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BMJ Open is committed to open peer review. As part of this commitment we make the peer review history of every article we publish publicly available. When an article is published we post the peer reviewers’ comments and the authors’ responses online. We also post the versions of the paper that were used during peer review. These are the versions that the peer review comments apply to. The versions of the paper that follow are the versions that were submitted during the peer review process. They are not the versions of record or the final published versions. They should not be cited or distributed as the published version of this manuscript. BMJ Open is an open access journal and the full, final, typeset and author-corrected version of record of the manuscript is available on our site with no access controls, subscription charges or pay-per-view fees (http://bmjopen.bmj.com). If you have any questions on BMJ Open’s open peer review process please email
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The impact of the communication and patient hand-off tool
SBAR on patient safety – a systematic review
Journal: BMJ Open
Manuscript ID bmjopen-2018-022202
Article Type: Research
Date Submitted by the Author: 17-Feb-2018
Complete List of Authors: Müller, Martin; Inselspital Universitatsspital Bern, Department of Emergency Medicine; Universitat zu Koln Institut fur Gesundheitsokonomie und Klinische Epidemiologie Jürgens, Jonas; Universitat zu Koln Institut fur Gesundheitsokonomie und Klinische Epidemiologie Redaelli, Marcus; Universitat zu Koln Institut fur Gesundheitsokonomie und Klinische Epidemiologie Klingberg, Karsten; Inselspital Universitatsspital Bern, Department of
Emergency Medicine Hautz, Wolf; Inselspital, University of Bern, Department of Emergency Medicine Stock, Stephanie; Universitat zu Koln Institut fur Gesundheitsokonomie und Klinische Epidemiologie
Keywords:
ACCIDENT & EMERGENCY MEDICINE, Information management < BIOTECHNOLOGY & BIOINFORMATICS, EDUCATION & TRAINING (see Medical Education & Training), Health & safety < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Quality in health care < HEALTH SERVICES ADMINISTRATION & MANAGEMENT
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The impact of the communication and patient hand-off tool
SBAR on patient safety – a systematic review
Martin Müller1.2, Jonas Jürgens2, Marcus Redaèlli2, Karsten Klingberg1, Wolf E. Hautz1,
Stephanie Stock2
1 Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern,
Bern, Switzerland.
2 Institute of Health Economics and Clinical Epidemiology, University Hospital of Cologne,
Cologne, Germany
MM: martin.mueller2@insel.ch
JJ: jonasjuergens@gmx.de
MR: marcus.redaelli@uk-koeln.de
KK: k.klingberg@vodafone.de
WH: wolf.hautz@insel.ch
SS: stephanie.stock@uk-koeln.de
Address of correspondence
Martin Müller, Dr. med. Dipl.-Math. M. Sc.,
Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern,
Bern, Switzerland. Phone: +41 (0)31 632 2111. Fax: +41 (0)31 632 24 50.
E-mail: martin.mueller2@insel.ch
Manuscript word count: 2907
Abstract word count: 285
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ABSTRACT
Objectives: Communication breakdown is one of the main causes of adverse events in
clinical routine, particularly in handover situations. The communication tool SBAR (Situation,
Background, Assessment, and Recommendation) was developed to increase handover
quality and is widely assumed to increase patient safety. The objective of this review is to
summarise the literature on the effect of SBAR on the occurrence of adverse events.
Design: A systematic review of articles published on SBAR was performed in PUBMED,
EMBASE, CINAHL, Cochrane Library, and PsycINFO in January 2017. All original research
articles on SBAR fulfilling the following eligibility criteria were included: i) SBAR was
implemented into clinical routine, ii) the investigation of SBAR was the primary objective of
the study, and iii) at least one patient outcome was reported.
Setting: A wide range of settings within primary and secondary care and nursing homes.
Participants: A wide range of sociodemographic groups.
Primary and secondary outcome measures: Aspects of patient safety defined as the
occurrence or incidence of adverse events (e.g. mortality, secondary ICU admission).
Results: Eleven studies conducted in different settings such as hospitals, a rehabilitation
centre and nursing homes were identified. The objectives of the studies were to improve
team communication in general, intra- and interdisciplinary patient hand-off and
communication in telephone calls from nurses to physicians in specific scenarios. Some
studies reported weak evidence for an improvement of patient safety after the
implementation of SBAR. No study found a significant increase in the occurrence of adverse
events after the implementation of SBAR.
Conclusions: This review indicates a trend towards improved patient safety through SBAR
implementation but found no conclusive evidence. There is a lack of high quality research on
this widely used communication and patient hand-off tool.
Trial registration: none
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Key words: SBAR, hand-off situation, interprofessional communication, patient safety,
adverse event
Strengths and limitations
• This systematic review was conducted in accordance with the Cochrane
Collaboration standards using a validated tool for quality assessment of the identified
studies.
• Five well-known databases as well as the references of the included studies were
searched using an open search strategy. However, only one randomized-controlled
trial, two controlled clinical trials and eight before-after studies could be included in
the analysis.
• Reliability of the study selection, data extraction and rating of the study quality was
ensured using two independent reviewers. Due to heterogeneity of the studies, it was
not possible to test for publication bias, a potential important bias in this field.
• We did not differentiate the broad range of adverse events or sentinel events, but
subsume them under patient safety in order to provide a first insight into the
relationship between SBAR and patient safety. Therefore, a large heterogeneity of
the study outcomes and study settings impeded a direct comparison or pooling of the
outcomes.
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INTRODUCTION
In its report “To Err Is Human”, the Institute of Medicine estimated that between 44,000 and
98,000 patients die in the United States due to medical errors each year.1 Thus, more deaths
result from error then are caused by motor vehicle accidents, breast cancer, or AIDS. Among
these errors, communication breakdowns are frequent. The Joint commission reported that
poor communication was a contributing factor in more than 60% of all events reviewed.2
Poor communication is found in many different health care settings and is especially
prominent in patient hand-offs and settings were fast and effective management is
indispensable. Such settings include the operating room,3 the intensive care unit (ICU),4 and
the emergency department (ED).5 The components and processes of communications are
complex and hold many opportunities for misunderstanding.6 To overcome these barriers,
communication strategies are desirable which take little time and effort to complete, deliver
comprehensive information efficiently, encourage interprofessional collaboration, and limit
the probability of errors.7-9
The SBAR (situation, background, assessment, recommendation) instrument (see Table 1)
and its derivatives ISBAR, SBAR-R, ISBARR, ISOBAR fulfil this need and are widely used in
different health care facilities as a communication and hand-off tool both intra- and
interprofessional.10-13 The SBAR tool is regarded as a communication technique that
increases patient safety and is current “best practice” to deliver information in critical
situations.14
Patient safety is crucial to the delivery of effective, high-quality healthcare15 and is defined by
the World Alliance for Patient Safety of the World Health Organisation (WHO) as “the
reduction of risk of unnecessary harm associated with healthcare to an acceptable
minimum“.16 To illustrate the impact of patient safety on healthcare quality, the incidence of
adverse events is commonly cited. Following the definition of Brennan, et al.17, adverse
events are injuries that are caused by medical conduct resulting in prolonged hospitalisation
and/or producing disability at the time of discharge.
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However, the actual effect of SBAR on communication quality and patient outcome is far
from clear. The wide adoption of SBAR (or any other communication strategy) without proven
benefit may thus paradoxically limit improvements, because a problem presumably solved
will be less addressed. Thus, the purpose of this systematic review is to summarize the
available evidence and evaluate the impact of the implementation of SBAR in the clinical
setting on patient safety as measured by the incidence of adverse events.
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Table 1. The SBAR communication technique, adapted table.14 18-20
Questions Description Example
18
S Situation
What is going on with the patient? What is the situation you are calling/communicate about?
First, the speaker presents the situation, by identifying herself, stating the patient’s name and briefly describing the problem.
“Dr Preston, I’m calling about Mr. Lakewood, who’s having trouble breathing.”
B Background
What is the background or context on this patient?
The speaker then provides the background, providing the patient’s diagnosis or reason for admission, medical status and relevant history. The patient’s chart is reviewed and questions the other care provider may have are anticipated
“He’s a 54 year old man with chronic lung disease who has been sliding downhill, and now he’s acutely worse.”
A Assessment
What is the problem? Then specific information on vital signs, recent labs and other quantitative or qualitative data related to the patient’s current state are provided. This section can include a provisional diagnosis or clinical impression
“I don’t hear any breath sounds in his right chest. I think he has a pneumothorax.”
R Recommendation
What is the next step in the management of the patient?
An informed suggestion for the continued care of the patient has to be made by the speaker. The immediate need is explained clearly and specifically, including what is necessary to address the problem.
“I need you to see him right now. I think he needs a chest tube.”
The tool is available for download from the website of the Institute for Healthcare Improvement.7
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METHODS
Search strategy
A systematic search for articles published on SBAR was performed in PUBMED, EMBASE,
CINAHL, Cochrane Library, and PsycINFO via OvidSP®. The search was conducted in
January 2017. It was augmented by a review of the references of all articles included. Search
terms used in all electronic medical databases were SBAR, ISBAR, SBAR-R, ISBARR, and
ISOBAR (combined as text words with the Boolean operator ‘OR’). No restrictions were
applied in terms of time, language, or type of article. No review protocol exists.
Inclusion criteria
All original research articles on SBAR fulfilling the following eligibility criteria were included:
i) SBAR was implemented into clinical routine, ii) the investigation of SBAR was the primary
objective of the study (as opposed to e.g. SBAR as part of a larger quality improvement
initiative), and iii) at least one patient outcome was reported (see below: Data synthesis).
Exclusion criteria included: i) articles that only describe the SBAR tool but provide no
evaluation data, ii) studies that report a larger project in which SBAR played just a minor role,
and iii) studies that did not provide data on SBAR’s effects on patient safety.
Selection of studies
Studies were evaluated in two steps: 1.) Two trained reviewers (JJ, MM) reviewed all
abstracts and titles for eligibility. 2.) If the eligibility of an article could not be clearly
determined, the article was included for further full-text evaluation in a second step.
In case of dissent, the reviewers solved the divergence by consensus or, if necessary, by
involving a third reviewer (MR).
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Data extraction
The following data were extracted out of the included articles using a pre-defined form in
Microsoft® Excel for Mac 2011 (Version 14.7.2, Microsoft Corporation, Redmond,
Washington, United States): characteristics of the study (study setting, study design, and
information to evaluate the risk of bias, see below), characteristics of the study population
and possible control group (type and number of trained people), characteristics of the
intervention (type and duration), and outcome data on patients safety including time/period of
measurement). To ensure high accuracy and completeness of the data extraction by MM and
JJ, data extraction was checked by KK.
Quality assessment
Methodological quality of the studies included was assessed with the ‘Quality Assessment
Tool for Quantitative Studies’ developed by the Effective Public Health Practice Project
Canada.21 The tool is recommended by the Cochrane Collaboration22 as it evaluates the full
range of quantitative study designs. It has been evaluated for interrater reliability, content
and construct validity.23 The identified studies were assessed on 18 criteria in six domains
(selection bias, study design, confounders, blinding, data collection methods, withdrawals
and drop-outs). Studies were rated as “strong”, “moderate”, or “weak” in each domain. An
accompanying algorithm consolidates the six ratings into an overall score.
Two reviewers (JJ, MM) independently assessed the quality of each study. The final
assessment of each study was determined by consensus between the two reviewers and, if
necessary, by involving a third reviewer (WH).
Data synthesis
The intra-class correlation coefficient using Stata’s ICC command with a two-way mixed-
effects model was calculated to quantify the rater agreement on study inclusion as well as on
quality ratings of the studies included.
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The primary outcome parameter assessed were all potential aspects of patient safety (e.g.
mortality, secondary ICU admission). In accordance with the definition of the WHO, aspects
of patient safety were defined through outcome parameters measuring the occurrence or
incidence of adverse events. Thus, survey outcomes or team perceptions were excluded as
outcomes.
The heterogeneity of reported study designs, outcome measures, settings, and forms of
SBAR interventions does not allow to pool data across the included studies. Characteristics
and results of the studies are thus presented in a narrative form.
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RESULTS
Systematic review process
Article identification and inclusion is depicted in Figure 1. The literature search identified
1,053 articles. Seven hundred and one (701) articles remained after exclusion of duplicates;
607 articles were excluded after reviewing the titles and abstracts. Of the remaining 94
articles analysed in full-text, eleven articles were included into this review. The rater
agreement on inclusion was ICC=0.90 (95% CI: 0.86, 0.94). No additional studies were
identified through screening of the references of the articles included.
Quality assessment
Rater agreement on the studies quality ratings was excellent (ICC 0.85, 95% 0.78, 0.90).
Only the RCT by Field, et al.24 was rated as “strong” and one controlled trial by Randmaa, et
al.25 as ‘moderate’ in the overall study quality, while the remaining studies were rated as
‘weak’ (Figure 2). In all studies except the RCT by Field, et al.24 confounders were not
controlled for in the study design or analysis.
The applied measurement tools for data collection were evaluated as either not valid or not
reliable in six26-31 of the included studies. Only two studies used a tool with known properties
of validity and reliability or performed specific actions to increase both.31 32
Except for the study by Christie and Robinson,26 in which the selected individuals were not
described in sufficient detail, the study quality regarding selection bias was overall rated as
‘moderate’.
Patients were largely blinded to the SBAR intervention (as clinical staff was the subject of
SBAR training), although most outcome assessors must be assumed not blinded. Blinding
was not described in most of the studies resulting in a ‘moderate’ rating in this category.
We further found study reporting to be incomplete mostly. While main outcomes, study
objectives, and the applied SBAR intervention were described in all studies, there was a lack
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of reporting on statistical tests27 28 32 33 and number of persons that were trained.24 26 28 30 32 33
Sample size calculations to ensure sufficient power were not reported in any study.
In two studies29 33 the study length for evaluation of adverse events was no longer than one
month with only a small number of events reported in this time period.
Study setting and study characteristics
All identified articles were published in recent years (2006-2016). Eight of the thirteen studies
were conducted in North America,24 27-29 31-34 three studies were performed in Europe.25 26 30
Most of the studies used a before-after intervention design.26-28 30-34 In two studies, a non-
randomised controlled-trial25 29 and in one study a randomised-controlled trial24 were reported
(Table 2).
The studies focused on three different study sites: i) hospitals in seven studies,25 26 28-30 32 33 ii)
a rehabilitation centre in one study (geriatric/musculoskeletal unit27), and iii) nursing homes in
three studies.24 31 34 Some studies that introduced the SBAR tool into a hospital setting
restricted the intervention to specific units (anaesthesiological,29 surgical,25 or medicosurgical
30 33) while other introduced the SBAR tool to all departments.26 28 32 The number of staff
trained ranged from 3829 to 15525, but often was not specified (Error! Reference source not
found.).24 26 28 30 32
The study period was mainly dependent on the time period that the patient outcomes were
measured and ranged between two29 and 24 months25 31 but was not specified in two
studies.26 28
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Table 2. Study characteristics
Study Setting Study design
Target (T) and Intervention (I) Patient outcome
Haig (2006) 32
OSF St. Joseph Medical Centre Bloomington, Illinois, U.S. All departments
Before-after study
T: communication between clinicians (in verbal and written form) I: educational programs for all clinical staff
1. Adverse patient events 2. Adverse drug events No exact definitions provided. Retrospective chart review (each month 20 randomly selected charts)
Christie (2009)26
South Devon Healthcare Foundation Trust, Tobay, United Kingdom All departments
Before-after study
T: patient hand-off I: educational program for all clinical staff
1. Hospital mortality 2. Adverse events 3. Cardiac arrests 4. MRSA bacteraemias No exact definitions provided.
Andreoli (2010)27
Toronto Rehabilitation Institute, University of Toronto, Canada Geriatric and musculoskeletal rehabilitation department
Before-after study
T: team communication (for the priority issue of prevention of falls and management) I: educational program for all clinical/non-clinical staff and unit leaders
1. Incidence of Falls 2. Severity of falls (categorized in 4 levels: no harm,
minor, moderate, major) 3. Near-miss reporting No exact definitions provided. Retrospective chart review + “safety reporting” (by an online reporting system)
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Study Setting Study design
Target (T) and Intervention (I) Patient outcome
Field (2011) 24
Nursing homes (n=26), State of Connecticut, U.S.
