Une communicationefficaceet effective entreles ... · 30/05/17 1 Une communicationefficaceet effective entreles prestatairesde soins: SBAR Filip Haegdorens, PhD student Universiteit

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Unecommunication efficace eteffectiveentre lesprestataires desoins:SBAR

FilipHaegdorens,PhDstudentUniversiteitAntwerpenMarieMisselyn,verpleegkundigecardiochirurgieUZA

DISCUSSION

Danslapratique:

Pouvez vous donner l’exemple d’unproblème concret auseindevotreorganisation où lacommunication ajouéun rôle principal?

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Environnement àhaut risque

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Gestion durisque

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Déclaration

‘‘Un séjour dansun hôpital estpotentiellement mortel’

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TheInstitute ofMedicine (USA)

2000 2001

‘To err ishuman’

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• 44.000à98.000patientsdécèdentchaqueannéedansleshôpitauxaméricainsàcaused’erreursévitables

• Typesd’erreurs:- Communication- Diagnostic- Traitement- Prévention

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†43.458 †42.297 †16.516

44.000 à 98.000 patients décèdent chaqueannée dans les hôpitaux américains à caused’erreurs évitables44.000 à 98.000 patients 4.000 à 98.000

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Quels dangers représentent les soinsde santé?

• Une plusgrandeattentionpourlasécuritéaviation >soins desanté

• Quelle est l’expérience desgens danslesecteur dessoins desanté?- Sécurité principalement satisfaisante(7/10)

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Crossingthequality chasm

Gouffre (chasm)entre laréalité etce quereprésentent dessoins desantéoptimaux

Nous nepouvons plusattendreConnaissances médicales=enpleindéveloppement Qualité dessoins≠assurée

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Erreurs évitables dans domaine des Soins de santé sont dues aux lacunes de l’organisation, non pas de l’individuDomaine des Soins de santé = complexe

à Essayer d’éviter les erreurs n’apporte pas de solution. Mieux vaut adapter l’organisationdes Soins de santé…

Erreurs évitables à lésions ou décès

§ Lésions évitables§ Décès évitables

“Il y a beaucoup de chances que chaque soignanty ait déjà été confronté “

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Adverseevent

Lésion nonintentionnelle ou complication causée parlesoignant ou le système desoins

1. Invalidité àlasortie2. Décès3. Prolongement deladurée

d’admission

Problème international

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Pays Bas

4,1%detous lespatients décédés=décès évitablesàAnnuellement1482–2032patients

Belgique

23%detous lespatients en2000à secours =échec(failureto rescue)

Erreurs évitables=“Adverseevents”:Médicales:7,1%Chirurgicales:6,3%

Ladifférence entre hôpitaux est +++

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Belgique

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Critical Care Medicine www.ccmjournal.org 1053

Objective: The objectives of this study are to determine the preva-lence and preventability of adverse events requiring an unplanned higher level of care, defined as an unplanned transfer to the ICU or an in-hospital medical emergency team intervention, and to assess the type and the level of harm of each adverse event.Design: A three-stage retrospective review process of screening, record review, and consensus judgment was performed.Setting: Six Belgian acute hospitals.

Patients: During a 6-month period, all patients with an unplanned need for a higher level of care were selected.Interventions: The records 6-month period, the records of all patients with an unplanned need for a higher level of care were assessed by a trained clinical team consisting of a research nurse, a physician, and a clinical pharmacist.Measurements and Main Results: Adverse events were found in 465 of the 830 reviewed patient records (56%). Of these, 215 (46%) were highly preventable. The overall incidence rate of patients being transferred to a higher level of care involving an adverse event was 117.6 (95% CI, 106.9–128.3) per 100,000 patient days at risk, of which 54.4 (95% CI, 47.15–61.65) per 100,000 patient days at risk involving a highly preventable adverse event. This means that 25.9% of all unplanned transfers to a higher level of care were associated with a highly preventable adverse event. The adverse events were mainly associated with drug therapy (25.6%), surgery (23.7%), diag-nosis (12.4%), and system issues (12.4%). The level of harm varied from temporary harm (55.7%) to long-term or permanent impairment (19.1%) and death (25.2%). Although the direct causality is often hard to prove, it is reasonable to consider these adverse events as a contributing factor.Conclusion: Adverse events were found in 56% of the reviewed records, of which almost half were considered highly preventable. This means that one fourth of all unplanned transfers to a higher level of care were associated with a highly preventable adverse event. (Crit Care Med 2015; 43:1053–1061)Key Words: adverse events; intensive care unit; medical emergency team; patient safety; record review; unplanned intensive care admission

Adverse events (AEs) are a world-wide concern for health-care professionals, policy makers, and patients. An AE is 1) an unintended injury or complication, which results

in 2) disability at discharge, death, or prolongation of hospital

Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. This is an open access article dis-tributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.DOI: 10.1097/CCM.0000000000000932

1Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.

2Antwerp Management School, Health Care Management, Antwerp, Belgium.

3Vzw Jessa ziekenhuis, Hasselt, Belgium.4Ziekenhuis Oost Limburg, Genk, Belgium.5Algemeen Ziekenhuis Turnhout, Turnhout, Belgium.6Center for Health Services and Nursing Research, Catholic University Leuven, Belgium.

Ms. Marquet prepared the study, conducted the pilot and the multicenter study, and analyzed and interpreted the data. She is the article’s guarantor. Ms. Marquet, Mr. Droogmans, and Dr. Kox were the members of the clinical team. Dr. Schrooten performed the sample size calculation and gave advice in work-ing with Open Clinica and the statistical programs. Dr. Claes, Ms. De Troy, Dr. Weekers, Dr. Vandersteen, dr. Vlayen, Dr. Schrooten, and Dr. Vleugels made critical revisions to the article for important intellectual content. Dr. Vleugels was the initiator of the project. All authors read and approved the final article.Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).Supported, in part, by Limburg Sterk Merk (LSM), Hasselt, Belgium. LSM is a foundation of public use that supports healthcare and economic develop-ment projects.The authors’ institutions received grant support from LSM.For information regarding this article, E-mail: [email protected] or [email protected]

One Fourth of Unplanned Transfers to a Higher Level of Care Are Associated With a Highly Preventable Adverse Event: A Patient Record Review in Six Belgian Hospitals

Kristel Marquet, RN, MSc, PhD student1; Neree Claes, MD, PhD, eMBA1,2; Elke De Troy, MSc3; Gaby Kox, MD1; Martijn Droogmans, MSc1,3; Ward Schrooten, MD, PhD1,4; Frank Weekers, MD, PhD5; Annemie Vlayen, MSc, PhD; Marjan Vandersteen, MD, PhD1; Arthur Vleugels, MD, PhD1,6

Clinical Investigations


Preventability of the AEsThe reviewers considered 215 AEs (46%) to be highly prevent-able AEs; 209 AEs (44.6%) and 44 AEs (9.4%) were considered low or not preventable, respectively (Fig. 1). This means that 215 of the unplanned transfers (25.9%) to a higher level of care were related to a highly preventable AE. The overall incidence rate of highly preventable AEs requiring a higher level of care was 54.4 (95% CI, 47.15–61.65) per 100,000 patients days at risk.

Type of the AEsThe AEs were mainly associated with drug therapy (n = 134, 25.6%), surgery (n = 124, 23.7%), diagnosis (n = 65, 12.4%), system issues (n = 65, 12.4%), and procedural (n = 49, 9.4%) (Table 3). The drug-related AEs were mainly associated with antibiotics and antithrombotic agents.

OutcomesAll the observed AEs required a higher level of care. This has important implications for the patients and their relatives. The severity of the harm, however, varied. A redo or additional sur-gery was necessary for 110 patients with an AE(s) (23.7%). Over-all, 259 AEs (55.7%) resulted in temporary harm with a complete recovery expected within 12 months, while 89 AEs (19.1%) caused long-term or permanent impairment or resulted in per-manent institutional or nursing care. The all-cause mortality rate of the patients with an AE was 25.2% (117 of 465 patients).

Nevertheless, in the group of patients without the detection of an AE, also 28.7% of the patients died. The majority of these patients had multiple comorbidities and polypharmacy.

In this study, the causality of the mortality was not dis-cussed. However, in the group of patients with an unplanned transfer to higher level of care, 243 died, 98.4% of these deceased patients had no preexisting do-not-resuscitate order; 117 (48.1%) had an AE of which 62 (51.7%) were highly pre-ventable. Therefore, 25.5% of the deceased patients (62 of 243) suffered from a highly preventable AE.

