1. SBAR – improving communication 28th September 2010 Presenter: Julie Parry

2. What can go wrong ? handover: Patient with poor appetite referred to dietetic service by medical staff on 16/1/07 (documented in medical notes). Patient not actually referred to dietician until 25/1/07 (onward) = 9 day delay in treatment + assessment of patient. Communication breakdown between ward… and… transfer: on transfer 24 ‑ 8 ‑ 06. On 29 ‑ 8 ‑ 06 seen on… No feeding regime present. Assumed by… to be self caring with Bolus Peg feeding – not the case patient had not been trained to be self caring had been fed with pump on ward… bolus feeding insufficient amount and inappropriate storage of feed, not flushing Peg sufficient and taking oral diet and fluids when should be nil by mouth as per medical notes from ward. This document extracted from Quarterly Data Summary Issue 12 (May 2009). See www.npsa.nhs.uk/nrls/patient-safety-data/quarterly-data-reports for the complete report.

3. Catheter inserted by Staff Nurse …….there was no return of urine - however balloon was inflated. Noted blood in urine bag. Doctor informed. ….patient distressed, rolling around in agony. Blood coming from urethra - blood in urine bag. Attempt at bladder washout - unsuccessful. Catheter removed by doctor and noted to be a female catheter…

4. 4 Communication Issues Leading Factor in Root Causes Collation of sentinel event-related data reported to The Joint Commission (1995-2005). Available http://www.jointcommission.org/SentinelEvents/Statistics/ http://www.jointcommission.org/SentinelEvents/Statistics/

5. Recognising and responding appropriately to early signs of deterioration in hospitalised patients - NPSA November 2007 There are problems on call when you don’t know patients. The nurse will say ‘their blood pressure just dropped.....’ they should be able to give the clinical context so you can work out how serious this is...’ (junior doctor)

6. Patient presented to A& E in urine retention, had female catheter fitted yesterday by his district nurse, patient states that she said she had no male catheters and did he mind having a female one.

7. NPSA – November 2007 Nurses need to be more assertive »(focus groups) Nurses may struggle to communicate in a manner that would convince the doctors of the urgency »(ethnographic analysis) Information is lost at handovers »(interviews) Difficult for nurses to communicate the perceived urgency to medical staff »(literature review)

8. SBAR TOOL S – Situation: What is happening at the present time? B – Background: What are the circumstances leading up to this situation? A – Assessment: What do I think the problem is? R – Recommendation: What should we do to correct the problem?

9. Why SBAR? The SBAR technique provides –a framework for communication between members of the health care team about a patient's condition. –an easy-to-remember, concrete mechanism useful for framing any conversation, especially critical ones, requiring a clinician’s immediate attention and action. –It allows for an easy and focused way to set expectations for what will be communicated and how between members of the team, which is essential for developing teamwork and fostering a culture of patient safety.

10. Process SBAR can be used in any clinical speciality it has been commonly used in conjunction with an Early Warning Score and has been included in Alert training courses A number of organisations are using this as a structure for reporting to the senior management team

11. Learning points It is essential that SBAR template reflects local needs an education programme is in place before SBAR is tested all parties involved in the process have been involved in the training

12. Handovers The transfer of information (along with authority and responsibility) during transitions in care across the continuum for the purpose of ensuring the continuity and safety of the patient’s care.

13. Type of handovers Rescuing patients On call responsibilities Critical reports (laboratory and imaging ) External patient transfers (home, nursing homes) Other transitions in care ( inter-ward, radiology, physiotherapy) Patient hand-overs –Level of care (cross coverage) Nursing shift change Medical staff transferring care –Theatre to Intensive care

14. Research Pothier, D, Monteiro, P, Mooktiar, M, Shaw, A “Pilot study to show the loss of important data in nursing handover”. British Journal of Nursing, 2005, vol14, No. 20. 12 Simulated Patients 5 consecutive handover cycles – 3 different styles Verbal handover resulted in loss of all data Note taking style resulted in loss of 31% Form with verbal handover resulted in minimal loss

15. Implementation Suggestions Assess all points where hand over's occur Concurrently monitor process at all points Conduct gap analysis Identify champions, medical staff, nurses, leadership

16. Implementation Suggestions Select a consistent approach to hand over's Develop a policy and procedure? Test the change Educate staff Implement the policy? Test the change and spread Monitor & report findings

17. Why Consistency is Needed Complicating factors inhibit consistency –Differences in styles of communication –Cultural background –Hierarchy of decision making –Level of respect between medical staff and nurses –Level of empowerment

18. Focuses on the patient and individual needs Increases the odds of consistent quality of care to the patient Requires all staff to become more intentional and disciplined in their interaction with each other Consistency in Communication

19. Standardised Communication Focuses on the patient not the people Standardised format allows all parties to have common expectations: –What is going to be communicated –How the communication is structured –Required elements

20. Assertive Communication is: Being organised in thought and communication Not expecting perfection while looking for clarification/common understanding Owned by the entire team – not just a “subordinate” skill set It must be valued by the receiver to be successful

21. Assertion Is Not Aggressive/hostile, Confrontational, Ambiguous, or Ridiculing

22. Why is Assertion So Hard? Hierarchy of decision making Lack of common mental model Don’t want to look “stupid” Not sure I’m right Culture

23. I - SBAR I – introduction S - ituation (the current issue ) B - ackground (brief, related to the point) A - ssessment (what you found/think) R – ecommendation/request (what you want next)

24. Introduction State your name and unit I am calling about (patient name)

25. Patient age Gender Pre-op diagnosis Procedure Patient stable/unstable Situation

26. Pertinent medical history Allergies Sensory Impairment Medication given Blood given – units available Musculoskeletal restrictions Background

27. Observations Isolation required Skin Risk factors Issues I am concerned about Assessment

28. Specific care required immediately or soon Priority areas ⁻ Pain control ⁻ IV pump ⁻ Family communication Recommendation/Request

29. Helpful tools for SBAR Forms/Templates Check lists Prompt cards Note pads Stickers on/next to phones

30. Thank you for listening Any questions