SBAR

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Hand Off Communication

• SBAR
• Guada Allen, RN, BSN, CMSRN
• Staff Educator SLMV

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What is hand-off communication?

• Interactive process of passing patient specific
  information from one caregiver to another
• PURPOSE
• Ensure continuity and safety of the patients
  care
• Provide accurate information about a patients
  care, treatment, and services, current condition
  and any recent or anticipated changes
• Provides an opportunity to ask and respond to
  questions
• JCAHO, 2007

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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

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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

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Barriers to communication

• Not listening
• Giving advice
• Expressing approval or disapproval
• Defending
• Requesting an explanation Why?
• Belittling feelings
• Changing the subject
• Rural Connection, 2007

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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 persons stress level
• Participate in active listening
• Rural Connection, 2007

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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?

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SBAR for hand-off commumication

• S Situation
• B Background
• A Assessment
• R - Recommendation

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Sbar

• 1. SSituation
• -Introduction, Patient Problem, Assessment
  (Vital Signs), Stated Concern related to
  assessment.
• 2. BBackground
• -Pertinent information related to the
  situation admit date, surgical day, current
  meds, lab results, other clinical information.

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Sbar

• 3. AAssessment
• -What is the nurses assessment of the
  situation? I think the problem is __________.
• Im not sure what the problem is, but the
  patient is deteriorating.
• 4. RRecommendation
• -I suggest or request that you transfer the
  patient, come see the patient, talk to the
  patient
• -Do you want any tests like (CXR, ABG, EKG)

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Prior to calling

• Assess
• Prepare data
• Discuss
• Know whom to call
• Know admitting diagnosis
• Read (read the progress note)
• Have list of allergies, medications and lab/test
  results
• Know code status

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Rural Connection, 2007
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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 patients medical record
  and be reviewed and countersigned by the
  prescriber as soon as possible

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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

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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

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Telephone Verbal Orders

• Must always be
• READ BACK!

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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

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Examples

• Dosage parameter used must be written.
• Example
• Prednisone 6mg po daily x 10 days
• Orders must specify the medication dose for
  liquid drugs. Do not order it by volume.
• Example
• Tylenol 150mg NOT 5ml

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SBAR SCENERIO Nurse communicating with Physician

• Read the following scenario and then fill in the
  SBAR as you would tell it to the physician.
• Mrs. Vastin is an 80 year old women admitted to
  the hospital yesterday with a diagnosis of
  abdominal pain. She is on a clear liquid diet.
  She was stable until approximately 2 hours ago
  when she started to complain of increased
  abdominal pain. Dr Rispy was called at that time
  and ordered Morphine 2mg IV every 2 hours as
  needed. Morphine 2mg relieved her pain and she
  was doing better. A hour later, the nursing
  assistant went into the room to do vital signs
  and called you immediately. Her vitals were Temp
  101.8 BP 80/62 HR 122 RR 25 and her level of
  consciousness was decreased. She has not had any
  labs since this am and has a capped IV.

• S
• B
• A
• R

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SBAR SCENERIO Nurse communicating with Physician

• S
• B
• A
• R

Dr. Rispy this is Julie RN I have a 80 year old
female Pt who has decreased responsiveness. Her
systolic blood Pressure has dropped 20points and
her LOC is decreased..
She was admitted yesterday with abdominal pain.
She was stable until 2 hours ago when she
started to complain of more pain which you gave
a morphine order for. That relieved her pain and
she seemed to be doing fine until just a few
minutes ago.
Current vitals 80/62 122 25 temp 101.8
Decreased level of consciousness
I am concerned about this patient may have an
Infection and that she may get shocky. Would you
like me to do a stat CBC, blood cultures and
start fluids? When should I call you again if
necessary?
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SBAR SCENERIO RN communicating to another RN

• Read the following scenario and then fill in the
  SBAR to communicate with another nurse.
• Shift Report
• Patient Mr. Celli, in Rm 56 was admitted 3days
  ago for pneumonia by Dr Lava. Today the patients
  breathing treatments have been switched to every
  4 hours due to increase difficulty in breathing.
  He seems comfortable after getting the breathing
  treatments. His lungs are decreased at the bases
  with crackles on the right. He is wearing oxygen
  at 4 Liters which was just increased. His pulse
  oximetry is at 91. Bp 120/68 R 24 (per breathing
  treatment) P 100 Temp 100. Just recently paged
  the Dr Lava and received an order for a stat
  chest x-ray and CBC and Tylenol prn The chest
  x-ray and CBC are getting done now and Mr. Celli
  just received a breathing treatment and 2
  Tylenol. You should page Dr Lava with results.

• S
• B
• A
• R

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SBAR SCENERIO RN communicating to another RN
Admitted for pneumonia. Respiratory status
decreasing.

• S
• B
• A
• R

History of lung cancer. Increase in oxygen need.
Respiratory treatments q4hours. Physician aware.

Vitals 120/68, R 24 (pre treatment), Temp 100.
Decreased lung sounds, 4l O2 _at_ 91 , decrease in
lung sounds crackles in bases. X-ray labs
being done Tylenol given.
Watch pt closely and call MD with results of
chest x-ray. Continue 4 hour breathing
treatments.
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Lets Practice

• It is 300am 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 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?

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References

• Agency of Healthcare Research and Quality.
  (2009). Available at http//www.innovations.ahrq.
  gov/content.aspx?id2313
• Joint Commission (2007). Available at
• http//www.jointcommission.org/PatientSafety/Natio
  nalPatientSafetyGoals/08_hap_npsgs.htm
• Rural Connection. (2007). Nurses as Teachers.
  Boise, Idaho.