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Communicating Changes in Condition: Using the SBAR tool
Presented by: Kristi Wergin (30-minute Webinar) [9/24/2013]
Candy Hanson: Hi everybody, this is Candy Hanson with Stratis Health, the Quality Improvement
Organization in Minnesota and also the program manager. I want to welcome you to this
educational session. This session is being recorded and will be available on the Stratis
Health website at StratisHealth.org.
Our featured guest speaker is Kristi Wergin, a program manager at Stratis Health. She
provides quality improvement leadership for Minnesota Nursing Homes as part of the
Centers for Medicare and Medicaid Services Quality Improvement Organization contract.
Currently, she’s leading a team effort that is helping about 170 Minnesota Nursing
homes in their quality improvement efforts, as part of the Acting Together to Improve
Excellence.
Kristi has over 30 years experience as a registered nurse with specific background in
elder care, which includes direct resident care as a nursing assistant and staff nurse, as
well as work in quality improvement, staff development, leadership, management and
customer/employee satisfaction. She had the opportunity to receive the interact training
at the INTERACT Institute in January of 2013, and has been providing training in the use
of the INTERACT tools to nursing homes, participating in care transitions work with
Stratis Health.
Please welcome Kristi Wergin.
Kristi Wergin: Thank you Candy. In your work to improve transitions of care, you’ve all learned about
the importance of good communication within your homes, as well as between settings
of care. SBAR, which stands for Situation Background Assessment & Recommendation,
is a tool designed to improve communication. At the conclusion of this webinar…
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You should be able to describe the purpose of the SBAR communication form
and change and condition progress note,
Describe each section of the SBAR, and
Be able to answer frequently asked questions that will help you implement the
use of SBAR in your home
We will be looking at the INTERACT SBAR tool, which I’m sure some of you are familiar
with, so bear with us and maybe at the end you’ll have some things you can share with
us about using this tool.
The INTERACT SBAR tool was developed as part of the INTERACT program and
INTERACT stands for Interventions to Reduce Acute Care Transfers and it is a quality
improvement program that focuses on the management of acute change in resident
conditions. It includes clinical and education tools and strategies for use in everyday
practice in long-term care facilities.
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One in four patients admitted to a skilled nursing facility are readmitted to the hospital
within 30 days. Such transfers can result in numerous consultations of hospitalization
and billions of dollars in unnecessary healthcare expenditures. The goals of INTERACT
are:
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To improve care,
To improve the management of residents with a change in conditions,
Reduce the frequency of potentially avoidable transfers to the acute hospital
The INTERACT tools are free to use and can be accessed at http://INTERACT2.net/,
which is on the slides.
Nursing homes can safely reduce hospital transfers…
 By preventing conditions from becoming severe enough to require
hospitalization through early identification and assessment of changes in
resident condition,
 By managing some conditions in the nursing home without transfer when
feasible and safe, or
 By improving advanced care planning and the use of palliative care plans
when appropriate as an alternative to hospitalization for some residents.
The INTERACT Program has four categories of tools to address these three points.
1.
2.
3.
4.
Quality improvement tools
Communication tools
Decision support tools
Advanced care planning tools
SBAR is one of the communications tools.
INTERACT tools are meant to be used together in your daily work in the nursing home.
Here is an overview of INTERACT tools. The INTERACT tools are listed in the blue
boxes in the first and third columns of the slide overview. The center column shows the
steps that occur as the resident is admitted to the nursing home and has a change of
condition. You can see where each tool comes into play as the change of condition is
recognized and acted upon.
The SBAR form and progress note is used to notify the physician or physician extender
of a change in condition. I may say physician a lot, but whenever I say physician I’m
referring to the physician, nurse practitioner, physicians assistant, any kind of position
extender. It can also be used to share information about a resident during transition such
as communicating with the hospital as part of the transfer process.