RCT T: telephone communication between nurses and physicians (in anticoagulation management) I: educational program for all nursing staff
1. INR values within the target range (2.0 - 3.0) 2. Preventable adverse events related to warfarin-
therapy (haemorrhagic and thromboembolic events)
Quarterly reviews of nursing home records by pairs of physician-reviewers
Freitag (2011) 28
Rush Oak Park hospital, Oak Park, Illinois, U.S. All departments
Before-after study
T: nursing hand-off (between shifts and units) I: interactive teaching, nursing staff, patient care technicians
1. Inpatient Fall Rate 2. Restrained Patients Rate 3. Catheter Associated Urinary Tract Infections Rate No exact definitions provided. Retrospective chart review
Telem (2011)29
The Mount Sinai Hospital, New York, NY State, U.S. Department of Surgery
CCT T: physician hand-off (trained general surgery vs. untrained subspecialty surgery residents (n=20) I: interactive teaching for general surgery residents, subspecialty residents as controls
Sentinel events: unexpected occurrence involving death or serious physical or psychological injury or the risk thereof and necessitating immediate investigation and response Morbidity and mortality surgical database and hospital performance improvement initiative
De Meester (2013)30
Antwerp University Hospital, Antwerp, Belgium All departments (16 wards of the surgical and internal medicine department)
Before-after study
T: nursing hand-off (between shifts), communication in cases of deteriorating patients (nurses calling physicians) I: interactive teaching
Serious adverse event defined as unexpected occurrence involving death or ICU admission or call of the cardiac arrest team Retrospective analysis of medical records and internal emergency calls (performed by a trained expert)
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Study Setting Study design
Target (T) and Intervention (I) Patient outcome
Randmaa (2014)25
Country Council of Gävleborg, Sweden (University of Gävle) Department of Anaesthesiology of two clinics
CCT
T: communication in hospital (priority: physician and nurse hand-off) I: interactive teaching
Adverse events with communication failure as a root cause Prospective analysis of “safety reports” (=CIRS)
Jarboe (2015)31
Nursing centre and rehabilitation facility (n.r.), southern Maryland, U.S.
Before-after study
T: communication between nurses and physicians (in notifying providers of change in resident status) I: educational session, integration into competency training
1. Overall number of transfers to acute care hospitals
2. Types of transfers by clinical condition criteria 3. Transfers resulting in hospital admission Not specified how the data were obtained.
Pineda (2015)33
New Jersey hospital (n.r.), Medical-surgical unit
Before-after study
T: nursing hand-off I: educational session
Patient falls
Devereaux (2016)34
Nursing/post-acute care facility (n.r.), performed by University of Pittsburgh, Pennsylvania, U.S.
Before-after study
T: communication between nurses and physicians (in notifying providers of change in patient status) I: introduction of condition-specific SBARs
1. Transfers to hospital 2. Hospitalisations 3. 30-day readmissions Not specified how the data were obtained.
Abbreviations: CCT: Clinical Controlled Trial, CIRS: Critical Incident Reporting System, h: hour(s), I: intervention, ICU: Intensive Care Unit, INR: International Normalised Ratio, m: month(s), MRSA: Methicillin-Resistant Staphylococcus aureus, min: minute(s), n: number, n.s.: not specified, pre: pre intervention, post: post intervention, RCT: Randomised-Controlled Trial, SBAR: Subject Background Assessment Recommendation, T: Target, U.S.: Unites States of America
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Interventions
A detailed description of the wide range of implementation strategies of SBAR in the studies
included is provided in Error! Reference source not found..
For example, in the study by Haig, et al.32, SBAR was implemented by several actions as a
communication tool for all hospital staff. First SBAR was selected as the organisations key
project in 2005. Hospital leaders (e.g. medical director, chief nurse officer) were actively
promoting the use of SBAR among staff. Subsequently, an interdisciplinary team established
meetings twice a week for a period of one year to further support the implementation of
SBAR. Within the process, SBAR was incorporated into several hospital programs. Multiple
SBAR trigger tools (poster, pocket cards, telephone-stickers) and reporting documents in
SBAR format (e.g. shift hand-off sheet, incident reports) were disseminated within the
hospital.
In contrast, in the study by Telem, et al.29, SBAR was implemented to improve resident hand-
off for general surgery residents. A single training session of two and a half hours length was
conducted.. Each of the remaining studies implemented a particular SBAR intervention
(Error! Reference source not found.). SBAR trigger tools were used in most studies24-28 32.
Overall, identified implementation strategies were educational programs (7 studies24 26 27 30-33),
organisational / human support (7 studies24-28 32 33), and interactive teaching (7 studies25-31)
including group discussions and role-play.
SBAR was implemented for different reasons: in two studies, the aim of the intervention was
to improve team communication in general27 32 while five studies focussed on patient hand-off
either between nurses or interprofessional.25 26 28 33 The four remaining studies aimed to
improve communication in a particular situation such as telephone calls between nurses and
physicians for anticoagulation management24 or in case of patient deterioration.30 31 34
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Patient outcome
The patient outcomes varied widely over the identified studies (Table 3). Some studies
measured additional specific endpoints relevant for patient safety (e.g. cardiac arrest,
Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemias, international normalized
ratio (INR) values or catheter-associated urinary tract infection rates).
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Table 3. Patient outcome
Objective/ Study
Patient outcome Results, including one-look summary Outcome measure
Team communication in general
Haig (2006)32
Adverse patient events Decrease: 90 to 49 per 1,000 patient days# Pre: 1m Post: 12m Adverse drug events Decrease: Events from 30 to 18 per 1,000 patient days#
Andreoli (2010)27
Falls incidence Total falls showed an increasing trend on the study teams# n.r. Falls severity (4 levels) Decreasing trend across major falls (4 vs. 2) both the
organization and the study units#
Near-miss reporting Decreasing trend across both the organization and the study units#
Patient hand-off – nurses
Freitag (2011)28
Inpatient Fall Rate Reduction of 5%# n.r.
Restrained Patients Rate Reduction of 31%#
Catheter Associated Urinary Tract Infections Rate
Reduction of 34%#
Pineda (2015)33
Patient falls 2 falls (pre) vs. 0 falls (post)#
Pre: 1m Post: 1m
Patient hand-off – physician
Telem (2011)29
Sentinel events No statistical significant difference in sentinel events, general surgical vs. surgical subspecialty interns (one sentinel event)
Pre: 1m Post: 1m
Patient hand-off – physician and nurses
Randmaa (2014)25
CIRS events (communication errors)
Decrease from 31% to 11%, p<0.0001
Pre: 12m Post: 12m
Christie (2009)26
Hospital mortality 11% reduction in hospital mortality# n.r.
Adverse events 65% reduction of adverse events#
Cardiac arrests 8% reduction of cardiac arrests#
MRSA bacteraemias 83% reduction of MRSA bacteraemia#
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Objective/ Study
Patient outcome Results, including one-look summary Outcome measure
Telephone communication from nurse to doctor – anticoagulation management
Field (2011)24
INR values within the target range (2.0 - 3.0)
4.5% more time in the therapeutic range than in control homes (95% CI: 0.3%-8.7%)
55,167 resident days (intervention homes) vs. 53,601 (control)
Preventable adverse events related to warfarin-therapy
Statistically non-significant reduction, odds ratio 0.9 (95% CI: 0.5-1.4)
Telephone communication from nurse to doctor – Deteriorating/status change of a patient
De Meester (2013)30*
Unexpected death Significant decrease from 0.99 to 0.34/1000 admissions (RRR = −227%, 95% CI = −793 to −20; p < 0.001)
Pre: 10m Post: 10m
ICU admission Significant increase from 13.1 to 14.8/1000 admissions (RRR = 50%, 95% CI: 30-64%, p=0.001)
Call of cardiac arrest team No significant difference (p>0.05)
Jarboe (2015)31
Overall number of transfers to acute care hospitals
No significant difference (p = 0.482) Pre: 12m Post: 8m
Types of transfers by clinical condition criteria
No significant difference in i) preventable resident transfer group, p=0.927 or ii) emergent resident transfer groups,
Transfers resulting in hospital admission
No significant difference (p = 0.662)
Devereaux (2016)34
30-day readmissions Significant reduction, 0.12 vs. 0.04, p=0.012 Pre: 3m Post: 3m
Transfers to hospital Significant reduction, 0.44 vs. 0.24, p<0.001
Avoidable hospitalisations Significant reduction, 0.15 vs. 0.05, p=0.007
Abbreviations: CI, confidence interval, month(s), ICU: Intermediate Care Unit, n: number, n.r.: not reported, pre/post: duration of outcome measurement pre/post intervention, RRR: Relative Risk Reduction, SBAR: Subject Background Assessment Recommendation, vs.: versus
Legend: : evidence for improvement, : no evidence of a change, : reduction of patient safety, (small ( ) = descriptive improvement, big ( ) = statistically significant improvement) *and nursing hand-off (between shifts), #no statistical analysis or further information were provided.
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Team communication in general
While one of the two studies that focused on the team communication in general32 found a
reduction of adverse patient as well as of drug events, a study that focused on falls in a
rehabilitation centre27 found mixed results with a decrease in major falls, but an increase in the
incidence of overall falls. Both studies did not provide a statistical analysis of their results.
Patient hand-off
Two studies focused on patient hand-off between nursing shifts.28 33 A reduction in the number of
patient falls was reported in both studies. In addition, restrained patients rate and catheter
associated urinary tract infection rate were decreased about one third in one of these studies.28
One controlled trial evaluated the effect of SBAR vs. no-SBAR training on patient hand-offs by
physicians on surgical wards.29 The number of identified sentinel events was not statistically
different between the study groups. However, only one sentinel event was reported over the
whole study period.
Both studies that focussed on patient hand-off between physicians and nurses reported an
improvement in patient safety related outcome.25 26 The critical incidence reporting system (CIRS)
events due to communication breakdowns decreased significantly from 31% to 11%25.
Furthermore a reduction in hospital mortality (-11%), MRSA bacteraemias (-83%), adverse
events (-65%) an cardiac arrests (-8%) was found.26 While Randmaa, et al.25 conducted a
controlled clinical trial, the study design by Christie and Robinson26 was a before-after-study.
Telephone communication between nurse and physician
Three trials tried to increase the quality of telephone communication between nurse an physician
when nurses reported deterioration or other status changes of patients.30 31 34
In one study, the number of unexpected death was significantly decreased from 0.99 to 0.34 per
1000 admissions (p<0.001), while ICU admissions increased (13.1 to 14.8 per 1000 admissions)
without a significant difference in the call for a cardiac arrest team (p>0.05).30
Another trial studied transfers from nursing homes to acute care hospitals34 and found a
significant reduction in 30-day readmissions (0.12 vs. 0.04, p=0.012) and avoidable
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hospitalisations (0.15 vs. 0.05, p=0.007). Another study with a similar setting could not find
significant differences with regard to preventable patient transfers (p=0.927) or emergent patient
transfer (p=0.565).31
Field, et al.24 showed a statistically significant improvement in the management of anti-coagulated
patients in nursing centres using a randomised controlled design: the INR values of patients was
4.5% more time in the therapeutic range in the intervention homes than in control homes (95% CI
3.1%-8.7%). They further report a non-significant reduction of adverse warfarin-related events in
the intervention homes (odds ratio 0.87, 95% CI 0.54-1.4).
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DISCUSSION
This is the first systematic review to assess the effect that the implementation of a widely adopted
communication strategy has on patient related outcomes. Because communication breakdowns
have been repeatedly identified as a major source of adverse events and medical error,1 2 35
implementation of a strategy such as SBAR seems a face valid remediation approach. However,
the unreflected adoption of SBAR may paradoxically limit improvements in health care
communication, because once a problem appears to be solved, less research will be conducted
on it.
It has been previously argued that downstream targets of educational interventions (such as the
implementation of a specific communication strategy) are often difficult to assess due to possible
dilution of the effect of any intervention.36 37 Indeed, implementation of SBAR may only directly
affect communication among health professionals, which in turn may or may not affect health care
conduct, which then may result in altered patient outcome. Arguably, there are many other
effective agents along this path that may dilute the effect of SBAR implementation on patient
outcome. We would however argue that because it has been possible in the past to relate
adverse events to communication breakdowns,1 5 35 it should just as well be possible to
demonstrate the effect on patient safety of interventions targeted at remediating such
communication breakdowns.
The results of our review indeed question the wide spread adoption of SBAR, at least from a
patient safety perspective. Studies investigating the effect of SBAR on patient outcome are mostly
of limited quality and yield heterogeneous results. Many studies identified here were before-after
studies. It is thus difficult to differentiate between changes attributed to the implementation of
SBAR and changes attributable to other factors that had changed over time, such as increased
awareness.
The strongest evidence identified in our review comes from a single RCT investigating the effect
of SBAR implementation in nursing homes on anticoagulation management of patients under
warfarin.27 However, because warfarin is increasingly substituted by direct oral anticoagulants
less difficult to dose,38 the relevance of this finding may cease over time.
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Furthermore, we found strong evidence that the use of SBAR in telephone communication to
inform the physician of deteriorating patients leads to i) a significant decrease in unexpected
death39 and ii) a significant reductions in transfers to hospitals, 30-day readmissions, and
avoidable hospitalisations from nursing homes.40 Thus, SBAR implementation in telephone
communication seems to positively affect patient outcome.
Notably, no study in our review found a significant increase in the occurrence of adverse events
after to the implementation of SBAR. Thus, also SBAR implementation may not always improve
patient safety, it does at least not appear to cause any harm.
A number of studies have investigated “soft” outcomes such as employee satisfaction39 40 and
interdisciplinary communication41 42 in relation to SBAR. In those, a positive resonances of
employees after the introduction of SBAR were reported43-47 with improvements of the
communication perception and interdisciplinary teamwork48-52 as well as the quality of the
communication.25 53-58 Especially in patient hand-off the quality of the communication and the
completeness of transferred information was increased after the implementation of SBAR.26 59-61.
Furthermore, less time was needed for the patient hand-off in several studies.58 59 62 Whether and
how these findings translate to patient outcome remains to be investigated.
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CONCLUSION
In summary, many authors claim that SBAR improves patient safety, but evidence of its
effectiveness on patient outcome is limited. Future studies are needed to demonstrate the benefit
of SBAR in terms of patient safety. However, SBAR might be an adaptive tool that is suitable for
many healthcare settings, in particular when clear and effective interpersonal communication is
required.
Source of funding: none
Conflict of interest: WH has received payment from the AO Foundation Zürich for educational
consultations and congress invitations from Mundipharma Basel. All other authors report nothing
to disclose.
Contributorship: all authors contributed to the conception of the review, analysis and
interpretation of the results and the final approval of the manuscript. Study design: Martin
Müller, Jonas Jürgens, Marcus Redaèlli, Wolf Hautz, Stephanie Stock. Literature search and
assessment (acquisition of data): Martin Müller, Jonas Jürgens, Karsten Klingberg. Drafting
the manuscript: Martin Müller, Jonas Jürgens, Marcus Redaèlli, Wolf Hautz. Critical revision
of the manuscript for intellectual content: Martin Müller, Jonas Jürgens, Marcus Redaèlli,
Karsten Klingberg, Wolf Hautz, Stephanie Stock.
Data sharing statement: There are no additional data available.
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56. Woodhall LJ, Vertacnik L, McLaughlin M. Implementation of the SBAR communication
technique in a tertiary center. JEN: Journal of Emergency Nursing 2008;34(4):314-17.
57. Wyckoff A, Larsen K, Alexander R, et al. Huntsman Cancer Hospital SBAR project. Oncology
Nursing Forum 2009;36(3):12-12.
58. Zhu H, McCrea N, Kelsall W. Improving the paediatric handover: Quality, safety and SBAR.
Archives of Disease in Childhood 2014;99:A82.
59. Cornell P, Townsend Gervis M, Yates L, et al. Impact of SBAR on Nurse Shift Reports and
Staff Rounding. MEDSURG Nursing 2014;23(5):334-42.
60. Moseley BD, Smith JH, Diaz-Medina GE, et al. Standardized sign-out improves completeness
and perceived accuracy of inpatient neurology handoffs. Neurology 2012;79(10):1060-64.
61. Thompson JE, Collett LW, Langbart MJ, et al. Using the ISBAR handover tool in junior
medical officer handover: a study in an Australian tertiary hospital. Postgraduate Medical
Journal 2011;87(1027):340-44.
62. Sohi D, Scotney E, Sowerbutts H, et al. Significantly improving the efficiency of
communication in paediatrics. Archives of Disease in Childhood 2011;96:A90-A91.
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FIGURE AND APPENDIX LEGENDS
Figure 1. Flowchart of the systematic review process
Abbreviations: SBAR, Situation Background Assessment Recommendation.
Figure 2. Quality assessment of the included study
Error! Reference source not found.
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Flowchart of the systematic review process Abbreviations: SBAR, Situation Background Assessment Recommendation.
279x361mm (300 x 300 DPI)
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Quality assessment of the included study
114x191mm (300 x 300 DPI)
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Appendix A. Details of the implemented intervention
Study Activities Objective(s) Who was trained?
How many were trained?
Haig (2006)32
1. Educational programs (class or video) – Incorporation in several hospital programs 2. Trigger tools* 3. Organizational/human support: – leadership (human and financial support) – interdisciplinary spread team
Communication between clinicians (in verbal and written form)
All clinical staff n.r.
Christie (2009)26
1. Interactive teaching – simulated scenarios 2. Educational programs (class or video, 10-15min) 3. Trigger tools* 4. Organizational/human support – project team (meetings fortnightly) – SBAR as structure in trust meetings
Patient hand-off All clinical staff n.r.
