sbar rev jan 10
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8/8/2019 SBAR REV Jan 10
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SBARSBARIMPROVING COMMUNICATIONIMPROVING COMMUNICATION
AMONG CAREGIVERSAMONG CAREGIVERS
January 2010
Policy C-118 Handoff CommunicationDuring Patient Transfers
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ObjectivesObjectives
Upon completion of this module the RN will be able to:Upon completion of this module the RN will be able to:
Recall the reasons for using SBAR in the clinical settingRecall the reasons for using SBAR in the clinical setting
Describe what SBAR stands for and gives a clinicalDescribe what SBAR stands for and gives a clinicalindication for its useindication for its use
Describe steps to take if patientDescribe steps to take if patients need remains unmet afters need remains unmet after
using SBAR to communicate to a physicianusing SBAR to communicate to a physician
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JCAHO Patient Safety GoalJCAHO Patient Safety Goal
IMPROVE THE EFFECTIVENSS OFIMPROVE THE EFFECTIVENSS OF
COMMUNICATION AMONGCOMMUNICATION AMONGCAREGIVERSCAREGIVERS
SBAR is one method of meeting this PatientSBAR is one method of meeting this PatientSafety goal by standardizing communicationSafety goal by standardizing communicationamong caregivers.among caregivers.
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WHY SHOULD WE BE TALKING?WHY SHOULD WE BE TALKING?
The overwhelming majority of untoward andThe overwhelming majority of untoward and
sentinel events involve communication failuresentinel events involve communication failurebetween healthcare providersbetween healthcare providers
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COMMUNICATION IS EASIER IF:COMMUNICATION IS EASIER IF:
THERE IS A STANDARD MODEL FORTHERE IS A STANDARD MODEL FORCOMMUNICATIONCOMMUNICATION EVERYONE IS AWARE OF THE MODELEVERYONE IS AWARE OF THE MODEL EVERYONE USES THE MODEL TOEVERYONE USES THE MODEL TOCOMMUNICATE PATIENT INFORMATIONCOMMUNICATE PATIENT INFORMATION
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When to Use SBAR CommunicationWhen to Use SBAR Communication
Technique at MUHATechnique at MUHA
Transferring orTransferring or handing offhanding off a patient froma patient fromone caregiver or department to anotherone caregiver or department to another Change of shift reportChange of shift report Communicating a patient situation to a physicianCommunicating a patient situation to a physicianor other provideror other provider
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ASSERTION INASSERTION IN
COMMUNICATIONCOMMUNICATION
SBAR facilitates assertive communicationSBAR facilitates assertive communication
Individuals speak up and state theirIndividuals speak up and state their
information with appropriate persistence untilinformation with appropriate persistence untilthere is a clear resolutionthere is a clear resolution
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KEY IS BEING PREPAREDKEY IS BEING PREPARED
Have I assessed this patient myself before I call?Have I assessed this patient myself before I call?
Do I have on hand:Do I have on hand: The chart?The chart?
List of meds, IV fluids, labs?List of meds, IV fluids, labs?
Most recent vital signs?Most recent vital signs?
Have I read the most recent progress notes?Have I read the most recent progress notes?
What do I want to happen as a result of this call?What do I want to happen as a result of this call?
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SBAR FRAMEWORK FORSBAR FRAMEWORK FOR
COMMUNICATIONCOMMUNICATION
SS Situation:Situation: What is the problem?What is the problem?BB
Background:Background: How did we get here?How did we get here?
AA AAssessment:ssessment: What is the data?What is the data?RR
Recommendation:Recommendation: What are we going toWhat are we going to
do to address the problem?do to address the problem?
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SBAR Steps for CommunicationSBAR Steps for Communication
SS SITUATION:SITUATION:What is the problem?What is the problem? State your name and unitState your name and unit I am calling about (pt name and room #)I am calling about (pt name and room #) The problem I am calling about is:The problem I am calling about is:
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SBARSBAR
BBBACKGROUNDBACKGROUND
How did we get here?How did we get here?
Admission diagnosis and date of admissionAdmission diagnosis and date of admission PertinentPertinentmedical historymedical history AA briefbriefsynopsis of the treatment to datesynopsis of the treatment to date Code statusCode status
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SBARSBAR
AA--ASSESSMENTASSESSMENT
What is the data?What is the data?
Most recent vital signsMost recent vital signs SignificantSignificantassessment findingsassessment findings SignificantSignificantlabs or other resultslabs or other results
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SBARSBAR
RR
RECOMMENDATIONRECOMMENDATION
What are we going to do to address theWhat are we going to do to address theproblem?problem?
Transfer the patient to the ICU?Transfer the patient to the ICU?