As I mentioned before, SBAR stands for Situation Background Assessment &
Recommendation. It is a communication tool whose purpose is:
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To improve communication with a change in resident condition,
To guide the nurse to use consistent language when sharing information about a
resident,
Standardized criteria that’s important to share when a change of condition is
noted, and
To provide a framework that has clear guidelines about what information to
share in an efficient and effective manner
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In addition to improving communication between nurses and physicians when there’s a
change of condition, nurses that learn to communicate using SBAR guidelines will find
the communication between staff, such as during shift reports, as well as across setting
of care is also improved.
To get you all familiar with this tool we will look at it one section at a time. Before
completing the form and calling the physician, nurse practitioner or physicians assistant,
it’s important that you gather information. At the top of the form there are items to check
off to remind you of the information you should review and collect prior to making the
call.
You should collect information about:
Vital signs
Progress notes
Recent labs and orders
When assessing the resident before the call, you might want to use the INTERACT care
plan or INTERACT acute changing condition file card, which if you aren’t already using
might be something you want to check into. They are a great help in completing the
assessment. Make sure you have all the relevant information prior to your call and don’t
forget about advanced directives, allergies, and medications. The checkbox reminds you
of what you should have available when you make your call.
The first section of the SBAR form is the S, which stands for situation.
When communicating information about a resident it is very important that you present a
clear and concise explanation of what you are seeing. Let’s say for example that you
notice one of your residents has had a change in mental status. Instead of waiting till the
resident presents with further symptoms, it would be best to call the physician to inform
them about the change of condition, when it was first noticed, if it has gotten worse,
better or stayed the same since being noted.
Also, don’t forget to share if there are things that make the symptom better or worse, and
if the resident has had this symptom in the past. If this is a recurring problem, check to
see what was done last time to treat the symptom. If something worked in the past then
suggest that as a treatment. If it wasn’t helpful then it’s important to share that as well, in
order for the resident to receive effective treatment as soon as possible.
Next is B, which stands for background.
This section allows you to provide context to the situation you find in the first section. Be
sure to include whether the resident you’re calling about is at your home for post acute
care or long-term care. Include the primary diagnosis, as well as other pertinent history.
For example, if you’re calling about a resident that has acute methyl changes you may
want to share that their primary diagnosis is dementia. Other pertinent history may
include that they haven’t eaten or drank for the past day, maybe has increase confusion,
and by that give specific examples of what you mean, and they have perhaps decreased
urine output and foul smelling urine.
Also include important medication information. For example, it’s important to indicate if
the resident is on 9:18, if you’re getting an order for an antibiotic. It’s best to share this
information now so you don’t have to call the doctor later for orders to check INRs while
being treated for the antibiotic or worse, if you don’t want to have to call up an adverse
drug event because INRs weren’t monitored while the resident was being treated with
the antibiotic.
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It’s also important to have vital signs ready when you call. There’s nothing worse than
being asked for this information and not having it. As I heard one physician comment,
they’re called vital signs for a reason. Not having this basic information may make you
lose your credibility and/or the physician may order a transfer due to his lacking
confidence in you.
Next and still part of the background section is a list of check off items. This section
contributes to the length of the tool; however, it’s easy to complete and it helps you
make sure you’ve given thought to all clinical issues before contacting a physician. This
list includes information about:
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Change in a residents mental status
Functional status
Respiratory system
GI system, and/or
Urinary changes
If there are no changes in some or all of these areas leave the section blank and go to
the next section. It’s really designed to be a quick way to review the systems, make sure
you’ve thought about it and that you share any changes with the physician relative to any
of those different systems.
The final question for the background part of the SBAR form directs you to check for
recent lab results and any advanced care planning and/or resident family preference for
care and information that may be pertinent. When completing this section you may find
that you do not have recent advanced care planning information. This should prompt you
to look at updating systems in your home to ensure these directions are always up to
date.
As I mentioned earlier there are several INTERACT tools that you may want to reference
related to advanced care planning.
The next section is A, which is for assessment or appearance.
Here’s your change to share what you think is going on with the resident. Generally
when making a call to a physician you have a pretty good idea of what might be going
on. You may often know this resident very well and/or have seen the presenting
symptoms many times in your work. Don’t be afraid to share what you’re thinking. That’s
the only way you’ll get what you’re hoping for.