The mean ICU LOS of patients with a highly preventable AE was 6.20 ± 7.3 days and had a median ICU LOS of 3.5 days (Q1–Q3, 2–8 d). The total ICU LOS of patients who had an UIA and a highly preventable AE was 1,166 days (5.64% of the total LOS ICU). Upon discharge, 301 patients with an AE went back to the original home situation (64.7%), and 47 patients (10.1%) required a different type of care than before the admission (transfer to another [university] hospital, rehabilitation center, nursing home). One hundred seventeen patients (25.2%) died during the hospitalization. Within 1, 3, and 6 months, respec-tively, 68 (19.6%), 105 (30.1%), and 131 (37.6%) of the surviv-ing patients with an AE had a readmission in the same hospital.

DISCUSSIONThe overall incidence of AEs requiring an unplanned higher level of care was 117.6 per 100,000 patient days at risk. A higher level of

Figure 1. Overview of the inclusion and review process of patients with an unplanned transfer to a higher level of care during a 6-month period. AE = adverse events, MET = medical emergency team.


Objective: The objectives of this study are to determine the preva-lence and preventability of adverse events requiring an unplanned higher level of care, defined as an unplanned transfer to the ICU or an in-hospital medical emergency team intervention, and to assess the type and the level of harm of each adverse event.Design: A three-stage retrospective review process of screening, record review, and consensus judgment was performed.Setting: Six Belgian acute hospitals.

Patients: During a 6-month period, all patients with an unplanned need for a higher level of care were selected.Interventions: The records 6-month period, the records of all patients with an unplanned need for a higher level of care were assessed by a trained clinical team consisting of a research nurse, a physician, and a clinical pharmacist.Measurements and Main Results: Adverse events were found in 465 of the 830 reviewed patient records (56%). Of these, 215 (46%) were highly preventable. The overall incidence rate of patients being transferred to a higher level of care involving an adverse event was 117.6 (95% CI, 106.9–128.3) per 100,000 patient days at risk, of which 54.4 (95% CI, 47.15–61.65) per 100,000 patient days at risk involving a highly preventable adverse event. This means that 25.9% of all unplanned transfers to a higher level of care were associated with a highly preventable adverse event. The adverse events were mainly associated with drug therapy (25.6%), surgery (23.7%), diag-nosis (12.4%), and system issues (12.4%). The level of harm varied from temporary harm (55.7%) to long-term or permanent impairment (19.1%) and death (25.2%). Although the direct causality is often hard to prove, it is reasonable to consider these adverse events as a contributing factor.Conclusion: Adverse events were found in 56% of the reviewed records, of which almost half were considered highly preventable. This means that one fourth of all unplanned transfers to a higher level of care were associated with a highly preventable adverse event. (Crit Care Med 2015; 43:1053–1061)Key Words: adverse events; intensive care unit; medical emergency team; patient safety; record review; unplanned intensive care admission

Adverse events (AEs) are a world-wide concern for health-care professionals, policy makers, and patients. An AE is 1) an unintended injury or complication, which results

in 2) disability at discharge, death, or prolongation of hospital

Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. This is an open access article dis-tributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.DOI: 10.1097/CCM.0000000000000932

1Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.

2Antwerp Management School, Health Care Management, Antwerp, Belgium.

3Vzw Jessa ziekenhuis, Hasselt, Belgium.4Ziekenhuis Oost Limburg, Genk, Belgium.5Algemeen Ziekenhuis Turnhout, Turnhout, Belgium.6Center for Health Services and Nursing Research, Catholic University Leuven, Belgium.

Ms. Marquet prepared the study, conducted the pilot and the multicenter study, and analyzed and interpreted the data. She is the article’s guarantor. Ms. Marquet, Mr. Droogmans, and Dr. Kox were the members of the clinical team. Dr. Schrooten performed the sample size calculation and gave advice in work-ing with Open Clinica and the statistical programs. Dr. Claes, Ms. De Troy, Dr. Weekers, Dr. Vandersteen, dr. Vlayen, Dr. Schrooten, and Dr. Vleugels made critical revisions to the article for important intellectual content. Dr. Vleugels was the initiator of the project. All authors read and approved the final article.Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).Supported, in part, by Limburg Sterk Merk (LSM), Hasselt, Belgium. LSM is a foundation of public use that supports healthcare and economic develop-ment projects.The authors’ institutions received grant support from LSM.For information regarding this article, E-mail: [email protected] or [email protected]

One Fourth of Unplanned Transfers to a Higher Level of Care Are Associated With a Highly Preventable Adverse Event: A Patient Record Review in Six Belgian Hospitals

Kristel Marquet, RN, MSc, PhD student1; Neree Claes, MD, PhD, eMBA1,2; Elke De Troy, MSc3; Gaby Kox, MD1; Martijn Droogmans, MSc1,3; Ward Schrooten, MD, PhD1,4; Frank Weekers, MD, PhD5; Annemie Vlayen, MSc, PhD; Marjan Vandersteen, MD, PhD1; Arthur Vleugels, MD, PhD1,6

Belgique

Patients postoperatifs (6 jours)§ 8 sur 1000 décès inattendus§ 6 % réintervention urgente imprévuePatients médicaux et chirurgicaux§ 3 sur 1000 arrêt cardiaque pour lequel SMUR interne§ 13 sur 1000 transfert Soins Intensifs imprévu(SI)

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België– recentonderzoek

Medischenchirurgischepatiënten

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Table 3: Patient characteristics, clinical confounders and crude outcomes

Control Intervention p

Patient characteristics

Patient admissions 34,267 35,389

Age (mean, SD) 58.9 (18.6) 59.9 (18.2) 0.165#

Males (%) 49.0 51.0 0.268*

Reason for admission: medical (%) 52.3 47.7 0.419*

Clinical confounders

Charlson Comorbidity Index (mean, SD) 1.44 (1.0) 1.59 (1.1) <0.001#

Nursing Hours Per Patient Day (mean, SD) 2.49 (0.6) 2.75 (0.7) <0.001#

Crude outcome indicators §

Ward mortality 12.5 12.8 0.156*

Ward mortality without DNR code 7.3 7.2 0.055#

Hospital mortality (72h after discharge from the ward) 13.7 14.1 0.170*

Resuscitation team calls 2.7 2.2 0.556*

All transfers to the ICU 10.4 20.1 0.819*

* Generalised Linear Mixed Model (GLMM), # Linear Mixed Model (LMM), § rate per 1000 admissions (Generalised) Linear Mixed Model adjusted for clustering (ward) and study time (period) SD: standard deviation, DNR: Do Not Resuscitate, ICU: Intensive Care Unit



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Age (mean, SD) 58.9 (18.6) 59.9 (18.2) 0.165#

Males (%) 49.0 51.0 0.268*












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Age (mean, SD) 58.9 (18.6) 59.9 (18.2) 0.165#

Males (%) 49.0 51.0 0.268*












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Table 4: Primary outcomes

control rate per 1000

admissions (n)

intervention rate per 1000

admissions (n) ICC model 1

OR (95% CI) model 2

PD/OR (95% CI) Unexpected

death 1.5 (52) 0.7 (23) 0.0720 0.82 (0.34-1.95)

-0.00023 (-0.00128-0.00083) §

Cardiac arrest with

CPR 1.3 (46) 1.0 (35) 0.1281 0.71

(0.33-1.52) 0.54

(0.18-1.64)

Unplanned ICU

admission 6.5 (224) 10.3 (363) 0.0468 1.23

(0.91-1.65) 1.24

(0.84-1.83)

- ICC: intraclass correlation coefficient - model 1: Generalised Linear Mixed Model (odds ratio) adjusted for clustering (ward) and study time (period) - model 2: Generalised Linear Mixed Model (odds ratio) adjusted for clustering (ward), study time (period), CCI and NHPPD - model 2 §: Linear Mixed Model (proportional difference) adjusted for clustering (ward), study time (period), CCI and NHPPD - OR: odds ratio - PD: proportional difference (intervention effect)

Belgique

Extrapolation données RHM 2000:

§ 2487 décès inattendus (6ième jour postop)§ 2155 appels SMUR interne pour arrêt cardiaque§ 10 776 transferts imprévus soins intensifs (SI)

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Belgique

Tous les jours:

§ 7 décès inattendus (6ième jour postop)§ 6 appels SMUR interne pour arrêt cardiaque§ 30 transferts imprévus Soins Intensifs(SI)

D’où vient le problème?

Chaque jour,deshumains meurent demanière imprévuedansnos hôpitaux

84%detous lespatients enarrêtcardiaque présentent dessignes dedétérioration précoce

Hillman etal,2001

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D’où vient le problème?

