8/20/2013
Improve Outcomes through
Effective Communication
M
Mary
Narayan,
N
MSN, RN, HHCNS-BC, COS-C
Home Health Clinical Nurse Specialist
Narayan Associates
mary.narayan@cox.net
Objectives
1 Discuss issues & barriers to effective
1.
communication between home health clinicians
& physicians.
2. Describe how to prepare for &
follow-through on SBAR
communication.
communication
3. Apply SBAR communication
to specific home health
situations.
1
8/20/2013
Joint Commission reports….
„
.
„
Almost 70% of sentinel
events related to
communication problems.
„
„
„
„
Ineffective
Inadequate
Untimely
Happens in home care too
„
„
And Ï hospitalizations
And Ð outcomes
“ What we have here is a
failure to communicate.”
Cool Hand Luke, 1967
2
8/20/2013
Research in Nurse-Physician
Communication
Training in communication methods differs
„ Nurses: Narrative, timed sequence, descriptive
„ Physicians: Concise bullet-point summaries
„
When nurses call, doctors want to know:
„
What is the problem?
p
„
What do you need me to do?
„
By when do I need to respond?
„
Nurses lose physician’s attention and their credibility if they
can’t get to the point in first 10 seconds.
„
Research in Nurse-Physician
Communication
„
„
Physicians
Ph
i i
& nurses both
b th learned
l
d that
th t doctor
d t is
i “in
“i charge”
h
”
BUT hierarchical communication is not effective in complex
situations
„
Healthcare is complex
„ Culture/gender/pecking order are barriers
to effective communication
Nurses are less likely to communicate if they
feel psychologically unsafe. “If I speak up….”
„
Will I be subject to anger or ridicule.
„
Will it be worth it? Will it make a difference?
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8/20/2013
Came out of military operations and aviation
industry
4
8/20/2013
Solution =
SBAR Communication
ƒ Situational Briefing Model
ƒ Practical structure for communicating critical
information concisely.
ƒ Relevant, timely, important data communicated
succinctly.
ƒ SBAR Communication
ƒ Situation. The problem. “Punch”
ƒ Background. The context.
ƒ Assessment. Analysis of situation.
ƒ Recommendation. The fix.
9
Subordinates to Commanders :
Averting Disaster
Nuclear Submarine
Sailor to captain
S: Emergency!
B: Ship above
position
A: Our p
Their position
Crash imminent!
R: Go down! Not up!
S:
B:
A:
R:
Airplane
Co-pilot to pilot
Emergency!
In path of other plane!
Crash imminent
Pull up; turn left!
5
8/20/2013
Evolution of SBAR
„
Leonard Graham
Leonard,
Graham, Bonacum–Kaiser
Bonacum Kaiser Permanente (2004)
„
Institute for Healthcare Improvement (2006)
„
Home Health Quality Initiative (2007)
„
Joint Commission’s National Patient
Safety Goals (2008)
Evidence in Home Healthcare
„
„
„
Kogan, Underwood,
Kogan
Underwood Desmond
Desmond, Hayes & Lucien (2010)
(2010),
Physician communication in managing community-dwelling
older adults. Home Healthcare Nurse, 28(2):105-114.
Evdokimoff, M. (2011). One home health agency’s quality
improvement project to decrease rehospitalization. Home
Healthcare Nurse
Nurse, 29(3),
(3) 180 – 193.
193
AHRQ (2012): Outcomes:
Ï Effective communication
Ï Patient outcomes
Ï Collaboration
Ï Patient satisfaction
6
8/20/2013
The SBAR about SBAR
„
„
„
„
Situation: Inadequate communication in health care Î
Ð quality of care, Ï hospitalizations and Ï costs
Background:
„
Nurses and physicians communicate differently
„
Hierarchy -> lack of assertive communication
„
Lack of Structure ->
> missed information
Assessment: Need for one effective
communication method for all clinicians
Recommendation: SBAR communication
SBAR Communication
Situation
•Capture
attention
• Clinical problem
•
•
•
Background
•Context
•
•
Assessment
•Current
status
•Analysis
Recommendation
•Action
•
statement
needed
•Timeframe
I am … from… agency
Patient name
Problem is…
Age, Diagnoses
Recent relevant medical
hx
Current relevant
assessment data
•
I think the patient has….
