maria jensen, npp, mph, rn marina cecere, npp, mph, rn renee mcleod-sordjan, dnp, fnp-bc, rn
TRANSCRIPT
SBAR AND EMR COMMUNICATION
TOOLSMaria Jensen, NPP, MPH, RNMarina Cecere, NPP, MPH, RN
Renee McLeod-Sordjan , DNP, FNP-BC, RN
Introduction
A review of reports from JACHO shows that communication failures to hand over effectively were implicated at the root of over 70 percent of sentinel events for hospitals and clinics to improve care.
Shendell-Falik, N., Feinson, M., & Mohr, B.J., (2007). Enhancing patient safety; Improving the patient handoff process though appreciative inquiry. The Journal of Nursing Administration, 37(2), 95-104.
Goals
National Patient Safety Goal 2: “Improve the effectiveness of communication among caregivers”.This addition requires hospitals to implement a standardized approach to hand-off communications and provide an opportunity for staff to ask and respond to questions about patient’s care.
Joint Commission on Accreditation of Healthcare Organizations: Sentinel Event Statistics-June30,2005. Retrieved
http://www.jcaho.org/accredited+organizations/sentinel+event/sentinel+eventsttistics.htm
Factors that contribute towards failure to identify & manage deteriorating patient.
Insufficient information, faulty exchanges of existing information
Ambiguous and unclear information Lack of timely and effective exchange of pertinent
information when alerting to concerns about patient condition
Ineffective communication and handover of medically or mentally compromised patients
Leonard, M., Graham, S., & Bonacum, D. (2004). The Human Factor. The Critical Importance of Effective Teamwork and Communication in Providing Safe Care. Quality and Safety in Health care 13 85-90
Where do things fall through the cracks?
Systems – Information, test results, diagnosis
Communication – handovers, transitions in care
Failure to plan, failure to recognize, failure to rescue
SBAR
Is a structured method for communicating critical information that requires immediate attention and action
Offers hospitals and care facilities a solution to bridge the gap in communication, including hand-off patient transfers
It creates a shared expectation between the sender and receiver of the information being shared
EMR
Minimize medicals errors by providing safety checks on prescription dosages, drug-to drug interactions, duplicate therapies, and a patient’s previous adverse reactions
Improves workflow and staff communication Track test results Reduce costs Improve health, and improve efficiency and
networking.
Hillestad, R., Bigelow, J., Bower, A., Girosi, F., Meili, R., Scoville, R., & Taylor, R., (2005).Can electronic medical record systems transform health care? Potential health benefits, savings, and cots. Health Affairs (Project Hope),24(5), 1103-1117. doi:10.1377/hlthaff.24.5.1103
Outcomes
SBAR (PSYCH) + EMR = ENHANCED COMMUNICATION AND NURSE
SATISFACTION
Current SBAR
SSITUATIONMy name is: __________________Speaking to RN_____________Unit/Area I am calling from:Patient’s NamePt.’s chief complaintWhat happened? Legal status 939 2PC Voluntary
BBACKGROUNDAdmission diagnosis and date of ERState the pertinent medical history:A brief synopsis of the treatment/medication given to date:
Vital signs are:UCG:____ Urine Tox._________ Results of LAB/ Diagnostics
AASSESSMENT/MMSE
SUICIDAL YES OR NO ____HOMICIDAL YES OR NO ________ EXPLAIN_______
AGITATION/AGGRESSION YES/NO______IMPULSE CONTROL_________
GROSS INPAIRMENT ADL’S YES/NO EXPLAIN ________
RRECOMMENDATION
Medication/Tests
Enhanced SBAR for Practice Improvement Project
SSITUATIONMy name is: __________________Speaking to RN_____________Unit/Area I am calling from:Patient’s NamePt.’s chief complaintWhat happened? Accepting PSYCHIATRY ________ Medical MD___________________Legal status 939 2PC Voluntary
BBACKGROUNDAdmission diagnosis and date of ERState the pertinent medical history: RESPIRATORY____CARDIAC______SKIN_____A brief synopsis of the treatment/medication given to date:FALLS POTENTIAL YES/NO_____ELOPMENT POTENTIAL______DIET_____Vital signs are:UCG:____ Urine Tox._____ Substance abuse history____ Last use_____ Results of LAB/ Diagnostics Tests/ACCU CHECK______ XR/MRI RESULTS________
AASSESSMENT/MMSE ALERT/ORIENTED TIME___PERSON ____PLACE___SITUATION_______ MOOD: Depressed___Anxious____Elated_____OTHER_____ AFFECT:Depressed___Anxious____Neutral_____Blunted_____Flat____OTHER------ THOUGHT PROCESS: Goal directed____ Tangential______FOI______OTHER___ DELUSIONS: ___ TYPE_____ HALLUCINATIONS:___________TYPE_________ SUICIDAL YES OR NO ____HOMICIDAL YES OR NO ________ EXPLAIN_______ AGITATION/AGGRESSION YES/NO______IMPULSE CONTROL_________ EXPLAIN______ IF YES, TIME OF MEDICATION GIVEN
_________ GROSS INPAIRMENT ADL’S YES/NO EXPLAIN ________
RRECOMMENDATION Medication/Tests/Txs. order to be given in the unit until P.E. rendered ___
Neuro checks____ F.S_____ Other______
Psychiatric Patient Admission Process
Decision to admit patient by ED
physician
Psychiatrist writes orders
ER nurse performs admission assessment
ER utilizes handoff communication
Psychiatry nurse receives mental status
info YesUtilizes SBAR to obtain
mental status examHandoff complete
No
Psychiatry nurse receives mental status
info
Receives direct information regarding patient behavior from
psychiatrist
Psychiatric Patient Admission Process Status Post Process
ED nurses use SBAR
Recruitment
ED Nurses and Psychiatric Nurses during admission process of psychiatric patients
Plan
EMR satisfaction survey
Focus Group
Nursing Education regarding SBAR
Implementation
Post- Survey & Evaluation
REFERENCE
Hillestad, R., Bigelow, J., Bower, A., Girosi, F., Meili, R., Scoville, R., & Taylor, R., (2005).Can electronic medical record systems transform health care? Potential health benefits, savings, and cots. Health Affairs (Project Hope),24(5), 1103-1117. doi:10.1377/hlthaff.24.5.1103
Joint Commission on Accreditation of Healthcare Organizations: Sentinel Event Statistics-June 30,2005. Retrievedhttp://www.jcaho.org/accredited+organizations/sentinel+event/sentinel+eventsttistics.htm Leonard, M., Graham, S., & Bonacum, D. (2004). The Human Factor. The Critical Importance of Effective Teamwork and Communication in Providing Safe Care. Quality and Safety in Health care 13 85-90
Shendell-Falik, N., Feinson, M., & Mohr, B.J., (2007). Enhancing patient safety; Improving the patient handoff process though appreciative inquiry. The Journal of Nursing Administration, 37(2), 95-104