SBAR AND EMR COMMUNICATION

TOOLSMaria Jensen, NPP, MPH, RNMarina Cecere, NPP, MPH, RN

Renee McLeod-Sordjan , DNP, FNP-BC, RN

Introduction

A review of reports from JACHO shows that communication failures to hand over effectively were implicated at the root of over 70 percent of sentinel events for hospitals and clinics to improve care.

Shendell-Falik, N., Feinson, M., & Mohr, B.J., (2007). Enhancing patient safety; Improving the patient handoff process though appreciative inquiry. The Journal of Nursing Administration, 37(2), 95-104.

Goals

National Patient Safety Goal 2: “Improve the effectiveness of communication among caregivers”.This addition requires hospitals to implement a standardized approach to hand-off communications and provide an opportunity for staff to ask and respond to questions about patient’s care.

Joint Commission on Accreditation of Healthcare Organizations: Sentinel Event Statistics-June30,2005. Retrieved

http://www.jcaho.org/accredited+organizations/sentinel+event/sentinel+eventsttistics.htm

Factors that contribute towards failure to identify & manage deteriorating patient.

Insufficient information, faulty exchanges of existing information

Ambiguous and unclear information Lack of timely and effective exchange of pertinent

information when alerting to concerns about patient condition

Ineffective communication and handover of medically or mentally compromised patients

Leonard, M., Graham, S., & Bonacum, D. (2004). The Human Factor. The Critical Importance of Effective Teamwork and Communication in Providing Safe Care. Quality and Safety in Health care 13 85-90

Where do things fall through the cracks?

Systems – Information, test results, diagnosis

Communication – handovers, transitions in care

Failure to plan, failure to recognize, failure to rescue

SBAR

Is a structured method for communicating critical information that requires immediate attention and action

Offers hospitals and care facilities a solution to bridge the gap in communication, including hand-off patient transfers

It creates a shared expectation between the sender and receiver of the information being shared

EMR

Minimize medicals errors by providing safety checks on prescription dosages, drug-to drug interactions, duplicate therapies, and a patient’s previous adverse reactions

Improves workflow and staff communication Track test results Reduce costs Improve health, and improve efficiency and

networking.

Hillestad, R., Bigelow, J., Bower, A., Girosi, F., Meili, R., Scoville, R., & Taylor, R., (2005).Can electronic medical record systems transform health care? Potential health benefits, savings, and cots. Health Affairs (Project Hope),24(5), 1103-1117. doi:10.1377/hlthaff.24.5.1103

Outcomes

SBAR (PSYCH) + EMR = ENHANCED COMMUNICATION AND NURSE

SATISFACTION

Current SBAR

SSITUATIONMy name is: __________________Speaking to RN_____________Unit/Area I am calling from:Patient’s NamePt.’s chief complaintWhat happened? Legal status 939 2PC Voluntary

BBACKGROUNDAdmission diagnosis and date of ERState the pertinent medical history:A brief synopsis of the treatment/medication given to date:

Vital signs are:UCG:____ Urine Tox._________ Results of LAB/ Diagnostics

AASSESSMENT/MMSE

SUICIDAL YES OR NO ____HOMICIDAL YES OR NO ________ EXPLAIN_______

AGITATION/AGGRESSION YES/NO______IMPULSE CONTROL_________

GROSS INPAIRMENT ADL’S YES/NO EXPLAIN ________

RRECOMMENDATION

Medication/Tests

 

Enhanced SBAR for Practice Improvement Project

SSITUATIONMy name is: __________________Speaking to RN_____________Unit/Area I am calling from:Patient’s NamePt.’s chief complaintWhat happened? Accepting PSYCHIATRY ________ Medical MD___________________Legal status 939 2PC Voluntary

BBACKGROUNDAdmission diagnosis and date of ERState the pertinent medical history: RESPIRATORY____CARDIAC______SKIN_____A brief synopsis of the treatment/medication given to date:FALLS POTENTIAL YES/NO_____ELOPMENT POTENTIAL______DIET_____Vital signs are:UCG:____ Urine Tox._____ Substance abuse history____ Last use_____ Results of LAB/ Diagnostics Tests/ACCU CHECK______ XR/MRI RESULTS________

AASSESSMENT/MMSE ALERT/ORIENTED TIME___PERSON ____PLACE___SITUATION_______ MOOD: Depressed___Anxious____Elated_____OTHER_____ AFFECT:Depressed___Anxious____Neutral_____Blunted_____Flat____OTHER------ THOUGHT PROCESS: Goal directed____ Tangential______FOI______OTHER___ DELUSIONS: ___ TYPE_____ HALLUCINATIONS:___________TYPE_________ SUICIDAL YES OR NO ____HOMICIDAL YES OR NO ________ EXPLAIN_______ AGITATION/AGGRESSION YES/NO______IMPULSE CONTROL_________ EXPLAIN______ IF YES, TIME OF MEDICATION GIVEN

_________ GROSS INPAIRMENT ADL’S YES/NO EXPLAIN ________

RRECOMMENDATION Medication/Tests/Txs. order to be given in the unit until P.E. rendered ___

Neuro checks____ F.S_____ Other______

 

Psychiatric Patient Admission Process

Decision to admit patient by ED

physician

Psychiatrist writes orders

ER nurse performs admission assessment

ER utilizes handoff communication

Psychiatry nurse receives mental status

info YesUtilizes SBAR to obtain

mental status examHandoff complete

No

Psychiatry nurse receives mental status

info

Receives direct information regarding patient behavior from

psychiatrist

Psychiatric Patient Admission Process Status Post Process

ED nurses use SBAR

Recruitment

ED Nurses and Psychiatric Nurses during admission process of psychiatric patients

Plan

EMR satisfaction survey

Focus Group

Nursing Education regarding SBAR

Implementation

Post- Survey & Evaluation

REFERENCE

Hillestad, R., Bigelow, J., Bower, A., Girosi, F., Meili, R., Scoville, R., & Taylor, R., (2005).Can electronic medical record systems transform health care? Potential health benefits, savings, and cots. Health Affairs (Project Hope),24(5), 1103-1117. doi:10.1377/hlthaff.24.5.1103

Joint Commission on Accreditation of Healthcare Organizations: Sentinel Event Statistics-June 30,2005. Retrievedhttp://www.jcaho.org/accredited+organizations/sentinel+event/sentinel+eventsttistics.htm Leonard, M., Graham, S., & Bonacum, D. (2004). The Human Factor. The Critical Importance of Effective Teamwork and Communication in Providing Safe Care. Quality and Safety in Health care 13 85-90

Shendell-Falik, N., Feinson, M., & Mohr, B.J., (2007). Enhancing patient safety; Improving the patient handoff process though appreciative inquiry. The Journal of Nursing Administration, 37(2), 95-104