Andreoli (2010)27
1. Interactive teaching – role-playing (real-life case examples) 2. Educational programs (class or video, 4h) 3. Trigger tools* 4. Organizational/human support – “SBAR champions” – project team (weekly meetings)
Team communication (for the priority issue of falls prevention and management)
All clinical staff non-clinical staff unit-leaders
85
Field (2011)24
1. Educational programs (class or video) – training (for one representative of each nursing
home) 2. Trigger tools* 3. Organizational/human support – calls with the representative of nursing home
Telephone communication between nurses and physicians (in anticoagulation management)
Nursing staff n.r.
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Study Activities Objective(s) Who was trained?
How many were trained?
Freitag (2011)28
1. Interactive teaching – staff coaching within work (initial phase) 2. Educational programs (class or video, 1h) 3. Trigger tools* 4. Organizational/human support – project team – SBAR champion
Nursing hand-off (between shifts and units)
Nursing staff Patient care technicians
n.r.
Telem (2011)29
Interactive teaching (2,5h) – video scenarios – role-playing – group discussions
Physician hand-off General surgery
45
De Meester (2013)30
1. Interactive teaching (2-days, for 1-2 “reference nurse”/ward)
– group discussions, coaching – role-playing 2. Training session (2h, for all nurses by „reference
nurses“) 3. Educational programs (class or video, 4h)
Nursing hand-off (between shifts) Communication in cases of deteriorating patients (nurses calling physicians)
Nursing staff n.r.
Randmaa (2014)25
1. Interactive teaching – role-playing 2. Trigger tools* 3. Organisational/human report – active motivation to use SBAR in clinical practice
Communication in hospital (priority physician hand-off & nurse hand-off)
All clinical staff n.r.
Jarboe (2015)31
1. Educational session (mandatory, 1h) – training to use the SBAR communication tool 2. Organisational/human support – policy change – integration of SBAR into the annual nurse
competency training
Communication between nurses and physicians (in notifying providers of change in resident status)
Nursing staff 66
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Study Activities Objective(s) Who was trained?
How many were trained?
Pineda (2015)33
1. Educational session – four separate staff meetings 2. Organisational/human support – integration of SBAR into nursing hand-off
Nursing hand-off (between shifts)
Nursing staff n.r.
Devereaux (2016)34
Introduction of condition-specific SBARs for the most common reasons for transfer to acute care hospitals
Communication between nurses and physicians (in notifying providers of change in resident status)
Nursing staff
60
Abbreviations:, FA, First author, h: hour(s), m: month(s), min: minute(s), n: number, n.r.: not reported, SBAR: Subject Background Assessment Recommendation
* Trigger tools such as poster/pocket cards, telephone-stickers, screensavers, sheets in SBAR format
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PRISMA 2009 Checklist
Section/topic # Checklist item Reported
on page #
TITLE
Title 1 Identify the report as a systematic review, meta-analysis, or both. 1
ABSTRACT
Structured summary 2 Provide a structured summary including, as applicable: background; objectives; data sources; study eligibility criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions and
implications of key findings; systematic review registration number.
2
INTRODUCTION
Rationale 3 Describe the rationale for the review in the context of what is already known. 3
Objectives 4 Provide an explicit statement of questions being addressed with reference to participants, interventions, comparisons, outcomes, and study design (PICOS).
4
METHODS
Protocol and registration 5 Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if available, provide registration information including registration number.
6
Eligibility criteria 6 Specify study characteristics (e.g., PICOS, length of follow!up) and report characteristics (e.g., years considered,
language, publication status) used as criteria for eligibility, giving rationale. 6
Information sources 7 Describe all information sources (e.g., databases with dates of coverage, contact with study authors to identify additional studies) in the search and date last searched.
6
Search 8 Present full electronic search strategy for at least one database, including any limits used, such that it could be repeated.
6
Study selection 9 State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable,
included in the meta!analysis). 6+7
Data collection process 10 Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators.
7
Data items 11 List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and
simplifications made. 7
Risk of bias in individual
studies
12 Describe methods used for assessing risk of bias of individual studies (including specification of whether this was
done at the study or outcome level), and how this information is to be used in any data synthesis. 7
Summary measures 13 State the principal summary measures (e.g., risk ratio, difference in means). 7+8
Synthesis of results 14 Describe the methods of handling data and combining results of studies, if done, including measures of consistency
(e.g., I2
) for each meta!analysis. 8
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PRISMA 2009 Checklist
Section/topic # Checklist item Reported
on page #
Risk of bias across studies 15 Specify any assessment of risk of bias that may affect the cumulative evidence (e.g., publication bias, selective
reporting within studies). -
Additional analyses 16 Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta-regression), if done, indicating
which were pre!specified. -
RESULTS
Study selection 17 Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally with a flow diagram.
Figure 1
Study characteristics 18 For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period) and provide the citations.
Table 2
Risk of bias within studies 19 Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12). Figure 2
Results of individual studies 20 For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each
intervention group (b) effect estimates and confidence intervals, ideally with a forest plot. Table 3
Synthesis of results 21 Present results of each meta-analysis done, including confidence intervals and measures of consistency. -
Risk of bias across studies 22 Present results of any assessment of risk of bias across studies (see Item 15). -
Additional analysis 23 Give results of additional analyses, if done (e.g., sensitivity or subgroup analyses, meta-regression [see Item 16]). -
DISCUSSION
Summary of evidence 24 Summarize the main findings including the strength of evidence for each main outcome; consider their relevance to key groups (e.g., healthcare providers, users, and policy makers).
20+21
Limitations 25 Discuss limitations at study and outcome level (e.g., risk of bias), and at review-level (e.g., incomplete retrieval of identified research, reporting bias).
21+22
Conclusions 26 Provide a general interpretation of the results in the context of other evidence, and implications for future research. 23
FUNDING
Funding 27 Describe sources of funding for the systematic review and other support (e.g., supply of data); role of funders for the systematic review.
23
From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed1000097
For more information, visit: www.prisma!statement.org.
Page 2 of 2
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The impact of the communication and patient hand-off tool
SBAR on patient safety – a systematic review
Journal: BMJ Open
Manuscript ID bmjopen-2018-022202.R1
Article Type: Research
Date Submitted by the Author: 17-May-2018
Complete List of Authors: Müller, Martin; Inselspital Universitatsspital Bern, Department of Emergency Medicine; Universitat zu Koln Institut fur Gesundheitsokonomie und Klinische Epidemiologie Jürgens, Jonas; Universitat zu Koln Institut fur Gesundheitsokonomie und Klinische Epidemiologie Redaelli, Marcus; Universitat zu Koln Institut fur Gesundheitsokonomie und Klinische Epidemiologie Klingberg, Karsten; Inselspital Universitatsspital Bern, Department of
Emergency Medicine Hautz, Wolf; Inselspital, University of Bern, Department of Emergency Medicine Stock, Stephanie; Universitat zu Koln Institut fur Gesundheitsokonomie und Klinische Epidemiologie
<b>Primary Subject Heading</b>:
Evidence based practice
Secondary Subject Heading: Communication, Evidence based practice, Medical management
Keywords:
ACCIDENT & EMERGENCY MEDICINE, Information management < BIOTECHNOLOGY & BIOINFORMATICS, EDUCATION & TRAINING (see Medical Education & Training), Health & safety < HEALTH SERVICES
ADMINISTRATION & MANAGEMENT, Quality in health care < HEALTH SERVICES ADMINISTRATION & MANAGEMENT
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1
The impact of the communication and patient hand-off tool
SBAR on patient safety – a systematic review
Martin Müller1,2, Jonas Jürgens2, Marcus Redaèlli2, Karsten Klingberg1, Wolf E. Hautz1,
Stephanie Stock2
1 Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern,
Bern, Switzerland.
2 Institute of Health Economics and Clinical Epidemiology, University Hospital of Cologne,
Cologne, Germany.
MM: martin.mueller2@insel.ch
JJ: jonasjuergens@gmx.de
MR: marcus.redaelli@uk-koeln.de
KK: k.klingberg@vodafone.de
WH: wolf.hautz@insel.ch
SS: stephanie.stock@uk-koeln.de
Address of correspondence
Martin Müller, Dr. med. Dipl.-Math. M. Sc.,
Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern,
Bern, Switzerland. Phone: +41 (0)31 632 2111. Fax: +41 (0)31 632 24 50.
E-mail: martin.mueller2@insel.ch
Manuscript word count: 4006 (Introduction – Conclusions, excluding Tables)
Abstract word count: 298
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ABSTRACT
Objectives: Communication breakdown is one of the main causes of adverse events in
clinical routine, particularly in handover situations. The communication tool SBAR (Situation,
Background, Assessment, and Recommendation) was developed to increase handover
quality and is widely assumed to increase patient safety. The objective of this review is to
summarise the impact of the implementation of SBAR on patient safety.
Design: A systematic review of articles published on SBAR was performed in PUBMED,
EMBASE, CINAHL, Cochrane Library, and PsycINFO in January 2017. All original research
articles on SBAR fulfilling the following eligibility criteria were included: i) SBAR was
implemented into clinical routine, ii) the investigation of SBAR was the primary objective, and
iii) at least one patient outcome was reported.
Setting: A wide range of settings within primary and secondary care and nursing homes.
Participants: A wide range of sociodemographic groups.
Primary and secondary outcome measures: Aspects of patient safety (patient outcomes)
defined as the occurrence or incidence of adverse events
Results: Eight studies with a before-after design and three controlled clinical trials performed
in different clinical settings met the inclusion criteria. The objectives of the studies were to
improve team communication, patient hand-offs, and communication in telephone calls from
nurses to physicians. The studies were heterogeneous with regard to study characteristics,
especially patient outcomes. In total, 26 different patient outcomes were measured, of which
eight were reported to be significantly improved. Eleven were described as improved but no
further statistical tests were reported, and six outcomes did not change significantly. Only
one study reported a descriptive reduction in patient outcomes.
Conclusions: This review found moderate evidence for improved patient safety through
SBAR implementation, especially when used to structure communication over the phone.
However, there is a lack of high quality research on this widely used communication tool.
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Trial registration: none
Key words: SBAR, hand-off situation, interprofessional communication, patient safety,
adverse event
Strengths and limitations
• This systematic review was conducted in accordance with the Cochrane
Collaboration standards using a validated tool for quality assessment of the identified
studies.
• Five well-known databases as well as the references of the included studies were
searched using an open search strategy. Only one randomized-controlled trial, two
controlled clinical trials and eight before-after studies could be included in the
analysis.
• Reliability of the study selection, data extraction and rating of the study quality was
ensured using two independent reviewers. Due to heterogeneity of the studies, it was
not possible to test for publication bias, a potential important bias in this field.
• We did not differentiate the broad range of adverse events or sentinel events, but
subsume them under patient safety in order to provide a first insight into the
relationship between SBAR and patient safety. Therefore, a large heterogeneity of
the study outcomes and study settings impeded a direct comparison or pooling of the
outcomes.
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INTRODUCTION
“To Err Is Human”, a milestone to raise awareness for patient safety, was published almost
twenty years ago. In this report, the Institute of Medicine estimated that between 44,000 and
98,000 patients die due to medical errors in the United States annually.1 Studies in
subsequent years found that even these numbers are likely underestimated.2-4 Consequently,
more deaths result from medical error then are caused by motor vehicle accidents, breast
cancer, or Acquired Immune Deficiency Syndrome (AIDS). Among these errors,
communication breakdowns are frequent. The Joint Commission reported that poor
communication was a contributing factor in more than 60% of all events they reviewed.5
Poor communication is found in many different health care settings and is especially
prominent in patient hand-offs and settings were fast and effective management is
indispensable. Such settings include the perioperative period,6 the intensive care unit (ICU),7
and the emergency department (ED).8 The components and processes of communications
are complex and prone to misunderstanding.9 To overcome these barriers, communication
strategies are desirable which take little time and effort to complete, deliver comprehensive
information efficiently, encourage interprofessional collaboration, and limit the probability of
error.10-12 The SBAR (situation, background, assessment, recommendation) instrument (see
Table 1) and its derivatives ISBAR, SBAR-R, ISBARR, ISOBAR fulfil this need and are
widely used in different health care facilities as a communication and hand-off tool both intra-
and interprofessionaly.13-16 By virtue of a clear structure, SBAR calls for the provision of all
relevant information, organized in a logical fashion.17 Furthermore, it enables a preparation
before the communication process,17 18 and because sender and receiver share the same
mental model, understanding and awareness are expected to be higher.19 Besides, it
reduces inhibitions especially in hierarchical context by encouraging the sender to provide a
personal assessment and suggestion of the situation (“Recommendation”).20 The SBAR tool
is regarded as a communication technique that increases patient safety and is current “best
practice” to deliver information in critical situations.17 21
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Patient safety is crucial for the delivery of effective, high-quality healthcare22 and is defined
by the World Alliance for Patient Safety of the World Health Organisation (WHO) as “the
reduction of risk of unnecessary harm associated with healthcare to an acceptable
minimum“.23 To illustrate the impact of patient safety on healthcare quality, the incidence of
adverse events is commonly cited. Following the definition of Brennan, et al.24, adverse
events are injuries that are caused by medical conduct resulting in prolonged hospitalisation
and/or disability at the time of discharge.
A number of studies have investigated “soft” outcomes such as employee satisfaction25 26
and interdisciplinary communication27 28 in relation to SBAR. Positive resonances of
employees after the introduction of SBAR were reported29-33 with improvements of the
communication perception and interdisciplinary teamwork34-38 as well as the quality of the
communication.39-45 Especially in patient hand-off the quality of the communication and the
completeness of transferred information was increased after the implementation of SBAR.46-
49. Furthermore, less time was needed for the patient hand-off in several studies.45 47 50
However, the actual effect of SBAR on patient outcome is unclear. The wide adoption of
SBAR (or any other communication strategy) without proven benefit may paradoxically limit
improvements, because a problem presumably solved will be less addressed. Thus, the
purpose of this systematic review is to summarize the available evidence for and evaluate
the impact of the implementation of SBAR in clinical settings on patient safety as measured
by the incidence of adverse events.
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Table 1. The SBAR communication technique, adapted table17 19 51 52
Questions Description Example
S Situation
What is going on with the patient? What is the situation you are calling/communicate about?
First, the speaker presents the situation, by identifying himself, stating the patient’s name and briefly describing the problem.
“Dr Preston, I’m calling about Mr Lakewood, who’s having trouble breathing.”
B Background
What is the background or context on this patient?
The speaker then provides the background, such as the patient’s diagnosis or reason for admission, medical status and relevant history. The patient’s chart is reviewed and questions the other care provider may have are anticipated
“He’s a 54 year old man with chronic lung disease who has been sliding downhill, and now he’s acutely worse.”
A Assessment
What is the problem? Then specific information on vital signs, recent labs and other quantitative or qualitative data related to the patient’s current state are provided. This section can include a provisional diagnosis or clinical impression
“I don’t hear any breath sounds in his right chest. I think he has a pneumothorax.”
R Recommendation
What is the next step in the management of the patient?
An informed suggestion for the continued care of the patient has to be made by the speaker. The immediate need is explained clearly and specifically, including what is necessary to address the problem.
“I need you to see him right now. I think he needs a chest tube.”
The tool is available for download from the website of the Institute for Healthcare Improvement.10
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METHODS
Search strategy
A systematic search for articles published on SBAR was performed in PUBMED, EMBASE,
CINAHL, Cochrane Library, and PsycINFO via OvidSP®. The search was conducted in
January 2017. It was augmented by a review of the references of all articles included. Search
terms used in all electronic medical databases were SBAR, ISBAR, SBAR-R, ISBARR, and
ISOBAR (combined as text words with the Boolean operator ‘OR’). The detailed search
strategy is provided in Appendix A. No restrictions were applied in terms of time, language,
or type of article. No review protocol exists.
Eligibility criteria
All original research articles on SBAR fulfilling the following eligibility criteria were included:
• SBAR was implemented into clinical routine,
• the investigation of SBAR was the primary objective of the study (as opposed to e.g.
SBAR as part of a larger quality improvement initiative),
• at least one patient outcome was reported (e.g. mortality or secondary ICU
admission). In accordance with the definition of the WHO23, aspects of patient safety
(patient outcomes) were defined through outcome parameters measuring the
occurrence or incidence of adverse events.
Exclusion criteria were:
• articles that only describe the SBAR tool but provide no evaluation data on patient
outcome,
• studies that report a larger project in which SBAR was not the main intervention under
investigation (because in such studies the attribution of any effect to SBAR is
impossible),
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• studies that only report, survey outcomes or team perceptions.
Selection of studies
Studies were evaluated in two steps: 1.) Two trained reviewers (JJ, MM) reviewed all
abstracts and titles for eligibility. 2.) If the eligibility of an article could not be clearly
determined, the article was included for further full-text evaluation in a second step.
In case of dissent, the reviewers solved the divergence by consensus or, if necessary, by
involving a third reviewer (MR).
Data extraction
The following data were extracted out of the included articles using a pre-defined form in
Microsoft® Excel for Mac 2011 (Version 14.7.2, Microsoft Corporation, Redmond,
Washington, United States): characteristics of the study (study setting, study design, and
information to evaluate the risk of bias, see below), characteristics of the study population
and possible control group (type and number of trained people), characteristics of the
intervention (type and duration), and outcome data on patients safety including time/period of
measurement). To ensure high accuracy and completeness of the data extraction by MM and
JJ, data extraction was checked by KK.