Un arrêt cardiaque à l’hôpital est souvent lerésultat de nombreuses heures voire de jours de détérioration

àRCP(Réanim. CardioPulm.) = ensuite inefficace

Dans 54% des cas les soins ne sont pas optimaux avant un transfert aux SoinsIntensifs(SI)

Konrad,2010|McQuillan etal,1998

Quelles sont lescauses?

3domaines

1. Observations insuffisantes

2. Détérioration nonreconnue

3. Assistancemédicale retardée

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NationalPatient SafetyAgency,2007

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Quelles sont lescauses?

3domaines

1. Observations insuffisantes

2. Détérioration nonreconnue

3. Assistancemédicale retardée

àcommunication suboptimaleentre lesprestataires desoins

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Communicationsecteur dessoins desanté

Problèmes danslacommunication dans:

2/3detous lesévènements sérieux

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Streetetal,2011|Haig etal,2006

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Communicationdanslessoins desanté

TheJointCommission

à lamauvaise communication est laprincipalecause dedommages aupatient

à une communication efficace faitladifférence entre lavieetlamort

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TheJointCommission,2016

Communicationurgentevs.non urgente

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Communicationurgente

• Détérioration clinique dupatient• Peu detemps• Souvent interdisciplinaire• Adaptationrapide detherapie

à Communiquer defaçon complète maisconcise estessentiel!

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Dommage

Temps

Risque

Correctionproblème

Problèmerésolu

DébutdommageStart

évènement

Detection

Diagnostic


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à Frustration quand déclin état patient :“quand le médecin arrive t’il?”

Communiquer defaçon correcte=facteurclef pourassistancemédicale rapide!

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Sur le terrain …

l’infirmière expérimentée

“Il faut debonnescompétences encommunication etun peud’assertivité pourdire aumédecin ce qui sepasse.Pourmoi c’estindispensable,deplus,jepersévère jusqu’à ce quej’aiun planpouraider monpatient.”

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Infirmiers débutants

“Jenemesentais passoutenu etj’ai l’impression quejedevaisfairefaceseul àlasituation.”“Audébut j’étais enpeu enpanique maisquand le médecinétait là cela apassétrès vite.”

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Communicationnonurgente

• Briefing/Rapport• Moyenne.20min• Intradisciplinaire

Rapportineffectif entre soignants aun impacténorme surlasécurité dupatient

à Rapportbref =perted’informationà Rapportlong=nonstructuré etconfus

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Haig etal,2006

Communicationnonurgente

• 10-15%journée detravail =briefing

• Durée dubriefingdépend de:- Nombre patients- Turnover- Degré d’attention- Population patients (connus vs pasconnus)

à Utilisation croissante d’interims/pool d’infirmiers =population moins connue

à Impactsur communication etsécurité ?

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Streetetal,2010

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Problèmes liés àlacommunication

Quelles sont lescauses possibles

41

Problèmes liés àlacommunication

• Variation dustyle decommunication• Inconsistence entre briefingetréalité• Manque detemps• Distraction etéléments dérangeants• Informationspéculative,sansintérêt etrépétitive

à Enormepotentiel engendrant l’erreur!

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Novak etal,2012

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Standardisation

Aviation,marine,aérospatial,ect.à situations complexes

- Chaque membre del’équipe=aussi importante!- Moments transition sont dangereux- Systèmes etaccords préviennent leserreursà Utilisent communication standardisée

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Standardisation

Soins desanté=complexes,haut-risques

Modèle classique• Hiérarchiqueàmédecin =décide,infirmier exécute• Expertsindividuels• Nonréfléchi /pasdesystème

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Standardisation

Adoptionsystèmes d’autres secteurs aux soins desanté

“Simplerules arebestfor managingcomplexenvironments”

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Leonardetal,2004

SBAR

• Situation• Background• Assessment• Recommendation

46

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SBAR

Issu àl’origine del’USNAVYà sous-marins nucléaires

“Une méthode standardisée qui aidelessoignants àcommuniquer defaçon structurée ”

Indépendamment de:- Assertivité/personalité- Niveaudeformation- Styledecommunication

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SBAR

à Créer“modèle mental”commun dansun environnementsécurisant (nonpunitif)

“tous sur lamême ligne“

Batir un pontentremédecins etinfirmiers …

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Infirmiers vs.médecins

Infirmierà plutôt narratif,récit étenduMédecinà plutôt to-the-point

Infirmier médecin

Pasdediagnostic Cherche àsavoirce qui sepasse

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SBARexemple

I IdentificationS SituationB BackgroundA AssessmentR RecommendationR Readback

50

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- Identifiez vous ainsi que votre patientetvotre unité

“Allo,vous parlez à Marieduservicedesurgences,jevous appelle ausujet deMr.Dupont enchambre 4auxurgences ”

1. Identification

(Que sepasse t’il?Situationactuelle)

- - diagnostic,interventionchirurgicale- Statut DNR

- - Médecin traitant- Quels sont lesfaits?

2. Situation

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(Que sepasse t’il?)

“Ilressent une pression sur lapoitrine depuis 10minutes”

2. Situation

(Eléments essentiels dupasséconcernant lepatientjusqu’à présent)

- - Antécédents médicaux- - Motifd’admission- - Traitement actuel/diagnostic- - Médicaments

3. Background– Contexte

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(Eléments essentiels dupasséconcernant lepatientjusqu’à présent)

“Cepatientest entré à 13havecdesdouleurs épigastriques etdesvomissements.J’ai faitune prise desangetil aune ligne IVavec1lNacl /24h.Ilaégalement reçu une dosedeLitican.Il neprend pasdemédicaments etn’a pasd’antécédents médicaux ”

3. Background– Contexte

(Que pensez vous delasituation)

- Paramètres- Etat clinique- Testssupplémentaires- Sentimentd’insécurité- Problème primaire

4. Assessment– Evaluation

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(Que pensez vous delasituation)

“Ence momentil adel’hypotension (90/44)etaunpouls élevé (109)avecunNEWSde5etunrisqueclinique moyen.Ilseplaintdd’essouflement etesttrès pâle.Sasaturationest bonne,98%.Jepense quec’est d’ordre cardiologique ”

4. Assessment– Evaluation

(Que voulez vous?)

- Assistance du médecin- Adaptation de la thérapie- Diagnostic- Avis statut DNR

5. Recommendation

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(Que voulez vous?)

“Jevoudrais que vous veniez voir dès que possible.J’ai unmauvais pressentiment.Est ce que jeprends unECG?”

5. Recommendation

60

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6. Readback- Répétition

à Répétition del’ordre

“Donc jeprends un électrocardiogramme etjemetslepatient sousmonitoring“

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SBAR

• Une structure connue etprévisible• Brève maiseffective

à Réfléchir sur le problème etsur une solutionpossibleavant decommuniquer

62

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Façon decommuniquer

EnplusdeSBARlafaçon decommuniquer est égalementimportantedansune situation critique

Voudriezvousvenirvoirmon...

Jedésire quevous veniez voir mon…

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Assertivité adéquate

- Polie maisdéterminée- Soutenue parl’organisation(accords)- Lesinfirmiers peuvent dire:“Jedésire quevous veniez

voir le patient maintenant ”

- Pasde“hint&hope”-->parler defaçon indirecte=ineffectif

- Donnerun argumentconcret pourquoi- Pasdediscussion (situation d’urgence)

64

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Assertivité adéquate

65

Leonardetal,2004

Assessment

Créez le cadre nécessaire afin quel’infirmier puisse dire:

“Jenesais pasexactement ce qui sepasseavec ce patientmaisj’ai besoin d’aide médicale“

à Attention,toujours combinéavec SBAR(informationconcrète sur l’état général)

66

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Quand SBAR?

Passeulement poursituations urgentes.

à Briefing(oral /écrit)

- Bref- Complet- Pasd’information superflue- Chaque collègue attend cette structure

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Safetybriefing

Partage d’information crucialepourtous lescollèguesavant le briefingindividuel de1à1

But:à Eviter perted’information qui doit êtreconnuedetous

etdonner apercu rapide despatients àrisque

Exemples contenu Safetybriefing: risque dechutes,nomsidentiques,troubles dedéglutition ,àjeûn,dépendent d’unpacemakerexterne,diabétique,comportement defuite,délire,fixation,surveillanceaigue,infidèle àlathérapie,…

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Pauze– 20min

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71

72

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Effet sur laqualité dessoins

73

Please cite this article in press as: De Meester K, et al. SBAR improves nurse–physician communication and reduces unexpected death: A pre andpost intervention study. Resuscitation (2013), http://dx.doi.org/10.1016/j.resuscitation.2013.03.016

ARTICLE IN PRESSG Model

RESUS-5547; No. of Pages 5

Resuscitation xxx (2013) xxx– xxx

Contents lists available at SciVerse ScienceDirect

Resuscitation

jo u rn al hom epage : www.elsev ier .com/ locate / resusc i ta t ion

Clinical paper

SBAR improves nurse–physician communication and reduces unexpected death:A pre and post intervention study!