•
I think the pt needs…
Do you want me to…
•
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8/20/2013
If Patient Has a “Situation”
„
Symptoms
„
„
Signs
„
„
„
What patient reports
What you see, hear,
palpate, measure
New problem
Exacerbation
Zone Tools
Yellow =
“Situation”
Clinical Judgment
Critical Thinking
HHQI
Fundamentals of
Reducing Acute Care
Hospitalizations BPIP
8
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Before calling physician…
„
„
„
„
1.
2.
3.
4.
Critical thinking
Clinical judgment
In-depth data gathering
What does MD need to know?
Assess the patient
Determine urgency
Review Medical Record
Organize data
Before calling physician,
1) Assess the patient
Symptom & physical assessment
„
Focus in on diagnosis & S/S with a “focused
comprehensive assessment” of system(s) involved
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8/20/2013
Body Systems
„
„
„
„
Cardiovascular
Respiratory
Neurological
Gastrointestinal
„
„
„
„
„
Genitourinary
Musculoskeletal
Integumentary
Endocrine
Immunologic
Which system(s) is/are involved?
What assessment techniques can you use?
What data will the doctor want to know?
Before calling physician,
2) Determine urgency
How quickly must I communicate?
„ What is the severity/urgency?
„ What is the risk for hospitalization?
„
„
„
Routine
R
ti – Within
Withi business
b i
hours
h
Urgent – Within 6 to 12 hours
Emergent – Within 1 to 2 hours
10
8/20/2013
Before calling physician,
3) Review Medical Record
„
„
„
„
„
„
„
„
„
Age & Diagnoses
Reason for home care
Recent assessments
Recent change in POC
Lab results
Medications
Allergies
Pharmacy number
Advanced Directives
Before calling physician,
4) Organize data
Organize data
„
„
„
Primary & secondary data
SBAR format
What do you need physician to do?
Required:
„
Critical thinking
„
Clinical judgment
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Clinician Call to Physician
Try to make it 60 seconds or less!
Situation
10 seconds
Background
20 seconds
Assessment
20 seconds
Recommendation
10 seconds
Situation
„
Your name
name, discipline
discipline,
agency
„
Patient’s name
„
Patient’s problem
„
„
„
Concise statement
Reason for concern
Sign/symptom & severity
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8/20/2013
Background
„
„
„
Age
g
Relevant diagnoses
Relevant recent events
„
„
„
„
Hospital discharge
Surgical procedures
New medication started
Other relevant history
„
„
Advanced directives
No caregiver in the home
Assessment - Data
„
Physical assessment data pertinent to problem
„
Clinical judgment and critical thinking required
„
Primary not secondary data
„
Not whole assessment
„
Omit the normal…
„
“Rest of assessment normal.”
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Assessment – “Diagnosis”
„
Wh t iis your analysis
What
l i off the
th problem?
bl ?
„
How severe & urgent is the problem?
„
Hints
„
„
It “might be…” “I think it could be…”
If no clue, what body system seems involved?
Recommendation
What do y
you want to
happen and by when?
„
„
„
„
What action is needed?
What option(s) do you recommend?
By when is action needed?
Hints:
„
„
Focus on goal & team approach: “To
prevent avoidable hospitalization, do
you think we should try….”
