- Introduction and Purpose
- Human Factors are responsible for a high number of preventable accidents in Anesthesia practice. It is important that procedures insure the successful transfer of patient care information to different providers for various reasons such as: breaks, meals, and shift changes (Wright, 2013). An ineffective handover programs impacts patient care negatively, due to avoidable error resulting from lack of, or incorrect communications (Klim, et al, 2013)
- Practitioners agree that appropriate handover procedures are usually clinical decisions decided at the bed side (Klim, et al, 2013). Errors can likely be avoided if procedures are set in place that standardize the process, yet remains responsive to adapting situations (Wright, 2013).
- Currently there are many initiatives to improve handoff and subsequently patient outcomes (Donnelly, Clauser, Weisman, (2012).
- Commonly, practitioners use e-mail to convey critical care information (Donnelly, Clauser, Weisman, (2012).
- Failure to include detailed patient information and anticipatory guidance is the greatest problem (Flemming, Hübner, 2013)
- Standardizing hand-off notes and presentations improves recall and retention of patient details (Mitchell, et al, 2013)
- Situation-Background-Assessment-Recommendation (SBAR) is a commonly used model for standardizing hand-off care (Tews, Liu, Treat, 2012)
- Technique allows for fast communication of relevant data and was developed by the navy.
- Adapted by Kaiser Permanente for health care use.
- SBAR has been very successful and is fast being disseminated through various departments at many hospitals.
- Implementing SBAR methodology during care hand-off procedures will decrease the rate of avoidable errors.
- Needs Assessment
- The current state of affairs
- Medical errors are stressful for both the practitioner and patient (Stangierski, et al, 2012).
- Medical errors and resultant adverse conditions may lead to up to ninety-eight thousand deaths per year (Kels, Grant-Kels, 2012).
- Different hospital systems employ different systems using either SBAR, or PATIENT acronyms as models, with various implementations of electronic health records for managing hand-off patient care.
- What should be current
- Medical and surgical departments should standardize hand-off reports of patients.
- Practitioners should be using applications on hand held devices based on the SBAR protocols for creating a centralized, standard hand off report that anyone involved in the patient’s care can review.
- Lower rates of medical errors leading to adverse events due to a lack of communication between practitioners managing a patient.
- Information needed
- Rates of medical errors that occur purely as a result of hand-off error, such as: incomplete or lack of communication of relevant patient data, problems to be anticipated with the patient, confusion regarding the information from the hand off.
- Sufficient experience with SBAR and the prompts that prove to be the most effective for practitioners when a patient is being handed over to them.
- List of hospitals that currently use SBAR as their standardized patient hand-off report and results of implementation.
- Information regarding hand-held devices that would potentially be used to transmit and display the relevant information.
- Application developers that would be able to make a front-end and back-end for an application that would be based on SBAR protocols.
- Qualitative information regarding the ease of use of such an application and the experience of the practitioner-user.
- Methodology
- Intervention
- Implementation of a hand-held-device-based system that would walk practitioners through entering information on SBAR prompts and then read by other practitioners when hand-off occurs.
- Target Population
- Hospitalized patients that remain hospitalized through breaks, meals, and shift changes, and thus will not be continuously cared for by the same practitioner from entry to exit from the health care facility.
- Settings
- In-patient hospital department with high turnover of personnel during the course of a day, such as a surgery or anesthesia department.
- Variables
- Independent Variables
- Patient pathology and department admission
- Hand-off protocols used
- Dependent Variables
- Rate of medical errors leading to adverse events
- Proximal cause of death of inpatient’s
- Outcome Measures and Evaluation Plan
- Randomized interventional case control study
- Intervention: practitioner use of hand held hand off reporting in care of the patient
- Controls: practitioners use current system for conducting hand-off of patient care
- Quantitative Data
- Rates of adverse events
- Time spent conducting hand off
- Qualitative Data
- Practitioner perception of ease of use of the hand-off system
- Instruments
- Hand held devices with application based on SBAR protocols.
- Informatics infrastructure appropriate for sharing data acquired by the hand-held device and displaying it to interested parties.
- Data compiled in appropriate format to be utilized by interpretive software such as SAS, SPSS, or STATA.
- Work Plan
- Construct an application based on the SBAR protocols that can be used on common hand held devices.
- Construct appropriate back-end processes
- Conduct controlled intervention
- Determine the rate that medical error that lead to adverse patient effects as a result of poor communication between practitioners.