Quality assessment
Methodological quality of the studies included was assessed with the ‘Quality Assessment
Tool for Quantitative Studies’ developed by the Effective Public Health Practice Project
Canada.53 The tool is recommended by the Cochrane Collaboration54 as it evaluates the full
range of quantitative study designs. It has been evaluated for interrater reliability, content
and construct validity.55 The identified studies were assessed on 18 criteria in six domains
(selection bias, study design, confounders, blinding, data collection methods, as well as
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withdrawals and drop-outs). Studies were rated as “strong”, “moderate”, or “weak” in each
domain. An accompanying algorithm consolidates the six ratings into an overall score.
Two reviewers (JJ, MM) independently assessed the quality of each study. The final
assessment of each study was determined by consensus between the two reviewers and, if
necessary, by involving a third reviewer (WH).
Data synthesis
The intra-class correlation coefficient using Stata’s ICC command with a two-way mixed-
effects model was calculated to quantify the rater agreement on study inclusion as well as on
quality ratings of the studies included.
The heterogeneity of reported study designs, outcome measures, settings, and forms of
SBAR interventions does not allow to pool data across the studies that met the inclusion
criteria. Characteristics and results of the studies are presented in a narrative form.
Patient and Public Involvement
No patients were involved in the design, recruitment or conduct of the study. The results of
this review will not be disseminated to patients included in the trials of the review.
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RESULTS
Systematic review process
Article identification and inclusion is depicted in Figure 1. The literature search identified
1,053 articles. Seven hundred and one (701) articles remained after exclusion of duplicates;
607 articles were excluded after reviewing the titles and abstracts. Of the remaining 94
articles analysed in full-text, eleven articles were included into this review. The rater
agreement on inclusion was ICC=0.90 (95% CI: 0.86, 0.94). No additional studies were
identified through screening of the references of the included articles.
Quality assessment
Rater agreement on the studies quality ratings was excellent (ICC 0.85, 95% 0.78, 0.90).
The RCT by Field, et al.56 was rated as “strong” and one controlled trial by Randmaa, et al.42
as ‘moderate’ in the overall study quality, while the remaining nine studies were rated as
‘weak’ (Figure 2).
Three studies were rated as strong in the study design category as they were controlled
clinical trials.42 56 57 Eight studies used a before-after study design resulting in a weak rating in
the study design category.
Except for the study by Christie and Robinson,46 in which the selected individuals were not
described in sufficient detail, the study quality regarding selection bias was rated as
‘moderate’.
The study by Field, et al.56 used a randomized controlled trial as a design with facility as a
randomization unit. Thus, by study design the results were controlled for potential (known
and unknown) confounders such as infrastructure, patient safety culture, and management.
No other study controlled for confounders in the study design or analysis (weak rating).
While main outcomes, study objectives, and the applied SBAR intervention were described in
all studies, blinding was not described in any, but one of the studies (9.1%), resulting in a
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‘moderate’ rating in this category. In one of the controlled trials56, the reviewers who rated the
patient safety outcome were blinded in regard to the intervention (strong rating).
Overall, there was a lack of reporting on statistical tests58-61 and number of persons that were
trained.46 56 58 60-62 Sample size calculations to ensure sufficient power were not reported in
any of the studies.
Study setting and study characteristics
Eight of the analysed studies (72.7%) used a before-after intervention design,46 58-64 while in
two studies (18.2%) a non-randomised controlled-trial42 57 and in one study (9.2%) a
randomised-controlled trial56 were reported.
All identified articles were published in recent years (2006-2016). Eight (72.7%) of the eleven
studies were conducted in North America,56-61 63 64 the remaining three (27.3%) were
performed in Europe.42 46 62
The studies focused on three different study sites: i) hospitals in seven studies (63.6%),42 46 57
58 60-62 ii) a rehabilitation centre (geriatric/musculoskeletal unit) in one study59 (9.2%), and iii)
nursing homes in three studies (27.3%).56 63 64 Four of the studies that introduced the SBAR
tool into a hospital setting restricted the intervention to specific units (anaesthesiological,57
surgical,42 or medicosurgical61 62) while three trials introduced the SBAR tool to all
departments.46 58 60 Nurses were trained in the use of SBAR in all studies. In five studies
(45.5%), additionally other clinical staff e.g. physicians were trained also.42 46 57-59 The number
of staff members trained ranged from 3857 to 15542, but was not specified in five studies 46 56
58 60 62 (Appendix B).
The study period was mainly dependent on the time period that the patient outcomes were
measured and ranged between two57 and 24 months42 63 and was not specified in two
studies.46 60
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Intervention targets
A detailed description of the wide range of implementation strategies of SBAR in the studies
included is provided in Appendix C.
In two studies (18.2%), the aim of the intervention was to improve team communication in
general58 59 while five studies (45.5%) focused on patient hand-offs either between nurses or
interprofessional.42 46 60 61 The four remaining studies (36.4%) aimed to improve
communication in a particular situation such as telephone calls between nurses and
physicians for anticoagulation management56 or in case of patient deterioration.62-64
Implementation strategies were educational programs (7 studies46 56 58 59 61-63), organisational
/ human support (7 studies42 46 56 58-61), and interactive teaching (7 studies42 46 57 59 60 62 63)
including group discussions and role-play. Additional SBAR trigger tools (poster, pocket
cards, telephone-stickers) were used in six studies (54.5%).42 46 56 58-60
Patient outcome
All studies included assessed the effect of SBAR implementation on the outcome of
inpatients, none the outcome of outpatients. The patient outcomes and outcome
measurements varied widely over the identified studies (Appendix D). Three studies (27.3%)
measured general patient outcomes such as adverse patient/drug events46 57 58, while the
remaining eight studies (72.7%) used specific adverse event outcomes such as
anticoagulation related56 and patient-fall related adverse events59-61 as well as unplanned
events such as ICU admissions,62 death/cardiac arrests,46 62 and transfer to hospitals.63 64
Other patient outcomes included Methicillin-resistant Staphylococcus aureus (MRSA)
bacteraemias46 and catheter-associated urinary tract infection rates.60
The duration of measurement of the patient outcomes in the pre/controlled phase
respectively the post/intervention phase ranged from one month57 61 to twelve months42 and
was not reported in three studies.46 59 60 Three of the studies42 58 62 controlled the use of SBAR
by staff survey or review of medical records and identified high use rates within daily routine.
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Effect of SBAR on patient outcomes
Overall summary
The main study characteristics and the effects of SBAR on the studied patient outcomes are
summarised in Table 2.
In total, 26 different patient outcomes were measured. Of these, eight outcomes measured in
five studies42 56 61 62 64 significantly improved and eleven patient outcomes measured in four
before-after studies46 58-60 are described as improving without the report of a statistical test.
Six outcomes did not change significantly. One study descriptively reported an increase of
adverse events,59 none found a significant reduction of patient safety. The reported results of
the studies are shown in detail in Appendix D.
Team communication in general
While one of the two before-after studies that focused on team communication in general58
found a reduction of adverse patient as well as of drug events, a study that focused on falls
in a rehabilitation centre59 found mixed results with a decrease in major falls, but an increase
in the incidence of overall falls. Both studies did not provide a statistical analysis of their
results.
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Table 2. Study characteristics and outcomes sorted by effect on patient safety, study design, and year. If a study reported
outcomes with different effects on patient safety, the study results are listed separately
Study Design Setting How SBAR was used Patient outcome defined as Effect
Field (2011)56 RCT Nursing home
Telephone communication from nurse to doctor – Anticoagulation management
INR values within the target range
Randmaa (2014)42
CCT Hospital Patient hand-off – physician and nurses CIRS events (communication errors)
De Meester (2013)62*
BAS Hospital Telephone communication from nurse to doctor – Deteriorating/status change of a patient
i) Unexpected death and ii) ICU admission
Pineda (2015)61 BAS Hospital Patient hand-off – nurses Patient falls
Devereaux (2016)64
BAS Nursing home
Telephone communication from nurse to doctor – Deteriorating/status change of a patient
i) 30-day readmissions ii), transfers to hospital, and iii) avoidable hospitalisations
Haig (2006)58 BAS Hospital Team communication in general i) Adverse patient and ii) drug events
Andreoli (2010)59
BAS Rehab. clinic
Team communication in general i) Falls severity (4 levels), ii) near-miss reporting
Freitag (2011)60 BAS Hospital Patient hand-off – nurses i) Inpatient Fall Rate, ii) Restrained Patients Rate, and iii) Catheter Associated UTI
Christie (2009)46
BAS Hospital Patient hand-off – physician and nurses i) Hospital mortality, ii) adverse events, iii) cardiac arrests, iv) MRSA bacteriaemias
Field (2011)56 RCT Nursing home
Telephone communication from nurse to doctor – Anticoagulation management
Preventable AE related to warfarin-therapy
Telem (2011)57 CCT Hospital Patient hand-off – physician Sentinel events
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Study Design Setting How SBAR was used Patient outcome defined as Effect
De Meester (2013)62*
BAS Hospital Telephone communication from nurse to doctor – Deteriorating/status change of a patient
Call of cardiac arrest team
Jarboe (2015)63 BAS Nursing homes
Telephone communication from nurse to doctor – Deteriorating/status change of a patient
i) Overall number of transfers to acute care hospitals, ii) types of transfers by clinical condition criteria, iii) transfers resulting in hospitalization
Andreoli (2010)59
BAS Rehab. clinic
Team communication in general Falls incidence
Abbreviations: AE: Adverse Event, BAS: Before-After-Study, CCT: Clinical Controlled Trial, CIRS: Critical Incident Reporting System: ICU: Intensive Care Unit, INR: International Normalized Ratio, MRSA: Methicillin-Resistant Staphylococcus Aureus, RCT: Randomized Controlled Trial, UTI: Urinary Tract Infection. Legend: : : Statistically significant evidence for improvement, : descriptive evidence for improvement (no statistical test reported), : no significant evidence of a change, : descriptive reduction of patient safety. *and nursing hand-off (between shifts)
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Patient hand-off
All, but one57 of the five studies42 46 57 60 61 that focused on patient hand-offs reported an
improvement of patient safety. Two before-after studies focused on patient hand-off between
nursing shifts.60 61 A reduction in the number of patient falls was reported in both studies. In
addition, restrained patients rate and catheter associated urinary tract infection rate decreased
about one third in one of these studies.60 Both studies that focused on patient hand-offs between
physicians and nurses reported an improvement in patient safety related outcome.42 46
In a controlled clinical trial in a hospital (department of anaesthesiology of two clinics), the critical
incidence reporting system (CIRS) events due to communication breakdowns decreased
significantly from 31% to 11%42 and one before-after-study of a hospital found a reduction in
hospital mortality (-11%), MRSA bacteraemias (-83%), adverse events (-65%), and cardiac
arrests (-8%) after SBAR implementation (no further statistical analysis reported).46
One controlled clinical trial evaluated the effect of SBAR vs. no-SBAR training on patient hand-offs
by physicians on surgical wards.57 The number of identified sentinel events was not statistically
different between the study groups. One sentinel event was reported over the whole study period.
Telephone communication between nurse and physician
Three trials tried to increase the quality of telephone communication between nurse and physician
when nurses reported deterioration or other status changes of patients.62-64 Two studies reported
significant improvements in the study patient outcome under investigation while one study could
not find a significant change.64
Field, et al.56 showed a statistically significant improvement in the management of anti-coagulated
patients in nursing centres using a randomised controlled design: the INR value of patients was
4.5% more time within in the therapeutic range in the intervention homes than in control homes
(95% CI 3.1%-8.7%). They further reported a non-significant reduction of adverse warfarin-related
events in the intervention homes (odds ratio 0.9, 95% CI 0.5-1.4).
In one before-after study, the number of unexpected death was significantly decreased from 0.99
to 0.34 per 1000 admissions (p<0.001), while ICU admissions increased (13.1 to 14.8 per 1000
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admissions) without a significant difference in the frequency with which a cardiac arrest team was
called.62
Another before-after trial studied transfers from nursing homes to acute care hospitals64 and found
a significant reduction in 30-day readmissions (0.12 vs. 0.04, p=0.012) and avoidable
hospitalisations (0.15 vs. 0.05, p=0.007). A study with a similar setting, but a longer study period
(20 months vs. 6 months) could not find significant differences with regard to preventable patient
transfers (p=0.927) or emergent patient transfer (p=0.565).63
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DISCUSSION
Summary of main results
The present systematic review assesses the effect of the implementation of the widely adopted
communication strategy SBAR on patient related outcomes. Because communication breakdowns
have been repeatedly identified as a major source of adverse events and medical error,1 5 65
implementation of a strategy such as SBAR seems a valid remediation approach.
Eleven studies, eight with a before-after design and three controlled trials, met the inclusion criteria.
SBAR was implemented through different strategies in three different clinical settings (hospitals,
rehabilitation centre, and nursing homes) and with a broad range of objectives to improve i) team
communication in general, ii) intra- and interdisciplinary patient hand-offs, and iii) communication in
telephone calls from nurses to physicians. In total, 26 different patient outcomes were measured.
Eight significantly improved, eleven were described as improving (but no further statistical test
were reported), six outcomes did not change significantly, and one study reported a descriptive
reduction in patient outcomes. The overall study quality was high or moderate in two studies only,
all other studies showed a weak study quality.
Quality of the evidence
The strongest evidence identified in our review comes from a single RCT investigating the effect of
SBAR implementation in nursing homes on anticoagulation management of patients under
warfarin.27 However, because warfarin is increasingly substituted by direct oral anticoagulants less
difficult to dose,66 the relevance of this finding may cease over time. Furthermore, adverse events
related to warfarin therapy, the primary outcome parameter in this study, did not differ significantly
between the intervention and control group. We found further evidence that the use of SBAR in
telephone communication to inform the physician of a deteriorating patient leads to i) a significant
decrease in unexpected death26 and ii) a significant reductions in transfers to hospitals, 30-day
readmissions, and avoidable hospitalisations from nursing homes.25 Therefore, SBAR
implementation in telephone communication seems to positively affect patient outcome. However,
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one study conducted in a similar setting63 (nursing home, unplanned hospital admission) but with a
longer study period could not find any significant difference between the pre and post
implementation phase in the patient outcomes. One explanation for the differences in the findings
might be, that the use of SBAR (not reported in the two studies) decreased over time, thus the
effect vanished.
Study periods were short at least in two trials57 61 (two months only). As a consequence, only one
sentinel event in one controlled clinical trial57 over the study period was reported.
Power calculations were missing in all studies. Thus, the lack of significant differences between the
groups in these studies could not be interpreted adequately. Furthermore, in almost half of the
reported outcomes, no statistical tests were performed. Notably, no study in our review found a
significant increase in the occurrence of adverse events after to the implementation of SBAR, but
Andreoli et al. (2010) descriptively reported an increase in fall incidence while the fall severity was
reduced at the same time. This study’s findings illustrate the difficulty with most of the studies
findings included in the review. Some might argue, that the implementation of SBAR in patient fall
reporting has just led to an increased awareness regarding patient falls. Consequently, the
reporting of patient falls and especially of less severe falls increased, resulting in a decrease of the
patient fall severity overall.
It has been previously argued that downstream targets of educational interventions (such as the
implementation of a specific communication strategy) are often difficult to assess due to possible
dilution of the effect of any intervention.67 68 Indeed, implementation of SBAR may only directly
affect communication among health professionals, which in turn may or may not affect health care
conduct, which then may result in altered patient outcome. Arguably, there are many other
effective agents along this path that may dilute the effect of SBAR implementation on patient
outcome. We would argue that because it has been possible in the past to relate adverse events to
communication breakdowns,1 8 65 it should just as well be possible to demonstrate the effect on
patient safety of interventions targeted at remediating such communication breakdowns.
One reason for the current failure to demonstrate such effects may be that studies investigating the
effect of SBAR on patient outcome are mostly of limited quality and yield heterogeneous results.
Many studies identified were before-after studies. It is thus difficult to differentiate between
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changes attributed to the implementation of SBAR and changes attributable to other factors that
had changed over time, such as increased awareness. Process measures in regard to parameters
of communication were not measured in any of the included studies, but several not included
studies suggest an improvement of communication through the implementation of SBAR.39-45 The
lack of process measures within the included studies reduces internal validity and impedes the
interpretation of the present results with regard to causation. Consequently, the unreflected
adoption of SBAR may paradoxically limit improvements in health care communication, because
once a problem appears to be solved, less research will be conducted on it.
