1. Clinician Module SBAR: Made Easy SBAR
Welcome to the clinician education module on the communication technique known as SBAR. Please have your discipline specific care track available, that is, for nurses, therapists or social workers. These can be found at on the Best Practice Intervention Page for Physician Relationships.

2. Objectives Recognize the need for a structured communication process
Define SBAR
Describe how improving communication will support reducing avoidable acute care hospitalizations
Apply SBAR technique into daily practice
After this session you will understand how the SBAR communication technique evolved and recognize the need for a structured communication process. You will be able to define the acronym of SBAR and describe how using such a communication technique can support the national healthcare priority of reducing avoidable acute care hospitalizations. Most importantly, after participating in this interactive session, SBAR Made Easy, you will be able to incorporate the SBAR technique into your daily practice.

3. Home Care Challenges Changes in payment system
Burdensome paperwork/data collection
Higher acuity level
Communication methods beyond face to face (e.g. phone, fax, )
Home health care faces unique challenges, with changes in the payment system taking a priority at this time. With the cumbersome data collection and high acuity level of patients discharged from hospitals, it is more important than ever to foster processes that support efficient care delivery. Communication can be particularly challenging in home health care because so often, the sharing of patient information is not done face-to-face. We often rely on the telephone to communicate, and that might be while multi-tasking from a cell phone while driving. With advancing communication technologies, we may be sharing information via a fax or or even through text messaging. We must have a standardized approach to accurately share our message and achieve desired results.

4. US Navy Nuclear Submarine
THE NEED:
The ability to communicate clearly, effectively and efficiently in just seconds
Communication Model
S = Situation
B = Background
A = Assessment
R = Resolution
IHI, 2006
Communication challenges are not unique to health care.
Submarine officers and crew needed a ‘situational briefing model’ to communicate clearly, effectively and efficiently in just seconds. The US Navy developed the SBAR communication model which included a brief description of the situation at hand, pertinent background, an assessment of the problem and a plan for resolution. This SBAR approach organizes the message in a consistent and concise manner.

5. Healthcare and submarines
How are submarines & healthcare operations alike?
Exist in “harms’ way”
Require timely action to avert disaster
24X7 operations
Lots of turnover and cultural diversity
Deal with fear, fatigue, interruptions, distractions
At the root of their adverse outcomes unclear, in concise, or inaccurate information
How are submarines & healthcare operations alike?
Both exist in “harms’ way”
Both require timely action to avert disaster
Both operate 24X7
Both experience lots of turnover and cultural diversity
Both deal with fear, fatigue, interruptions, & distractions
Both have at the root of their adverse outcomes unclear, in concise, or inaccurate information
A team of physicians from Kaiser Permanente of Colorado modified this technique for healthcare. It is now gaining a strong support nationally among home health agencies.

6. SBAR: IHI Connection Institute for Healthcare Improvement
Focus on improving health care
Modified the Navy’s SBAR
R – Recommendation rather than Resolution
The Institute for Healthcare Improvement, IHI, is a not-for-profit organization leading the improvement of health care throughout the world.
IHI modified the Navy’s SBAR by keeping the
Situation, Background and Assessment, but changed the R – to Recommendation instead of the Navy’s Resolution. This allows for the clinician to make a recommendation to the physician about the patient’s situation.

7. SBAR: Home Care Connection
Condenses messages
Promotes critical thinking
Interdisciplinary communication
Physician communication
SBAR is perfect for improving communications in a home health agency.
This simple technique condenses messages so they contain only concise and significant information about the patient and allows clinicians to verbalize their assessment of the situation, that is, what they think is happening and what recommendations/actions the clinician feels are needed to correct the problem.
SBAR can also be a method used to communicate between disciplines, that is, nurse to nurse, therapist to nurse, home health aide to supervisor, etc or with physicians to improve communications and outcomes, including reducing avoidable acute care hospitalizations.

8. S-B-A-R Stands for … S = Situation What is going on with the patient
B = Background
What is the clinical background information that is pertinent to the situation
A = Assessment
What I think—conclusions
R = Recommendation
What is needed and in what time frame
SBAR as it applies to home care is:
S = Situation
B = Background
A = Assessment
R = Recommendation
We will demonstrate specific examples in a few minutes.

9. SBAR: Preparation
Ensure all pertinent patient information is available before you contact the physician
Name
Medical record number
Age
Diagnosis
Medication list
Allergies
Vital signs
Lab results
Advance Directive
What is the minimal but pertinent information that you will need? Have that information collected before you get the physician or his office on the line. Some example of important information are contained on this slide.

10. To help you gather your information and collect your thoughts prior to making your phone call, we have designed a worksheet based on the SBAR method of communication to assist you. These are located in the form room under SBAR worksheet label.