“Would you recommend….”; “Should
we consider...”: “I think… might work…”
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8/20/2013
SBAR Communication about Exacerbation of COPD Symptoms Situation: • Dr. (name), this is (your name, discipline) from (name of your home health agency). • I am calling about (patient’s name), who is experiencing increased dyspnea. SBAR
for
COPD
Exacerbation
Background: • Patient’s age ______ • Primary diagnoses: COPD ( GOLD stage, if known: A‐Mild, B‐Moderate, C‐Severe, D‐Very Severe); other primary/pertinent diagnoses • Recent important events. Examples include: o Admitted to home care on (date) for (reason for home care) o Discharged from the hospital on (date) after being treated for ___________. • Oxygen use: _________ liters/minute, intermittent or continuous • Current respiratory medications, and frequency of use; recent increased frequency • DNR status if applicable
pp
• Have available: Medication Profile, allergies and phone number of pharmacy Assessment: (Only report primary/abnormal/pertinent data) • Patient’s current symptoms: Œ Dyspnea: Severity on Berg Scale: 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10 ˆ Intermittent ˆ Constant Œ Cough: ˆ Increased frequency ˆ Increased sputum ˆ Increased purulence description Œ ˆ Fatigue ˆ Restlessness ˆ Anorexia ˆ Difficulty sleeping ˆ Vomiting ˆ Anxious Œ When did symptoms develop? __________ How severe are symptoms? ______________ • Physical assessment: Œ Vital signs: Temp ________ Pulse _________ RR ________ BP __________ SaO2 _________
Œ Mental status changes: LOC _________________ ˆ Confusion ˆ Anxiety Œ Skin color: ˆ Cyanosis Location: ______________________ Capillary refill _________________ Œ Breathing effort: ˆ Tripod positioning ˆ Pursed lip breathing ˆ Retractions ˆ Nasal flaring Œ Sputum: Color: _______________ Consistency: ________________ Amount _______________ Œ Lung sounds: ˆ Crackles ˆ Wheeze ˆ Diminished Location: ________________________ Œ Peripheral edema: 1+ˆ 2+ˆ 3+ˆ 4+ˆ • Analysis Examples
Analysis Examples
Œ I believe the patient has developed a respiratory tract infection. Œ The patient’s COPD symptoms may have exacerbated because of today’s air quality alert. Œ The patient’s COPD seems to have exacerbated but there are no signs of respiratory infection. Recommendation: “We may be able to avoid hospitalization…” “We may be able to catch this early…” ˆ Antibiotic: Indicated for increase in dyspnea/sputum volume/sputum purulence ˆ Systemic corticosteroid: Prednisolone, oral, 30‐40 mg, daily for 10‐14 days. ˆ Short‐acting bronchodilators: ˆ change route to via nebulizer ˆ change frequency to every 4 hours ˆ change/add beta‐agonist or anticholinergic to ˆ Home oxygen therapy: Titrate to liters/minute to reach oxygen saturation of _______ (88‐92%) ˆ Increase visit frequency to ___________ (every day x 2‐3 days) to monitor treatment plan effectiveness. Additional Interventions: ˆ No exposure to smoke/air pollution ˆ Institute coughing/deep breathing/postural drainage.
ˆ Force fluids to (2 to 2 ½ quarts). ˆ Teach relaxation and energy conservation techniques SBAR Communication about Exacerbation of Heart Failure SBAR
about
Heart Failure
Exacerbation
Situation: • Dr. (name), this is (your name, discipline) from (name of your home health agency). • I am calling about (patient’s name), who is showing signs of fluid overload. Background: (Review medical record, Medication Profile, last visit notes, labs, etc.) • Patient’s age ______ • Primary diagnoses: Stage __ (if known) heart failure; other primary/pertinent diagnoses (if any) • Recent important events. Examples include: o Admitted to home care on (date) for (reason for home care) o Discharged from the hospital on (date) after being treated for (reason for hospitalization) o Non‐adherence to medication therapy or low‐sodium diet due to confusion and no caregiver. o Patient has been hospitalized for HF 3 times in past 2 months. • DNR status if applicable
DNR
if
li bl
Assessment: (Only report primary/abnormal/pertinent data) • Patient’s current symptoms: Œ SOB ˆ DOEˆ Orthopneaˆ Confusion ˆ Fatigueˆ Œ Other pertinent symptoms ____________________________________________________ Œ When did symptoms develop? __________ How severe are symptoms? ______________ • Physical assessment: Œ Vital signs: Pulse ____ RR _____ BP _________ O2 sat _____ Œ Current weight _______ Weight gain _____ lbs in ______ days. Œ Extra heart sounds (S3, S4) ˆ Œ Lung sounds: Crackles (rales) ˆ Location: _____________________________________ Œ Jugular vein distension ˆ Peripheral edema: 1+ˆ 2+ˆ 3+ˆ 4+ˆ Œ Abdominal girth ______ in/cm which is an increase of _______ in/cm since ___________ Œ Urine color/output: _____________________________________________ • Patient’s diuretic medication(s): __________________ [Loop diuretics (e.g. Lasix) preferred for HF] • Have available: Medication Profile, allergies and phone number of pharmacy • Analysis: Examples include: Œ I believe patient is having an exacerbation of heart failure. Œ Patient states he won’t go back to hospital and he wants to be treated at home or die. Œ Patient’s fluid overload seems to be related to non‐adherence due to forgetfulness and confusion. Recommendation: Examples include: • To avoid rehospitalization, should the diuretic be increased to try to resolve the problem? • Would you like to order oral (or IV push) Lasix to see if we can avoid a hospitalization? • Should I follow up diuretic therapy with labs in a couple of days? Electrolytes? BUN? Creatinine? • Could I have orders for a dietician referral to review the low sodium diet? • Could we refer to MSW to assist family determine caregiving options related to diet and med administration needs? • Since patient has end‐stage HF and patient does not want to go back to hospital, could we have orders for a DNR and refer to palliative/hospice care? 15
8/20/2013
Physician Responds
Appropriately
„
„
„
„
Repeat orders
Call back when/under what circumstances?
