Improving handover in the ED setting “SBAR“

Objectives of the “SBAR Squad from A&E” Where we are Where we need to be What do our staff think How far have we got Where are we going

TAPS questions (Additional) “The SBAR Squad from A&E” What we were trying to achieve and why it was important: What worked well: What we have learned to take this forward:

Where we are?

Our Objective: To deliver high quality, evidence-based, effective, efficient and patient-centred care for ALL patients in the Emergency Department. PHASE 1 INITIAL ASSESSMENT Assessment - initial (complaint, physiology and allocate prioritisation) Planning - (investigations needed/ ordered, obvious decision to admit - DTA, start now if appropriate) Treatment - (immediate treatment/ resuscitation required) PHASE 2 DETAILED ASSESSMENT & TREATMENT Detailed assessment Chase results of investigations ordered Instigate further investigations if required EARLY Start treatment plan Management plan defined and delivered (with diagnosis, treatment plan and discharge plan) PHASE 3 MANAGEMENT & DISCHARGE PLANNING PHASE 4 ED EXIT – PLANNING & DELIVERY –SBAR Start Processes To: A) Discharge Home from ED using SBAR B) Admit to In-hospital Specialty Bed Base SBAR C) Admit to ED Observation Ward/CDU SBAR If delay in discharge from ED for any reason, inform appropriate person. TARGET TIMES TO SEE A DOCTOR DAILY & WEEKLY PERFORMANCE RESULTS FOR EACH PHASE STRATEGIC PLANNING AND EVALUATION IN THE EMERGENCY DEPARTMENT 0-15min window 15mins-90mins Window 90mins-3hrs Window 3-4hr window ED Senior Nurse SBAR ED SpR or Cons SBAR Duty Bed Manager If there is a breach (>4hrs in the Dept) in your area, please identify ways to prevent it in the future) Category 1(Resuscitation) =Immediate Category 2(Emergency) = Within 10mins Category 3(Urgent) = Within 1hr Category 4(Non-urgent) = Within 1hr Patient arrival to discharge MUST BE WITHIN 4 HRS for all patients. If delay in discharge from ED for any reason, inform appropriate person. Our Target:

What are the causes of error Fletcher NPSA 2008

Juliette Cosgrove: Q. “are we reporting enough?”

UCD IR1s 2011 [chart]

Knowledge application Process & system design Measuring success Teamworking & LEADERSHIP Training Where we need to be

What do our staff think? “a methodical order: name, age, gender, condition, plan, any risk to staff or patient” - nurse, grade 5. “simple clear patient details - complaint \ problem \ plan \ what needed \ & additional info.” – CSW. “everyone needs to handover following the same structure in the trust.” – Sister grade 6. “any further documentation needs to be short & concise. Already stress on 'time factors' with many other requirements for patients in ED; throughout [ED] stay and d/c to ward.” – Sister grade 7. “S: PC B: Meds & PMH A: impression / exam R: plan“- SpR in ED.

What do our staff think? Q1. The Emergency Department is a busy environment where the safety systems in place are robust and require no change. Please indicate the level of risk you perceive to be associated with the following patient events : Q12. Discussion with other speciality nursing or medical colleagues In the hospital. 1 Strongly Disagree 2345 DisagreeNeutralAgree Strongly Agree Low Risk Moderate High Risk Risk

How far have we got? Audit ( ED Cons Shift Team Leader snapshots x2) SBAR templates for key areas of the ED Developing context specific SBAR

Audit of practice Applied a development SBAR tool ( sticker in the ED notes) 10% and 15% adherence – not good! Positives: –Allowed refinement of tool –Embedded SBAR in minds of staff –Led to discussion and outcome to embed in ED notes

EMERGENCY DEPT PLANNING & HANDOVER Situation Likely diagnosis & other possible Dx? Background Co-morbidities? Assessment Present physiology (MEWS, GCS)? Active problems Investigations completed & those still required? Recommendations Acute therapy given? Further therapy required and when? Handover to (their name, grade, specialty) : Your name, grade & time of referral? SBAR template embedded into ED Notes

Senior Handover SBAR

SBAR for CDU protocols

S SITUATION  Name  Age  Consultant  Diagnosis  Treatment / Interventions  Resuscitation Status _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ ____ B BACKGROUND  Relevant medical history / surgical history  Medical / AHP consultations  Previous tests / treatments  Psychosocial issues  Allergies _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ ___________ A ASSESSMENT  Physical assessment  Mental health assessment / cognition  Vital signs / O 2 requirements  Lines - IV, CVC, PICC, Arterial  Pain score / analgesia  Wounds / pressure ulcers  Drains or tubes  Mobility  Nutritional status  Risk assessments (MEWS, MUST, VIP scores, MRSA/ decolonisation status and falls assessment.)  Pathology results  Patient /carer education _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ ___________________________________ R RECOMMENDATION  Care plan /care pathway  Orders needing completion  Pending treatments or tests  Discharge planning _____________________________________ _____________________________________ _____________________________________ _____________________________________ ______________ R READBACK  Oncoming staff (listener) confirms understanding of recommendations _____________________________________ _____________________________________ _____________________________________ _____________________________________ ______________

Where are we going! Embedding SBAR into ED notes Developing context specific SBAR within umbrella of improved handover Development of better communications with rest of hospital around SBAR Developing a tool for adherence and quality of content of SBAR in context specific situations