Limitations
This systematic review has some limitations. Efforts were undertaken to identify all relevant trials to
evaluate the impact of SBAR implementation in clinical practice on patient safety. Five well-known
databases as well as the references of the studies that met the inclusion criteria were searched
using an open search strategy. No grey literature was searched, thus trials could have been
missed. Further, we did not contact any author to ask for raw data to perform additional statistical
analysis. Publication bias could not be assessed leading to an important source of bias. The
heterogeneity of the data impeded a meta-analysis. This systematic review was conducted in
accordance with the Cochrane Collaboration standards using a validated tool for quality
assessment of the identified studies. Reliability of the study selection, data extraction and rating of
the study quality was ensured using two independent reviewers. We did not differentiate the broad
range of adverse events or sentinel events, but subsume them under patient safety/outcome in
order to provide a first insight into the relationship between SBAR and patient safety. The inclusion
criteria were restricted to trials that reported at least one “hard” patient outcome parameter to
evaluate SBAR’s impact on patient safety. Evidence of improvement of potentially “soft” outcomes
such as an increase in employee satisfaction25 26 and interdisciplinary communication27 28 with
improvements of the communication perception, interdisciplinary teamwork34-38, completeness46-49
and efficiency45 47 50 of the communication were not reported in this review. Last, trials in which
SBAR was a minor component of a complex intervention only were not included in this review.
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These trials may contain potential evidence for an improvement of patient safety through the
implementation of SBAR.
Implications for practice and research
Five of the studies42 56 61 62 64 including the two moderate/high quality studies found significantly
improved patient safety outcomes. Four other before-after studies46 58-60 reported descriptive
improved patient outcomes. On the one hand these findings emphasise the potential importance of
implementation of SBAR in the clinical practice to improve i) telephone communication from nurse
to doctors in critical situations, ii) general patient hand-off as well as iii) team communication in
general. However, the quality of the evidence is low and four studies56 57 62 63 reported no significant
changes of other relevant outcomes and even a descriptive increase of patient falls also.59 Best
evidence was found in telephone communication between nurses and physicians. This should
raise awareness and demands future high quality-research as the unreflected adoption of SBAR
may paradoxically limit improvements in health care communication, because once a problem
appears to be solved, less research will be conducted on it.
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CONCLUSION
In summary, many authors claim that SBAR improves patient safety. There is some evidence of
the effectiveness of SBAR implementation on patient outcome, but this evidence is limited to
specific circumstances such as communication over the phone. Especially high quality studies are
lacking. Future studies are needed to further demonstrate the benefit of SBAR in terms of patient
safety and keep raising the awareness of communication errors. SBAR might be an adaptive tool
that is suitable for many healthcare settings, in particular when clear and effective interpersonal
communication is required.
Source of funding: none
Conflict of interest: WH has received payment from the AO Foundation Zürich for educational
consultations and congress invitations from Mundipharma Basel. All other authors report nothing to
disclose.
Contributorship: All authors contributed to the conception of the review, analysis and
interpretation of the results and the final approval of the manuscript. Study design: Martin Müller,
Jonas Jürgens, Marcus Redaèlli, Wolf Hautz, Stephanie Stock. Literature search and assessment
(acquisition of data): Martin Müller, Jonas Jürgens, Karsten Klingberg. Drafting the manuscript:
Martin Müller, Jonas Jürgens, Marcus Redaèlli, Wolf Hautz. Critical revision of the manuscript for
intellectual content: Martin Müller, Jonas Jürgens, Marcus Redaèlli, Karsten Klingberg, Wolf Hautz,
Stephanie Stock.
Acknowledgements: The authors want to thank the Gottfried und Julia Bangerter-Rhyner-
Foundation for their ad personam grant «Young Talents in Clinical Research» for MM.
Data sharing statement: There are no additional data available.
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FIGURE AND APPENDIX LEGENDS
Figure 1. Flowchart of the systematic review process
Abbreviations: SBAR, Situation Background Assessment Recommendation.
Figure 2. Quality assessment of the included studies
Appendix A. Full search strategy and results of all databases
Appendix B. Characteristics of the included studies
Appendix C. Details of the implemented intervention
Appendix D. Details of the results
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!"#$$%&%'(
)%"*+,$,(
-*&'&.&*&/0(
),$%/&1&"2/&3%(
Titles and abstracts
screened
(n = 701)
!
Records excluded (n = 607)
Full-text articles excluded (n = 83)
a topic different from
the communication model SBAR
no implementation of
SBAR into clinical
practice no focus on SBAR
(SBAR as minor part
of a more complex intervention)
Poster/Abstract of an
included study
no measurement of patient safety-related
outcomes
Studies included into
qualitative synthesis (n = 11)
Records identified through database searching: MEDLINE (239), EMBASE (451), PsycINFO (156), CINAHL (189), Cochrane
Central Register of Controlled Trials (18)
(n = 1,053)
Records after duplicates removed
(n = 701)
1
63
2
1
16
Full-text articles assessed for eligibility*
(n = 94)
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Quality assessment of the included study
114x191mm (300 x 300 DPI)
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Appendix A. Full search strategy and results of all databases
Medline search expression# Searches (on all fields)#1 SBAR 164#2 ISBAR 13#3 SBAR-R 1#4 ISBARR 2#5 ISOBAR 61#6 #1 OR #2 OR #3 OR #4 OR #5 239Database searched on 30.01.2017.
EMBASE search expression# Searches (on all fields)#1 SBAR 277#2 ISBAR 26#3 SBAR-R 1#4 ISBARR 2#5 ISOBAR 147#6 #1 OR #2 OR #3 OR #4 OR #5 451Database searched on 30.01.2017.
PsycINFO search expression# Searches (on all fields)#1 SBAR 141#2 ISBAR 11#3 SBAR-R 1#4 ISBARR 1#5 ISOBAR 18#6 #1 OR #2 OR #3 OR #4 OR #5 156Database searched on 30.01.2017.
CINAHL search expression# Searches (on all fields)#1 SBAR 168#2 ISBAR 11#3 SBAR-R 1#4 ISBARR 2#5 ISOBAR 11#6 #1 OR #2 OR #3 OR #4 OR #5 189Database searched on 30.01.2017.
Cochrane Central Register of Controlled Trials# Searches (on all fields)#1 SBAR 10#2 ISBAR 2#3 SBAR-R 0#4 ISBARR 0#5 ISOBAR 7#6 #1 OR #2 OR #3 OR #4 OR #5 18Database searched on 30.01.2017.
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Appendix B. Characteristics of the included studies
Study Setting Department Design Target Intervention Patient outcome
1. Adverse patient events
2. Adverse drug events
1. Hospital mortality
2. Adverse events
3. Cardiac arrests
1. Incidence of Falls
2. Severity of falls (categorized in 4 levels:
no harm, minor, moderate, major)
1. INR values within the target range
2. Preventable adverse events related to
warfarin-therapy
1. Inpatient Fall Rate
2. Restrained Patients Rate
3. Catheter Associated UTI Rate
Telem
(2011)
The Mount Sinai Hospital,
New York, NY State, U.S.
Surgery CCT Physician hand-off (trained
general surgery vs.
untrained subspecialty
surgery residents (n=20)
Interactive teaching:
residents,
subspecialty residents
as controls
Sentinel event (unexpected occurrence
involving death or serious physical or
psychological injury or the risk thereof and
necessitating immediate investigation)
De Meester
(2013)
Antwerp University
Hospital, Antwerp, Belgium
All BAS Nursing hand-off (between
shifts), Communication:
deteriorating patients
(nurses calling physicians)
Interactive teaching Serious adverse event (=unexpected
occurrence involving death or ICU
admission or call of the cardiac arrest
team)
Haig
(2006)
BAS
Christie
(2009)
BAS
Andreoli
(2010)
BAS
OSF St. Joseph Medical
Centre Bloomington,
Illinois, U.S.
All
Field
(2011)
Nursing homes (n=26),
State of Connecticut, U.S.
RCT
Freitag
(2011)
Communication between
clinicians (in verbal and
written form)
Educational program:
all clinical staff
Educational program:
all clinical staff
Educational program:
all clinical/non-clinical
staff & unit leaders
Educational program:
all nursing staff
Interactive teaching:
nursing staff, patient
care technicians
-
All Nursing hand-off (between
shifts and units)
Telephone communication
between nurses and
physicians anticoagulation
management)
Patient hand-off
Toronto Rehabilitation
Institute, University of
Toronto, Canada
South Devon Healthcare
Foundation Trust, Tobay,
United Kingdom
Rush Oak Park hospital,
Oak Park, Illinois, U.S.
Team communication
(prevention of falls and
management)
All
Geriatric &
musculo.
rehabilitation
BAS
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Randmaa
(2014)
Country Council of
Gävleborg, Sweden
(University of Gävle)
Anesthesiol. CCT Communication in hospital
(priority: physician and
nurse hand-off)
Interactive teaching Adverse events with communication failure
as a root cause
1. Transfers to acute care hospitals
2. Types of transfers by clinical condition
3. Transfers resulting in hospitalisation
Pineda
(2015)
New Jersey hospital (n.s.), Medico-
surgical
BAS Nursing hand-off Educational session Patient falls
1. Transfers to hospital
2. Hospitalisations
3. 30-day readmissions
Jarboe
(2015)
Nursing centre and
rehabilitation facility (n.s.),
southern Maryland, U.S.
BAS -
Abbreviations: BAS: Before-After-Study, CCT: Clinical Controlled Trial, CIRS: Critical Incident Reporting System, ICU: Intensive Care Unit, INR: International
Normalised Ratio, MRSA: Methicillin-Resistant Staphylococcus aureus, n: number, n.s.: not specified, RCT: Randomised-Controlled Trial, SBAR: Subject
Background Assessment Recommendation, U.S.: Unites States of America; UTI, Urinary Tract Infection.
Devereaux
(2016)
Nursing/post-acute care
facility (n.s.), performed by
University of Pittsburgh,
Pennsylvania, U.S.
BAS
Educational session,
integration into
competency training
Communication between
nurses and physicians (in
notifying providers of
change in patient status)
Communication between
nurses and physicians (in
notifying providers of
change in resident status)
Introduction of
condition-specific
SBAR
-
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Appendix C. Details of the implemented intervention
Study Activities Objective(s) Who was trained?How many
were trained?
1. Educational programs (class or video) Communication between clinicians
! Incorporation in several hospital programs (in verbal and written form)
2. Trigger tools*
3. Organizational/human support:
! leadership (human and financial support)
! interdisciplinary spread team
1. Interactive teaching
! simulated scenarios
2. Educational programs (class or video, 10-15min)
3. Trigger tools*
4. Organizational/human support
! project team (meetings fortnightly)
! SBAR as structure in trust meetings
1. Interactive teaching Team communication All clinical staff,
! role-playing (real-life case examples) (for the priority issue of falls non-clinical staff,
2. Educational programs (class or video, 4h) !"#$#%&'(%)*%+),*%*-#,#%&. unit-leaders
3. Trigger tools*
4. Organizational/human support
! ÒSBAR championsÓ
! project team (weekly meetings)
1. Educational programs (class or video) Telephone communication
! training (for one representative of each nursing home) /#&0##%)%1"2#2)*%+)!342'5'*%2
2. Trigger tools* (in anticoagulation management)
3. Organizational/human support
! calls with the representative of nursing home
1. Interactive teaching Nursing hand-off Nursing staff,
! staff coaching within work (initial phase) (between shifts and units) patient care
2. Educational programs (class or video, 1h) 5%'5'*%2
3. Trigger tools*
4. Organizational/human support
! project team
! SBAR champion
Freitag
(2011)
n.r.
Haig (2006) All clinical staff n.r.
Christie
(2009)
Patient hand-off All clinical staff n.r.
Andreoli
(2010)
85
Field (2011) Nursing staff n.r.
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Interactive teaching (2,5h)
! video scenarios
! role-playing
! group discussions
1. Interactive teaching (2-days, for 1-2 Òreference
nurseÓ/ward)
Nursing hand-off (between shifts)
! group discussions, coaching
! role-playing Communication in cases of
2. Training session (2h, for all nurses by ãreference nursesÒ) )+#&#"'("*&'%-)!*&'#%&2
3. Educational programs (class or video, 4h) )6%1"2#2)5*77'%-)!342'5'*%2.
1. Interactive teaching Communication in hospital
! role-playing (priority physician hand-off &
2. Trigger tools* )%1"2#)3*%+8(99.
3. Organisational/human report
! active motivation to use SBAR in clinical practice
1. Educational session (mandatory, 1h) Communication between nurses
! training to use the SBAR communication tool )*%+)!342'5'*%2
2. Organisational/human support (in notifying providers of chang
! policy change )'%)"#2'+#%&)2&*&12.
! integration of SBAR into the annual nurse competency
training
1. Educational session
! four separate staff meetings
2. Organisational/human support
! integration of SBAR into nursing hand-off
Communication between nurses
and physicians
(in notifying providers of change in
resident status)
Abbreviations: FA, First author, h: hour(s), m: month(s), min: minute(s), n: number, n.r.: not reported, SBAR: Subject Background Assessment
Recommendation
Pineda
(2015)
Nursing hand-off (between shifts) Nursing staff n.r.
Devereaux
(2016)
Introduction of condition-specific SBARs for the most
common reasons for transfer to acute care hospitals
Nursing staff 60
Randmaa
(2014)
All clinical staff n.r.
Jarboe
(2015)
Nursing staff 66
Telem
(2011)
Physician hand-off General surgery
staff
45
De Meester
(2013)
Nursing staff n.r.
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Appendix D. Details of the results
TeamcommunicationingerneralAdverse patient events Pre: 1m Decrease: 90 to 49 per 1,000 patient days#
Adverse drug events Post: 12m Decrease: Events from 30 to 18 per 1,000 patient days#
Falls incidence Total falls showed an increasing trend on the study teams#
Falls severity (4 levels) Decreasing trend across major falls (4 vs. 2) both the organization and the study units#
Near-miss reporting Decreasing trend across both the organization and the study units#
Patienthand-off–nursesInpatient Fall Rate Reduction of 5%#
Restrained Patients Rate Reduction of 31%#
Catheter Associated UTI Reduction of 34%#
Pre: 1m
Post: 1m
Patienthand-off–physicianPre: 1m
Post: 1m
Patienthand-off–physicianandnursesPre: 12m
Post: 12m
Hospital mortality 11% reduction in hospital mortality#
Adverse events 65% reduction of adverse events#
Cardiac arrests 8% reduction of cardiac arrests#
MRSA bacteraemias 83% reduction of MRSA bacteraemia#
n.r.
n.r.
n.r.
Morbidity and mortality surgical database and hospital performance improvement initiative
Prospective analysis of “safety reports” (=CIRS)
n.s.
Retrospective chart review + “safety reporting” (by an online reporting system)
Retrospective chart review
n.s.
Randmaa (2014)
CIRS events (communication errors)
Decrease from 31% to 11%, p<0.0001
Christie (2009)
Sentinel events No statistical significant difference in sentinel events, general surgical vs. surgical subspecialty interns (one sentinel event)
Freitag (2011)
Pineda (2015)
Patient falls 2 falls (pre) vs. 0 falls (post)#
Andreoli (2010)
Objective/
Telem (2011)
Patient outcome (PO) Results detail Study
Haig (2006)
Duration of PO measurementPOcollection
Retrospective chart review (each month 20 randomly selected charts)
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Telephonecommunicationfromnursetodoctor–anticoagulationmanagementINR values within the target range (2.0 - 3.0)
4.5% more time in the therapeutic range than in control homes (95% CI: 0.3%-8.7%)
Preventable AE related to warfarin-therapy
Statistically non-significant reduction, odds ratio 0.9 (95% CI: 0.5-1.4)
Telephonecommunicationfromnursetodoctor–Deteriorating/statuschangeofapatientUnexpected death Pre: 10m Significant decrease from 0.99 to 0.34/1000 admissions
(RRR = −227%, 95% CI = −793 to −20; p < 0.001)Post: 10m Significant increase from 13.1 to 14.8/1000 admissions
(RRR = 50%, 95% CI: 30-64%, p=0.001)
Call of cardiac arrest team No significant difference (p>0.05)
Transfers to acute care hospitals
Pre: 12m No significant difference (p = 0.482)
Types of transfers by clinical condition criteria
Post: 8m No significant difference in i) preventable transfer group, p=0.927 or ii) emergent transfer group, p=0.565
Transfers resulting in hospitalization
No significant difference (p = 0.662)
30-day readmissions Pre: 3m Significant reduction, 0.12 vs. 0.04, p=0.012
Transfers to hospital Post: 3m Significant reduction, 0.44 vs. 0.24, p<0.001
Avoidable hospitalisations Significant reduction, 0.15 vs. 0.05, p=0.007
55,167 resident days (intervention homes) vs. 53,601 (control)
Quarterly reviews of nursing home records by pairs of physician-reviewers
Devereaux (2016)
Field (2011)
Abbreviations: CI, confidence interval, month(s), ICU: Intermediate Care Unit, n: number, n.r.: not reported, pre/post: duration of outcome measurement pre/post intervention, RRR: Relative Risk Reduction, SBAR: Subject Background Assessment Recommendation, vs.: versus
De Meester (2013)*
ICU admission
Jarboe (2015)
n.s.
n.s.