K. De Meestera,b,∗, M. Verspuyb, K.G. Monsieursa,c, P. Van Bogaerta,b

a Antwerp University Hospital, Wilrijkstraat 10, 2650 Edegem, Belgiumb Faculty of Medicine and Health Sciences, Division of Nursing and Midwifery Sciences, University of Antwerp, Universiteitsplein 1, 2610 Wilrijk, Belgiumc Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610 Wilrijk, Belgium

a r t i c l e i n f o

Article history:Received 20 December 2012Received in revised form 8 March 2013Accepted 17 March 2013Available online xxx

Keywords:Rapid response systemInter-professional communicationSBARUn-expected deathSerious adverse eventUnplanned intensive care unit admission

a b s t r a c t

Background: The Joint Commission International Patient Safety Goal 2 states that effective communicationbetween health care workers needs to improve. The aim of this study was to determine the effect of SBAR(situation, background, assessment, recommendation) on the incidence of serious adverse events (SAE’s)in hospital wards.Method: In 16 hospital wards nurses were trained to use SBAR to communicate with physicians in casesof deteriorating patients. A pre (July 2010 and April 2011) and post (June 2011 and March 2012) inter-vention study was performed. Patient records were checked for SBAR items up to 48 h before a SAE. Aquestionnaire was used to measure nurse–physician communication and collaboration.Results: During 37,239 admissions 207 SAE’s occurred and were checked for SBAR items, 425 nurseswere questioned. Post intervention all four SBAR elements were notated more frequently in patientrecords in case of a SAE (from 4% to 35%; p < 0.001), total score on the questionnaire increased in nurses(from 58 (range 31–97) to 64 (range 25–97); p < 0.001), the number of unplanned intensive care unit(ICU) admissions increased (from 13.1/1000 to 14.8/1000 admissions; relative risk ratio (RRR) = 50%;95% CI 30–64; p = 0.001) and unexpected deaths decreased (from 0.99/1000 to 0.34/1000 admissions;RRR = −227%; 95% CI −793 to −20; NNT 1656; p < 0.001). There was no difference in the number of cardiacarrest team calls.Conclusion: After introducing SBAR we found increased perception of effective communication and col-laboration in nurses, an increase in unplanned ICU admissions and a decrease in unexpected deaths.

© 2013 Elsevier Ireland Ltd. All rights reserved.

1. Introduction

The Joint Commission International Patient Safety Goal num-ber 2 (Standard IPSG 2) states that effective communication amonghealth care workers has to improve.1 According to the Instituteof Medicine the six aims in the 21st-century health care systemare: safe, effective, patient-centred, timely, efficient and equitable.2

Many potential barriers have been reported in nurse–physiciancommunication such as lack of structure, hierarchy, language, cul-ture, sex and difference in communication style.3–5 Nurses tend tobe more detailed in their communications whereas physicians usemore brief statements.4 In the context of critical events, nurses and

! A Spanish translated version of the abstract of this article appears as Appendixin the final online version at http://dx.doi.org/10.1016/j.resuscitation.2013.03.016.

∗ Corresponding author at: Antwerp University Hospital, Wilrijkstraat 10, 2650Edegem, Belgium.

E-mail addresses: [email protected],[email protected] (K. De Meester).

physicians often communicate over the phone which makes thesecommunications error-prone.6 Up to 65% of serious adverse events(SAEs) include communication as a contributing factor.7 Root causeanalysis of SAEs on wards reveals failure in three domains.8 First,no observations are made for a prolonged period and/or changesin vital signs are not detected. Second, despite the recording ofvital signs, clinical deterioration is not recognized and/or no actionis taken. Finally, when deterioration is recognized and assistancesought, medical attention is delayed. This delay in receiving medicalattention can originate from sub-optimal nurse–physician com-munication or collaboration.8 In answer to these three domains offailure, rapid response systems (RRSs) have been widely introducedalthough they are not supported by a high level of evidence.9

It remains uncertain which elements of RRSs contribute mostto patient outcome but there is growing awareness that theeffect depends on the different components such as the abilityto detect and interpret deterioration, to communicate clearly andto start the correct response without delay.10 By implementinga standard observation protocol incorporating the modified earlywarning score (MEWS), better and accurate patient observation and

0300-9572/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved.http://dx.doi.org/10.1016/j.resuscitation.2013.03.016

Please cite this article in press as: De Meester K, et al. SBAR improves nurse–physician communication and reduces unexpected death: A pre andpost intervention study. Resuscitation (2013), http://dx.doi.org/10.1016/j.resuscitation.2013.03.016

ARTICLE IN PRESSG Model

RESUS-5547; No. of Pages 5

K. De Meester et al. / Resuscitation xxx (2013) xxx– xxx 5

4.1. Study limitations

The study design had the limitations of similar cohort studieswith historical controls, it reflects only a single centre, and we can-not conclude that the effect solely resulted from our intervention.Therefore the results cannot be generalised. No conversations wererecorded or analysed to verify if SBAR was really used. There wasa drop in nurse survey participation. Doctors were not instructedor educated neither in the use of SBAR nor in critical thinking. Thisshould be the next step for improvement and has to be investigated.In addition, we recommend future studies to clarify the factors thatsupport the shift to more predicted and controlled “unplanned ICUadmissions” and the effect on patient outcome.

5. Conclusion

The introduction of SBAR communication in our tertiary uni-versity referral hospital increased the perception of effectivecommunication and collaboration in nurses. Nurses were betterprepared to call a doctor after the introduction of SBAR by usingSBAR items in patient records. The number of unplanned ICU admis-sions increased in the post intervention period and the number ofunexpected deaths decreased. The number of Cardiac Arrest Teamcalls stayed the same. This means a shift in the direction of earlierdetection, trigger and response potentially attributable to SBAR.

Conflict of interest statement

No conflicts of interest to declare.

References

1. Joint Commission International. Joint Commission International AccreditationStandards for Hospitals. 4th Edition. Illinois USA: Joint Commission Interna-tional; 2011.

2. Institute of Medicine. Crossing the Quality Chasm. Washington DC, USA:National Academy Press; 2001.

3. Thomas EJ, Sexton JB, Helmreich RI. Discrepant attitudes about teamwork amongcritical care nurses and physicians. Crit Care Med 2003;31:956–9.

4. Greenfield L. Doctors and nurses: A troubled partnership. Ann Surg1999;230:279–88.

5. Robinson P, Gorman G, Slimmer LW, et al. Perceptions of Effective and IneffectiveNurse–Physician Communication in Hospitals. Nurs Forum 2010;45:206–16.

6. Rabøl LI, Andersen ML, Østergaard D, Bjørn B, Lilja B, Mogensen T. Descrip-tions of verbal communication errors between staff. An analysis of 84 root causeanalysis-reports from Danish hospitals. BMJ Qual Saf 2011;20:268–74.

7. Haig KM, Sutton S, Whittington J. SBAR: A shared Mental Model for ImprovingCommunication Between Clinicians. Jt Comm J Qual Patient Saf 2006;32:167–75.

8. Luettel B, Beaumont K, Healey F. Recognizing and responding appropriately toearly signs of deterioration in hospitalized patients. London, UK: NHS NationalPatient Safety Agency;; 2007.

9. Soar J, Mancini ME, Bhanji F, et al. Part12: Education, implementation, andteams: 2010 International Consensus on cardiovascular resuscitation andEmergency Cardiovascular Care Science with Treatment recommendations.Resuscitation 2010;81:e288–330.

10. Devita MA, Smith GA, Adam SK, et al. dentifying the hospitalized patient incrisis-A consensus conference on the afferent linb of Rapid Response Systems.Resuscitation 2010;81:375–82.

11. De Meester K, Das T, Hellemans K, et al. Impact of a standardized nurse observa-tion protocol including MEWS after intensive care unit discharge. Resuscitation2013;84:184–8.

12. Leonard M, Graham S, Bonacum D. The human factor: the critical importance ofeffective teamwork and communication in providing safe care. Qual Saf HealthCare 2004;13:i85–90.

13. Vazirani S, Hays RD, Shapiro MF, et al. Effect of a multidisciplinary interventionon communication and collaboration among physicians and nurses. Am J CritCare 2005;14:71–7.