11. Communicating with Physicians
40 patients a day
need to cue the physician to who we are and who the patient is
may only see our patients every couple months or less
Let’s examine using SBAR for communication with a physician. Keep in mind, when communicating with physicians, they may be seeing 40 patients a day. We need to not only be able to be to the point, but we need to cue the physician to who we are and who the patient is. For example, Mr. Smith and Mr. Jones may be very similar clinically and maybe only see the physician every couple months.

12. SBAR Technique 10-15 SECONDS only
(S) Situation: What is the situation you are reporting?
Identify self, agency, patient, patient location
What is going on with the patient. A concise statement of the problem
10-15 SECONDS only
Now you are ready to place the call. Start with the situation which is the S in SBAR. The situation information will contain, Who you are and who the patient is. Next describe What is going on – this must be a concise statement of the problem taking seconds.

13. SBAR Technique
(B) Background: Clinical background information that is pertinent to the situation
The admitting diagnosis and date of admission
List of current medications, allergies, IV fluids, etc.
Most recent vital signs
Lab results: provide the date and time test was done and results of previous tests for comparison
Advance Directive
For the background, only give what is pertinent to the situation. This usually will include why you are seeing the patient. List those medications and/or allergies that are relevant to the situation at hand. Know which vital signs and lab values need communicated. It may or may not be pertinent to provide advance directive information. Your clinical judgment will determine what information is needed to achieve the best outcome for the patient.

14. (A) Assessment: SBAR Technique What are the clinician’s?
What is the analysis ?
Is this problem severe or life threatening?
Next is your assessment – synthesizing the data you have gathered. This data will lead you to your assessment or analysis of the situation-basically defining the problem as you see it. Your analysis is what your conclusion of the problem is.

15. SBAR Technique (R) Recommendation:
What action/recommendation is needed to correct the problem?
What solution can you offer the physician?
What do you need from the physician to improve the patient’s condition?
Finally the R is what solution you can recommend. This is your opportunity to let the physician know what home health has to offer. Be specific as to what you need from the physician to make this happen. If you are requesting an order change, state the order as you would like for it to appear. If you are suggesting a medication, state the dose and frequency that you would like to see given.

16. SBAR Interdisciplinary Communication Example
SBAR: Activity #1
SBAR Interdisciplinary Communication Example
Let’s do an example of how SBAR can be used to facilitate clear communication between care disciplines.

17. SBAR Interdisciplinary Communication
demonstrates using SBAR to communicate issues, problems or opportunities for improvement to coworkers or supervisors.
SITUATION –
State what is happening at the present time that has warranted the SBAR communication.
Example: Hi, Kathy, this is Brian. I am calling to report that my patient, Mrs. L., has an elevated blood pressure this morning and admits to feeling very anxious.
For this example, the Home Health Nurse Nikki, is speaking to her supervisor Kathy. She is concerned about Mrs. L who has an elevated BP today on her visit.
An example of communicating the S or situation in SBAR is as follows: Hi, Kathy, this is Nikki. I am calling to report that my patient, Mrs. L., has an elevated blood pressure this morning and admits to feeling very anxious.
Nikki has identified herself, her patient and what the problem is at the present time. She describes the elevated BP and the anxious feeling in less than 10 seconds.
Kathy now knows what to listen for as Nikki goes on with the situation.

18. SBAR Interdisciplinary Communication
Background
BACKGROUND –
Explain circumstances leading up to this situation. Put the situation into context for the reader/listener.
Example: Mrs. L’s blood pressure is 188/92 (R) which is up from 126/80, 186/90 (L). Her pulse has increased from 64 bpm (regular rate and rhythm) to 98 bpm (regular rate and rhythm). There are no other abnormal symptoms are present during my assessment. The patient has verbalized that she is somewhat nervous and jumpy but denies any unusual activity or stress. She also has a history of panic attacks.
Nikki continues with the RELEVANT background on the problem-the B in SBAR.
“ Mrs. L’s blood pressure is 188/92 (R) which is up from 126/80, 186/90 (L). Her pulse has increased from 64 bpm (regular rate and rhythm) to 98 bpm (regular rate and rhythm). There are no other abnormal symptoms are present during my assessment. The patient has verbalized that she is somewhat nervous and jumpy but denies any unusual activity or stress. She also has a history of panic attacks. “

19. SBAR Interdisciplinary Communication
Background
BACKGROUND –
Explain circumstances leading up to this situation. Put the situation into context for the reader/listener.
Example: Mrs. L’s blood pressure is 188/92 (R) which is up from 126/80, 186/90 (L). Her pulse has increased from 64 bpm (regular rate and rhythm) to 98 bpm (regular rate and rhythm). There are no other abnormal symptoms are present during my assessment. The patient has verbalized that she is somewhat nervous and jumpy but denies any unusual activity or stress. She also has a history of panic attacks.
Nikki has defined the important information in the current problem, notes in gray on the slide. These include the current Blood pressure which is of concern to her. . She also noted the previous BP for comparison and trending information. She stated the current and previous heart rate, the feelings Mrs. L expressed and the relevant history of panic attacks. As you can see, an entire medical history is not important in this particular situation. So Nikki has limited her information to the facts that are relevant to her upcoming assessment.

