One of the most important factors in determining the outcome of an acutely ill patient is the quality of the communication between the clinicians involved. It has long been recognised that when this communication is sub-optimal, patient safety is compromised.1,2
In a review of all cases that were resolved in 2010, the State Claims Agencies clinical risk team lists communication failure as second of the top root causes identified.³ It has been suggested that a structured method of communication would improve the quality of information exchange.4
The Acute Medicine Programme has proposed that the ISBAR tool be utilised as the model that all healthcare staff use to structure clinical communication. This tool is a slight adaptation of the SBAR tool, which was developed in the US navy for standardising important and urgent communication in nuclear submarines. It is well established in many settings, including aviation and some acute medical environments, and encourages staff to gather the appropriate information and provides a framework for organising this information in a clear and concise format (see Table 1).
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Background
The Acute Medicine Programme has recommended that the introduction of the National Early Warning Score (NEWS) is supported by the COMPASS multidisciplinary education programme. Participants who attend the programme are introduced to the ISBAR tool in the pre-course manual in addition to further explanations of its use and interactive skills training during face-to-face training.
St Luke’s General Hospital is a 246-bed hospital, which provides surgical, medical, obstetric and paediatric services to the population it serves. Preparation and training for the transition from a modified Early Warning Score, which was in use for a number of years before NEWS commenced in September 2011.
During this preparation, key stakeholders explored the idea of introducing the ISBAR tool to the clinical areas in a structured and readily available sticker format. In addition to facilitating staff to communicate in a clear, concise manner, the use of a pro-forma ISBAR sticker could be filed as evidence of this communication. This would replace the requirement for staff to document this exchange in the traditional manner.
Advice from other sites, which had previously or were in the process of looking at developing such a sticker was sought, and following consultation with all key personnel, a pro-forma sticker was developed (see Table 2).
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Pilot study
A pilot study on the use of the sticker was run on a 14-bed general ward, which facilitates primarily surgical and medical patients. This study was approved by the St Luke’s General Hospital National Early Warning Score Project Group. Because patient data was unnecessary, approval from an ethics committee was not required. The aim of the pilot was to evaluate the perceived usefulness of the sticker, utilising a self-efficacy questionnaire on communication.
This questionnaire was aimed at evaluating nursing staff’s perception of self-efficacy in communicating a deteriorating patient’s condition in two domains:
Verbal notification of the deterioration to the appropriate physician
Documentation of this communication in a clear and concise manner.
Utilising a Likert scale with a score of one to five, where one indicated ‘not at all’ and five indicated ‘extremely’, the staff was asked to identify how confident they felt on their ability in these two domains in relation to areas such as patient assessment findings, concerns regarding the patient, requesting a review or intervention.
All 14 nursing staff on the ward were asked to complete this questionnaire prior to the introduction of the sticker. A total of eight questionnaires were returned. The sticker was then made available for use on the ward for a period of four weeks. Stickers were readily available at convenient locations beside telephones in an adhesive sticker format in order to facilitate ease of filing.
All nursing staff had attended prior COMPASS training and further support on the use of ISBAR stickers was provided by two of the COMPASS training faculty. The sticker was completed and filed in the patients’ nursing notes when an increase in the patients EWS, indicating a deterioration in the patients condition, prompted a medical review. Following the four weeks, pilot nursing staff were again asked to complete the same questionnaire. A total of eight questionnaires were returned.
Results
Overall, there was an increase in scores from the pre- to the post-pilot questionnaires. Scores of one and two indicating ‘none at all’ or ‘no’ confidence in their ability to communicate to a physician that a patient is deteriorating and to document this event totalled eight in the pre-questionnaire compared to none in the post.
Score of three indicating some degree of confidence increased by one in the post questionnaire but score of four increased from total of 50 to 57 and score of five remained the same at 95. See Table 3 for the total score results.
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Questions one and two, which looked at the area of communicating information about patient’s current status and assessment findings, show an increase in respondents who scored a five in both the areas of verbal communication and its documentation.
One respondent had indicated a score of two in the area of documentation of the patient’s current status prior to the sticker pilot, whereas four was the lowest score for this question post.
Questions five and six, which asked staff to indicate their confidence levels on requesting a patient review or intervention, show somewhat conflicting results. Perceived confidence levels in requesting an appropriate order/intervention in a direct manner increased slightly in the post questionnaire, but confidence levels were slightly reduced to request a physician to come and see the patient based on assessment findings. In addition, question eight, which looked at providing an organised description of a patient’s status to a physician who is not familiar with the patient, reported a slight reduction in confidence.
Questions three and 10 looked at confidence levels in providing and documenting information in an organised, succinct manner. Overall, there was a slight increase in these areas in the post pilot questionnaire, although the number of fives scored in 10a fell from five to three post-pilot with a corresponding increase in fours scored.
Discussion
Generally the nursing staff reported high confidence levels in their ability to communicate issues regarding a patient’s condition to medical personnel, even prior to the use of ISBAR sticker. As the majority of the nursing staff on the unit had attended COMPASS training prior to the pilot, one has to consider the possibility that they were already using the ISBAR method of communication albeit in a less formal format. However, of note are the scores of one and two pre-pilot regarding documentation of this communication in the areas of:
Giving clinical findings in an organised manner
Requesting an intervention
Communicating when faced with unhelpful behaviour and
Providing information about a patient not known to the physician which were not reported in the post pilot questionnaire.
As loss of information during handover and between staff groups has been reported as a frequent characteristic of reported incidents, the formal use of ISBAR in sticker format may improve communication between members of the multidisciplinary team as well as ensuring accurate handover of all information between shifts.5
Acknowledgements
Karen O’ Hanrahan, CNM 1 and all nursing staff who participated in pilot study and completed research questionnaires. Helen Molloy, practice development facilitator, St Luke’s General Hospital Early Warning Score Governance Group
References
JCAHO. Sentinel event statistics. 2006. Available at: http://www.jointcomission.org/sentinelevents/statistics/
Greenberg, CC et al. Patterns in communication breakdowns resulting in injury to surgical patients. Journal of American College of Surgeons. 2007; 204: 533-40
State Claims Agency Newsletter, January 2012
Drayton, E, Henriksen, K. Communication failure: Basic components, contributing factors and the call for structure. Journal on Quality and Patient Safety. 2007; 33(1): 34-37
Rabol, LR et al. Republished error management: Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals. BMJ Quality & Safety. 2011; 20: 268-274
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