Retrospective analysis of medical records and internal emergency calls (performed by a trained expert)
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PRISMA 2009 ChecklistPRISMA 2009 ChecklistPRISMA 2009 ChecklistPRISMA 2009 Checklist
Section/topic # Checklist item Reported on page #
TITLE
Title 1 Identify the report as a systematic review, meta-analysis, or both. 1
ABSTRACT
Structured summary 2 Provide a structured summary including, as applicable: background; objectives; data sources; study eligibility criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions and implications of key findings; systematic review registration number.
2
INTRODUCTION
Rationale 3 Describe the rationale for the review in the context of what is already known. 4+5
Objectives 4 Provide an explicit statement of questions being addressed with reference to participants, interventions, comparisons, outcomes, and study design (PICOS).
5
METHODS
Protocol and registration 5 Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if available, provide registration information including registration number.
7
Eligibility criteria 6 Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered,
language, publication status) used as criteria for eligibility, giving rationale. 7
Information sources 7 Describe all information sources (e.g., databases with dates of coverage, contact with study authors to identify additional studies) in the search and date last searched.
7
Search 8 Present full electronic search strategy for at least one database, including any limits used, such that it could be repeated.
7, App A
Study selection 9 State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable,
included in the meta-analysis). 8
Data collection process 10 Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators.
8+9
Data items 11 List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made.
8
Risk of bias in individual studies
12 Describe methods used for assessing risk of bias of individual studies (including specification of whether this was done at the study or outcome level), and how this information is to be used in any data synthesis.
8+9
Summary measures 13 State the principal summary measures (e.g., risk ratio, difference in means). 9
Synthesis of results 14 Describe the methods of handling data and combining results of studies, if done, including measures of consistency (e.g., I
2) for each meta-analysis.
9
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PRISMA 2009 ChecklistPRISMA 2009 ChecklistPRISMA 2009 ChecklistPRISMA 2009 Checklist
Page 1 of 2
Section/topic # Checklist item Reported on page #
Risk of bias across studies 15 Specify any assessment of risk of bias that may affect the cumulative evidence (e.g., publication bias, selective reporting within studies).
-
Additional analyses 16 Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta-regression), if done, indicating which were pre-specified.
-
RESULTS
Study selection 17 Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally with a flow diagram.
Figure 1
Study characteristics 18 For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period) and provide the citations.
Table 2, App. B+C
Risk of bias within studies 19 Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12). Figure 2
Results of individual studies 20 For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each intervention group (b) effect estimates and confidence intervals, ideally with a forest plot.
Table 2, App D
Synthesis of results 21 Present results of each meta-analysis done, including confidence intervals and measures of consistency. -
Risk of bias across studies 22 Present results of any assessment of risk of bias across studies (see Item 15). -
Additional analysis 23 Give results of additional analyses, if done (e.g., sensitivity or subgroup analyses, meta-regression [see Item 16]). -
DISCUSSION
Summary of evidence 24 Summarize the main findings including the strength of evidence for each main outcome; consider their relevance to key groups (e.g., healthcare providers, users, and policy makers).
18
Limitations 25 Discuss limitations at study and outcome level (e.g., risk of bias), and at review-level (e.g., incomplete retrieval of identified research, reporting bias).
18-21
Conclusions 26 Provide a general interpretation of the results in the context of other evidence, and implications for future research. 22
FUNDING
Funding 27 Describe sources of funding for the systematic review and other support (e.g., supply of data); role of funders for the systematic review.
22
From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed1000097
For more information, visit: www.prisma-statement.org.
Page 2 of 2
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The impact of the communication and patient hand-off tool
SBAR on patient safety – a systematic review
Journal: BMJ Open
Manuscript ID bmjopen-2018-022202.R2
Article Type: Research
Date Submitted by the Author: 11-Jul-2018
Complete List of Authors: Müller, Martin; Inselspital Universitatsspital Bern, Department of Emergency Medicine; Universitat zu Koln Institut fur Gesundheitsokonomie und Klinische Epidemiologie Jürgens, Jonas; Universitat zu Koln Institut fur Gesundheitsokonomie und Klinische Epidemiologie Redaelli, Marcus; Universitat zu Koln Institut fur Gesundheitsokonomie und Klinische Epidemiologie Klingberg, Karsten; Inselspital Universitatsspital Bern, Department of
Emergency Medicine Hautz, Wolf; Inselspital, University of Bern, Department of Emergency Medicine Stock, Stephanie; Universitat zu Koln Institut fur Gesundheitsokonomie und Klinische Epidemiologie
<b>Primary Subject Heading</b>:
Evidence based practice
Secondary Subject Heading: Communication, Evidence based practice, Medical management
Keywords:
ACCIDENT & EMERGENCY MEDICINE, Information management < BIOTECHNOLOGY & BIOINFORMATICS, EDUCATION & TRAINING (see Medical Education & Training), Health & safety < HEALTH SERVICES
ADMINISTRATION & MANAGEMENT, Quality in health care < HEALTH SERVICES ADMINISTRATION & MANAGEMENT
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The impact of the communication and patient hand-off tool
SBAR on patient safety – a systematic review
Martin Müller1,2, Jonas Jürgens2, Marcus Redaèlli2, Karsten Klingberg1, Wolf E. Hautz1,
Stephanie Stock2
1 Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern,
Bern, Switzerland.
2 Institute of Health Economics and Clinical Epidemiology, University Hospital of Cologne,
Cologne, Germany.
MM: martin.mueller2@insel.ch
JJ: jonasjuergens@gmx.de
MR: marcus.redaelli@uk-koeln.de
KK: k.klingberg@vodafone.de
WH: wolf.hautz@insel.ch
SS: stephanie.stock@uk-koeln.de
Address of correspondence
Martin Müller, Dr. med. Dipl.-Math. M. Sc.,
Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern,
Bern, Switzerland. Phone: +41 (0)31 632 2111. Fax: +41 (0)31 632 24 50.
E-mail: martin.mueller2@insel.ch
Manuscript word count: 4026 (Introduction – Conclusion, excluding Tables)
Abstract word count: 300
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ABSTRACT
Objectives: Communication breakdown is one of the main causes of adverse events in
clinical routine, particularly in handover situations. The communication tool SBAR (Situation,
Background, Assessment, and Recommendation) was developed to increase handover
quality and is widely assumed to increase patient safety. The objective of this review is to
summarise the impact of the implementation of SBAR on patient safety.
Design: A systematic review of articles published on SBAR was performed in PUBMED,
EMBASE, CINAHL, Cochrane Library, and PsycINFO in January 2017. All original research
articles on SBAR fulfilling the following eligibility criteria were included: i) SBAR was
implemented into clinical routine, ii) the investigation of SBAR was the primary objective, and
iii) at least one patient outcome was reported.
Setting: A wide range of settings within primary and secondary care and nursing homes.
Participants: A variety of heath professionals including nurses and physicians.
Primary and secondary outcome measures: Aspects of patient safety (patient outcomes)
defined as the occurrence or incidence of adverse events
Results: Eight studies with a before-after design and three controlled clinical trials performed
in different clinical settings met the inclusion criteria. The objectives of the studies were to
improve team communication, patient hand-offs, and communication in telephone calls from
nurses to physicians. The studies were heterogeneous with regard to study characteristics,
especially patient outcomes. In total, 26 different patient outcomes were measured, of which
eight were reported to be significantly improved. Eleven were described as improved but no
further statistical tests were reported, and six outcomes did not change significantly. Only
one study reported a descriptive reduction in patient outcomes.
Conclusions: This review found moderate evidence for improved patient safety through
SBAR implementation, especially when used to structure communication over the phone.
However, there is a lack of high-quality research on this widely used communication tool.
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Trial registration: none
Key words: SBAR, hand-off situation, interprofessional communication, patient safety,
adverse event
Strengths and limitations
• This systematic review was conducted in accordance with the Cochrane
Collaboration standards using a validated tool for quality assessment of the identified
studies.
• Five well-known databases as well as the references of the included studies were
searched using an open search strategy.
• Reliability of the study selection, data extraction, and rating of the study quality was
ensured using two independent reviewers.
• Studies in which SBAR was part of a larger quality improvement initiative and
outcomes that did not measure the incidence of adverse events were not included in
this review.
• The heterogeneity of the studies impeded to test for publication bias or to perform a
meta-analysis.
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INTRODUCTION
Patient safety is crucial for the delivery of effective, high-quality healthcare1 and is defined by
the World Alliance for Patient Safety of the World Health Organisation (WHO) as “the
reduction of risk of unnecessary harm associated with healthcare to an acceptable
minimum“.2 To illustrate the impact of patient safety on healthcare quality, the incidence of
adverse events is commonly cited. Following the definition of Brennan, et al.3, adverse
events are injuries that are caused by medical conduct resulting in prolonged hospitalisation
and/or disability at the time of discharge. The Joint Commission reported that poor
communication is a contributing factor in more than 60% of all hospital adverse events they
reviewed.4 Poor communication is found in many different health care settings and is
especially prominent in patient hand-offs and settings were fast and effective management is
indispensable. Such settings include the perioperative period,5 the intensive care unit (ICU),6
and the emergency department (ED).7 The components and processes of communications
are complex and prone to misunderstanding.8 To overcome these barriers, communication
strategies are desirable which take little time and effort to complete, deliver comprehensive
information efficiently, encourage interprofessional collaboration, and limit the probability of
error.9-11 The SBAR (situation, background, assessment, recommendation) instrument (see
Table 1) and its derivatives ISBAR, SBAR-R, ISBARR, ISOBAR fulfil this need and are
widely used in different health care facilities as a communication and hand-off tool both intra-
and interprofessionaly.12-15 By virtue of a clear structure, SBAR calls for the provision of all
relevant information, organized in a logical fashion.16 Furthermore, it enables a preparation
before the communication process,16 17 and because sender and receiver share the same
mental model, understanding and awareness are expected to be higher.18 Besides, it
reduces inhibitions especially in hierarchical context by encouraging the sender to provide a
personal assessment and suggestion of the situation (“Recommendation”).19 The SBAR tool
is regarded as a communication technique that increases patient safety and is current “best
practice” to deliver information in critical situations.16 20
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A number of studies have investigated “soft” outcomes such as employee satisfaction21 22
and interdisciplinary communication19 23 in relation to SBAR. Positive resonances of
employees after the introduction of SBAR were reported24-28 with improvements of the
communication perception and interdisciplinary teamwork29-33 as well as the quality of the
communication.34-40 Especially in patient hand-off the quality of the communication and the
completeness of transferred information was increased after the implementation of SBAR.41-
44. Furthermore, less time was needed for the patient hand-off in several studies.40 42 45
However, the actual effect of SBAR on patient outcome is unclear. The wide adoption of
SBAR (or any other communication strategy) without proven benefit may paradoxically limit
improvements, because a problem presumably solved will be less addressed. Thus, the
purpose of this systematic review is to summarize the available evidence for and evaluate
the impact of the implementation of SBAR in clinical settings on patient safety as measured
by the incidence of adverse events.
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Table 1. The SBAR communication technique, adapted table16 18 46 47
Questions Description Example
S Situation
What is going on with the patient? What is the situation you are calling/communicate about?
First, the speaker presents the situation, by identifying himself, stating the patient’s name and briefly describing the problem.
“Dr Preston, I’m calling about Mr Lakewood, who’s having trouble breathing.”
B Background
What is the background or context on this patient?
The speaker then provides the background, such as the patient’s diagnosis or reason for admission, medical status and relevant history. The patient’s chart is reviewed and questions the other care provider may have are anticipated
“He’s a 54 year old man with chronic lung disease who has been sliding downhill, and now he’s acutely worse.”
A Assessment
What is the problem? Then specific information on vital signs, recent labs and other quantitative or qualitative data related to the patient’s current state are provided. This section can include a provisional diagnosis or clinical impression
“I don’t hear any breath sounds in his right chest. I think he has a pneumothorax.”
R Recommendation
What is the next step in the management of the patient?
An informed suggestion for the continued care of the patient has to be made by the speaker. The immediate need is explained clearly and specifically, including what is necessary to address the problem.
“I need you to see him right now. I think he needs a chest tube.”
The tool is available for download from the website of the Institute for Healthcare Improvement.9
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METHODS
Search strategy
A systematic search for articles published on SBAR was performed in PUBMED, EMBASE,
CINAHL, Cochrane Library, and PsycINFO via OvidSP®. The search was conducted in
January 2017. It was augmented by a review of the references of all articles included. Search
terms used in all electronic medical databases were SBAR, ISBAR, SBAR-R, ISBARR, and
ISOBAR (combined as text words with the Boolean operator ‘OR’). The detailed search
strategy is provided in Appendix A. No restrictions were applied in terms of time, language,
or type of article. No review protocol exists.
Eligibility criteria
All original research articles on SBAR fulfilling the following eligibility criteria were included:
• SBAR was implemented into clinical routine,
• the investigation of SBAR was the primary objective of the study (as opposed to e.g.
SBAR as part of a larger quality improvement initiative),
• at least one patient outcome was reported (e.g. mortality or secondary ICU
admission). In accordance with the definition of the WHO2, aspects of patient safety
(patient outcomes) were defined through outcome parameters measuring the
occurrence or incidence of adverse events.
Exclusion criteria were:
• articles that only describe the SBAR tool but provide no evaluation data on patient
outcome,
• studies that report a larger project in which SBAR was not the main intervention under
investigation (because in such studies the attribution of any effect to SBAR is
impossible),
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• studies that only report, survey outcomes or team perceptions.
Selection of studies
Studies were evaluated in two steps: 1.) Two trained reviewers (JJ, MM) reviewed all
abstracts and titles for eligibility. 2.) If the eligibility of an article could not be clearly
determined, the article was included for further full-text evaluation in a second step.
In case of dissent, the reviewers solved the divergence by consensus or, if necessary, by
involving a third reviewer (MR).
Data extraction
The following data were extracted out of the included articles using a pre-defined form in
Microsoft® Excel for Mac 2011 (Version 14.7.2, Microsoft Corporation, Redmond,
Washington, United States): characteristics of the study (study setting, study design, and
information to evaluate the risk of bias, see below), characteristics of the study population
and possible control group (type and number of trained people), characteristics of the
intervention (type and duration), and outcome data on patients safety including time/period of
measurement). To ensure high accuracy and completeness of the data extraction by MM and
JJ, data extraction was checked by KK.
Quality assessment
Methodological quality of the studies included was assessed with the ‘Quality Assessment
Tool for Quantitative Studies’ developed by the Effective Public Health Practice Project
Canada.48 The tool is recommended by the Cochrane Collaboration49 as it evaluates the full
range of quantitative study designs. It has been evaluated for interrater reliability, content
and construct validity.50 The identified studies were assessed on 18 criteria in six domains
(selection bias, study design, confounders, blinding, data collection methods, as well as
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withdrawals and drop-outs). Studies were rated as “strong”, “moderate”, or “weak” in each
domain. An accompanying algorithm consolidates the six ratings into an overall score.
Two reviewers (JJ, MM) independently assessed the quality of each study. The final
assessment of each study was determined by consensus between the two reviewers and, if
necessary, by involving a third reviewer (WH).
Data synthesis
The intra-class correlation coefficient using Stata’s ICC command with a two-way mixed-
effects model was calculated to quantify the rater agreement on study inclusion as well as on
quality ratings of the studies included.
The heterogeneity of reported study designs, outcome measures, settings, and forms of
SBAR interventions does not allow to pool data across the studies that met the inclusion
criteria. Characteristics and results of the studies are presented in a narrative form.
Patient and Public Involvement
No patients were involved in the design, recruitment or conduct of the study. The results of
this review will not be disseminated to patients included in the trials of the review.
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RESULTS
Systematic review process
Article identification and inclusion is depicted in Figure 1. The literature search identified
1,053 articles. Seven hundred and one (701) articles remained after exclusion of duplicates;
607 articles were excluded after reviewing the titles and abstracts. Of the remaining 94
articles analysed in full-text, eleven articles were included into this review. The rater
agreement on inclusion was ICC=0.90 (95% CI: 0.86, 0.94). No additional studies were
identified through screening of the references of the included articles.
Quality assessment
Rater agreement on the studies quality ratings was excellent (ICC 0.85, 95% 0.78, 0.90).
The RCT by Field, et al.51 was rated as “strong” and one controlled trial by Randmaa, et al.37
as ‘moderate’ in the overall study quality, while the remaining nine studies were rated as
‘weak’ (Figure 2).
Three studies were rated as strong in the study design category as they were controlled
clinical trials.37 51 52 Eight studies used a before-after study design resulting in a weak rating in
the study design category.
Except for the study by Christie and Robinson,41 in which the selected individuals were not
described in sufficient detail, the study quality regarding selection bias was rated as
‘moderate’.
The study by Field, et al.51 used a randomized controlled trial as a design with facility as a
randomization unit. Thus, by study design the results were controlled for potential (known
and unknown) confounders such as infrastructure, patient safety culture, and management.
No other study controlled for confounders in the study design or analysis (weak rating).
While main outcomes, study objectives, and the applied SBAR intervention were described in
all studies, blinding was not described in any, but one of the studies (9.1%), resulting in a
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‘moderate’ rating in this category. In one of the controlled trials51, the reviewers who rated the
patient safety outcome were blinded in regard to the intervention (strong rating).