14. Kaizer Permanente of Colorado. SBAR Technique for Communication: A Situa-tional Briefing Model report to physician about a critical situation [Institute forHealthcare Improvement web site] Evergreen Colorado USA 2004 Available at:http://www.ihi.org/knowledge/Pages/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.aspx. Accessed December 6, 2012.

15. Hillman K, Chen J, Cretikos M, et al., MERIT study investigators. Introduction ofthe medical emergency team (MET) system: a cluster randomized controlledtrial. Lancet 2005;365:2091–7.

16. Subbe CP, Kruger M, Rutherford P, et al. Validation of a modified Early WarningScore in medical admissions. Q J Med 2001;94:507–10.

17. Deakin CD, Nolan JP, Soar J, et al. European Resuscitation Council Guidelinesfor Resuscitation 2010 Section 4. Adult advanced life support. Resuscitation2010;81:1305–52.

18. Scheffer BK, Rubenfeld MG. A consensus statement on critical thinking in nurs-ing. J Nurs Educ 2000;39:352–9.

19. McGloin H, Adam SK, Ainger M. Unexpected deaths and referrals to intensivecare of patients on general wards. Are some cases potentially avoidable? J R CollPysicians Lond 1999;33:255–9.

20. Peberdy MA, Cretikos M, Abella BS, et al. Recommended guidelines for monitor-ing, reporting, and conducting research on medical emergency team, outreach,and rapid response systems: an Utstein-style scientific statement. A Scien-tific Statement from the International Liaison Committee on Resuscitation; theAmerican Heart Association Emergency Cardiovascular Care Committee; theCouncil on Cardiopulmonary, Perioperative, and Critical Care; and the Interdisci-plinary Working Group on Quality of Care and Outcomes Research. Resuscitation2007;75:412–33.

21. SPSS® [computer program], Version 20.0. Chicago, Illinois, USA: IBM; 2012.22. Bello J, Quinn P, Horrell L. Maintaining patient safety through innovation: an

electronic SBAR communication tool. Comput Inform Nurs 2011;29:481–3.23. Velji K, Baker GR, Fancott C, Andreoli A, Boaro, et al. Effectiveness of an Adapted

SBAR Communication Tool for a Rehabilitation Setting. Heath Q 2008;11:72–9.24. Andreoli A, Fancott C, Velji K, et al. Using SBAR to communicate falls

risk and management in inter-professional rehabilitation teams. Health Q2010;13:94–101.

25. Field TS, Tjia J, Mazor Km, et al. Randomized Trial of a Warfarin CommunicationProtocol for Nursing Homes: an SBAR-based Approach. Am J Med 2011;124,179e1-e7.

26. Haig KM, Sutton S, Whittington J. SBAR: A shared mental model for improvingcommunication between clinicians. Jt Comm J Qual Patient Saf 2006;32:167–77.

27. Beckett CD, Kipnis G. Collaborative communication: Integrating SBAR toimprove quality/patient safety outcomes. J Healthc Qual 2009;31:19–28.

28. Dunsford J. Structured Communication: Improving Patient Safety with SBAR.Nurs Womens Health 2009;13:384–90.

29. Woodhall LJ, Vertacnik L, McLaughlin M. Implementation of the SBAR commu-nication technique in a tertiary center. J Emerg Nurs 2008;34:314–7.

30. Brindley PG, Reynolds SF. Improving verbal communication in critical caremedicine. J Crit Care 2011;26:155–9.

31. Christie P, Robinson H. Using a communication framework at handover to boostpatient outcomes. Nurs Times 2009;105:13–5.

32. Compton J, Copeland K, Flanders S, et al. Implementing SBAR across a largemultihospital health system. Jt Comm J Qual Patient Saf 2012;38:261–8.

33. Pope BB, Rodzen L, Spross G. Raising the SBAR: how better communicationimproves patient outcomes. Nursing 2008;38:41–3.

34. Ludikhuize J, de Jonge E, Goossens A. Measuring adherence among nursesone year after training in applying the Modified Early Warning Score andSituation-Background-Assessment-Recommendation instruments. Resuscita-tion 2011;82:1428–33.

35. Riesenberg LA, Leitzsch J, Cunnningham JM. Nursing Handoffs: A SystematicReview of the Literature. AJN 2010;110:24–34.

36. Rosenstein A, O’Daniel M. Disruptive behavior and clinical outcomes: percep-tions of nurses and physicians. Am J Nur 2005;105:54–64, quiz 64-5.

37. Shearer B, Marshall S, Buist MD, et al. What stops hospital staff from followingprotocols? An analysis of the incidence and factors behind the failure of bedsideclinical staff to activate the rapid response system in a multi-campus Australianmetropolitan healthcare service. BMJ Qual Saf 2012;21:569–75.

38. Lippert A, Peterson JA. Rapid response systems-More pieces to the puz-zle. Resuscitation 2012 Nov 21. pii:S0300-9572(12)00896-9. doi:10.1016/j.resuscitation.2012.11.010.

39. Ludikhuize J, Dongelmans DA, Smorenburg SM, et al. How nurses and physiciansjudge their own quality of care for deteriorating patients on medical wards:Self-assessment of quality of care is suboptimal. Crit Care Med 2012;40:2982–6.


74

CLINICAL RESEARCH STUDY

Randomized Trial of a Warfarin Communication Protocolfor Nursing Homes: an SBAR-based ApproachTerry S. Field, DSc,a Jennifer Tjia, MD, MSCE,a Kathleen M. Mazor, EdD,a Jennifer L. Donovan, PharmD,b

Abir O. Kanaan, PharmD,b Leslie R. Harrold, MD, MPH,a George Reed, PhD,a Peter Doherty, BS,a Ann Spenard, MSN,c

Jerry H. Gurwitz, MDa

aMeyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Fallon Community Health Plan, FallonClinic, Worcester, Mass; bMassachusetts College of Pharmacy and Health Sciences, Worcester, Mass; cQualidigm, Inc. Middletown, Conn.

ABSTRACT

BACKGROUND: More than 1.6 million Americans currently reside in nursing homes. As many as 12% ofthem receive long-term anticoagulant therapy with warfarin. Prior research has demonstrated compellingevidence of safety problems with warfarin therapy in this setting, often associated with suboptimalcommunication between nursing home staff and prescribing physicians.METHODS: We conducted a randomized trial of a warfarin management protocol using facilitated telephonecommunication between nurses and physicians in 26 nursing homes in Connecticut in 2007-2008.Intervention facilities received a warfarin management communication protocol using the approach“Situation, Background, Assessment, and Recommendation” (SBAR). The protocol included an SBARtemplate to standardize telephone communication about residents on warfarin by requiring informationabout the situation triggering the call, the background, the nurse’s assessment, and recommendations.RESULTS: There were 435 residents who received warfarin therapy during the study period for 55,167resident days in the intervention homes and 53,601 in control homes. In intervention homes, residents’international normalized ratio (INR) values were in the therapeutic range a statistically significant 4.50%more time than in control homes (95% confidence interval [CI], 0.31%-8.69%). There was no differencein obtaining a follow-up INR within 3 days after an INR value !4.5 (odds ratio 1.02; 95% CI, 0.44-2.4).Rates of preventable adverse warfarin-related events were lower in intervention homes, although this resultwas not statistically significant: the incident rate ratio for any preventable adverse warfarin-related eventwas .87 (95% CI, .54-1.4).CONCLUSION: Facilitated telephone communication between nurses and physicians using the SBARapproach modestly improves the quality of warfarin management for nursing home residents. (Registeredon ClinicalTrials.gov; URL:http://clinicaltrials.gov/. Registration number: NCT00682773).© 2011 Elsevier Inc. All rights reserved. • The American Journal of Medicine (2011) 124, 179.e1-179.e7

KEYWORDS: Communications; Long-term care; Nursing homes; Protocol; Warfarin

As many as 12% of the 1.6 million American nursing homeresidents receive long-term oral anticoagulant therapy withwarfarin to prevent strokes and other thromboembolicevents. Prior research has demonstrated compelling evi-dence of safety problems with warfarin therapy in nursinghomes resulting from suboptimal warfarin management anderrors in prescribing and monitoring.1-3 In our previousstudies, we estimated that there may be as many as 34,000fatal, life-threatening, or serious adverse warfarin-relatedevents per year in the nursing home setting, the majority ofwhich may be preventable.1,4,5 An important contributor tomany of these events appeared to be the lack of key infor-

Funding: Supported by a grant from the Agency for Healthcare Re-search and Quality (R01HS016463), Rockville, Md. The funding agencydid not have a role in study design, data collection, analysis, or manuscriptpreparation.

