Hand-Off Communications from the Emergency Department

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Hand-Off Communications from the Emergency
Department

• Robin Gordon,
• Paris Community Hospital
• Paris, IL

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Review of Regulatory Standards

• EMTALA
• Joint Commission National Patient Safety Goals

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EMTALAPart of COBRA

• Designed to prevent hospitals from refusing to
  treat emergency patients or transferring them to
  charity hospitals or county hospitals because
  they are unable to pay or are covered by Medicaid.

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Conditions Covered by EMTALA

• Danger to patient health, function, organ or body
• Acute undiagnosed pain
• Pregnancy with contractions present
• Psychiatric disturbances
• Symptoms of substance abuse

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REMEMBER!

• If the hospital does not have the capacity,
  capability, or resources to provide stabilizing
  treatment for an emergency, an appropriate
  transfer must be arranged for the patient to a
  facility with the capacity, capability, and
  resources to provide the stabilizing treatment.

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What is an Appropriate Transfer?

• The Transferring Hospital has provided treatment
  to the individual with an emergency medical
  condition within capacity of the hospital
• The Transferring Hospital has obtained agreement
  to accept the patient from the Receiving
  Hospital, including identifying a Physician to
  accept the patient

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What is an Appropriate Transfer?(continued)

• The Transferring Hospital has provided sufficient
  data, including medical records, X-Rays, lab
  reports as available, to the Receiving Hospital
  to facilitate continuing evaluation and treatment
• The Transferring Physician has certified the
  transfer and arranged for the use of appropriate
  mode of transportation, personnel, and equipment

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Joint CommissionNational Patient Safety Goal 2

• Improve the effectiveness of communication among
  caregivers
• 2C Measure, assess, and if appropriate, take
  action to improve the timeliness of reporting,
  and the timeliness of receipt by the responsible
  licensed caregiver, of critical tests and
  critical results and values.

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Joint CommissionNational Patient Safety Goal 2

• Improve the effectiveness of communication among
  caregivers
• 2E Implement a standardized approach to
  hand-off communications, including an
  opportunity to ask and respond to questions.

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Joint CommissionNational Patient Safety Goal 2

• Improve the effectiveness of communication among
  caregivers
• 2E Implement a standardized approach to
  hand-off communications, including an
  opportunity to ask and respond to questions.

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• The primary objective of a hand-off is to
  provide accurate information about a patients
  care, treatment, services, current condition, and
  any recent or anticipated changes.

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• Implementation Expectations
• Interactive allowing for the opportunity for
  questioning
• Up-to-date information
• Verification of information received
• Opportunity for receiver to review relevant
  information
• Minimizing interruptions during hand-offs

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Important Information to Hand Off

• Presenting Problem
• Current Situation
• Verification of Understanding

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Development of SBAR for the Emergency Department
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Problem with effective communication

• Missing patient information from shift to shift
• Missing patient information from department to
  department
• Not everyone thinks of all of the same
  information when giving report. ER will give you
  what is important to them but other nurses often
  think along different lines.

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PDCA
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What are your needs?

• Each facility needs to research what their
  specific informational needs are and can adjust
  the SBAR to fit those needs.
• We started out with the basic SBAR and informal
  training.

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Informal training

• Printing 3x5 note cards for the nurses to carry
  in their pockets
• Printing large examples and placing at the
  nurses station and in the report room
• Talking with staff at departmental meeting and in
  flyers of what the SBAR and need for the nurses
  to use the tool for each report

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SBAR fitting your needs

• The SBAR has broken down the pertinent
  information into four areas
• Situation
• Background
• Assessment
• Recommendations

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Situation

• Patient name
• Room number
• Admission date
• Physician(s)

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Background

• Co-morbidities
• Allergies
• Code status
• Current vitals
• Recent medication given/blood thinners
• Abnormal or pertinent labs/diagnostics
• Special communication needs
• Significant psychosocial issues

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Background (cont.)

• LOC
• Oxygenation
• Tubes/lines/drains/isolation

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Assessment

• Review of orders
• Readiness for surgery/procedure
• Mobility or safety issues

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Recommendations

• Goal of treatment
• Reason for transfer
• Anything left to do?

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Audit

• Informal audit
• Come into report and see what was being said
• Would have cards at the side but still went off
  the kardex often forgetting valuable information
• Critical Care went off of their report sheets
• We needed something different

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What was wrong?

• Nurses did not feel as if the information flowed
• Nurses did not have a clear understanding of what
  was expected
• Ive been giving report for ____ years I know
  what Im doing

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Revamping SBAR

• Looked at how to change SBAR to better fit our
  needs
• Used the same basic format just changed the
  background and assessment
• Again we used the 3x5 note card for visual
  reminders
• Also took a more formal approach with the
  education process

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The new SBARSituation

• Patient name
• Room number
• Admission date
• Managing MD
• Code status
• Diagnosis
• Age
• Brief statement or concerns

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Background

• Co-Morbidities (medical history)
• Allergies
• Recent medications given/blood thinners
• Abnormal or pertinent labs/diagnostics
• Special communication needs
• Significant psychosocial issues
• Procedures done in last 24 hours and outcomes
• Safety issues

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Assessment

• Biophysical assessment (abnormals)
• Vital signs
• Implantable devices
• Dressing changes
• NG/Drain output
• IV fluids/drips/site when is site to be changed
• Current pain score-what has been done to manage
  pain
• Rhythm (if on telemetry)
• Review of orders

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Recommendations

• Do we need a change in the plan?
• What are you concerned about?
• What are your comfortable with?
• Discharge planning
• Pending labs/x-rays, ect.
• We need to request a change in _______(diet,
  activity, medication)
• We need to request a consult with PT/OT/ST,
  dietician, diabetes educator

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Formal education

• Held workshops for staff members
• Small groups
• Visual and verbal presentations of present way
  and SBAR way to give report
• Staff shown how important information could be
  missed and by having a consistent manner in which
  to give report the receiving nurse would know if
  something is missing
• Each staff member would give report to another
  using the SBAR format with the guidance of an
  instructor.
• Each staff member was required to competency with
  the SBAR approach

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Audit

• Audit sheets were made to encompass the SBAR
  report process (See example in packet)
• Coordinators and House Supervisors audited
• Shift report
• Intradepartmental transfers
• Transfers to other facilities

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How was it going?

• Noted some improvement but still work needed
• Nurses still were reading off of the kardex
  instead of giving a true handoff report
• Interdepartmental transfers still needed work

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Start the process again

• After reviewing the process it was decided the
  kardex needed to be changed to a SBAR format
• Again in this process we are coming up with one
  for the hospital as a whole but using a weekly
  audit to fit the needs of the patient information
• To change critical care report sheet

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After the kardex change

• Audits reveal better reporting
• Still need for improvement
• Will use one on one approaches with the nurses
  regarding their effort in embracing the SBAR
  format
• Will continue the Audits

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Our Goal

• To implement a Rapid Response Team
• Need Nurse to MD SBAR
• Requires having understanding and being able to
  effectively use the SBAR

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Examples of SBAR