Providing this assessment is certainly part of the recently updated Minnesota Nurse
Practice Act, which calls for RNs to provide a comprehensive assessment of the health
status of a patient through the collection, analysis and synthesis of data used to
establish a health status baseline and plan of care, as well as address changes in a
patient’s condition. This is right out of the nurse practice act.
It’s also in the scope of practice for an LPN in Minnesota, whose called on to conduct ‘a
focused assessment of a health status of an individual patient through the collection and
comparison of data to normal findings and the individual patient’s current health status,
and report changes and responses to interventions in an ongoing manner to a registered
nurse or appropriate licensed healthcare provider for delegated or assigned tasks or
activities.’
There are always questions about whether or not an LPN can make an assessment and
as you read in the nurse practice act, it’s not only okay but it’s required. Don’t be afraid
to. You’re simply giving your assessment from the information you’ve gathered.
The next section is R, which is your chance to request what you want.
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If you feel you’re able to care for this resident in your facility let the physician know.
Some examples of requests you might have might include:
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Perhaps the physician doesn’t know you can provide IVs at your home. This is
an opportunity to let them know that, if that’s something that’s appropriate.
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Maybe you think it’s important to do some more evaluation before transferring
the resident. Don’t be afraid to ask for x-rays, labs orders,
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Perhaps the resident has an O2 stat in the 70s, but the resident wants comfort
care only. Let the physician know and ask the physician for a comfort care or
hospice order.
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Maybe the resident has an O2 set in the 70s and they’re full code. In that case
you want to ask for an order to transfer them to the hospital if it’s an emergency.
So, if you have some direction in your head before making the call, and again gathering
all the information on the SBAR helps lead you in that direction, it’s much more likely that
you’ll be providing care that’s in the best interest of the resident.
The SBAR tool is pretty straightforward, I think you’ll all agree, and many of you I’m sure
if you did it will find out it’s not rocket science. As you’re teaching staff to use the SBAR
and encouraging them to get on board and everybody to consistently use this tool,
sometimes there are a lot of questions that come up about the tool, so I want to provide
you with some answers to those questions in order to help you out as you’re trying to
encourage the use of this tool.
One is that it’s going to take so long. You look at it, it’s a lot of pages and it’s like oh my
goodness, I know all this stuff why do I have to write it down. You might hear that and a
way you can respond is to say try it out if you’ve never used it in your home before. Find
a champion, someone who’s excited about using it, on one unit, one day, one nurse on
one shift and time it to see how it works. You may have to make some changes based
on the experiment or PDSA, but let the staff know then how long it really takes and it
might avoid redundancy.
It might take the place of other things you’re doing also. Remind the staff about the time
it takes to make several calls to the physician if you don’t have all the information in the
first place or what about the time it takes to complete an admission to the hospital,
maybe you can avoid some of these time consuming admissions if you don’t send them
to the hospital to begin with.
Another question is… what about all the check boxes. These check boxes were added in
INTERACT three, so I don’t think they were available on the INTERACT two SBAR form,
so this is recently updated. The check boxes are helpful. They also make it longer which
is why I think people ask about it. They are helpful to guide the nursing assessment.
They structure the primary care clinician communications. They help reduce the potential
for illegible notes and they are also important for electronic health records.
If you have an electronic health record or if you’re working on that down the line, you can
find if you have check boxes you can grab information much easier from that and use the
DHR in your quality improvement efforts. They are also a quick way to get important
information because it reminds you somewhat of what you should be looking at.
What about the A section? That’s the assessment, there are always lots of questions
about can we really do this? You’ll notice on the tool that the RNs and LPNs are a
different line for assessment, and that’s because it’s kind of state specific. I think we’re
ahead of the curve in Minnesota as far as spelling out what LPNs can do, but it’s not
always clear. Sometimes there are more limitations in other states.
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As I said before, some nurses are uncomfortable making suggestions to physicians, but
as I previously mentioned this is certainly within the scope of the Minnesota Nurse
Practice Act for RNs and LPNs. We’re actually required to do it, and we’re good at it so
we might as well share that information.