Conflict of Interest: There are no conflicts of interest for any of theauthors in this study.

Authorship: All authors had access to the data and a role in writing themanuscript.

Requests for reprints should be addressed to Terry S. Field, DSc,Meyers Primary Care Institute, 630 Plantation Street, Worcester, MA01605.

E-mail address: [email protected]

0002-9343/$ -see front matter © 2011 Elsevier Inc. All rights reserved.doi:10.1016/j.amjmed.2010.09.017

CLINICAL RESEARCH STUDY

Randomized Trial of a Warfarin Communication Protocolfor Nursing Homes: an SBAR-based ApproachTerry S. Field, DSc,a Jennifer Tjia, MD, MSCE,a Kathleen M. Mazor, EdD,a Jennifer L. Donovan, PharmD,b

Abir O. Kanaan, PharmD,b Leslie R. Harrold, MD, MPH,a George Reed, PhD,a Peter Doherty, BS,a Ann Spenard, MSN,c

Jerry H. Gurwitz, MDa

aMeyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Fallon Community Health Plan, FallonClinic, Worcester, Mass; bMassachusetts College of Pharmacy and Health Sciences, Worcester, Mass; cQualidigm, Inc. Middletown, Conn.

ABSTRACT

BACKGROUND: More than 1.6 million Americans currently reside in nursing homes. As many as 12% ofthem receive long-term anticoagulant therapy with warfarin. Prior research has demonstrated compellingevidence of safety problems with warfarin therapy in this setting, often associated with suboptimalcommunication between nursing home staff and prescribing physicians.METHODS: We conducted a randomized trial of a warfarin management protocol using facilitated telephonecommunication between nurses and physicians in 26 nursing homes in Connecticut in 2007-2008.Intervention facilities received a warfarin management communication protocol using the approach“Situation, Background, Assessment, and Recommendation” (SBAR). The protocol included an SBARtemplate to standardize telephone communication about residents on warfarin by requiring informationabout the situation triggering the call, the background, the nurse’s assessment, and recommendations.RESULTS: There were 435 residents who received warfarin therapy during the study period for 55,167resident days in the intervention homes and 53,601 in control homes. In intervention homes, residents’international normalized ratio (INR) values were in the therapeutic range a statistically significant 4.50%more time than in control homes (95% confidence interval [CI], 0.31%-8.69%). There was no differencein obtaining a follow-up INR within 3 days after an INR value !4.5 (odds ratio 1.02; 95% CI, 0.44-2.4).Rates of preventable adverse warfarin-related events were lower in intervention homes, although this resultwas not statistically significant: the incident rate ratio for any preventable adverse warfarin-related eventwas .87 (95% CI, .54-1.4).CONCLUSION: Facilitated telephone communication between nurses and physicians using the SBARapproach modestly improves the quality of warfarin management for nursing home residents. (Registeredon ClinicalTrials.gov; URL:http://clinicaltrials.gov/. Registration number: NCT00682773).© 2011 Elsevier Inc. All rights reserved. • The American Journal of Medicine (2011) 124, 179.e1-179.e7

KEYWORDS: Communications; Long-term care; Nursing homes; Protocol; Warfarin

As many as 12% of the 1.6 million American nursing homeresidents receive long-term oral anticoagulant therapy withwarfarin to prevent strokes and other thromboembolicevents. Prior research has demonstrated compelling evi-dence of safety problems with warfarin therapy in nursinghomes resulting from suboptimal warfarin management anderrors in prescribing and monitoring.1-3 In our previousstudies, we estimated that there may be as many as 34,000fatal, life-threatening, or serious adverse warfarin-relatedevents per year in the nursing home setting, the majority ofwhich may be preventable.1,4,5 An important contributor tomany of these events appeared to be the lack of key infor-

Funding: Supported by a grant from the Agency for Healthcare Re-search and Quality (R01HS016463), Rockville, Md. The funding agencydid not have a role in study design, data collection, analysis, or manuscriptpreparation.

Conflict of Interest: There are no conflicts of interest for any of theauthors in this study.

Authorship: All authors had access to the data and a role in writing themanuscript.

Requests for reprints should be addressed to Terry S. Field, DSc,Meyers Primary Care Institute, 630 Plantation Street, Worcester, MA01605.

E-mail address: [email protected]

0002-9343/$ -see front matter © 2011 Elsevier Inc. All rights reserved.doi:10.1016/j.amjmed.2010.09.017

30/05/17

38


75

Feature Article

Examining the feasibility and utility of an SBAR protocol in long-term care

Susan M. Renz, DNP, RN, GNP-BC a,*, Marie P. Boltz, PhD, RN, GNP-BC b, Laura M. Wagner, PhD, RN c,Elizabeth A. Capezuti, PhD, RN, FAANd, Thomas E. Lawrence, MD e

aAdult-Gerontology Primary Care Nurse Practitioner Program, University of Pennsylvania School of Nursing, Rm. 344, Claire M. Fagin Hall, 418 Curie Blvd., Philadelphia, PA19104, USAbNew York University College of Nursing, 726 Broadway, 10th floor, New York, NY 10003, USAcDepartment of Community Health Systems, School of Nursing, University of California, San Francisco, #511R, 2 Koret Way, San Francisco, CA 94143, USAdDr. John W. Rowe Professor in Successful Aging, New York University College of Nursing, 726 Broadway, 10th floor, New York, NY 10003, USAeMain Line Health Center e Newtown Square, 3855 W. Chester Pike, Suite 300 Newtown Square, PA 19073, USA


Article history:Received 21 October 2012Received in revised form25 April 2013Accepted 29 April 2013Available online 27 May 2013

Keywords:Interprofessional communicationNursing home qualitySBAR

a b s t r a c t

Ineffective nurseephysician communication in the nursing home setting adversely affects resident careas well as the work environment for both nurses and physicians. Using a repeated measures design, thisquality improvement project evaluated the influence of SBAR (Situation; Background of the change;Assessment or appearance; and Request for action) protocol and training on nurse communication withmedical providers, as perceived by nurses and physicians, using a preepost questionnaire. The majority(87.5%) of nurses respondents found the tool useful to organize information and provide cues on what tocommunicate to medical providers. Limitations expressed by some nurses included the time to completethe tool, and communication barriers not corrected by the SBAR tool. Project findings, including reportedphysician satisfaction, support the use of SBAR to address both issues of complete documentation andtime constraints.

! 2013 Mosby, Inc. All rights reserved.

Consumer and regulatory expectations to prevent avoidableinjuries have created an imperative to create a culture of safety innursing homes.1e3 Communication between nurses and medicalproviders (e.g., physicians, physician assistants, and nurse practi-tioners) that supports effective clinical decision-making is criticalto support this mandate.4 There is evidence that ineffective nurseeprovider communication in this setting adversely affects residentcare, with associated reports of unnecessary psychotropic use5 andavoidable hospitalizations,1,6 for example. Additionally, poorcommunication causes increased stress and frustration, anddiminished workplace relationships for both nurses andphysicians.7

Although physicians have cited concerns about nurse compe-tence in the nursing home setting,8 knowledge deficits do notaccount for all the problems with communication. In general,a combination of individual, group, and organizational factors,including cognitive workload, differing priorities between profes-sional roles, and hierarchical relationships, complicate communi-cation.9,10 Most of the communication between nurses and medicalproviders in the long-term care setting occurs within the context of

brief telephone conversations; many calls occur after hours and onweekends to covering physicians.11,12 As a result, important clinicaldecisions are made by providers who are relying on informationfrom the nurse on the telephone because the provider is unfamiliarwith the resident. The quality of this exchange is influenced by bothprovider and nurse behaviors.8,12

Tjia and colleagues12 reported several barriers to communica-tion perceived by nurses including: lack of physician openness tocommunication (rushed and/or not open to nurses’ views), logisticchallenges (including noise and lack of privacy), lack of profes-sionalism (rudeness and disrespect), and language barriers (accentand use of jargon), as well as inconsistencies in nurse preparedness.Problems related to timing, clarity, and content of informationconveyed,12,13 as well as the nurse’s ability to organize andcommunicate information14 have been cited as culprits contrib-uting to poor communication. These challenges may be mitigatedthrough the development and implementation of structuredcommunication protocols and training of nursing staff on thesemethods.9,14,15 Standardizing the structure of critical communica-tions helps the speaker organize thoughts and be prepared withcritical information, and helps the receiver to be focused on theimportant points of the message by eliminating the less importantaspects.16e18 One communication protocol increasingly andcommonly used in healthcare is the SBAR (Situation, Background,Assessment, and Recommendation) approach.