20. SBAR Interdisciplinary Communication
BACKGROUND – Explain circumstances leading up to this situation. Put the situation into context for the reader/listener.
Example: Mrs. L’s blood pressure is 188/92 (R) up from 126/80, 186/90 (L). Her pulse has increased from 64 bpm (regular rate and rhythm) to 98 bpm (regular rate and rhythm). No other abnormal symptomatology evident during my assessment. The patient has verbalized that she is somewhat nervous and jumpy but denies any unusual activity or stress. She also has a history of panic attacks. .
RECOMMENDATION – What would you do to correct the problem? Example: I would like you to notify the physician of these findings and ask if we can have a social worker referral for an evaluation to r/o psychosocial issues that may be causing Mrs. L’s suspected panic attacks. I would also like you to visit the patient in the a.m. to assess her vital signs. I will plan to call the physician tomorrow with our findings to see if he would like to schedule Mrs. L for an office visit.
SBAR Interdisciplinary Communication
Assessment .
Assessment
State what is happening at the present time that has warranted the SBAR communication.
Example: “ Kathy, I think Mrs. L is anxious and might be having a panic attack. She states this is similar to ones she has had before.
After setting up the situation for her supervisor by giving her the important information in the S and B portions of the SBAR communication, Nikki defines what she has determined to be the problem- the A part of SBAR. “
“ Kathy, I think Mrs. L is anxious and might be having a panic attack. She states this is similar to ones she has had before. “
Again she is brief but gives relevant information

21. SBAR Interdisciplinary Communication
Recommendation
Recommendation
What would you do to correct the problem?
Example: “I would like to notify the physician of these findings and ask if we can have a social worker referral for an evaluation to r/o psychosocial issues that may be causing Mrs. L’s suspected panic attacks. I would also like to visit the patient in the a.m. to assess her vital signs. I will plan to call the physician tomorrow with our findings to see if he would like to schedule Mrs. L for an office visit.”
Now that Nikki has given her assessment of the problem, Nikki gives Kathy the recommendation which she is suggestion to solve the problem -the R part of SBAR.
Nikki identifies a three pronged approach to this problem.
“I would like to notify the physician of these findings and ask if we can have a social worker referral for an evaluation to r/o psychosocial issues that may be causing Mrs. L’s suspected panic attacks. I would also like you to visit the patient in the a.m. to assess her vital signs. I will plan to call the physician tomorrow with our findings to see if he would like to schedule Mrs. L for an office visit”
Her three suggestions are to:
1. Get a social work consult
Visit the patient tomorrow for follow up
Assess tomorrow if she needs to have a physician office visit follow up.

22. SBAR in action -less than 20 seconds
S-Hi, Kathy, this is Brian. I am calling to report that my patient, Mrs. L., has an elevated blood pressure this morning and admits to feeling very anxious.
B-Mrs. L’s blood pressure is 188/92 (R) which is up from 126/80, 186/90 (L). Her pulse has increased from 64 bpm (regular rate and rhythm) to 98 bpm (regular rate and rhythm). There are no other abnormal symptoms are present during my assessment. The patient has verbalized that she is somewhat nervous and jumpy but denies any unusual activity or stress. She also has a history of panic attacks.
A-Kathy, I think Mrs. L is anxious and might be having a panic attack. She states this is similar to ones she has had before.
R-“I would like to notify the physician of these findings and ask if we can have a social worker referral for an evaluation to r/o psychosocial issues that may be causing Mrs. L’s suspected panic attacks. I would also like to visit the patient in the a.m. to assess her vital signs. I will plan to call the physician tomorrow with our findings to see if he would like to schedule Mrs. L for an office visit.”
As you can see, Nikki has used SBAR to communicate a problem, describe the context of the problem, give her assessment and a recommended solution to it in less than 20 seconds. This slide summarizes that conversation.

23. Interdisciplinary Communication: Voice mail/face to face Hand offs
How to Use SBAR at DHCH
Interdisciplinary Communication:
Voice mail/face to face
Hand offs
Report to managers and peers
Message to office staff to forward to physician
During case conferences
Consider when you might use the SBAR technique for interdisciplinary communication within DHCH. This process eventually will become second nature so that you can use it when leaving a voice mail or even a face to face report. Think about using the process when reporting to managers, team leaders and your colleagues. If you are calling from the road with a message that needs forwarded to a physician office – use the SBAR technique to keep the message concise. You might even incorporate the process into case conferences to stay focused and efficient.