- Control for degree of patient morbidity and co-morbidities (patient with traumatic crush injuries is more likely to die than patient with uncomplicated pneumonia)
- Determine the rate that medical error that lead to adverse patient effects
- Control for degree of patient morbidity and co-morbidities (patient with traumatic crush injuries is more likely to die than patient with uncomplicated pneumonia)
- Dissemination of Results
- New England Journal of Medicine
- PLOS One
- Resolution of Challenges
- Must resolve whether application exists for patient hand-off that is based on SBAR protocols, or if one needs to be developed. This can be done with research and outsourcing.
- No further challenges have been identified at this stage.
Works Cited:
Donnelly, M.J., Clauser, J.M., Weissman, N.J. (2012). An intervention to improve
ambulatory care handoffs at the end of residency. J Grad Med Educ., 4(3), 381-384. doi: 10.4300/JGME-D-11-00233.1
Flemming, D., Hübner, U. (2013). How to improve change of shift handovers and
collaborative grounding and what role does the electronic patient record system play? Results of a systematic literature review. Int J Med Inform., 82(7), 580-592. doi: 10.1016/j.ijmedinf.2013.03.004.
Klim, S., et al. (2013). Developing a framework for nursing handover in the emergency
Mitchell, E.L., et al. (2013). Improving the quality of the surgical morbidity and mortality
conference: a prospective intervention study. Acad Med., 88(6). 824-830. doi: 10.1097/ACM.0b013e31828f87fe.
Stangierski, A., et al. (2012). Medical errors – not only patients’ problem. Arch Med Sci.,
8(3). 569-574. doi: 10.5114/aoms.2012.29413.
Tews, M.C., Liu, J.M., Treat, R. (2012). Situation-Background-Assessment-
Recommendation (SBAR) and Emergency Medicine Residents' Learning of Case Presentation Skills. J Grad Med Educ., 4(3), 370-373. doi: 10.4300/JGME-D-11-00194.1.
Wright, S.M. (2013). Examining Transfer of Care Processes in Nurse Anesthesia
Practice: Introducing the PATIENT Protocol. AANA J., 81(3). 225-32.
References not cited in outline:
Cornell, P., et al. (2013). Improving shift report focus and consistency with the situation,
background, assessment, recommendation protocol. J Nurs Adm., 43(7-8), 422-
428. doi: 10.1097/NNA.0b013e31829d6303
[This study evaluated the efficacy of SBAR in improving shift reports. It concluded that as a result of the implementation of SBAR that reports were more focused and more time was spent discussing the patient as opposed to physical task of writing information.]
De Meester, K., et al. (2013). SBAR improves nurse-physician communication and
reduces unexpected death: A pre and post intervention study. Resuscitation, 84(9), 1192-1196. doi: 10.1016/j.resuscitation.2013.03.016.
[This study sought to evaluate the effectiveness of SBAR on the incidence of adverse events in the hospital. After SBAR was implemented in the wards, the perception amongst practitioners was an increase in communication, an increase in admissions to the Intensive Care Unit, and ultimately a decreased in the rates of unexpected death.]
Hickey, A., Gleeson, M., Kellett, J. (2012). READS: the rapid electronic assessment
documentation system. Br J Nurs., 21(22), 1333-1336, 1338-1340.
[This is a review of an electronic health records system that is based on the SBAR protocols. Print outs produce properly formatted reports and average recording time was 6.6 minutes. Pain presentation was the fastest to be entered, whereas altered mental status and reduced mobility complaints took the longest to enter into the computer. The program measures workload, and provides a platform for easy sharing of data.]
Kesen, K.S. (2011). Role-play using SBAR technique to improve observed
communication skills in senior nursing students. J Nurs Educ., 50(2), 79-87. doi: 10.3928/01484834-20101230-02.
[Study reviewed data from undergraduate nursing students using the SBAR protocols. Students who did role-playing games with the SBAR protocols had significantly higher communication scores than students who did not use role-play in the learning environment.]
Vardaman, J.M., et al. (2012). Beyond communication: the role of standardized protocols
in a changing health care environment. Health Care Manage Rev., 37(1), 88-97. doi: 10.1097/HMR.0b013e31821fa503.
[SBAR is more than just a tool that standardizes communication, but rather it allows the practitioners to develop schema that accelerates nurse decision-making. It also aids in providing legitimacy for younger nurses, and reinforces standardization of procedures.]
Renz, S.M., et al. (2013). Examining the feasibility and utility of an SBAR protocol in
long-term care. Geriatr Nurs., 34(4), 295-301. doi: 10.1016/j.gerinurse.2013.04.010.
[Evaluation of the SBAR protocol on communications between physicians and nurses using pre and posttest questionnaires. Nurses complained that the time to complete the protocols was too long, whereas physician satisfaction was high. Despite the nurses complaints, study findings support the use of SBAR for full documentation within time constraints.]