This work was supported in part by Grant UL1 TR000038 from the National Centerfor the Advancement of Translational Sciences (NCATS), National Institutes ofHealth.* Corresponding author. Tel.: þ1 610 574 6246; fax: þ1 610 722 0895.

E-mail addresses: [email protected], [email protected] (S.M. Renz).


Geriatric Nursing

journal homepage: www.gnjournal .com

0197-4572/$ e see front matter ! 2013 Mosby, Inc. All rights reserved.http://dx.doi.org/10.1016/j.gerinurse.2013.04.010

Geriatric Nursing 34 (2013) 295e301

Feature Article

Examining the feasibility and utility of an SBAR protocol in long-term care

Susan M. Renz, DNP, RN, GNP-BC a,*, Marie P. Boltz, PhD, RN, GNP-BC b, Laura M. Wagner, PhD, RN c,Elizabeth A. Capezuti, PhD, RN, FAANd, Thomas E. Lawrence, MD e

aAdult-Gerontology Primary Care Nurse Practitioner Program, University of Pennsylvania School of Nursing, Rm. 344, Claire M. Fagin Hall, 418 Curie Blvd., Philadelphia, PA19104, USAbNew York University College of Nursing, 726 Broadway, 10th floor, New York, NY 10003, USAcDepartment of Community Health Systems, School of Nursing, University of California, San Francisco, #511R, 2 Koret Way, San Francisco, CA 94143, USAdDr. John W. Rowe Professor in Successful Aging, New York University College of Nursing, 726 Broadway, 10th floor, New York, NY 10003, USAeMain Line Health Center e Newtown Square, 3855 W. Chester Pike, Suite 300 Newtown Square, PA 19073, USA


Article history:Received 21 October 2012Received in revised form25 April 2013Accepted 29 April 2013Available online 27 May 2013

Keywords:Interprofessional communicationNursing home qualitySBAR

a b s t r a c t

Ineffective nurseephysician communication in the nursing home setting adversely affects resident careas well as the work environment for both nurses and physicians. Using a repeated measures design, thisquality improvement project evaluated the influence of SBAR (Situation; Background of the change;Assessment or appearance; and Request for action) protocol and training on nurse communication withmedical providers, as perceived by nurses and physicians, using a preepost questionnaire. The majority(87.5%) of nurses respondents found the tool useful to organize information and provide cues on what tocommunicate to medical providers. Limitations expressed by some nurses included the time to completethe tool, and communication barriers not corrected by the SBAR tool. Project findings, including reportedphysician satisfaction, support the use of SBAR to address both issues of complete documentation andtime constraints.

! 2013 Mosby, Inc. All rights reserved.

Consumer and regulatory expectations to prevent avoidableinjuries have created an imperative to create a culture of safety innursing homes.1e3 Communication between nurses and medicalproviders (e.g., physicians, physician assistants, and nurse practi-tioners) that supports effective clinical decision-making is criticalto support this mandate.4 There is evidence that ineffective nurseeprovider communication in this setting adversely affects residentcare, with associated reports of unnecessary psychotropic use5 andavoidable hospitalizations,1,6 for example. Additionally, poorcommunication causes increased stress and frustration, anddiminished workplace relationships for both nurses andphysicians.7

Although physicians have cited concerns about nurse compe-tence in the nursing home setting,8 knowledge deficits do notaccount for all the problems with communication. In general,a combination of individual, group, and organizational factors,including cognitive workload, differing priorities between profes-sional roles, and hierarchical relationships, complicate communi-cation.9,10 Most of the communication between nurses and medicalproviders in the long-term care setting occurs within the context of

brief telephone conversations; many calls occur after hours and onweekends to covering physicians.11,12 As a result, important clinicaldecisions are made by providers who are relying on informationfrom the nurse on the telephone because the provider is unfamiliarwith the resident. The quality of this exchange is influenced by bothprovider and nurse behaviors.8,12

Tjia and colleagues12 reported several barriers to communica-tion perceived by nurses including: lack of physician openness tocommunication (rushed and/or not open to nurses’ views), logisticchallenges (including noise and lack of privacy), lack of profes-sionalism (rudeness and disrespect), and language barriers (accentand use of jargon), as well as inconsistencies in nurse preparedness.Problems related to timing, clarity, and content of informationconveyed,12,13 as well as the nurse’s ability to organize andcommunicate information14 have been cited as culprits contrib-uting to poor communication. These challenges may be mitigatedthrough the development and implementation of structuredcommunication protocols and training of nursing staff on thesemethods.9,14,15 Standardizing the structure of critical communica-tions helps the speaker organize thoughts and be prepared withcritical information, and helps the receiver to be focused on theimportant points of the message by eliminating the less importantaspects.16e18 One communication protocol increasingly andcommonly used in healthcare is the SBAR (Situation, Background,Assessment, and Recommendation) approach.

This work was supported in part by Grant UL1 TR000038 from the National Centerfor the Advancement of Translational Sciences (NCATS), National Institutes ofHealth.* Corresponding author. Tel.: þ1 610 574 6246; fax: þ1 610 722 0895.

E-mail addresses: [email protected], [email protected] (S.M. Renz).


Geriatric Nursing

journal homepage: www.gnjournal .com

0197-4572/$ e see front matter ! 2013 Mosby, Inc. All rights reserved.http://dx.doi.org/10.1016/j.gerinurse.2013.04.010

Geriatric Nursing 34 (2013) 295e301


76

SBAR improves communication andsafety climate and decreases incidentreports due to communication errorsin an anaesthetic clinic: a prospectiveintervention study

Maria Randmaa,1,2,3 Gunilla Mårtensson,1,3 Christine Leo Swenne,3

Maria Engström1,3

To cite: Randmaa M,Mårtensson G, LeoSwenne C, et al. SBARimproves communication andsafety climate and decreasesincident reports due tocommunication errors in ananaesthetic clinic: aprospective interventionstudy. BMJ Open 2014;4:e004268. doi:10.1136/bmjopen-2013-004268

▸ Prepublication history forthis paper is available online.To view these files pleasevisit the journal online(http://dx.doi.org/10.1136/bmjopen-2013-004268).

Received 16 October 2013Revised 6 December 2013Accepted 19 December 2013

For numbered affiliations seeend of article.

Correspondence toMaria Randmaa;[email protected]

ABSTRACTObjectives: We aimed to examine staff members’perceptions of communication within and betweendifferent professions, safety attitudes and psychologicalempowerment, prior to and after implementation of thecommunication tool Situation-Background-Assessment-Recommendation (SBAR) at ananaesthetic clinic. The aim was also to study whetherthere was any change in the proportion of incidentreports caused by communication errors.Design: A prospective intervention study withcomparison group using preassessments andpostassessments. Questionnaire data were collectedfrom staff in an intervention (n=100) and a comparisongroup (n=69) at the anaesthetic clinic in two hospitalsprior to (2011) and after (2012) implementation ofSBAR. The proportion of incident reports due tocommunication errors was calculated during a 1-yearperiod prior to and after implementation.Setting: Anaesthetic clinics at two hospitals inSweden.Participants: All licensed practical nurses, registerednurses and physicians working in the operatingtheatres, intensive care units and postanaesthesia careunits at anaesthetic clinics in two hospitals wereinvited to participate.Intervention: Implementation of SBAR in ananaesthetic clinic.Primary and secondary outcomes: The primaryoutcomes were staff members’ perception ofcommunication within and between differentprofessions, as well as their perceptions of safetyattitudes. Secondary outcomes were psychologicalempowerment and incident reports due to error ofcommunication.Results: In the intervention group, there werestatistically significant improvements in the factors‘Between-group communication accuracy’ (p=0.039)and ‘Safety climate’ (p=0.011). The proportion ofincident reports due to communication errorsdecreased significantly (p<0.0001) in the interventiongroup, from 31% to 11%.

Conclusions: Implementing the communication toolSBAR in anaesthetic clinics was associated withimprovement in staff members’ perception ofcommunication between professionals and theirperception of the safety climate as well as with adecreased proportion of incident reports related tocommunication errors.Trial registration: ISRCTN37251313.

INTRODUCTIONTeamwork in operating theatres and inten-sive care units (ICUs) requires straightfor-ward, clear and consistent communication aswell as good collaboration. Nonetheless,communication breakdowns are frequentduring the preoperative, intraoperative and

Strengths and limitations of this study

▪ Despite recommendation of implementing Situation-Background-Assessment-Recommendation inhealthcare, there are a few intervention studieswith a comparison group, using preassessmentsand postassessments, evaluating staff members’perception of communication and safety attitudesas well as incident reports due to communicationerrors, thus the study adds new knowledge to thesubject area.

