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Changing practice

Using a communication framework at handover to boost patient outcomes

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A trust introduced a structure for presenting critical information at handover. This has aided communication between team members and benefited care

 

Authors

Peggy Christie, BSc, RGN, is modern matron, critical care; Hazel Robinson, BSc, RGN, is critical care outreach lead; both at South Devon Healthcare Foundation Trust, Torbay.

 

Abstract

Christie P, Robinson H (2009) Using a framework for good communication to improve quality of information at handover. Nursing Times; 105: 47, early online publication.

This article provides nurses with a simple structure to aid effective communication. It explains how one trust implemented the situation-background-assessment-recommendation (SBAR) structure to improve patient handover, and outlines the benefits for nurses and patients.

Keywords: Communication, Critically ill, SBAR, Deterioration

  • This article has been double-blind peer reviewed

 

Introduction

It is well recognised that the increased acuity and complexity of patients’ needs in a busy surgical or medical ward presents challenges for both nursing and medical staff.

The National Patient Safety Agency (2007) suggested that effective communication is a key factor in improving clinical practice and patient outcome. Some of the key comments in this report from both nursing and medical staff on difficulties with communication were:

  • Unclear documentation;
  • Nurses not communicating clearly;
  • If nurses are not confident and articulate on the telephone, they do not get the response they need;
  • Doctors find it difficult to prioritise, due to inadequate verbal handovers from nursing staff;
  • Doctors not always telling staff about changes to patient management.

NICE (2007) supported these findings and recommended that both nursing and medical staff should use a formal structured handover supported by a written plan. Unfortunately, these recommendations are not always followed in training. In our experience, nurse education has not prepared practitioners in the art of effective verbal communication. This is usually developed through observing peers and reflective clinical practice.

Experience in South Devon

In 2006 the South Devon Healthcare Foundation Trust joined phase two of the Safer Patients Initiative (SPI), which is supported by The Health Foundation. Key outcomes of this national initiative were:

  • A 15% reduction in hospital mortality;
  • A 30% reduction in adverse events;
  • A 30% reduction in cardiac arrests;
  • A 50% reduction in MRSA bacteraemias.

The use of SBAR was advocated as the structure for communication for the project and was published by the Institute for Healthcare Improvement (2004). This tool can be used at any part of the patient journey but it lends itself particularly well when used to hand over critical information.

SBARstands for:

  • Situation
  • Background
  • Assessment
  • Recommendation

How to use SBAR

The key to effective communication is preparation. Before picking up the telephone, nurses should gather the necessary information. Then they should use the structure in Table 1 to present the information gathered.

 

Table 1. Using the SBAR structure

Situation
  • Who you are
  • Where you are telephoning from
  • The patient’s name
  • What is the main problem?
    (This is the most important aspect to attract the other person’s attention immediately)
Background       
  • Date of admission and diagnosis
  • Relevant past medical history and treatment to date
    (It is imperative that this is brief, succinct and relevant)
Assessment
  • State your assessment of the patient
    (For example, vital signs, modified early warning score (MEWS), level of consciousness, acute confusion, medication, resuscitation status)
Recommendation
  • Explain what you need
  • Be specific about your request and the timeframe
  • Ask if there is anything else you can do before the other staff member arrives
  • Document the call including date, time and who you spoke to
  • If you are worried and do not receive the response you need you may need to escalate to a more senior clinician

 

The benefits of using a communication tool such as SBAR are that it encourages or promotes:

  • Accurate and relevant information to be shared;
  • Better patient experience;
  • Credibility of nursing handover;
  • Better decision making by medical staff;
  • Appropriate prioritisation of patients;
  • Improved time management;
  • Active listening.

Compare the two handovers in Table 2 and consider the following points:

  • Credible nursing practice;
  • Information for effective decision making and prioritisation;
  • Time management;
  • Patient experience.

Which structure would you choose to use from Table 2?

 Table 2. Communication structures

Structure 1

Doctor: Hi this is Matt, the surgical F1, you are bleeping me.

Nurse: Hello, this is staff nurse on Rose ward. Can you come and review a patient of mine please?

Doctor: What is the problem?

Nurse: His blood pressure is low.

Doctor: What is it?

Nurse: 88/45.

Doctor: What was it before?

Nurse: Not sure, let me go and get his charts. It was 135/70.

Doctor: What did the patient come in with?

Nurse: Hold on, let me get my handover sheet - he had a small bowel resection three days ago.

Doctor: What are his other vital signs?

Nurse: Hold on, I will just have a look - his temperature is 38.6ºC, pulse is 122/min, respirations 26/min, SpO2 93% on air.

Doctor: What is his urine output?

Nurse: Not sure, let me go and get his fluid balance charts. Sorry, can’t find it.

Doctor: What medications is he on?

Nurse: Let me go and get his prescription chart.

Doctor: Don’t worry, I will wander up later and review him.

Structure 2

Doctor: Hi this is Matt, the surgical F1, you are bleeping me.

Nurse

Situation: Hi, this is Sue, staff nurse on Rose Ward. I am contacting you regarding a Mr Smith who has suddenly become hypotensive. BP is 88/45.

Background: He had a small bowel resection three days ago and is receiving IV fluids at 125ml/hr. This man is normally fit and well with no relevant past medical history.

Assessment: His airway is patent, respirations 26/min. SpO2 93% on air. I have started him on 6L oxygen and his SpO2 has come up to 98%. Pulse is regular, rate 120/min, BP was 135/70 earlier, now 90/40. He is cool peripherally with a capillary refill of four seconds. His urine output has also dropped, over the past three hours 35ml, 20ml, 10ml. At the moment he is alert and complaining of abdominal pain. He has also been vomiting. Temperature is 38.7. I think he is septic, possibly abdominal.

