Critically important pieces of information can be concisely communicated in a standard framework if one tool is used institution-wide.1 A tool for hand-off communication that's gaining wide acceptance is the SBAR:
Situation-what's going on with the patient?
Background-what's the clinical background or context?
Assessment-what's the issue?
Recommendation-what should happen?2
In the clinical arenas, a patient report may be given numerous times. A shift-to-shift report from the primary nurse to the relief nurse, along with a report when transferring patients to procedural areas and upon returning to the floor, and a report from the emergency department or triage nurse to the floor nurse, as well as information reported to the healthcare provider are expected. Standardizing the information given and received will reduce error, and will pinpoint the information needed in every case. For example, a patient is prepared for surgery in the preoperative hold area and then transferred to the OR for surgery. The preoperative nurse would give the essential data to the circulating nurse in the SBAR format:
S: 10-year-old male scheduled for a tonsillectomy at 11:00 a.m. today
B: Has had a history of chronic sore throats for a year, no known drug allergies, no underlying health problems or past surgical history. Family history is negative for physical symptoms, however, he had an older sibling who died recently in a car accident, and patient's mother is emotionally distraught with her child undergoing general anesthesia for surgery, no matter how routine.
A: Temperature 98.4[degrees] F (36.9[degrees] C), Pulse 100, Respirations 24, Blood Pressure 110/60. Child has voiced no concerns about surgery or "going to sleep" for surgery.
R: Should do fine with the OR, how-ever will need to keep in communication with the mother to allay her concerns.
SBAR between caregivers
Likewise, a SBAR report to the physician will provide direct analysis of a patient situation as well as demonstrate RN autonomy. For example, an RN calling the physician in the middle of the night would offer data in the SBAR format, clarifying the exact issue:
S: "Dr. Jones, this is Pauline, the night nurse on 4-West. I am calling about Mabel Owens who's nauseated and vomiting."
B: "She is a 52-year-old patient of your partner, Dr. Roberts, who had a total abdominal hysterectomy 12 hours ago for dysfunctional uterine bleeding. She has an I.V. of D5NSS, is receiving I.V. antibiotics every 6 hours, and has been medicated for pain recently. She has no known drug allergies and no underlying chronic disease."
A: "Temperature is 99.2[degrees] F (37.3[degrees] C), pulse 110, respirations 24, blood pressure 146/78."
R: "I think she could use an antiemetic, either I.V. or rectal suppository."
A standardized, succinct report between care-givers such as the SBAR decreases the potential for error as well as ensures patient safety and quality outcomes.
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