Come see the patient ASAP?Come see the patient ASAP? Talk to patient and family about the code status?Talk to patient and family about the code status? Ask for a consultant to see the patient nowAsk for a consultant to see the patient now State treatment, i.e., fluids, chest tubes, painState treatment, i.e., fluids, chest tubes, painmedicationmedication
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CLINICAL EXAMPLECLINICAL EXAMPLE
SS SituationSituation -- Dr. Jones, IDr. Jones, Im Paul, an RN on 8East. Mr.m Paul, an RN on 8East. Mr.Jones in 810 is in respiratory distress.Jones in 810 is in respiratory distress. BB BackgroundBackground He was admitted for COPDHe was admitted for COPDexacerbation this morning, has been stable on 3L nasalexacerbation this morning, has been stable on 3L nasal
cannula, but is now acutely worse.cannula, but is now acutely worse.
AA AssessmentAssessment VS 98/62, HR 108, RR40, O2 sat 74%VS 98/62, HR 108, RR40, O2 sat 74%with a nonrebreather at 10L. His breath sounds arewith a nonrebreather at 10L. His breath sounds aredecreased on the right side. I think he may have adecreased on the right side. I think he may have a
pneumothorax.pneumothorax.
RR RecommendationRecommendation I need your to come see himI need your to come see himimmediately. Can we get some ABGs and a STAT portableimmediately. Can we get some ABGs and a STAT portablechest xchest x--ray?ray?
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HANDING OFFHANDING OFF
TRANSFERING A PATIENT TO ANOTHERTRANSFERING A PATIENT TO ANOTHERDEPARTMENT OR CAREGIVERDEPARTMENT OR CAREGIVER
MUHA has anMUHA has an SBAR HANDOFF REPORTSBAR HANDOFF REPORTGUIDEGUIDE This should always be used as the guide forThis should always be used as the guide forhanding off patients to another department orhanding off patients to another department or
caregivercaregiver Please review the information from the GuidePlease review the information from the Guideon the following slideson the following slides
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SBAR HANDSBAR HAND--OFF REPORT GUIDEOFF REPORT GUIDE
SITUATION: What is the problem?This is the report on (patient name & room #)
Introduce self, get name of person receiving report
Code status Isolation/type Allergies, (band on) Diagnosis Current condition (include recent changes) Special needs (spiritual, cultural, learning,communication, social)
Consults completed/planned
Admission Assessment complete
SITUATION: What is the problem?hat is the problem?This is the report on (patient name & room #)
Introduce self, get name of person receiving report
Code status Isolation/type Allergies, (band on)
Diagnosis Current condition (include recent changes) Special needs (spiritual, cultural, learning,communication, social)
Consults completed/planned
Admission Assessment complete
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SBAR HANDSBAR HAND--OFF REPORT GUIDEOFF REPORT GUIDE
BACKGROUND: How did we get here?
Key tests/critical results Current treatments
Plan of care
Significant patient complaints/problems (patient/family concerns/communication withphysician) Medication review due
Disposition of patient belongings
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SBAR HANDSBAR HAND--OFF REPORT GUIDEOFF REPORT GUIDE
ASSESSMENTASSESSMENT (CONTINUED)(CONTINUED)
Intake (diet, diet status, fluid intake)Intake (diet, diet status, fluid intake)
OutputOutput
Fluids/urine/emesisFluids/urine/emesis
Other (drains, tubesOther (drains, tubes))
EliminationElimination
CatheterCatheter
Bowel soundsBowel sounds
StoolsStools
Cognitive/Mental status issues/changesCognitive/Mental status issues/changes
Safety (restraints, fall risk, aspiration, suicide)Safety (restraints, fall risk, aspiration, suicide)
Restraints (type, physician order status, assessment)Restraints (type, physician order status, assessment)
Skin temperature/conditionSkin temperature/condition
Temperature/color/edema/hematomaTemperature/color/edema/hematoma
Evidence of skin breakdown/site/treatments in placeEvidence of skin breakdown/site/treatments in place
ActivityActivity
Mobility status/use of assistive devicesMobility status/use of assistive devices
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SBAR HANDSBAR HAND--OFF REPORT GUIDEOFF REPORT GUIDE
RECOMMENDATIONS:RECOMMENDATIONS:
What are we going to do to address the problem?What are we going to do to address the problem?
Anticipated changesAnticipated changes Tests/treatments neededTests/treatments needed
Pending resultsPending results
Information to give physician/other members ofInformation to give physician/other members ofhealthcare teamhealthcare team
Provide patient/family following informationProvide patient/family following information
ANY OTHER INFORMATION NEEDED?ANY OTHER INFORMATION NEEDED?
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Remember!Remember!
Always use the SBAR Handoff Report GuideAlways use the SBAR Handoff Report Guidewhen transferring a patient from onewhen transferring a patient from onedepartment or caregiver to anotherdepartment or caregiver to another
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CHECK LIST FORCHECK LIST FOR
COMMUNICATIONCOMMUNICATION Get personGet persons attention/make eye contacts attention/make eye contact Use the personUse the persons names name
Express your concernExpress your concern
SS --
SituationSituation
BB -- BackgroundBackground
AA--
AssessmentAssessment
RR
RecommendationRecommendation
Reassert if necessaryReassert if necessary
Go up the chain of command if necessaryGo up the chain of command if necessary
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Congratulations!Congratulations!
You have completed the lesson on SBAR.You have completed the lesson on SBAR.
Thank you!Thank you!
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