Overall, there was a lack of reporting on statistical tests53-56 and number of persons that were
trained.41 51 53 55-57 Sample size calculations to ensure sufficient power were not reported in
any of the studies.
Study setting and study characteristics
Eight of the analysed studies (72.7%) used a before-after intervention design,41 53-59 while in
two studies (18.2%) a non-randomised controlled-trial37 52 and in one study (9.2%) a
randomised-controlled trial51 were reported.
All identified articles were published in recent years (2006-2016). Eight (72.7%) of the eleven
studies were conducted in North America,51-56 58 59 the remaining three (27.3%) were
performed in Europe.37 41 57
The studies focused on three different study sites: i) hospitals in seven studies (63.6%),37 41 52
53 55-57 ii) a rehabilitation centre (geriatric/musculoskeletal unit) in one study54 (9.2%), and iii)
nursing homes in three studies (27.3%).51 58 59 Four of the studies that introduced the SBAR
tool into a hospital setting restricted the intervention to specific units (anaesthesiological,52
surgical,37 or medicosurgical56 57) while three trials introduced the SBAR tool to all
departments.41 53 55 Nurses were trained in the use of SBAR in all studies. In five studies
(45.5%), additionally other clinical staff e.g. physicians were trained also.37 41 52-54 The number
of staff members trained ranged from 3852 to 15537, but was not specified in five studies 41 51
53 55 57 (Appendix B).
The study period was mainly dependent on the time period that the patient outcomes were
measured and ranged between two52 and 24 months37 58 and was not specified in two
studies.41 55
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Intervention targets
A detailed description of the wide range of implementation strategies of SBAR in the studies
included is provided in Appendix C.
In two studies (18.2%), the aim of the intervention was to improve team communication in
general53 54 while five studies (45.5%) focused on patient hand-offs either between nurses or
interprofessional.37 41 55 56 The four remaining studies (36.4%) aimed to improve
communication in a particular situation such as telephone calls between nurses and
physicians for anticoagulation management51 or in case of patient deterioration.57-59
Implementation strategies were educational programs (7 studies41 51 53 54 56-58), organisational
/ human support (7 studies37 41 51 53-56), and interactive teaching (7 studies37 41 52 54 55 57 58)
including group discussions and role-play. Additional SBAR trigger tools (poster, pocket
cards, telephone-stickers) were used in six studies (54.5%).37 41 51 53-55
Patient outcome
All studies included assessed the effect of SBAR implementation on the outcome of
inpatients, none the outcome of outpatients. The patient outcomes and outcome
measurements varied widely over the identified studies (Appendix D). Three studies (27.3%)
measured general patient outcomes such as adverse patient/drug events41 52 53, while the
remaining eight studies (72.7%) used specific adverse event outcomes such as
anticoagulation related51 and patient-fall related adverse events54-56 as well as unplanned
events such as ICU admissions,57 death/cardiac arrests,41 57 and transfer to hospitals.58 59
Other patient outcomes included Methicillin-resistant Staphylococcus aureus (MRSA)
bacteraemias41 and catheter-associated urinary tract infection rates.55
The duration of measurement of the patient outcomes in the pre/controlled phase
respectively the post/intervention phase ranged from one month52 56 to twelve months37 and
was not reported in three studies.41 54 55 Three of the studies37 53 57 controlled the use of SBAR
by staff survey or review of medical records and identified high use rates within daily routine.
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Effect of SBAR on patient outcomes
Overall summary
The main study characteristics and the effects of SBAR on the studied patient outcomes are
summarised in Table 2.
In total, 26 different patient outcomes were measured. Of these, eight outcomes measured in
five studies37 51 56 57 59 significantly improved and eleven patient outcomes measured in four
before-after studies41 53-55 are described as improving without the report of a statistical test.
Six outcomes did not change significantly. One study descriptively reported an increase of
adverse events,54 none found a significant reduction of patient safety. The reported results of
the studies are shown in detail in Appendix D.
Team communication in general
While one of the two before-after studies that focused on team communication in general53
found a reduction of adverse patient as well as of drug events, a study that focused on falls
in a rehabilitation centre54 found mixed results with a decrease in major falls, but an increase
in the incidence of overall falls. Both studies did not provide a statistical analysis of their
results.
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Table 2. Study characteristics and outcomes sorted by effect on patient safety, study design, and year. If a study reported
outcomes with different effects on patient safety, the study results are listed separately
Study Design Setting How SBAR was used Patient outcome defined as Effect
Field (2011)51 RCT Nursing home
Telephone communication from nurse to doctor – Anticoagulation management
INR values within the target range
Randmaa (2014)37
CCT Hospital Patient hand-off – physician and nurses CIRS events (communication errors)
De Meester (2013)57*
BAS Hospital Telephone communication from nurse to doctor – Deteriorating/status change of a patient
i) Unexpected death and ii) ICU admission
Pineda (2015)56 BAS Hospital Patient hand-off – nurses Patient falls
Devereaux (2016)59
BAS Nursing home
Telephone communication from nurse to doctor – Deteriorating/status change of a patient
i) 30-day readmissions ii), transfers to hospital, and iii) avoidable hospitalisations
Haig (2006)53 BAS Hospital Team communication in general i) Adverse patient and ii) drug events
Andreoli (2010)54
BAS Rehab. clinic
Team communication in general i) Falls severity (4 levels), ii) near-miss reporting
Freitag (2011)55 BAS Hospital Patient hand-off – nurses i) Inpatient Fall Rate, ii) Restrained Patients Rate, and iii) Catheter Associated UTI
Christie (2009)41
BAS Hospital Patient hand-off – physician and nurses i) Hospital mortality, ii) adverse events, iii) cardiac arrests, iv) MRSA bacteriaemias
Field (2011)51 RCT Nursing home
Telephone communication from nurse to doctor – Anticoagulation management
Preventable AE related to warfarin-therapy
Telem (2011)52 CCT Hospital Patient hand-off – physician Sentinel events
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Study Design Setting How SBAR was used Patient outcome defined as Effect
De Meester (2013)57*
BAS Hospital Telephone communication from nurse to doctor – Deteriorating/status change of a patient
Call of cardiac arrest team
Jarboe (2015)58 BAS Nursing homes
Telephone communication from nurse to doctor – Deteriorating/status change of a patient
i) Overall number of transfers to acute care hospitals, ii) types of transfers by clinical condition criteria, iii) transfers resulting in hospitalization
Andreoli (2010)54
BAS Rehab. clinic
Team communication in general Falls incidence
Abbreviations: AE: Adverse Event, BAS: Before-After-Study, CCT: Clinical Controlled Trial, CIRS: Critical Incident Reporting System: ICU: Intensive Care Unit, INR: International Normalized Ratio, MRSA: Methicillin-Resistant Staphylococcus Aureus, RCT: Randomized Controlled Trial, UTI: Urinary Tract Infection. Legend: : : Statistically significant evidence for improvement, : descriptive evidence for improvement (no statistical test reported), : no significant evidence of a change, : descriptive reduction of patient safety. *and nursing hand-off (between shifts)
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Patient hand-off
All, but one52 of the five studies37 41 52 55 56 that focused on patient hand-offs reported an
improvement of patient safety. Two before-after studies focused on patient hand-off between
nursing shifts.55 56 A reduction in the number of patient falls was reported in both studies. In
addition, restrained patients rate and catheter associated urinary tract infection rate decreased
about one third in one of these studies.55 Both studies that focused on patient hand-offs between
physicians and nurses reported an improvement in patient safety related outcome.37 41
In their controlled clinical trial, Randmaa, et al.37 reported that the critical incidence reporting
system (CIRS) events due to communication breakdowns in the department of anaesthesiology of
two clinics decreased significantly from 31% to 11%. The before-after-study performed in a
hospital by Christie and Robinson41 found a reduction in hospital mortality (-11%), MRSA
bacteraemias (-83%), adverse events (-65%), and cardiac arrests (-8%) after SBAR
implementation (no further statistical analysis reported).
The controlled clinical by Telem, et al.52 evaluated the effect of SBAR vs. no-SBAR training on
patient hand-offs by physicians on surgical wards. The number of identified sentinel events was
not statistically different between the study groups. One sentinel event was reported over the
whole study period.
Telephone communication between nurse and physician
Three trials tried to increase the quality of telephone communication between nurse and physician
when nurses reported deterioration or other status changes of patients.57-59 Two studies reported
significant improvements in the study patient outcome under investigation while the study of
Devereaux, et al.59 could not find a significant change.
Field, et al.51 showed a statistically significant improvement in the management of anti-coagulated
patients in nursing centres using a randomised controlled design: the INR value of patients was
4.5% more time within in the therapeutic range in the intervention homes than in control homes
(95% CI 3.1%-8.7%). They further reported a non-significant reduction of adverse warfarin-related
events in the intervention homes (odds ratio 0.9, 95% CI 0.5-1.4).
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De Meester, et al.57 (before-after study) reported that the number of unexpected death was
significantly decreased from 0.99 to 0.34 per 1000 admissions (p<0.001), while ICU admissions
increased (13.1 to 14.8 per 1000 admissions) without a significant difference in the frequency with
which a cardiac arrest team was called.
Devereaux, et al.59 studied transfers from nursing homes to acute care hospitals using a before-
after trial and found a significant reduction in 30-day readmissions (0.12 vs. 0.04, p=0.012) and
avoidable hospitalisations (0.15 vs. 0.05, p=0.007). Jarboe58 used a similar setting, but a longer
study period (20 months vs. 6 months) and could not find significant differences with regard to
preventable patient transfers (p=0.927) or emergent patient transfer (p=0.565).
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DISCUSSION
Summary of main results
The present systematic review assesses the effect of the implementation of the widely adopted
communication strategy SBAR on patient related outcomes. Because communication breakdowns
have been repeatedly identified as a major source of adverse events and medical error,4 60 61
implementation of a strategy such as SBAR seems a valid remediation approach.
Eleven studies, eight with a before-after design and three controlled trials, met the inclusion criteria.
SBAR was implemented through different strategies in three different clinical settings (hospitals,
rehabilitation centre, and nursing homes) and with a broad range of objectives to improve i) team
communication in general, ii) intra- and interdisciplinary patient hand-offs, and iii) communication in
telephone calls from nurses to physicians. In total, 26 different patient outcomes were measured.
Eight significantly improved, eleven were described as improving (but no further statistical test
were reported), six outcomes did not change significantly, and one study reported a descriptive
reduction in patient outcomes. Study outcomes with statistically evidence for improvement included
INR values within the target range51 and unplanned transfers to hospitals59 in nursing homes, as
well as CIRS events due to communication errors37, patient falls56, unexpected death and ICU
admissions57 in hospitals. The overall study quality was high or moderate in two studies only, all
other studies showed a weak study quality.
Quality of the evidence
The strongest evidence identified in our review comes from a single RCT investigating the effect of
SBAR implementation in nursing homes on anticoagulation management of patients under
warfarin.27 However, because warfarin is increasingly substituted by direct oral anticoagulants less
difficult to dose,62 the relevance of this finding may cease over time. Furthermore, adverse events
related to warfarin therapy, the primary outcome parameter in this study, did not differ significantly
between the intervention and control group. We found further evidence that the use of SBAR in
telephone communication to inform the physician of a deteriorating patient leads to i) a significant
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decrease in unexpected death22 and ii) a significant reductions in transfers to hospitals, 30-day
readmissions, and avoidable hospitalisations from nursing homes.21 Therefore, SBAR
implementation in telephone communication seems to positively affect patient outcome. However,
one study conducted in a similar setting58 (nursing home, unplanned hospital admission) but with a
longer study period could not find any significant difference between the pre and post
implementation phase in the patient outcomes. One explanation for the differences in the findings
might be, that the use of SBAR (not reported in the two studies) decreased over time, thus the
effect vanished.
Study periods were short at least in two trials52 56 (two months only). As a consequence, only one
sentinel event in one controlled clinical trial52 over the study period was reported.
Power calculations were missing in all studies. Thus, the lack of significant differences between the
groups in these studies could not be interpreted adequately. Furthermore, in almost half of the
reported outcomes, no statistical tests were performed. Notably, no study in our review found a
significant increase in the occurrence of adverse events after to the implementation of SBAR, but
Andreoli et al. (2010) descriptively reported an increase in fall incidence while the fall severity was
reduced at the same time. This study’s findings illustrate the difficulty with most of the studies
findings included in the review. Some might argue, that the implementation of SBAR in patient fall
reporting has just led to an increased awareness regarding patient falls. Consequently, the
reporting of patient falls and especially of less severe falls increased, resulting in a decrease of the
patient fall severity overall.
It has been previously argued that downstream targets of educational interventions (such as the
implementation of a specific communication strategy) are often difficult to assess due to possible
dilution of the effect of any intervention.63 64 Indeed, implementation of SBAR may only directly
affect communication among health professionals, which in turn may or may not affect health care
conduct, which then may result in altered patient outcome. Arguably, there are many other
effective agents along this path that may dilute the effect of SBAR implementation on patient
outcome. We would argue that because it has been possible in the past to relate adverse events to
communication breakdowns,7 60 61 it should just as well be possible to demonstrate the effect on
patient safety of interventions targeted at remediating such communication breakdowns.
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One reason for the current failure to demonstrate such effects may be that studies investigating the
effect of SBAR on patient outcome are mostly of limited quality and yield heterogeneous results.
Many studies identified were before-after studies. It is thus difficult to differentiate between
changes attributed to the implementation of SBAR and changes attributable to other factors that
had changed over time, such as increased awareness. Process measures in regard to parameters
of communication were not measured in any of the included studies, but several not included
studies suggest an improvement of communication through the implementation of SBAR.34-40 The
lack of process measures within the included studies reduces internal validity and impedes the
interpretation of the present results with regard to causation. Consequently, the unreflected
adoption of SBAR may paradoxically limit improvements in health care communication, because
once a problem appears to be solved, less research will be conducted on it.
Limitations
This systematic review has some limitations. Efforts were undertaken to identify all relevant trials to
evaluate the impact of SBAR implementation in clinical practice on patient safety. Five well-known
databases as well as the references of the studies that met the inclusion criteria were searched
using an open search strategy. No grey literature was searched, thus trials could have been
missed. Further, we did not contact any author to ask for raw data to perform additional statistical
analysis. Publication bias could not be assessed leading to an important source of bias. The
heterogeneity of the data impeded a meta-analysis. This systematic review was conducted in
accordance with the Cochrane Collaboration standards using a validated tool for quality
assessment of the identified studies. Reliability of the study selection, data extraction and rating of
the study quality was ensured using two independent reviewers. We did not differentiate the broad
range of adverse events or sentinel events, but subsume them under patient safety/outcome in
order to provide a first insight into the relationship between SBAR and patient safety. The inclusion
criteria were restricted to trials that reported at least one “hard” patient outcome parameter to
evaluate SBAR’s impact on patient safety. Evidence of improvement of potentially “soft” outcomes
such as an increase in employee satisfaction21 22 and interdisciplinary communication19 23 with
improvements of the communication perception, interdisciplinary teamwork29-33, completeness41-44
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and efficiency40 42 45 of the communication were not reported in this review. Last, trials in which
SBAR was a minor component of a complex intervention only were not included in this review.
These trials may contain potential evidence for an improvement of patient safety through the
implementation of SBAR.
Implications for practice and research
Five of the studies37 51 56 57 59 including the two moderate/high quality studies found significantly
improved patient safety outcomes. Four other before-after studies41 53-55 reported descriptive
improved patient outcomes. On the one hand these findings emphasise the potential importance of
implementation of SBAR in the clinical practice to improve i) telephone communication from nurse
to doctors in critical situations, ii) general patient hand-off as well as iii) team communication in
general. However, the quality of the evidence is low and four studies51 52 57 58 reported no significant
changes of other relevant outcomes and even a descriptive increase of patient falls also.54 Best
evidence was found in telephone communication between nurses and physicians. This should
raise awareness and demands future high quality-research as the unreflected adoption of SBAR
may paradoxically limit improvements in health care communication, because once a problem
appears to be solved, less research will be conducted on it.
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CONCLUSION
In summary, many authors claim that SBAR improves patient safety. There is some evidence of
the effectiveness of SBAR implementation on patient outcome, but this evidence is limited to
specific circumstances such as communication over the phone. Especially high quality studies are
lacking. Future studies are needed to further demonstrate the benefit of SBAR in terms of patient
safety and keep raising the awareness of communication errors. SBAR might be an adaptive tool
that is suitable for many healthcare settings, in particular when clear and effective interpersonal
communication is required.
Source of funding: none
Conflict of interest: WH has received payment from the AO Foundation Zürich for educational
consultations and congress invitations from Mundipharma Basel. All other authors report nothing to
disclose.
