3 (S) Situation: What is the situation you are calling about? Identify self, agency, and patient name What is going on with the patient that is a cause for concern. A concise statement of the problem
20 SBAR Guidelines: Step 3 (cont.) (B) Background: What is the clinical background information that is pertinent to the situation? Admitting diagnosis and date of admission List of current medications, allergies, IV fluids, etc. Most recent vital signs Lab results: provide the date and time test was done and results of previous tests for comparison Medical history Recent clinical findings Advance Directive/code status
21 SBAR Guidelines: Step 3 (cont.) (A)Assessment: Share the results of your clinical assessment What are the clinician’s findings? What is the analysis and consideration of options? Is this problem severe or life threatening?
22 SBAR Guidelines: Step 3 (cont.) (R) Recommendation: What do you want to happen and by when? What action/recommendation is needed to correct the problem? What solution can you offer the physician? What do you need from the physician to improve the patient’s condition? In what time frame do you expect this action to take place?
23 SBAR Guidelines Physician preference –Telephone –Fax –Use of resident physicians –Coverage issues –Frequency of patient status updates
24 Scenario – Home Care Aide Helen the home health aide visits Mrs. Elmer twice a week for bathing. When Helen assists Mrs. Elmer to the bathroom today, she notices that the patient became increasingly short of breath. When Helen asks Mrs. Elmer about her increase in her shortness of breath, Mrs. Elmer responded by saying that it started last night. This morning when she weighed herself she noticed that she was 2 lbs heavier. Helen sat Mrs. Elmer on the chair and called Tammy, the patient ’ s primary nurse to find out what she should do.
25 Scenario – Home Care Aide S = Hi Tammy (nurse) this is Helen Adams the home health aide. I am at Mrs. Elmer’s house and she is experiencing more shortness of breath (SOB) when walking today.
26 Scenario – Home Care Aide B = When I walked Mrs. Elmer to the bathroom for her bath she had SOB than she didn’t have on Monday (today is Wednesday). Mrs. Elmer also verbalized that she weighs 2 lbs more than yesterday. I also noticed that her ankles are swollen. If I press on the swollen area and remove my finger you can see the indentation.
27 Scenario – Home Care Aide A = I think that it is her Congestive Heart Failure (CHF) again R = I think that you need to see Mrs. Elmer.
28 Scenario - Nursing Mr. Smith is a 78-year-old patient with CHF and HTN who lives with elderly wife. Today’s vital signs were: T , BP - 188/90, RR He is more SOB today as evidenced by an increased respiration rate and now SOB ambulating 8 feet (baseline ability - ambulate 20 feet). Lung sounds were previously clear, but today he has crackles in the posterior bilateral lower bases (1/3 rd lung fields). He usually has +1 edema, but today it is now +2 and slightly pitting. Mr. Smith’s wife forgot to weigh him for the last 3 days, but he has now gained 6 lbs. over 4 days.
29 Scenario - Nursing His current med regime includes: Digoxin, mg, every day; Lasix, 20 mg, every day; Slow-K, 20 meq, every day; and Prinivil, 5 mg, every day. He has no standing/prn orders. You talk with his wife about his compliance with his medication regimen and she states her daughter pre-fills the medications once a week. Upon examining the pillbox, it appears that the medications were given as ordered. His diet recall was not much different than his normal 2 gm Na diet, except for a ham dinner 2 days ago. His wife is anxious over his change in status. Nancy Nurse calls Dr. Gannon with the update.
30 Scenario - Nursing S = Dr. Gannon, I am Nancy Nurse from ABC Home Care. I am calling about Mr. James Smith, whose blood pressure, respirations & weight are elevated.
31 Scenario - Nursing B = Mr. Smith, a 78-year-old patient, with diagnosis of CHF & HTN. BP has increased to 188/90, resp. to 24. SOB when ambulating 8 feet, previously SOB at 20 feet. Wgt increased 6#/4 days. Crackles in the posterior bilateral lower bases (1/3 rd lung field). Compliant with medications. For the most part he is compliant with his 2 gm Na diet, with the exception of eating ham for dinner two days ago.
32 Scenario – Nursing A = Mr. Smith is experiencing fluid retention which may or may not have been exacerbated by the ham dinner.
33 Scenario – Nursing R = I would like to give Mr. Smith a dose of IV Lasix now and then continue with his daily Lasix p.o. dose in the a.m. I will have his wife measure his urine output for the next 24 hours to assess his diuresis. I would like an order to visit in the a.m. to assess his respiratory status, and urine output. May I draw a stat K+ level? I will call you with the visit results in the a.m. The on-call nurse will call his wife in 2 hours to assess Mr. Smith’s SOB and urine output. Mrs. Smith will be instructed on the s/s to watch for and to call if the patient’s SOB worsens.
34 Scenario – Physical therapist Mrs. Jones is a 78-year-old female. She lives in a one-story home with her elderly husband, who is also a patient on home care, and she is his primary caregiver. Mrs. Jones’s past medical diagnosis is HTN. She has become increasingly unsteady on her feet within the last several weeks. A referral was made to PT to evaluate lower extremity strengthening and gait training.
35 Scenario – Physical therapist Phillip Thomas’ (physical therapist) findings include: ambulates 15 – 20 feet using furniture & walls. Both ambulation and standing balance fair (-). Strength BLE 3+/5 & BUE 3+/5. No other gait abnormalities exist. Pt. showers alone and there are no grab bars or any other shower equipment. A fall risk assessment evidences the patient scored as high risk. PT initiates call to Dr. Gannon, the patient’s physician.
36 Scenario – Physical therapist S = Dr. Gannon, I am Phillip Thomas, a physical therapist at ABC Home Care. I am calling about Mrs. Helen Jones who was referred with weakness, and I am identifying as a high risk for falling.
37 Scenario – Physical therapist B = Mrs. Jones, a 78-year-old patient, lives at home with her elderly, ill husband. She scored at high risk on our falls risk assessment related to ambulating only with walls and furniture for support short distances; her balance is fair (-). She does not have any safety equipment in the bathroom (no grab bars). Her standing balance is fair. There is no other s/s at this time.
38 Scenario – Physical therapist A = Patient has developed some weakness with her legs and she has a balance issue that is putting her at risk for a fall. R = Patient needs an order for: a standard walker and a medical social worker referral to assess Mrs. Jones declining condition, which may negatively impact her ability to care for her husband
39 Summary SBAR provides a method of clearly communicating the pertinent information from a clinical encounter Empowers all members of the healthcare team to provide their input into the patient situation including recommendations Assessment and recommendation phases provide an opportunity for discussion among the members of the health care team May not be comfortable at first for either senders or receivers of information
40 Ohio KePRO Rock Run Center, Suite Lombardo Center Drive Seven Hills, Ohio Tel: Fax All material presented or referenced herein is intended for general informational purposes and is not intended to provide or replace the independent judgment of a qualified healthcare provider treating a particular patient. Ohio KePRO disclaims any representation or warranty with respect to any treatments or course of treatment based upon information provided. Publication No OH-073-4/2007. This material was prepared by Ohio KePRO, the Medicare Quality Improvement Organization for Ohio, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.