Improving handover in the ED setting

“SBAR“

Objectives of the “SBAR Squad from A&E”

• Where we are

• Where we need to be

• What do our staff think

• How far have we got

• Where are we going

TAPS questions (Additional)

• “The SBAR Squad from A&E”

• What we were trying to achieve and why it was important:

• What worked well:

• What we have learned to take this forward:

Where we are?

Our

Objective:

To deliver high quality, evidence-based, effective, efficient and

patient-centred care for ALL patients in the Emergency Department.

PHASE 1

INITIAL ASSESSMENT

• Assessment - initial (complaint, physiology and allocate prioritisation)

• Planning -(investigations needed/ordered, obvious decision to admit - DTA, start now if appropriate)

• Treatment - (immediate treatment/resuscitation required)

PHASE 2

DETAILED ASSESSMENT

& TREATMENT

• Detailed assessment

• Chase results of investigations ordered

• Instigate further investigations if required EARLY

• Start treatment plan

• Management plan defined and delivered (with diagnosis, treatment plan and discharge plan)

PHASE 3

MANAGEMENT &

DISCHARGE PLANNING

PHASE 4

ED EXIT – PLANNING &

DELIVERY –SBAR

Start Processes To:

A) Discharge Home from ED using SBAR

B) Admit to In-hospital Specialty Bed Base SBAR

C) Admit to ED Observation Ward/CDU SBAR

If delay in discharge from ED for any reason, inform appropriate person.

TARGET TIMES TO SEE A DOCTOR DAILY & WEEKLY PERFORMANCE RESULTS

FOR EACH PHASE

STRATEGIC PLANNING AND EVALUATION IN THE EMERGENCY DEPARTMENT

0-15min window 15mins-90mins Window

90mins-3hrs Window

3-4hr window

• ED Senior Nurse SBAR

• ED SpR or Cons SBAR

• Duty Bed Manager

• If there is a breach (>4hrs in the Dept) in your area, please identify ways to prevent it in the future)

Category 1 (Resuscitation) = ImmediateCategory 2 (Emergency) = Within 10minsCategory 3 (Urgent) = Within 1hrCategory 4 (Non-urgent) = Within 1hr

Patient arrival to discharge MUST BE WITHIN 4 HRS for all patients.

If delay in discharge from ED for any reason, inform appropriate person.

Our Target:

What are the causes of error Fletcher NPSA 2008

Juliette Cosgrove: Q. “are we reporting enough?”

UCD IR1s 2011 [chart]

Knowledge application

Process & system design

Measuringsuccess

Teamworking & LEADERSHIP

Training

Where we need to be

What do our staff think?“a methodical order:

name, age, gender, condition, plan, any risk to staff or patient” - nurse, grade 5.

“simple clear patient details - complaint \ problem \ plan \ what needed \ & additional info.” – CSW.

“everyone needs to handover following the same structure in the trust.” – Sister grade 6.

“any further documentation needs to be short & concise. Already stress on 'time factors' with many other requirements for patients in ED; throughout [ED] stay and d/c to ward.” – Sister grade 7.

“S: PC

B: Meds & PMH

A: impression / exam

R: plan “ - SpR in ED.

What do our staff think?

Q1. The Emergency Department is a busy environment where the safety systems in place are robust and require no change.

Please indicate the level of risk you perceive to be associated with the following patient events :

Q12. Discussion with other speciality nursing or medical colleagues In the hospital.

1 Strongly Disagree

2 3 4 5

Disagree Neutral Agree Strongly Agree

1 2 3 4 5

Low Risk   Moderate   High Risk

    Risk  

How far have we got?

• Audit ( ED Cons Shift Team Leader snapshots x2)

• SBAR templates for key areas of the ED

• Developing context specific SBAR

Audit of practice

• Applied a development SBAR tool ( sticker in the ED notes)

• 10% and 15% adherence – not good!

• Positives:– Allowed refinement of tool– Embedded SBAR in minds of staff– Led to discussion and outcome to embed in

ED notes

EMERGENCY DEPT PLANNING &

HANDOVER

Situation•Likely diagnosis &other possible Dx?

Background•Co-morbidities?

Assessment•Present physiology (MEWS, GCS)?•Active problems•Investigations completed & those still required?

Recommendations•Acute therapy given?•Further therapy required and when?•Handover to (their name, grade, specialty) : •Your name, grade & time of referral?

SBAR template embedded into ED Notes

Senior Handover SBAR

SBAR for CDU protocols

SSITUATION

NameAgeConsultantDiagnosisTreatment / InterventionsResuscitation Status

_____________________________________________________________________________________________________________________________________________________________________________________________

BBACKGROUND

Relevant medical history / surgical historyMedical / AHP consultationsPrevious tests / treatmentsPsychosocial issuesAllergies

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

AASSESSMENT

Physical assessmentMental health assessment / cognitionVital signs / O2 requirementsLines - IV, CVC, PICC, ArterialPain score / analgesiaWounds / pressure ulcersDrains or tubesMobility Nutritional statusRisk assessments (MEWS, MUST, VIP scores, MRSA/ decolonisation status and falls assessment.) Pathology resultsPatient /carer education

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

RRECOMMENDATION

Care plan /care pathwayOrders needing completionPending treatments or testsDischarge planning

__________________________________________________________________________________________________________________________________________________________________

RREADBACK

Oncoming staff (listener) confirms understanding of recommendations

__________________________________________________________________________________________________________________________________________________________________

Where are we going!

• Embedding SBAR into ED notes

• Developing context specific SBAR within umbrella of improved handover

• Development of better communications with rest of hospital around SBAR

• Developing a tool for adherence and quality of content of SBAR in context specific situations