Contributorship: All authors contributed to the conception of the review, analysis and
interpretation of the results and the final approval of the manuscript. Study design: Martin Müller,
Jonas Jürgens, Marcus Redaèlli, Wolf Hautz, Stephanie Stock. Literature search and assessment
(acquisition of data): Martin Müller, Jonas Jürgens, Karsten Klingberg. Drafting the manuscript:
Martin Müller, Jonas Jürgens, Marcus Redaèlli, Wolf Hautz. Critical revision of the manuscript for
intellectual content: Martin Müller, Jonas Jürgens, Marcus Redaèlli, Karsten Klingberg, Wolf Hautz,
Stephanie Stock.
Acknowledgements: The authors want to thank the Gottfried und Julia Bangerter-Rhyner-
Foundation for their ad personam grant «Young Talents in Clinical Research» for MM.
Data sharing statement: There are no additional data available.
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2. World Health Organisation. Conceptual Framework for the International Classification for Patient
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10.08.2017).
3. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in
hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med
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FIGURE AND APPENDIX LEGENDS
Figure 1. Flowchart of the systematic review process
Abbreviations: SBAR, Situation Background Assessment Recommendation.
Figure 2. Quality assessment of the included studies
Appendix A. Full search strategy and results of all databases
Appendix B. Characteristics of the included studies
Appendix C. Details of the implemented intervention
Appendix D. Details of the results
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Flowchart of the systematic review process. Abbreviations: SBAR, Situation Background Assessment Recommendation.
53x51mm (300 x 300 DPI)
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Quality assessment of the included study
114x191mm (300 x 300 DPI)
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Appendix A. Full search strategy and results of all databases
Medline search expression# Searches (on all fields)#1 SBAR 164#2 ISBAR 13#3 SBAR-R 1#4 ISBARR 2#5 ISOBAR 61#6 #1 OR #2 OR #3 OR #4 OR #5 239Database searched on 30.01.2017.
EMBASE search expression# Searches (on all fields)#1 SBAR 277#2 ISBAR 26#3 SBAR-R 1#4 ISBARR 2#5 ISOBAR 147#6 #1 OR #2 OR #3 OR #4 OR #5 451Database searched on 30.01.2017.
PsycINFO search expression# Searches (on all fields)#1 SBAR 141#2 ISBAR 11#3 SBAR-R 1#4 ISBARR 1#5 ISOBAR 18#6 #1 OR #2 OR #3 OR #4 OR #5 156Database searched on 30.01.2017.
CINAHL search expression# Searches (on all fields)#1 SBAR 168#2 ISBAR 11#3 SBAR-R 1#4 ISBARR 2#5 ISOBAR 11#6 #1 OR #2 OR #3 OR #4 OR #5 189Database searched on 30.01.2017.
Cochrane Central Register of Controlled Trials# Searches (on all fields)#1 SBAR 10#2 ISBAR 2#3 SBAR-R 0#4 ISBARR 0#5 ISOBAR 7#6 #1 OR #2 OR #3 OR #4 OR #5 18Database searched on 30.01.2017.
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Appendix B. Characteristics of the included studies
Study Setting Department Design Target Intervention Patient outcome
1. Adverse patient events
2. Adverse drug events
1. Hospital mortality
2. Adverse events
3. Cardiac arrests
1. Incidence of Falls
2. Severity of falls (categorized in 4 levels:
no harm, minor, moderate, major)
1. INR values within the target range
2. Preventable adverse events related to
warfarin-therapy
1. Inpatient Fall Rate
2. Restrained Patients Rate
3. Catheter Associated UTI Rate
Telem
(2011)
The Mount Sinai Hospital,
New York, NY State, U.S.
Surgery CCT Physician hand-off (trained
general surgery vs.
untrained subspecialty
surgery residents (n=20)
Interactive teaching:
residents,
subspecialty residents
as controls
Sentinel event (unexpected occurrence
involving death or serious physical or
psychological injury or the risk thereof and
necessitating immediate investigation)
De Meester
(2013)
Antwerp University
Hospital, Antwerp, Belgium
All BAS Nursing hand-off (between
shifts), Communication:
deteriorating patients
(nurses calling physicians)
Interactive teaching Serious adverse event (=unexpected
occurrence involving death or ICU
admission or call of the cardiac arrest
team)
Haig
(2006)
BAS
Christie
(2009)
BAS
Andreoli
(2010)
BAS
OSF St. Joseph Medical
Centre Bloomington,
Illinois, U.S.
All
Field
(2011)
Nursing homes (n=26),
State of Connecticut, U.S.
RCT
Freitag
(2011)
Communication between
clinicians (in verbal and
written form)
Educational program:
all clinical staff
Educational program:
all clinical staff
Educational program:
all clinical/non-clinical
staff & unit leaders
Educational program:
all nursing staff
Interactive teaching:
nursing staff, patient
care technicians
-
All Nursing hand-off (between
shifts and units)
Telephone communication
between nurses and
physicians anticoagulation
management)
Patient hand-off
Toronto Rehabilitation
Institute, University of
Toronto, Canada
South Devon Healthcare
Foundation Trust, Tobay,
United Kingdom
Rush Oak Park hospital,
Oak Park, Illinois, U.S.
Team communication
(prevention of falls and
management)
All
Geriatric &
musculo.
rehabilitation
BAS
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Randmaa
(2014)
Country Council of
Gävleborg, Sweden
(University of Gävle)
Anesthesiol. CCT Communication in hospital
(priority: physician and
nurse hand-off)
Interactive teaching Adverse events with communication failure
as a root cause
1. Transfers to acute care hospitals
2. Types of transfers by clinical condition
3. Transfers resulting in hospitalisation
Pineda
(2015)
New Jersey hospital (n.s.), Medico-
surgical
BAS Nursing hand-off Educational session Patient falls
1. Transfers to hospital
2. Hospitalisations
3. 30-day readmissions
Jarboe
(2015)
Nursing centre and
rehabilitation facility (n.s.),
southern Maryland, U.S.
BAS -
Abbreviations: BAS: Before-After-Study, CCT: Clinical Controlled Trial, CIRS: Critical Incident Reporting System, ICU: Intensive Care Unit, INR: International
Normalised Ratio, MRSA: Methicillin-Resistant Staphylococcus aureus, n: number, n.s.: not specified, RCT: Randomised-Controlled Trial, SBAR: Subject
Background Assessment Recommendation, U.S.: Unites States of America; UTI, Urinary Tract Infection.
Devereaux
(2016)
Nursing/post-acute care
facility (n.s.), performed by
University of Pittsburgh,
Pennsylvania, U.S.
BAS
Educational session,
integration into
competency training
Communication between
nurses and physicians (in
notifying providers of
change in patient status)
Communication between
nurses and physicians (in
notifying providers of
change in resident status)
Introduction of
condition-specific
SBAR
-
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Appendix C. Details of the implemented intervention
Study Activities Objective(s) Who was trained?How many
were trained?
1. Educational programs (class or video) Communication between clinicians
! Incorporation in several hospital programs (in verbal and written form)
2. Trigger tools*
3. Organizational/human support:
! leadership (human and financial support)
! interdisciplinary spread team
1. Interactive teaching
! simulated scenarios
2. Educational programs (class or video, 10-15min)
3. Trigger tools*
4. Organizational/human support
! project team (meetings fortnightly)
! SBAR as structure in trust meetings
1. Interactive teaching Team communication All clinical staff,
! role-playing (real-life case examples) (for the priority issue of falls non-clinical staff,
2. Educational programs (class or video, 4h) !"#$#%&'(%)*%+),*%*-#,#%&. unit-leaders
3. Trigger tools*
4. Organizational/human support
! ÒSBAR championsÓ
! project team (weekly meetings)
1. Educational programs (class or video) Telephone communication
! training (for one representative of each nursing home) /#&0##%)%1"2#2)*%+)!342'5'*%2
2. Trigger tools* (in anticoagulation management)
3. Organizational/human support
! calls with the representative of nursing home
1. Interactive teaching Nursing hand-off Nursing staff,
! staff coaching within work (initial phase) (between shifts and units) patient care
2. Educational programs (class or video, 1h) 5%'5'*%2
3. Trigger tools*
4. Organizational/human support
! project team
! SBAR champion
Freitag
(2011)
n.r.
Haig (2006) All clinical staff n.r.
Christie
(2009)
Patient hand-off All clinical staff n.r.
Andreoli
(2010)
85
Field (2011) Nursing staff n.r.
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Interactive teaching (2,5h)
! video scenarios
! role-playing
! group discussions
1. Interactive teaching (2-days, for 1-2 Òreference
nurseÓ/ward)
Nursing hand-off (between shifts)
! group discussions, coaching
! role-playing Communication in cases of
2. Training session (2h, for all nurses by ãreference nursesÒ) )+#&#"'("*&'%-)!*&'#%&2
3. Educational programs (class or video, 4h) )6%1"2#2)5*77'%-)!342'5'*%2.
1. Interactive teaching Communication in hospital
! role-playing (priority physician hand-off &
2. Trigger tools* )%1"2#)3*%+8(99.
3. Organisational/human report
! active motivation to use SBAR in clinical practice
1. Educational session (mandatory, 1h) Communication between nurses
! training to use the SBAR communication tool )*%+)!342'5'*%2
2. Organisational/human support (in notifying providers of chang
! policy change )'%)"#2'+#%&)2&*&12.
! integration of SBAR into the annual nurse competency
training
1. Educational session
! four separate staff meetings
2. Organisational/human support
! integration of SBAR into nursing hand-off
Communication between nurses
and physicians
(in notifying providers of change in
resident status)
Abbreviations: FA, First author, h: hour(s), m: month(s), min: minute(s), n: number, n.r.: not reported, SBAR: Subject Background Assessment
Recommendation
Pineda
(2015)
Nursing hand-off (between shifts) Nursing staff n.r.
Devereaux
(2016)
Introduction of condition-specific SBARs for the most
common reasons for transfer to acute care hospitals
Nursing staff 60
Randmaa
(2014)
All clinical staff n.r.
Jarboe
(2015)
Nursing staff 66
Telem
(2011)
Physician hand-off General surgery
staff
45
De Meester
(2013)
Nursing staff n.r.
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Appendix D. Details of the results
TeamcommunicationingerneralAdverse patient events Pre: 1m Decrease: 90 to 49 per 1,000 patient days#
Adverse drug events Post: 12m Decrease: Events from 30 to 18 per 1,000 patient days#
Falls incidence Total falls showed an increasing trend on the study teams#
Falls severity (4 levels) Decreasing trend across major falls (4 vs. 2) both the organization and the study units#
Near-miss reporting Decreasing trend across both the organization and the study units#
Patienthand-off–nursesInpatient Fall Rate Reduction of 5%#
Restrained Patients Rate Reduction of 31%#
Catheter Associated UTI Reduction of 34%#
Pre: 1m
Post: 1m
Patienthand-off–physicianPre: 1m
Post: 1m
Patienthand-off–physicianandnursesPre: 12m
Post: 12m
Hospital mortality 11% reduction in hospital mortality#
Adverse events 65% reduction of adverse events#
Cardiac arrests 8% reduction of cardiac arrests#
MRSA bacteraemias 83% reduction of MRSA bacteraemia#
n.r.
n.r.
n.r.
Morbidity and mortality surgical database and hospital performance improvement initiative
Prospective analysis of “safety reports” (=CIRS)
n.s.
Retrospective chart review + “safety reporting” (by an online reporting system)
Retrospective chart review
n.s.
Randmaa (2014)
CIRS events (communication errors)
Decrease from 31% to 11%, p<0.0001
Christie (2009)
Sentinel events No statistical significant difference in sentinel events, general surgical vs. surgical subspecialty interns (one sentinel event)
Freitag (2011)
Pineda (2015)
Patient falls 2 falls (pre) vs. 0 falls (post)#
Andreoli (2010)
Objective/
Telem (2011)
Patient outcome (PO) Results detail Study
Haig (2006)
Duration of PO measurementPOcollection
Retrospective chart review (each month 20 randomly selected charts)
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Telephonecommunicationfromnursetodoctor–anticoagulationmanagementINR values within the target range (2.0 - 3.0)
4.5% more time in the therapeutic range than in control homes (95% CI: 0.3%-8.7%)
Preventable AE related to warfarin-therapy
Statistically non-significant reduction, odds ratio 0.9 (95% CI: 0.5-1.4)
Telephonecommunicationfromnursetodoctor–Deteriorating/statuschangeofapatientUnexpected death Pre: 10m Significant decrease from 0.99 to 0.34/1000 admissions
(RRR = −227%, 95% CI = −793 to −20; p < 0.001)Post: 10m Significant increase from 13.1 to 14.8/1000 admissions
(RRR = 50%, 95% CI: 30-64%, p=0.001)
Call of cardiac arrest team No significant difference (p>0.05)
Transfers to acute care hospitals
Pre: 12m No significant difference (p = 0.482)
Types of transfers by clinical condition criteria
Post: 8m No significant difference in i) preventable transfer group, p=0.927 or ii) emergent transfer group, p=0.565
Transfers resulting in hospitalization
No significant difference (p = 0.662)
30-day readmissions Pre: 3m Significant reduction, 0.12 vs. 0.04, p=0.012
Transfers to hospital Post: 3m Significant reduction, 0.44 vs. 0.24, p<0.001
Avoidable hospitalisations Significant reduction, 0.15 vs. 0.05, p=0.007
55,167 resident days (intervention homes) vs. 53,601 (control)
Quarterly reviews of nursing home records by pairs of physician-reviewers
Devereaux (2016)
Field (2011)
Abbreviations: CI, confidence interval, month(s), ICU: Intermediate Care Unit, n: number, n.r.: not reported, pre/post: duration of outcome measurement pre/post intervention, RRR: Relative Risk Reduction, SBAR: Subject Background Assessment Recommendation, vs.: versus
De Meester (2013)*
ICU admission
Jarboe (2015)
n.s.
n.s.
Retrospective analysis of medical records and internal emergency calls (performed by a trained expert)
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PRISMA 2009 ChecklistPRISMA 2009 ChecklistPRISMA 2009 ChecklistPRISMA 2009 Checklist
Section/topic # Checklist item Reported on page #
TITLE
Title 1 Identify the report as a systematic review, meta-analysis, or both. 1
ABSTRACT
Structured summary 2 Provide a structured summary including, as applicable: background; objectives; data sources; study eligibility criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions and implications of key findings; systematic review registration number.
2
INTRODUCTION
Rationale 3 Describe the rationale for the review in the context of what is already known. 4+5
Objectives 4 Provide an explicit statement of questions being addressed with reference to participants, interventions, comparisons, outcomes, and study design (PICOS).
5
METHODS
Protocol and registration 5 Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if available, provide registration information including registration number.
7
Eligibility criteria 6 Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered,
language, publication status) used as criteria for eligibility, giving rationale. 7
Information sources 7 Describe all information sources (e.g., databases with dates of coverage, contact with study authors to identify additional studies) in the search and date last searched.
7
Search 8 Present full electronic search strategy for at least one database, including any limits used, such that it could be repeated.
7, App A
Study selection 9 State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable,
included in the meta-analysis). 8
Data collection process 10 Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators.
8+9
Data items 11 List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made.
8
Risk of bias in individual studies
12 Describe methods used for assessing risk of bias of individual studies (including specification of whether this was done at the study or outcome level), and how this information is to be used in any data synthesis.
8+9
Summary measures 13 State the principal summary measures (e.g., risk ratio, difference in means). 9
Synthesis of results 14 Describe the methods of handling data and combining results of studies, if done, including measures of consistency (e.g., I
2) for each meta-analysis.
9
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PRISMA 2009 ChecklistPRISMA 2009 ChecklistPRISMA 2009 ChecklistPRISMA 2009 Checklist
Page 1 of 2
Section/topic # Checklist item Reported on page #
Risk of bias across studies 15 Specify any assessment of risk of bias that may affect the cumulative evidence (e.g., publication bias, selective reporting within studies).
-
Additional analyses 16 Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta-regression), if done, indicating which were pre-specified.
-
RESULTS
Study selection 17 Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally with a flow diagram.
Figure 1
Study characteristics 18 For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period) and provide the citations.
Table 2, App. B+C
Risk of bias within studies 19 Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12). Figure 2
Results of individual studies 20 For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each intervention group (b) effect estimates and confidence intervals, ideally with a forest plot.
Table 2, App D
Synthesis of results 21 Present results of each meta-analysis done, including confidence intervals and measures of consistency. -
Risk of bias across studies 22 Present results of any assessment of risk of bias across studies (see Item 15). -
Additional analysis 23 Give results of additional analyses, if done (e.g., sensitivity or subgroup analyses, meta-regression [see Item 16]). -
DISCUSSION
Summary of evidence 24 Summarize the main findings including the strength of evidence for each main outcome; consider their relevance to key groups (e.g., healthcare providers, users, and policy makers).
18
Limitations 25 Discuss limitations at study and outcome level (e.g., risk of bias), and at review-level (e.g., incomplete retrieval of identified research, reporting bias).
18-21
Conclusions 26 Provide a general interpretation of the results in the context of other evidence, and implications for future research. 22
FUNDING
Funding 27 Describe sources of funding for the systematic review and other support (e.g., supply of data); role of funders for the systematic review.
22
From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed1000097
For more information, visit: www.prisma-statement.org.
Page 2 of 2
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