Inappropriately -> C.U.S.S.
„
I am concerned…
d
„
I am uncomfortable…
„
The safety (of my patient) is at risk…
„
Stop and listen to me… We have a problem.
Other Barriers & Bulldozers
„
Know doctor
doctor’ss preference: best number
number, time
time, way
„
„
„
„
ƒ Fax
ƒ Office nurse
Leave message:
„
„
Secure e-mail
Give time frame & reachable number
Develop relationship with office staff
Policy/procedure on
elevating issue to next level
If MD rude, be professional,
remind yourself: it’s not you.
16
8/20/2013
When Else to Think “SBAR”
„
“Transitions”
Transitions & “handoffs”
handoffs
„
„
„
„
Coordination of Care
„
„
Referral to homecare
Transfer to hospital
Discharge to physician
Report to team members
Teach the patient/caregiver
SBAR Communication…
„
„
„
„
„
Evidence-based
Evidence
based communication strategy
Structured method for clearly communicating key
information comprehensively yet concisely
Empowers clinicians to provide input and make
recommendations
Encourages inter-professional
dialogue about assessment and
recommendations
Enhances safety & quality of care
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8/20/2013
References & Resources
„
„
„
„
„
Arizona Hospital and Healthcare Association. (2007). SBAR Communication
Standardization Toolkit. Phoenix: Author.
Beckett, C. & Kipnis, G. (2009). Collaborative communication: Integrating SBAR to improve quality/patient safety. outcomes.
Journal of Healthcare Quality, 31(5), 19-28.
Collaboration for Homecare Advances in Management &
Practice (CHAMP, n.d.) http://www.champ-program.org/
static/Review SBAR pdf
static/Review_SBAR.pdf
Home Health Quality Initiative (2007) SBAR: A Home
Health Package
Haig, K. M., Sutton, S., & Whittington, J. (2006). SBAR: A shared mental
model for improving communication between clinicians. Journal on Quality
and Patient Safety, 32(3), 167-175.
References & Resources
„
„
„
„
„
Kogan,
g , et al. (2010).
(
) Performance Improvement
p
in Managed
g Long-Term
g
Care: Physician Communication in managing community-dwelling older
adults. Home Healthcare Nurse, 28(2):105-114.
Leonard, et al. (2006). Using SBAR to improve communication between
care providers. Institute for Healthcare Improvement.
http://www.njha.com/qualityinstitute/pdf/630200633410PM63.pdf
Narayan, M. (2013). Using SBAR Communications in Efforts to Prevent
R h
Rehospitalizations.
it li ti
H
Home
H
Healthcare
lth
N
Nurse, 31(9).
9)
Maison, D. (2006). Effective communications are more important than ever:
A physician’s perspective. Home Healthcare Nurse, 24(3), 172-178.
Riesenberg, L. Leitzsch, J. , Cunningham, J. (2010). Nursing handoffs: A
systematic review. AJN, 110(4), 24-34.
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References & Resources
„
VNAA (2012)
Procedure 23:03
Clinical Procedure Manual
19