Use this SBAR report for ED trauma handoffs
ED nurses at the University of California Medical Center — Irvine use a protocol for handoffs that involves giving verbal reports to the accepting unit using the SBAR (Situation-Background-Assessment-Recommendation) format. Sanna K. Henzi, RN, MSN, trauma injury prevention coordinator, gives this example of an incomplete report:
"I am calling report on John Doe. He is a 40-year-old male that was in an accident today. Everything is negative, and vital signs are stable. Labs were done."
Here, Henzi gives an example of a more complete report in the SBAR format:
"Hi, this is Nurse H and I am calling report on John Doe. He is a 40-year-old male who was involved in a motor vehicle accident. He was a restrained passenger who was rear-ended by another car going approximately 45 mph. He has no medical history and takes no medications at home. He has no allergies. His primary physician is Dr. Johnson. He has been awake, alert, and oriented with a Glasgow Coma Score of 15 since arrival. He is moving all extremities and has good strength bilaterally. His chief complaint is neck pain, rated a 5 out of 10, and he remains in cervical-spine precautions until the trauma team clears him. He is to be kept NPO until cleared by the trauma team as well. CT scans have been completed of the head, cervical spine, chest, abdomen, and pelvis. We are pending reports from radiology. Last vital signs, 15 minutes ago, were temperature 36.6, pulse 80, respiratory rate 14, and blood pressure 120/80. Lung sounds are clear. The abdomen is soft and non-tender. The patient has two largebore IVs. The Right AC 18 gauge with 1 liter Lactated Ringers at TKO. The left AC has been saline locked. The patient received fentanyl 50 mcg slow IVP, and stated relief, with pain now 1 out of 10. The family is at the bedside, and the patient remains in good spirits. The patient is able to urinate into a urinal with assistance. A specimen was sent. Trauma labs were sent. Hemoglobin was 13.5, alcohol was negative, and tox screen negative. Skin is warm, dry, and intact. The patient is to be admitted for observation and clearance of cervical spine. Do you have any questions? Thanks, I will see you when I bring the patient upstairs."
Sources
For more information on assessment of patients involved in motor vehicle accidents, contact:
- Cam Brandt, RN, MS, CEN, CPN, Educator, Emergency Services Educator, Cook Children's Health Care System, Fort Worth, TX. Phone: (682) 885-1402. Fax: (682) 885-7499. E-mail: [email protected].
- Sanna K. Henzi, RN, MSN, Trauma Injury Prevention Coordinator, University of California, Irvine Medical Center. Phone: (714) 456-7417. Fax: (714) 456-7245. E-mail: [email protected].
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content