By Greg Freeman
A nursing team at Methodist Hospital in San Antonio developed a new process for handing off patients from the ED to a telemetry unit that improved patient care and decreased the number of rapid responses for recent transfers.
The hospital uses the popular Situation, Background, Assessment, and Recommendation (SBAR) process to improve continuity of care in handoffs, but nurses thought there still was room for improvement, says Denise Schmittou, BSN, RN, clinical nurse coordinator.
The Institute for Healthcare Improvement (IHI) provides this summary1 of SBAR:
- Situation: A concise statement of the problem;
- Background: Pertinent and brief information related to the situation;
- Assessment: Analysis and considerations of options;
- Recommendation: Action requested/recommended.
“SBAR is an easy-to-remember, concrete mechanism useful for framing any conversation, especially critical ones, requiring a clinician’s immediate attention and action,” IHI noted.1 “It allows for an easy and focused way to set expectations for what will be communicated and how between members of the team, which is essential for developing teamwork and fostering a culture of patient safety.”
The adult ED at Methodist includes 30 monitored beds and 12 hallway beds, with an average annual census of 61,000. Many patients are transferred to the 6 South unit for telemetry using SBAR, but the nurses on both units recognized gaps in the process that sometimes resulted in rapid response calls. The insufficient handoffs created stress and dissatisfaction among the nurses, and the units did not have a good relationship, says David Neave, RN, clinical specialty educator. A little digging revealed SBAR was not working the way the ED nurses expected.
“When we send patients to different departments, the biggest issue is communication. We wanted to improve the process, so we started with one unit as a pilot, and we asked them what would be the best way for us to communicate with them,” Neave explains. “That opened the door for us to realize that SBAR was providing them with just too much information. No one was really reading the SBAR when it was printed.”
Too Much to Read
The ED nurses thought the unit nurses wanted as much information on the patient as possible, because SBAR and good handoff practices are intended to provide all information that might be relevant to the patient’s care, Neave says. The goal of such best practices usually is to ensure no critical information is overlooked, leading to an adverse event.
“We had to look at whether our SBAR had too much information. Usually, people think that’s a good thing because there’s no harm in knowing more about your patient. But when nurses are getting a patient, they don’t have time to sit down and read through forms for 10 or 15 minutes,” Neave says. “We realized they don’t need that much information from us. They’re like us in the ED, in that sometimes less information helps us get the patient situated.”
Neave, Schmittou, and other ED members met with the director, manager, and several nurses from the telemetry unit to discuss how the SBAR process could be improved. The ED nurses also observed the unit’s huddles, which helped them better understand what information was most important.
Observing the huddles also helped improve communication and teamwork by bringing people together face to face rather than only knowing each other by phone, Neave says.
The team revised the way they use SBAR to send less information to the unit. A significant amount of detail was removed from the format.
“The prior SBAR had every possible thing that was part of the chart, demographics, and everything you could put in about the patient,” Schmittou says. “They just wanted the basics like diagnosis, medical history, allergies — the most important things they needed to know to take care of the patient immediately.”
The number of rapid response calls for transferred patients dropped off significantly because vital information was not overlooked, Schmittou says.
The change resulted in fewer calls to the ED asking for information on a transferred patient. Usually, that information was in the original, longer SBAR format. But the unit nurses did not have time to search it and find the one thing they needed to know, so they would just call the ED and ask.
“With the shorter version, they didn’t have to try to dig through all the information about their address, their next of kin, where they lived when they were 12 years old, to find out what they’re allergic to and why they’re really here,” Schmittou says. “By providing only what they really needed to know, it improved communication between them and us. We became more of a team.”
Fewer follow-up calls from the unit helped take pressure off the busy ED staff, Neave says.
The nursing team spent a year revising the process, from the initial research through presenting the new format and educating staff on the changes. There also was a delay because the team had to involve the hospital’s IT department to revise programming required for entering SBAR information. The project was supported by the American Association of Critical-Care Nurses.
Everyone Loves Tacos
The project was promoted as “Let’s Taco Bout SBAR”2 to grab people’s attention — and because tacos are such a part of San Antonio culture. The team served tacos at all their meetings, which greatly improved participation.
“Everybody knows SBAR, and when you say you’re going to talk about SBAR, everyone gets this irked feeling because you hear about it so much,” Neave says. “It was a fun way to get people over that first feeling and to be willing to work on the issue.”
In conjunction with the shorter SBAR format, the team also implemented a new process for communicating transfers from the ED to the unit. The ED charge nurse texts the unit charge nurse to say the patient is coming and to watch for the SBAR and provides the transferring nurse’s phone number. The unit charge nurse responds with the name and phone number of the nurse receiving the patient.
“They initially were hesitant to provide the names. There were delays because they didn’t know right away who would be assigned the patient, so there was some pushback there. Even the ED nurses were saying they didn’t want to give people their phone numbers,” Schmittou says. “But then they realized it is much easier if they text you and have that direct line instead of you having to stop and take a phone call. They got over the initial resistance to that.”
Other units heard of the improved process with the telemetry unit and wanted the same experience. The SBAR changes were adopted more widely throughout the hospital. Schmittou and Neave say one of the best results of the initiative is the overall improvement in communication and teamwork between the ED and other hospital units.
“Before this pilot project, the ED and the telemetry unit weren’t exactly the best of friends,” Schmittou notes. “But by solving that problem and working more closely to understand their needs, that unit actually is one that we communicate best with now. It helped solve that little tug of war we had going on.”
- Institute for Healthcare Improvement. SBAR tool: Situation-Background-Assessment-Recommendation.
http://bit.ly/2daqZpm
- Kinger N, Neave D, Schmittou D, West C. Let’s Taco Bout SBAR. American Association of Critical-Care Nurses CSI Project.
https://bit.ly/3Q8mQns