Then there’s the question of… every single time I call the doctor do I have to use this,
every time, for everything? No. Some seem all out of balance about the length of the
form because they think you have to use it every time you call the physician, but it’s just
designed to share a change in a resident’s condition. So if you’re just making a routine
call to the physician for things like lab results, etc. that doesn’t require the use of an
SBAR form.
However, it’s a great format to consider as a guide to progress notes, regarding changes
in a resident’s condition orders or in a care plan. Some people choose to make this part
of the record, it’s just up to the individual nursing home, as to whether they want to make
this a nursing note and put it in the record.
I was hoping to share a video but it’s not working with the webinar setup. I wanted to
share a link to a 10 steps SBAR video that’s good and short. It’s a link for those of you
who might want to see a short video showing a good example of a nurse using an SBAR
in a nursing home to report a change in a resident’s condition to a physician. It’s a good
example and may be helpful to the staff. I encourage you to look at that and if you have
a meeting and can bring that up to share with your staff to show them, sometimes it’s
easier than talking about it.
That’s it.
Candy Hanson: This concludes our webinar and we have about five minutes for questions and I’ll start, I
have two.
In the background part of the INTERACT 3 tool where you have check boxes for what
appears to me to be signs and symptoms and then underneath each one it says
describe signs or symptoms. You’ve already checked them there so what does that
mean?
Kristi Wergin: I think if you want to be any more specific if it’s out of the norm you can make a note.
Perhaps what you want to say isn’t in a check box this gives you a chance to add to that.
It’s not required.
Candy Hanson: I think it’s an important point, because as nurses we sometimes have difficulty because
we try to say too much and this is meant to be a brief summary type tool to use.
Kristi Wergin: An example might be like under mental status change, if you check increased confusion
you might want to get a little more specific. What are you seeing? That might be helpful,
if you say they’re more confused. You might want to say, you know, usually every other
day when we go in there right away when the daughter comes he/she always recognizes
the daughter and today they didn’t know who they were.
Candy Hanson: My second question is this. How are the physicians assistants and NT made aware of
the INTERACT? Is it common that most of them in the state of Minnesota are familiar
with it?
Kristi Wergin: That’s a good question but I can’t make that statement as to whether they’re familiar, I
just know the communities we’ve worked with through the care transitions work, the
physicians are not only aware of it but they appreciate it and usually give kudos if you
call and use the SBAR. They’re usually thankful.
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Candy Hanson: That’s what we’ve seen in our project as well, so perhaps if there are any other
questions or maybe you could share how you’re using the SBAR tool if you are currently
and how your physicians respond to it.
Are there any additional questions or comments?
Kristi Wergin: Does anyone have it as part of their EHR, like it’s in your system?
Natalie:
In Nosh City we have SBAR in our electronic health.
Candy Hanson: How does that work?
Natalie:
It’s working better now that we’ve done some more training on what we actually want in
the spots, because it’s less directed here. It’s just the boxes. We had to do some training
on what we want in those boxes.
Candy Hanson: I think that’s an important point, to make that that’s a decision you might want to make
for your facility. Do you want to guide your clinical staff on what type of data you want to
use for communicating with your physicians.
Natalie:
We actually use an INTERACT SBAR tool, but we don’t make them fill out the paper
forms, they just have to use that as a guide for, you should have this information when
you call the doctors or whoever you need to call. Then they can use it as a guide for how
to chart in the SBAR spot on the PCC.
Kristi Wergin: So it’s like a template.
Natalie:
Yes.
Candy Hanson: You use it as a template as you’re communicating verbally with your physicians?
Natalie:
Correct.
Candy Hanson: Thanks that’s great.
Does anyone else have anything to share? As I mentioned in the communication, this
session is recorded and we’re hoping it will be useful to you as an ongoing training and
orientation resource with your staff.
We will also send you an evaluation link and would appreciate your feedback.
We will now conclude the webinar. Thank you for joining us.
This material was prepared by Stratis Health, the Quality Improvement Organization for Minnesota, under a contract
with the Centers for Medicare & Medicaid Services (CMS), an agency of the US Department of Health and Human
Services. The contents presented do not necessarily reflect CMS policy. 10SOW-C7-13-132 102213
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