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

2. 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),

3. 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 tistics.htm

4. 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

5. 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

6. 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

7. 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), doi: /hlthaff

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

9. 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 PC 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

10. 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 PC 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______

11. 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

12. Psychiatric Patient Admission Process Status Post Process
ED nurses use SBAR

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

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

15. 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), doi: /hlthaff Joint Commission on Accreditation of Healthcare Organizations: Sentinel Event Statistics-June 30,2005. Retrieved 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 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),