Recommendation: I need you to come and see this patient now.

Doctor: OK, I am on my way

Nurse:Is there anything I can do before you get here?

Doctor: Can you give stat bolus of 500ml normal saline (trust patient group directive 1013) and organise an ECG.

Nurse: OK, see you in a minute.

 

 

Introducing the SBAR tool in South Devon

The mechanism for change used was the small tests of change or plan do study act (PDSA) cycle. This cycle is a methodology for continuous improvement to examine where you are and where you could be (Langley et al, 1996).

The benefit of using it is that following the initial trials of adopting the tool we can evaluate the results and act quickly on what we have learnt. The cycle is based on the principle that learning requires action and study of the outcomes.

This method of change is recommended by the Institute for Healthcare Improvement and Patient Safety First, the patient safety campaign in England to which 96% of acute trusts are signed up.

 

[x head] PDSA cycle methodology

It consists of four phases that are continuous and is usually illustrated as shown in Fig 1.

This approach to change and improvement should be a continuous cycle until optimal performance is achieved.

Introducing the SBAR tool in South Devon

The mechanism for change used was the small tests of change or plan do study act (PDSA) cycle. This is incorporated into the model for improvement, which examines where you are and where you could be (Langley et al, 1996; Fig 1).

The cycle is based on the principle that learning requires action and study of the outcomes. The benefit of using it, therefore, is that following the initial trials of adopting PDSA we can evaluate the results and act quickly on what we have learnt.

This method of change is recommended by the Institute for Healthcare Improvement and Patient Safety First, the patient safety campaign in England to which 96% of acute trusts are signed up.

PDSA cycle methodology

The cycle consists of four phases that are continuous and is usually illustrated as shown in Fig 1. This approach to change and improvement should be a continuous cycle until optimal performance is achieved.

 A PDSA cycle for introducing a communication tool

Plan

Main considerations:

  • Acceptance that communication was an issue within the organisation;
  • Acknowledgement that a communication tool was needed;
  • Key questions:
    - Who is best placed to roll this out?
    - How could we roll it out multiprofessionally?
    - What teaching methods and aids might be suitable?
    - How might we audit the change and ensure it is embedded?
    - How can we ensure the change is positive?
    - When and where shall we start?
    - Regular evaluation by the project team.

Do

Within the trust this initiative was rolled out to one ward first with the aid of well placed posters, stickers on telephones (compliant with infection control policy), supported with 10-15 minute teaching sessions at ward level and simulated scenarios. Clinical staff were actively encouraged to cascade the tool to their peers, which required active monitoring by ward managers and the project team.  

The initiative was then rolled out to all ward areas and multiprofessional teams. As mentioned previously, the SBAR communication tool can be used at any stage of the patient journey. Communication between wards was formalised by using specific handover sheets and receiver sheets using SBAR.

This format has also been used to structure trust meetings with positive results. Formal education was delivered at trust clinical induction and all other appropriate forums.

Study

Auditing this change proved challenging for the project team as initially it was unclear which was the most effective audit tool.

One of the measurements that worked well was for nurses receiving a patient transfer to document the information received and comment on the handover sheet if the information was robust. This data was then collated by the project team, which included the identification of the ward and the individual nurse handing over the patient. This data was collated and fed back to wards that were doing well and tests of change were implemented to ensure change had taken place for those wards finding this more challenging.

The quality of telephone referrals to the critical care outreach team was evaluated and supported with real time feedback and educational input.

One of the most powerful, accurately measured effects of this tool was from unpublished work carried out by the trust. This work showed clearly that at each handover, time taken was dramatically reduced from approximately 45 minutes to seven minutes. It appeared that before the introduction of SBAR, nursing staff had different perceptions on what should be included in the handover. They also used some of this time to catch up socially. SBAR offers a clear structure to the handover and has had a positive impact on the quality of information given.

It was recognised that the information for specialised areas had to be tailored to suit what was relevant to them.

Act

Tests of implemented change were performed regularly and new ideas on improvement readily put into practice where appropriate. These planned changes to the process were informed by issues identified at the fortnightly project team meetings.

One of the changes that improved patient handover between wards was for the accepting ward to lead the process. It was unclear why this should have had such an impact, possibly because the admitting ward had a clear view of the information needed to prepare for a patient admission.

Further education was given for wards that did not appear to be adapting to the change. The importance of cascading any SBAR education received was reiterated to staff.

Conclusion

The use of a communication tool such as SBAR addresses the key concerns identified by the NPSA and NICE. Introducing it to South Devon ensures that as a trust we comply with NICE guidance and, more importantly, ensures a positive patient experience/outcome.SBARhas also helped the trust to meet Safer Patients Initiative requirements. By July 2009 we had achieved an 11% reduction in hospital mortality, a 65% reduction in adverse events, an 8% reduction in cardiac arrests and an 83% reduction in MRSA bacteraemias.

A Main component in the project’s success was the support of the trust executive team, as well as strong ownership by staff at ward level. Results showed clear time management improvements, with this freed up time now used to complete other nursing duties.

Nursing staff were initially concerned that using the SBAR tool would lead to a delay in escalation and response in an emergency situation; however, this has not been the case. In emergency situations, such as calling the cardiac arrest team, staff follow local policies.    

One of the key lessons learnt by the organisation was to ensure a core group of trainers from all disciplines were identified.

For sustained action the concept should be part of continued education and championed by clinical staff throughout the organisation.

Box1has details for more information for trusts wishing to implement SBAR.

 

Box 1. Further information

  • Click here to see the Patient Safety First Measurement How-to Guide for more information on using PDSA
  • Click here to go to the Patient Safety First website for more information on using SBAR

 

 

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