1. SBAR – improving communication
13th September 2010
SBAR – improving communication
Presenter: Julie Parry

2. Patient with poor appetite referred to dietetic service by medical
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 for the complete report.

3. Communication Issues Leading Factor in Root Causes
Targets for Teamwork
Of over 3548 events, most of the ROOT CAUSES can be addressed by improved teamwork:
Improved communication, leadership, adherence to protocols and policies, sharing information, and moving toward a culture of quality and safety.
Collation of sentinel event-related data reported to The Joint Commission ( ). Available

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)

5. 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)

6. SBAR TOOL S – Situation: What is happening at the present 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?

7. 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.

8. 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

9. 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

10. 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.

11. Type of handovers 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

12. 5 consecutive handover cycles – 3 different styles
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.

13. Implementation Suggestions
Assess all points where hand over's occur
Concurrently monitor process at all points
Conduct gap analysis
Identify champions, medical staff, nurses, leadership

14. 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

15. Why Consistency is Needed
Complicating factors inhibit consistency
Differences in styles of communication
Cultural background
Hierarchy of decision making
Level of respect between medical staff and nurses
Level of empowerment

16. 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

17. 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

18. 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

19. Assertion Is Not Aggressive/hostile, Confrontational, Ambiguous, or
Ridiculing

20. 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

21. 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)

22. Introduction State your name and unit I am calling about I
(patient name) I

23. Situation Gender s Pre-op diagnosis Procedure Patient stable/unstable
Patient age
Gender
Pre-op diagnosis
Procedure
Patient stable/unstable s

24. Background Pertinent medical history Allergies Sensory Impairment B
Medication given
Blood given – units available
Musculoskeletal restrictions B

25. Assessment Isolation required A Skin Risk factors
Observations
Isolation required
Skin
Risk factors
Issues I am concerned
about A

26. Recommendation/Request
Specific care required
immediately or soon
Priority areas
Pain control
IV pump
Family communication R

27. Helpful tools for SBAR Forms/Templates Check lists Prompt cards
Note pads
Stickers on/next to phones

28. Thank you for listening
Any questions