SBAR AND EMR COMMUNICATION TOOLS Maria Jensen, NPP, MPH, RN Marina Cecere, NPP, MPH, RN Renee McLeod-Sordjan , DNP, FNP-BC, RN

Introduction A review of reports from JACHO shows that communication failures to hand over effectively were implicated at the root of over 70 percent of sentinel events for hospitals and clinics to improve care. Shendell-Falik, N., Feinson, M., & Mohr, B.J., (2007). Enhancing patient safety; Improving the patient handoff process though appreciative inquiry. The Journal of Nursing Administration, 37(2), 95-104.

Goals National Patient Safety Goal 2: “Improve the effectiveness of communication among caregivers”. This addition requires hospitals to implement a standardized approach to hand-off communications and provide an opportunity for staff to ask and respond to questions about patient’s care. Joint Commission on Accreditation of Healthcare Organizations: Sentinel Event Statistics-June 30,2005. Retrieved http://www.jcaho.org/accredited+organizations/sentinel+event/sentinel+eventst tistics.htm

Factors that contribute towards failure to identify & manage deteriorating patient. Insufficient information, faulty exchanges of existing information Ambiguous and unclear information Lack of timely and effective exchange of pertinent information when alerting to concerns about patient condition Ineffective communication and handover of medically or mentally compromised patients Leonard, M., Graham, S., & Bonacum, D. (2004). The Human Factor. The Critical Importance of Effective Teamwork and Communication in Providing Safe Care. Quality and Safety in Health care 13 85-90

Where do things fall through the cracks? Systems – Information, test results, diagnosis Communication – handovers, transitions in care Failure to plan, failure to recognize, failure to rescue

SBAR Is a structured method for communicating critical information that requires immediate attention and action Offers hospitals and care facilities a solution to bridge the gap in communication, including hand-off patient transfers It creates a shared expectation between the sender and receiver of the information being shared

EMR Minimize medicals errors by providing safety checks on prescription dosages, drug-to drug interactions, duplicate therapies, and a patient’s previous adverse reactions Improves workflow and staff communication Track test results Reduce costs Improve health, and improve efficiency and networking. Hillestad, R., Bigelow, J., Bower, A., Girosi, F., Meili, R., Scoville, R., & Taylor, R., (2005).Can electronic medical record systems transform health care? Potential health benefits, savings, and cots. Health Affairs (Project Hope),24(5), 1103-1117. doi:10.1377/hlthaff.24.5.1103

Outcomes SBAR (PSYCH) + EMR = ENHANCED COMMUNICATION AND NURSE SATISFACTION

S B A R Current SBAR SITUATION RECOMMENDATION My name is: __________________Speaking to RN_____________ Unit/Area I am calling from: Patient’s Name Pt.’s chief complaint What happened?   Legal status 939 2PC Voluntary B BACKGROUND Admission diagnosis and date of ER State the pertinent medical history: A brief synopsis of the treatment/medication given to date: Vital signs are: UCG:____ Urine Tox._________ Results of LAB/ Diagnostics A ASSESSMENT/MMSE SUICIDAL YES OR NO ____HOMICIDAL YES OR NO ________ EXPLAIN_______ AGITATION/AGGRESSION YES/NO______IMPULSE CONTROL_________ GROSS INPAIRMENT ADL’S YES/NO EXPLAIN ________ R RECOMMENDATION Medication/Tests

Enhanced SBAR for Practice Improvement Project SITUATION My name is: __________________Speaking to RN_____________ Unit/Area I am calling from: Patient’s Name Pt.’s chief complaint What happened?   Accepting PSYCHIATRY ________ Medical MD___________________ Legal status 939 2PC Voluntary B BACKGROUND Admission diagnosis and date of ER State the pertinent medical history: RESPIRATORY____CARDIAC______SKIN_____ A brief synopsis of the treatment/medication given to date: FALLS POTENTIAL YES/NO_____ELOPMENT POTENTIAL______DIET_____ Vital signs are: UCG:____ Urine Tox._____ Substance abuse history____ Last use_____ Results of LAB/ Diagnostics Tests/ACCU CHECK______ XR/MRI RESULTS________ A ASSESSMENT/MMSE ALERT/ORIENTED TIME___PERSON ____PLACE___SITUATION_______ MOOD: Depressed___Anxious____Elated_____OTHER_____ AFFECT:Depressed___Anxious____Neutral_____Blunted_____Flat____OTHER------ THOUGHT PROCESS: Goal directed____ Tangential______FOI______OTHER___ DELUSIONS: ___ TYPE_____ HALLUCINATIONS:___________TYPE_________ SUICIDAL YES OR NO ____HOMICIDAL YES OR NO ________ EXPLAIN_______ AGITATION/AGGRESSION YES/NO______IMPULSE CONTROL_________ EXPLAIN______ IF YES, TIME OF MEDICATION GIVEN _________ GROSS INPAIRMENT ADL’S YES/NO EXPLAIN ________ R RECOMMENDATION Medication/Tests/Txs. order to be given in the unit until P.E. rendered ___ Neuro checks____ F.S_____ Other______

Psychiatric Patient Admission Process Decision to admit patient by ED physician Psychiatrist writes orders ER nurse performs admission assessment ER utilizes handoff communication Psychiatry nurse receives mental status info Utilizes SBAR to obtain mental status exam Handoff complete Receives direct information regarding patient behavior from psychiatrist

Psychiatric Patient Admission Process Status Post Process ED nurses use SBAR

Recruitment ED Nurses and Psychiatric Nurses during admission process of psychiatric patients

Plan EMR satisfaction survey Focus Group Nursing Education regarding SBAR Implementation Post- Survey & Evaluation

REFERENCE Hillestad, R., Bigelow, J., Bower, A., Girosi, F., Meili, R., Scoville, R., & Taylor, R., (2005).Can electronic medical record systems transform health care? Potential health benefits, savings, and cots. Health Affairs (Project Hope),24(5), 1103-1117. doi:10.1377/hlthaff.24.5.1103 Joint Commission on Accreditation of Healthcare Organizations: Sentinel Event Statistics-June 30,2005. Retrieved http://www.jcaho.org/accredited+organizations/sentinel+event/sentinel+eventst tistics.htm Leonard, M., Graham, S., & Bonacum, D. (2004). The Human Factor. The Critical Importance of Effective Teamwork and Communication in Providing Safe Care. Quality and Safety in Health care 13 85-90 Shendell-Falik, N., Feinson, M., & Mohr, B.J., (2007). Enhancing patient safety; Improving the patient handoff process though appreciative inquiry. The Journal of Nursing Administration, 37(2), 95-104