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For peer review only

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

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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1



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: [email protected]

JJ: [email protected]

MR: [email protected]

KK: [email protected]

WH: [email protected]

SS: [email protected]

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: [email protected]

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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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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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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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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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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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)


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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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.

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Journal: BMJ Open

Manuscript ID bmjopen-2018-022202.R1


Date Submitted by the Author: 17-May-2018



<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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Martin Müller1,2, Jonas Jürgens2, Marcus Redaèlli2, Karsten Klingberg1, Wolf E. Hautz1,

Stephanie Stock2


Bern, Switzerland.


Cologne, Germany.












Manuscript word count: 4006 (Introduction – Conclusions, excluding Tables)


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ABSTRACT





summarise the impact of the implementation of SBAR on patient safety.




implemented into clinical routine, ii) the investigation of SBAR was the primary objective, and

iii) at least one patient outcome was reported.


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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adverse event




studies.


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





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



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


S Situation


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


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


A Assessment



R Recommendation





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7

METHODS

Search strategy





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


• 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.







Data extraction









Quality assessment






(selection bias, study design, confounders, blinding, data collection methods, as well as

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9

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.




Data synthesis





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







identified through screening of the references of the included articles.

Quality assessment


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.


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.


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).


measured and ranged between two57 and 24 months42 63 and was not specified in two

studies.46 60

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Intervention targets


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.


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)


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


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



Preventable AE related to warfarin-therapy

Telem (2011)57 CCT Hospital Patient hand-off – physician Sentinel events

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Call of cardiac arrest team

Jarboe (2015)63 BAS Nursing homes


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.


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


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


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.







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.



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.


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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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114x191mm (300 x 300 DPI)

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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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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


all clinical staff


all clinical/non-clinical

staff & unit leaders


all nursing staff


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


nurses and physicians (in

notifying providers of

change in patient status)




change in resident status)

Introduction of

condition-specific

SBAR

-

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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*


! 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)


! 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) &#53%'5'*%2

3. Trigger tools*


! project team

! SBAR champion

Freitag

(2011)

n.r.

Haig (2006) All clinical staff n.r.

Christie

(2009)


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)


! 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)


Jarboe

(2015)

Nursing staff 66

Telem

(2011)


staff

45

De Meester

(2013)

Nursing staff n.r.

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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#


Patienthand-off–nursesInpatient Fall Rate Reduction of 5%#


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#




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)



Christie (2009)


Freitag (2011)

Pineda (2015)


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)




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)


Transfers to acute care hospitals

Pre: 12m No significant difference (p = 0.482)


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


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




Devereaux (2016)

Field (2011)


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


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


5

METHODS


7

Eligibility criteria 6 Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered,



7


7, App A


included in the meta-analysis). 8


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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Page 1 of 2


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


Figure 1


Table 2, App. B+C


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




DISCUSSION


18


18-21


FUNDING


22


For more information, visit: www.prisma-statement.org.

Page 2 of 2

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Journal: BMJ Open

Manuscript ID bmjopen-2018-022202.R2


Date Submitted by the Author: 11-Jul-2018



<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



Martin Müller1,2, Jonas Jürgens2, Marcus Redaèlli2, Karsten Klingberg1, Wolf E. Hautz1,

Stephanie Stock2


Bern, Switzerland.


Cologne, Germany.












Manuscript word count: 4026 (Introduction – Conclusion, excluding Tables)


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2

ABSTRACT





summarise the impact of the implementation of SBAR on patient safety.




implemented into clinical routine, ii) the investigation of SBAR was the primary objective, and

iii) at least one patient outcome was reported.


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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3



adverse event




studies.


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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4

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





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



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


S Situation


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


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


A Assessment



R Recommendation





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7

METHODS

Search strategy





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


• 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.







Data extraction









Quality assessment






(selection bias, study design, confounders, blinding, data collection methods, as well as

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9

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.




Data synthesis





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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10

RESULTS







identified through screening of the references of the included articles.

Quality assessment


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.


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.


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).


measured and ranged between two52 and 24 months37 58 and was not specified in two

studies.41 55

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12

Intervention targets


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.


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




INR values within the target range

Randmaa (2014)37

CCT Hospital Patient hand-off – physician and nurses CIRS events (communication errors)



i) Unexpected death and ii) ICU admission

Pineda (2015)56 BAS Hospital Patient hand-off – nurses Patient falls

Devereaux (2016)59

BAS Nursing home


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




Telem (2011)52 CCT Hospital Patient hand-off – physician Sentinel events

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15




Call of cardiac arrest team

Jarboe (2015)58 BAS Nursing homes


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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16

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.


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.


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


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.







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.



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.


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Figure 2. Quality assessment of the included studies





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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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114x191mm (300 x 300 DPI)

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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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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)


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)


clinicians (in verbal and

written form)


all clinical staff


all clinical staff


all clinical/non-clinical

staff & unit leaders


all nursing staff


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




change in patient status)




change in resident status)

Introduction of

condition-specific

SBAR

-

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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*


! 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*


! 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)


! 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) &#53%'5'*%2

3. Trigger tools*


! project team

! SBAR champion

Freitag

(2011)

n.r.

Haig (2006) All clinical staff n.r.

Christie

(2009)


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)


! 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)


Jarboe

(2015)

Nursing staff 66

Telem

(2011)


staff

45

De Meester

(2013)

Nursing staff n.r.

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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#


Patienthand-off–nursesInpatient Fall Rate Reduction of 5%#


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#




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)



Christie (2009)


Freitag (2011)

Pineda (2015)


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)




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)


Transfers to acute care hospitals

Pre: 12m No significant difference (p = 0.482)


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


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




Devereaux (2016)

Field (2011)


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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TITLE


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


5

METHODS


7

Eligibility criteria 6 Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered,



7


7, App A


included in the meta-analysis). 8


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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Page 1 of 2


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


Figure 1


Table 2, App. B+C


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




DISCUSSION


18


18-21


FUNDING


22


For more information, visit: www.prisma-statement.org.

Page 2 of 2

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