Bedside Change of Shift Reporting

Objectives ▶ The Registered Nurse will: –Be able to verbalize and understand benefits of Bedside Report. –Demonstrate the use of AIDET, Managing up & white boards in bedside shift report –Describe components of effective bedside change of shift report. –Be able to demonstrate effective bedside report using SBAR handoff tool. 2

Nurse to nurse bedside report or handoff includes communication of important patient information between shift changes designed to transfer vital information for safe care of the patient that occurs in the presence of the patient. 3

4 Importance of Communication Ineffective communication is a root cause for greater than two-thirds of all sentinel events reported. Source: The Joint Commission’s Root Causes and Percentages for Sentinel Events (All Categories) January1995−December 2008

Traditional Report Traditional methods of report include verbal, note taking, phone recording and tape recording. - Disadvantages Variability Loss of critical information Irrelevant information No patient involvement Potential for medical errors

Advantages of Bedside Report for Nurses ▶ Eliminates the Blame game ▶ Eliminates irrelevant information ▶ Less interruptions ▶ Allows for a brief assessment of all patients ▶ Visualize patient & get a baseline assessment ▶ Encourages nurses’ ownership, accountability and teamwork ▶ Improves rapport/nurse-patient relationship 6

Joint Bedside Report 7 Step One: Preparation – Both the incoming & outgoing nurse meet at the door of the room of the patient –Bring copies of the created SBAR Bedside Shift Report Forms – Address all sensitive issues prior to entering the room Step Two: Patient Introduction – After knocking on the patient’s door, enter the room together. The outgoing nurse should introduce incoming nurse to the patient. Use AIDET & white board strategies at this time.

Addressing HIPAA concerns ▶ Step Three: HIPAA Compliance ▶ HIPAA acknowledges incidental disclosures may occur Health information can be disclosed for: –Treatment –Health care operations –Payment ▶ Not a HIPAA violation as long as: –Take reasonable safeguards to protect privacy such as closing the curtains or lowering voice if possible. –Disclose only or use the minimum necessary information ▶ Patients have the right to decide who will be involved in their care. Code of Federal Regulations; Incidental Uses and Disclosures- 45 CFR (a)(1)(iii)

9 Step Four: Begin SBAR What is SBAR? Joint Bedside Report cont... A framework for team members to effectively communicate information to one another.

SBAR provides…. Communicate the following information: Situation - Specify the patient’s name and current condition or situation. Explain what has happened to trigger this conversation. Background - State the admission date, his or her diagnosis, and pertinent medical history. Give a brief synopsis of what’s been done so far (e.g. lab test). Assessment - Give a summary of pt’s condition/situation. Explain what is the problem at hand. Expand upon your statement with specific signs and symptoms. Recommendation - Explain what you would like to see done (e.g., lab tests, treatments). State any new treatments or changes ordered. Include all items that require follow up.

SBAR tool 11

Situation 12 Communicate the following information: Situation -Specify the patient’s name and current condition or situation. Explain what has happened to trigger this conversation. Situation (Pt name) is a (age) (sex) admitted for (diagnosis) to Doctors (name of physician)’s service. Patient’s current situation is _____________________________________________________

Background 13 Communicate the following information: Background- State the admission date, his or her diagnosis, and pertinent medical history. Give a brief synopsis of what’s been done so far (e.g. lab test). Background  Language  DNR Allergies:___________  Pertinent Past Medical History:____________________________  Precautions (ie., no blood products, falls, isolation, sensory deficits):______________ Patient / Family Concerns: _________________________ Medications (pertinent issues / effectiveness): _________ ________________________________________________ Recent Interventions / Effectiveness: _________________ Abnormal Labs: _________________________________ Vital Signs/frequency: ____________________________ Pain status  PCA/Epidural  Next dose due:_____________________ IV/type: _________________ Insertion Date: _________ IV Fluid/rate:_________________________  I & O  Drains /Tubes: ______________________  Wounds / Dressings: __________________________  Pressure Ulcer:  Stage: ____  Location: ____________  Tx: _____________ Consults:_____________________ Anticipate Date of Discharge________

Assessment 14 Communicate the following information: Assessment- Give a summary of the patient’s condition or situation. Explain what is the problem at hand. Expand upon your statement with specific signs and symptoms. Assessment Systems: Discuss only systems pertinent to this patient Neurological / Mental Status  Level of consciousness  Dementia  Confusion  Depression Lungs / Respiratory  Lung sounds (crackles, rhonchi, wheezes)  Cough (productive (description), dry)  Shortness of breath, difficulty breathing, orthopnea  Respiratory rate  Oximetry  _____ liters/% via _____  BiPAP/CPAP_________ Cardiovascular:  Heart Rate  Regularity  SOB  Edema  Daily Weight GI:  Diet/tube feed _______________  Thickened Liquids  TPN  Abdominal Tenderness  Distention  Vomiting/Nausea  Last Bowel Movement  Constipation  Diarrhea  Colostomy GU:  Catheter Insertion Date __________ Due to Void:__________  Urine Color  Dysuria  Frequency Musculoskeletal:  Mobility Issues  Positioning Assistive Devices:  Wheel Chair  Cane  Walker  Other_____________________ Skin:  Temperature  Condition  Edema  Hematoma Discharge Plan / Issues:  Case Management  IPFER Other: (ie flu & pneumo status)______________________________ ___

Recommendation 15 Communicate the following information : Recommendation-Explain what you would like to see done (e.g., lab tests, treatments). State any new treatments or changes ordered. Include all items that require follow up. Recommendation  Care, treatments or orders requiring follow-up: _______________________  Pending treatment /tests: ________________________________________  Issues /Items left undone that require follow-up: ________________________

16 Step Five: Peer Check – After completing the tasks listed on the Joint Bedside Report Form, ask your peer for any additional patient information or pertinent details as necessary. Joint Bedside Report cont...

Sample of SBAR Report ▶

Case Scenarios

Electronic Resources in PRISM 19 Units will be trialing the PRISM Electronic SBAR resource and providing feedback. In BI-B; the two floors that will be trialing it are 1 North & 3 East.

RN Handoff

References Federal Guidelines 45CFR (a) (1) (iii) Nurse Bedside Shift Report Implementation Handbook, AHRQ Rush, Sandra. Bedside Reporting: Dynamic Dialog, Nursing Management (1/2012) Stewart, Jennifer. Successfully Implementation of Joint Bedside Report on a Med/Surg Unit, The Advisory Board Company (2011) BIMC Policy C-22