▪ The implementation was followed by the authorsusing manipulation check, involving randomisedstructured telephone interviews. To monitor theimplementation, the local interprofessional work-group conducted observations of handovers.

▪ The response rate was satisfying, exceeding 70%at baseline and follow-up in the two groups.

▪ The very natures of the quasi-experimentaldesign entail selection biases as the lack ofrandomisation.

Randmaa M, Mårtensson G, Leo Swenne C, et al. BMJ Open 2014;4:e004268. doi:10.1136/bmjopen-2013-004268 1

Open Access Research

group.bmj.com on May 5, 2016 - Published by http://bmjopen.bmj.com/Downloaded from

SBAR improves communication andsafety climate and decreases incidentreports due to communication errorsin an anaesthetic clinic: a prospectiveintervention study

Maria Randmaa,1,2,3 Gunilla Mårtensson,1,3 Christine Leo Swenne,3

Maria Engström1,3

To cite: Randmaa M,Mårtensson G, LeoSwenne C, et al. SBARimproves communication andsafety climate and decreasesincident reports due tocommunication errors in ananaesthetic clinic: aprospective interventionstudy. BMJ Open 2014;4:e004268. doi:10.1136/bmjopen-2013-004268

▸ Prepublication history forthis paper is available online.To view these files pleasevisit the journal online(http://dx.doi.org/10.1136/bmjopen-2013-004268).

Received 16 October 2013Revised 6 December 2013Accepted 19 December 2013

For numbered affiliations seeend of article.

Correspondence toMaria Randmaa;[email protected]

ABSTRACTObjectives: We aimed to examine staff members’perceptions of communication within and betweendifferent professions, safety attitudes and psychologicalempowerment, prior to and after implementation of thecommunication tool Situation-Background-Assessment-Recommendation (SBAR) at ananaesthetic clinic. The aim was also to study whetherthere was any change in the proportion of incidentreports caused by communication errors.Design: A prospective intervention study withcomparison group using preassessments andpostassessments. Questionnaire data were collectedfrom staff in an intervention (n=100) and a comparisongroup (n=69) at the anaesthetic clinic in two hospitalsprior to (2011) and after (2012) implementation ofSBAR. The proportion of incident reports due tocommunication errors was calculated during a 1-yearperiod prior to and after implementation.Setting: Anaesthetic clinics at two hospitals inSweden.Participants: All licensed practical nurses, registerednurses and physicians working in the operatingtheatres, intensive care units and postanaesthesia careunits at anaesthetic clinics in two hospitals wereinvited to participate.Intervention: Implementation of SBAR in ananaesthetic clinic.Primary and secondary outcomes: The primaryoutcomes were staff members’ perception ofcommunication within and between differentprofessions, as well as their perceptions of safetyattitudes. Secondary outcomes were psychologicalempowerment and incident reports due to error ofcommunication.Results: In the intervention group, there werestatistically significant improvements in the factors‘Between-group communication accuracy’ (p=0.039)and ‘Safety climate’ (p=0.011). The proportion ofincident reports due to communication errorsdecreased significantly (p<0.0001) in the interventiongroup, from 31% to 11%.

Conclusions: Implementing the communication toolSBAR in anaesthetic clinics was associated withimprovement in staff members’ perception ofcommunication between professionals and theirperception of the safety climate as well as with adecreased proportion of incident reports related tocommunication errors.Trial registration: ISRCTN37251313.

INTRODUCTIONTeamwork in operating theatres and inten-sive care units (ICUs) requires straightfor-ward, clear and consistent communication aswell as good collaboration. Nonetheless,communication breakdowns are frequentduring the preoperative, intraoperative and

Strengths and limitations of this study

▪ Despite recommendation of implementing Situation-Background-Assessment-Recommendation inhealthcare, there are a few intervention studieswith a comparison group, using preassessmentsand postassessments, evaluating staff members’perception of communication and safety attitudesas well as incident reports due to communicationerrors, thus the study adds new knowledge to thesubject area.

▪ The implementation was followed by the authorsusing manipulation check, involving randomisedstructured telephone interviews. To monitor theimplementation, the local interprofessional work-group conducted observations of handovers.

▪ The response rate was satisfying, exceeding 70%at baseline and follow-up in the two groups.

▪ The very natures of the quasi-experimentaldesign entail selection biases as the lack ofrandomisation.

Randmaa M, Mårtensson G, Leo Swenne C, et al. BMJ Open 2014;4:e004268. doi:10.1136/bmjopen-2013-004268 1

Open Access Research

group.bmj.com on May 5, 2016 - Published by http://bmjopen.bmj.com/Downloaded from

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Exercice pardeux

.Lisez le casusetfaites le rapportàvotre voisin selon SBAR

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Exercice 1:

Voici un extrait d’un dossierréel.Utilisez SBARpourremettre Dr Janssensaucourantpartéléphone.Votrevoisin joue le rôle dumédecin.

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Exercice 2:

Voici un extrait issu d’un dossierréel.Utilisez SBARpourfairele rapportàvotre collègue denuit.Cedernierestreprésenté parvotre voisin.

Appliquer SBARdansvotre organisation

Culturemédicaleà différente entre l’hôpital,lecentred’hébergement,centre psychiatrique,etc.

Considérez cette nouvelleintervention:“Bottom-up”“Top-down” =votre communication laisse àdésirer,employezSBAR

Préférezà Lesystème doit êtreadapté,nousemployonsdesoutilsstandardisésafind’assurerlasécuritéetd’améliorerlaqualitédurapportageetdelacommunication

Choississez descollaborateurssur le terrain qui soutiendront leprojet

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Appliquer SBARdansvotre organisation

Essentiel!

– Soutieninconditionnel deladirection– Impliquez lesmédecins– Leadership solide(infirmiers -chef)à

“Communiquer defaçon structurée est indispensable etjesoutiensentièrement le projet.“

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SBARdansvotre organisation

Processus évaluation d’une innovationà adoption1. Connaissances2. Conviction3. Décision4. Implémentation5. Confirmation

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Rogers,2010

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Connaissances• Exemples concrets personnelsà problème• Donnez l’information nécessaire sur le sujet• Suscitez l’intérêt etrestezsuccinct• Quoi,comment pourquoi?

Conviction (attitudefavorable/défavorable)• Opinionetsentiment/attitude• Mental :exemples pratiques(films)• Renforcement social

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Décision (adoptionou rejet)• Comparaison avec situation personnelle(petite échelle)• Trialby others (peutremplacerpropre test)• Réagir rapidementà solutionner probèmes• Toute l’organisation vs.graduellement

Implémentation• Innovation est appliquée• Solutionner nouveauxproblèmes éventuels(barrières)

Confirmation• Fêtez vosréussites• Mesurez etmontrez résultats (audits)

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Références

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Haig KM,SuttonS,Whittington J:SBAR:asharedmental modelfor improving communication between clinicians. Jt Comm JQual Patient Saf 2006,32(3):167-175.

Hillman KMetal.Antecedents to hospital deaths.InternMed J2001;31,343-348.

KonradD,Jäderling G,BellM,Granath F,Ekbom A,Martling CR:Reducing in-hospital cardiac arrests and hospital mortality byintroducing amedical emergency team. IntensiveCareMed 2010,36(1):100-106.

LeonardM:Thehumanfactor:the critical importance ofeffective teamworkand communication inproviding safecare. Qualityand SafetyinHealthCare2004,13(suppl_1):i85-i90.

McQuillan Petal.Confidential inquiry into quality ofcarebefore admission to intensivecare.BMJ1998;316,1853-1858.

NationalPatient SafetyAgency.(2007).Recognising and responding appropriately to early signs ofdeterioration inhospitalisedpatients.London:NationalPatient SafetyAgency.

Novak K,Fairchild R:Bedside reporting and SBAR:improving patient communication and satisfaction. JPediatr Nurs 2012,27(6):760-762.

RogersEM.(1995).Diffusion ofInnovations,Fourth Edition.FreePress.

StreetM,Eustace P,LivingstonPM,Craike MJ,KentB,PattersonD:Communicationatthe bedside to enhance patient care:Asurveyofnurses’experience and perspective ofhandover:Communicationduring nursing handover. InternationalJournalofNursing Practice 2011,17(2):133-140.

Documents

Une communicationefficaceet effective entreles ... · 30/05/17 1 Une communicationefficaceet effective entreles prestatairesde soins: SBAR Filip Haegdorens, PhD student Universiteit