1. Escalation of Care Quality & Safety Communication Improvement Tool – SBAR-D Based on Escalation of Care Project (Started Sept 2013) Ian Moyle – Clinical Matron & Sarah Wonnacott – Ward Sister (Wellington) Adapted from NHS Institute for Innovation & Improvement

2. Clinical deterioration can occur at any time in a patient’s illness but is more common following an emergency admission, during recovery from a serious illness and following surgery. Failure to recognise deterioration and act appropriately may culminate in cardio respiratory arrest Patient Safety First (2009)

3. What is SBAR-D SBAR-D is a structured method for communicating critical information that requires immediate attention and action SBAR-D improves communication, effective escalation and increases safety Its use is well established in many settings including the military, aviation and some acute medical environments SBAR-D has 5 steps - Situation - Background - Assessment - Recommendation - Decision

4. Why use SBAR-D? SBAR-D reduces the barriers to effective communication across different disciplines and levels of staff SBAR-D creates a shared mental model around all patient handovers and situations requiring escalation, or critical exchange of information SBAR-D is a memory prompt; easy to remember and encourages prior preparation for communication SBAR-D reduces the incidence of missed communication

5. How can SBAR-D help me? Easy to remember Clarifies what information needs communicating quickly Points to action are clearly highlighted Prevents “hinting & hoping”

6. Uses & Settings for SBAR-D? Inpatient & Outpatient Clinical & Non-clinical Matters Conversations with a physician (either in person or over the phone) Discussions with allied health professionals Conversations with peers Handovers Escalating concerns Activity: Think & identify what professionals can we escalate care to?

7. SBAR-D - SITUATION Identify yourself the ward/unit your are calling from Identify the patient by name and the reason for your report Describe your concern Firstly, describe the specific situation about which your are calling, including the patient’s name, consultant, patient location, resuscitation status, and vital signs. "This is Sarah, Ward Sister of Wellington Ward. The reason I'm calling is that Mrs. Taylor in bedspace C3 has become acutely short of breath, her vital signs have been stable from admission but deteriorated suddenly. She is also complaining of chest pain and there appears to be blood in her sputum.”

8. SBAR-D - BACKGROUND Give the patients reason for admission Explain significant medical history Overview of the patient’s background: Consider - Admitting diagnosis, date of admission, prior procedures, current medications, allergies, pertinent laboratory results and other relevant diagnostic results. “Mrs Taylor is a 69-year-old woman who was admitted from home three days ago with a community acquired pneumonia. She has been on intravenous antibiotics and appeared, until now, to be doing well. She is normally fit, well and independent and is under the care of Dr Myers.”

9. SBAR-D - ASSESSMENT What assessment tool? NEWS, GCS, Waterlow Score, MUST Score, CIWA Score, Diarrhoea Assessment Tool, eBICA & More! Always remember clinical impressions and concerns You need to think critically when informing the doctor of your assessment of the situation. This means that you have considered what might be the underlying reason for your patients condition If you do not have an assessment, you may say ‘I’m not sure what the problem is, but I am concerned.’ “ Mrs Taylor ‘s NEWS Score is 10 - because her oxygen saturation has dropped to 88 per cent on room air, her respiration rate is 24 per minute, her heart rate is 110 and her blood pressure is 85/50, in addition, she is also complaining of chest pain and she has had some haemoptysis.”

10. SBAR-D - RECOMMEDATION Explain what you need – be specific about your request and the time frame Make suggestions Clarify expectations Finally, what is your recommendation? This is, what would you like to happen by the end of the conversation with the professional? “I have initiated oxygen therapy to maintain saturations, I have commenced on Cardiac Monitoring, I would like you to come immediately to review Mrs Taylor, and would you like me to start a stat fluid challenge.”

11. SBAR-D - DECISION Confirm actions to be taken Confirm expectations Clarify expectations Finally, ACT! “We have agreed you will come immediately and I will commence a stat fluid challenge and prepare the patient for your review with an ECG” “Any order that is given on the phone needs to be repeated back to ensure accuracy.”

12. SBAR-D – Escalation Tree Escalate to a higher level as required Senior Nurse Senior Medic Outreach Service Clinical Site Co-ordinator Manager “ No response” = Escalate Higher “Delay in response” = Escalate Higher “No response” = Escalate Higher “Delay in response” = Escalate Higher

13. SBAR-D – NEWS Guidance Clinical response plan located on the front of the NEWS Chart “

14. SBAR-D – Escalation of Care Label Record SBAR-D communication on the Escalation of Care Label and stick into the Section 5 - Nursing Evaluation

15. SBAR-D – Activity / Role Play Think of a scenario Prepare for the imaginary contact Deliver SBAR-D escalation communication to group Group Feedback

16. Questions Presentation Based on Escalation of care Pilot (Wellington Ward) Ian Moyle (Clinical Matron) & Sarah Wonnacott (Ward Sister) September 2014 SBAR Tool & Content Adapted From: http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/sbar_-_situation_-_background_-_assessment_- _recommendation.html