SBARHilary M. Kile, RN BS

March, 2010

Hand – Off Communication

Interactive process of passing patient specific information from one caregiver to another PURPOSE:

Ensure continuity and safety of the patient’s care

Provide accurate information about a patient’s care, treatment, and services, current condition and any recent or anticipated changes

Provides an opportunity to ask and respond to questions

JCAHO, 2007

What is hand-off communication?

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

Why is it important?

Examples of patient hand-offNurse to Nurse – Shift ChangeNurse to Ancillary StaffNurse to PhysicianInterdepartmentalFacility to FacilityTransferring On-Call ResponsibilityReporting Critical Results

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

Barriers to communication

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 person’s stress

level Participate in active listening

Rural Connection, 2007

Standardized approach to hand-off communicationDiscussion: 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?

SBAR for hand-off commumicationS – SituationB – BackgroundA – AssessmentR - Recommendation

Patient name Age Physician Diagnosis Surgery(s) IMMEDIATE CONCERNS/RISKS related to this

patient * Anticipated changes in patient condition Any pending treatments or tests *

Situation

Brief pertinent medical history Code status Advance directive status Allergies (allergy band or NKA sticker on?) Mental health concerns (suicide risk?) * IVs/central lines Treatments Catheters-tubes-drains (labeled by type) Pending/CRITICAL tests/labs * Expected length of stay

Background

Assessment Vital signs RESPIRATORY: O2 amount/mode (weaning

process?) NEUROLOGICAL: (mental status, GCS, seizures) CIRCULATION SKIN: (incisions, wounds, injuries, skin care) GI/GU: (I/O, last BM, nutrition, weight) MUSCULOSKELETAL PSYCHOSOCIAL/communication: (suicide risk) * Pain level (where? new? best treatment?) Activity needs/mobility/FALL RISK * Infections/isolation status *

Recommendations Cultural and communication needs Pending orders Immunizations Smoking cessation documented Age specific needs-thermoregulation, sensory Patient preferences/involvement in care * Goals for this patient * Medications (IV/oral) & Medication Transfer

Form

Rural Connection, 2007

SBAR Example Scenario Scenario: A nurse wants to report a change in

patient condition to the Physical Therapist who is scheduled to work with the patient later in the day.

Situation: “Tom, this is Lisa on Orthopedic Unit. You’re scheduled to do PT with Mr. Jones, in room 5, this afternoon at 1400. I wanted to give you an update on his condition as it might change your plans for today’s therapy session.”

Background: “Mr. Jones had his hip surgery two days ago and has only been out of bed once since his surgery was completed. He has been complaining of intense pain in that area. This morning, his incision is reddened and there is an increase in the amount of drainage. Infectious Disease has been consulted.”

SBAR Example Scenario Assessment: “I’m thinking that Mr.

Jones has a surgical site infection. I have received his labs this morning and he does have an elevated WBC.”

Recommendation: “Tom, I would like to recommend that you either postpone your time with Mr. Jones or make this first session a very brief one.”

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 patient’s medical

record and be reviewed and countersigned by the prescriber as soon as possible

Telephone & Verbal ordersCreate 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

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

Telephone & Verbal Orders

Must always be

READ BACK!

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

Examples Dosage parameter used must be written.

Example:Prednisone 6mg po daily x 10 days(2mg/kg/day) weight = 3.0kg

Orders must specify the medication dose for liquid drugs. Do not order it by volume.

Example: Tylenol 150mg NOT 5ml

Let’s Practice It is 3:00am 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 the 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?

References Agency of Healthcare Research and Quality.

(2009). Available at: http://www.innovations.ahrq.gov/content.aspx?id=2313

Joint Commission (2007). Available at :http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/08_hap_npsgs.htm Rural Connection. (2007). Nurses as

Teachers. Boise, Idaho.