Clinical paperSBAR improves nurse–physician communication and reduces unexpected death: A pre and post intervention study☆
Introduction
The Joint Commission International Patient Safety Goal number 2 (Standard IPSG 2) states that effective communication among health care workers has to improve.1 According to the Institute of Medicine the six aims in the 21st-century health care system are: safe, effective, patient-centred, timely, efficient and equitable.2 Many potential barriers have been reported in nurse–physician communication such as lack of structure, hierarchy, language, culture, sex and difference in communication style.3, 4, 5 Nurses tend to be more detailed in their communications whereas physicians use more brief statements.4 In the context of critical events, nurses and physicians often communicate over the phone which makes these communications error-prone.6 Up to 65% of serious adverse events (SAEs) include communication as a contributing factor.7 Root cause analysis of SAEs on wards reveals failure in three domains.8 First, no observations are made for a prolonged period and/or changes in vital signs are not detected. Second, despite the recording of vital signs, clinical deterioration is not recognized and/or no action is taken. Finally, when deterioration is recognized and assistance sought, medical attention is delayed. This delay in receiving medical attention can originate from sub-optimal nurse–physician communication or collaboration.8 In answer to these three domains of failure, rapid response systems (RRSs) have been widely introduced although they are not supported by a high level of evidence.9 It remains uncertain which elements of RRSs contribute most to patient outcome but there is growing awareness that the effect depends on the different components such as the ability to detect and interpret deterioration, to communicate clearly and to start the correct response without delay.10 By implementing a standard observation protocol incorporating the modified early warning score (MEWS), better and accurate patient observation and interpretation of abnormal vital signs was achieved in our hospital.11 The components “detection” and “interpretation” were improved. It remained unclear whether in cases of patient deterioration the nurse–physician communication was clear and provided the best information to optimize collaboration so physicians could respond without delay. Dr. Michael Leonard, physician-leader at Kaizer Permanente in Denver introduced standardised communication with the SBAR (situation, background, assessment, and recommendation) structure to optimize effective communication.12, 13 By using the SBAR tool nurses could be empowered to formulate a recommendation to a physician. This is only possible after formal assessment of the patient and knowing the situation and the background of the patient. We hypothesized that if nurses are better prepared before calling a physician and by structuring the communication, physicians should be better informed and able to prioritise in their work, give the best orders and take the right actions.
The aim of this study was to determine the effect of standard SBAR communication in deteriorating patients on the perception of effective communication and collaboration between nurses and physicians and on the incidence of SAEs in adult hospital wards.
Section snippets
Design, setting and participants
We investigated SAEs and conducted a questionnaire for nurses pre and post the introduction of SBAR in the Antwerp University Hospital (AUH). AUH is the tertiary referral hospital of the University of Antwerp and has one campus of 573 beds. AUH provides all medical and surgical specialties but has no beds for chronic or psychiatric hospitalization. In the research period there were 244 beds on nine medical wards including a 10-bed cardiac care unit, 205 beds on seven surgical wards including
The questionnaire
The questionnaire was completed by 425 nurses. Nurses’ response rate in the pre intervention period was 72% (n = 245) and 53% in the post intervention period (n = 180). For questionnaire participants there were no demographic differences between pre and post intervention group (Table 1). The mean age of the respondents was 40 years, they were mainly female (90%) of Belgian nationality (92%) and worked as a nurse for 15 years. Sixty percent of the nurses had a bachelor degree. Nurses’ total score on
Discussion
To our knowledge, this is the first study to show a significant reduction in unexpected deaths after the introduction of SBAR.22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34 A systematic review of the literature on nursing handoff communication concluded that negative consequences of inadequate nursing handoffs are well-known but that little research has been done to identify best practices.35 The current study confirmed the Joint Commission Patient Safety Goal 2 (IPSG 2) statement regarding
Conclusion
The introduction of SBAR communication in our tertiary university referral hospital increased the perception of effective communication and collaboration in nurses. Nurses were better prepared to call a doctor after the introduction of SBAR by using SBAR items in patient records. The number of unplanned ICU admissions increased in the post intervention period and the number of unexpected deaths decreased. The number of Cardiac Arrest Team calls stayed the same. This means a shift in the
Conflict of interest statement
No conflicts of interest to declare.
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2013.03.016.