Bello, Jennifer BSN, RN-BC; Quinn, Paul MSN, CNM, RN-BC, NE-BC, CEN, CCRN; Horrell, Les CPFT
Section Editor(s): Thede, Linda Q. PhD, RN-BC
Assistant Nurse Manager (Ms Bello); Director of Nursing (Mr Quinn); and Clinical Informaticist for Nursing (Mr Horrell); White Plains Hospital, White Plains, NY
* Using informatics to increase patient safety
* Improving nurse-to-nurse communication during handoffs
* Multiuse of electronic data
Healthcare organizations have been charged with finding innovative ways to provide accurate and concise patient information, not only from nurse to nurse, but also among all healthcare disciplines. At White Plains Hospital in White Plains, NY, as part of our philosophy of shared governance and collaboration, various focus group meetings were held within the organization to assess the culture of safety within the institution and to gather feedback from members of the nursing staff regarding areas for improvement related to patient safety. One of the most frequent reports from the focus groups was the lack of communication among the nursing staff, specifically surrounding patient transfer from unit to unit, or during a shift handoff from nurse to nurse. The nurses resoundingly asked for improvements related to intraorganizational communication and overwhelmingly verbalized their fears and frustration with not having accurate and concise information to plan care for their patients.
The chief nursing officer convened an ad hoc communication committee to pool ideas and find a solution to the communication issues raised during the focus groups. The committee consisted of nurses at all levels of practice, including managers and bedside staff. After analyzing other solutions, the committee reached the conclusion that SBAR1 (situation, background, assessment, and recommendation), which describes a systematic, focused, and concise mechanism for the communication of pertinent patient information reporting, was the best mechanism to bridge the information gap during handoff.
Following the Joint Commission's2 National Patient Safety Goal 02.05.01, White Plains Hospital implemented SBAR reporting in a paper format, but despite efforts at educating staff to its use and efficacy, the SBAR forms were neither completed nor used as intended. For example, nurses would fill out only certain sections of the paper SBAR form, often omitting key pieces of information such as laboratory results or daily activity. Other times, nurses would include information that was too old or diagnoses that no longer applied. This was especially true for patients who had been hospitalized for several weeks. Worse, some nurses did not use the form at all.
The Communications Committee directed their efforts toward discovering why the nursing staff was not making more efficient use of the SBAR report. We found that while White Plains Hospital utilizes an all-electronic health record, nurses reported that charting electronically in addition to completing the SBAR in the paper format was too time consuming, cumbersome, and distracting. In addition, nurses questioned why the SBAR report had to be done on paper, when every other aspect of their documentation was done electronically. The Communications Council recognized this complaint as valid and suggested that the SBAR report be made electronic. A member of the Communications Council, then reported this to the Informatics Council, which recommended that the SBAR report be refined and revised into an electronic format.
White Plains Hospital implemented an all-electronic health record in 2006. The organization chose Meditech as its vendor for the project, and the initial rollout of the system occurred on all inpatient units. To date, the Meditech system has been successfully implemented in all areas of the hospital, including the outpatient areas and pharmacy. All disciplines, including social work, nutrition, physical medicine, and nursing, use the system to document electronically. In addition, our physicians utilize computer physician order entry, and all medical documentation and orders are entered directly into the electronic system.
Furthermore, the system allows for an electronic medication administration record with bedside medication verification scanning, which is utilized by our nursing and respiratory staff. Thus, the entire patient medical record including laboratory results and imaging, with the exception of consents, is contained within electronic record. Clinicians have access with the click of a menu to all previous visits back to 2006.
In creating an electronic SBAR form, our goal was to remove any charting redundancies. We first created a template of how we thought the form should look and sent it to the informaticist for nursing. He plotted the logistics for electronic storage of the desired information for the SBAR report was electronically stored and worked with the Meditech programmers to create a prototype of the new all-electronic SBAR document. This was then trialed in our test environment within the Meditech system, and all end-users were given an opportunity to make suggestions for further revisions.
In the Meditech documentation system, data from the assessment screens can be queried and combined with queried data from other sources to create reports. Using the same data for different purposes eliminates duplication of data entry and the need to toggle between multiple assessment screens to retrieve patient data. Table 1 demonstrates an example of hard-coded headers that appear in each section of the SBAR report (Table 1). Information to complete the form is imported from the medical record.
Not only is the most recent nursing documentation used in the SBAR report, but when disciplines outside nursing enter new patient data on their assessment screens, the report is updated with these data. We find this particularly useful because this information was identified by the original focus group as most often not communicated during intershift handoff.
There is also a discharge planning section that helps to decrease the gap between the night shifts face-to-face communications with day discharge planners. The completed SBAR report helps to ensure that the same consistent information is being communicated during handoff. A nurse who needs to handoff patient information can simply log into any computer and click an icon that leads directly to the SBAR report for the patient. The report can also be printed and used when a patient leaves the nursing unit or transfers out of the organization.
Having an all-electronic medical record allows any healthcare professional involved in a patient's care to use the electronic SBAR to see the most recent patient information. Because it met their needs for brevity and ease of use, the report has been well received by the nursing staff. In addition, as they became accustomed to using the SBAR report, the nurses became innovative in its use and began to preview the report prior to taking handoff from the emergency department, operating room, or a transferring unit. In addition, other departments such as radiology or cardiology access the report to recheck medication administration or previous vital signs. To help the nurses remember to use the new practice, the Communications Committee member created a slogan, modified from the popular Dunkin' Donuts television commercial, "Handoff Runs on SBAR," and strategically placed reminder cards at various computer terminals.
The electronic SBAR report has proven invaluable as a timesaving innovation and as a safety mechanism for ensuring the delivery of accurate patient information. Its ease of use and ability to be modified for our nurses' needs make it a strategic innovation on our journey toward excellence in an environment grounded on maintaining patient safety.
The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.
© 2011 Lippincott Williams & Wilkins, Inc.