24. From the physician…
“How the nurse communicates patient information will depend on whether I listen to the nurse or not.”
Let’s go back to physician communication.
“How the nurse communicates patient information will depend on whether I listen to the nurse or not.” This is a quote from a physician on the advisory panel for the national home health quality improvement support center. I think many physicians would echo this sentiment. The need for a standardized approach to communication with physicians is necessary to gain confidence and trust and the best possible outcome for the patient.

25. SBAR Physician Communication sample SBAR: Activity #2
The following example demonstrates using SBAR to communicate issues, problems or opportunities for improvement to physicians
Now let’s look at how a team member can use SBAR for physician communication.

26. SBAR Physician Communication
Situation .
SITUATION –
State what is happening at the present time that has warranted the SBAR communication.
Example: This is Carol from Duke Home Care. We are seeing Mrs. L for pressure ulcer treatment. I am calling to report, Mrs. L, has an elevated blood pressure this morning. She also told me that she feels very anxious
It looks like this.
This is Carol from Duke Home Care. We are seeing Mrs. L for pressure ulcer tretment. I am calling to report, Mrs. L, has an elevated blood pressure this morning. She also told me that she feels very anxious
Carol has concisely given the physician an idea of what her call is about.

27. SBAR Physician Communication
Background
BACKGROUND –
Explain circumstances leading up to this situation. Put the situation into context for the reader/listener
Example: Duke Home Health has been seeing Mrs. L for three weeks for care of a pressure ulcer. This is the first time her blood pressure has been elevated. Today her blood pressure is 188/92 (R); up from 126/80; 186/90 (L). Her pulse has increased from 64 bpm (regular rate and rhythm) to 98 bpm (regular rate and rhythm). No other abnormal symptoms evident during my assessment. The patient has verbalized that she is nervous and jumpy but denies any unusual activity or stress. She also stated that she has a history of panic attacks.
Carol goes on to give a little more background on Mrs. L and the problem.
Duke Home Health has been seeing Mrs. L for three weeks for care of a pressure ulcer. This is the first time her blood pressure has been elevated. Today her blood pressure is 188/92 (R); up from 126/80; 186/90 (L). Her pulse has increased from 64 bpm (regular rate and rhythm) to 98 bpm (regular rate and rhythm). No other abnormal symptoms evident during my assessment. The patient has verbalized that she is nervous and jumpy but denies any unusual activity or stress. She also stated that she has a history of panic attacks.
Here again she give relevant facts with trends to give the physician so they can get an idea of what the problem is along with the nurse

28. SBAR Physician Communication
Assessment
ASSESSMENT
What do you think the problem is?
Example: She has elevated blood pressure and pulse.
For the assessment portion she states that she has elevated BP and tachycardia. This is what is causing her concern

29. SBAR Interdisciplinary Communication
Recommendation
RECOMMENDATION –
What would you do to correct the problem?
Example: I can draw electrolytes and enzymes this morning and call you will the results. I am also requesting to have an order for a social worker to visit to r/o psychosocial issues. I will revisit Mrs. L tomorrow and contact you with our findings.
Her recommendations are stated like this:
I can draw electrolytes and enzymes this morning and call you will the results. I am also requesting to have an order for a social worker to visit to r/o psychosocial issues. I will revisit Mrs. L tomorrow and contact you with our findings.
At this point the physician has an idea of what your concerns are and what you think is an option to do to resolve the problem.

30. How to Use the SBAR Form with Physicians
Script for phone call to physician’s office
Fax
Hand deliver
How might you use this with physicians? Some home health agencies are using the SBAR tool to prepare a script when calling the physician office. One agency reported success with a physician who rarely returned calls until they started faxing him patient reports written in SBAR format. He replied, using the same format complete with orders. Even when meeting with physicians, having documentation in SBAR format will promote a much appreciated efficient use of time.

31. DHCH has designed fax sheet using SBAR which you can use for faxed communication with physicians or other health care providers.

32. ACH Connection  Physician understanding of patient problem
Improving Physician Communications with SBAR
 Physician understanding of patient problem
 Physician trust with clinician
Consider how using the SBAR communication approach might support reducing avoidable hospitalizations. Improving communication with physicians will enhance the physician understanding of the patient problem AND increase trust and confidence. This, in turn, will lead to opportunities for early and appropriate interventions that may reduce avoidable hospitalizations. Since rehospitaliztion is a measure for home health and ER visit are an outcome measure for hospice care, both programs can benefit from reducing ER visits or rehospitaliztion in their patients.
 Opportunity for early, appropriate intervention that may  reduce avoidable ACH

33. QUIZ
Congratulations. You have now completed SBAR: Made Easy. Please finish the quiz to complete this module.