The most common form of communication you will use as a nursing student and nurse is SBAR. Developed in the US Navy, SBAR was developed to streamline and improve communication between personnel on nuclear submarines, and has been adopted by the healthcare industry as an evidence-based tool. It provides clinicians with a systematic framework for conveying important information and, as such, has been shown to improve patient safety. In fact, the Joint Commission has identified communication failures as root causes of sentinel events and has identified effective communication as a key National Patient Safety Goal. SBAR provides clinicians an effective and easy-to-use format of communication when clarity is critical to patient outcomes.
What is SBAR?
SBAR stands for situation, background, assessment and recommendation.
- Situation: What is going on, why are you concerned?
- Background: Relevant patient information (diagnosis, recent VS, lab results, fluid balance, code status…any clinical information that is relevant to the current situation.)
- Assessment: What is your assessment of the patient/situation?
- Recommendation: What would you like the MD to do?
How to prepare before using SBAR
Before we dive into SBAR in detail with some scenarios, it’s important to know what you should do before you talk to the physician. S/he is going to ask you pertinent questions and it’s best if you can anticipate what those are and have the information in front of you when you approach them.
- Assess the patient yourself. Even if it’s just a very quick, focused assessment. Lay your eyes on the patient!
- Do you have orders in place that can address the issue you are currently facing? For example, if the patient is hypertensive with a BP of 187/104, check the MAR for an antihypertensive before you call asking for an antihypertensive!
- Make sure you’re calling the right MD. Many times patients will have multiple physicians managing their care, or perhaps the attending physician wants you to call the resident for any issues. For example, if it’s a surgical issue, you’re most likely calling the surgeon. Or, if the patient isn’t able to tolerate dialysis, you’d call the nephrologist. When getting report on patients, always get a rundown of the MDs on the patient’s care team.
- Be able to give a very brief overview of the patient’s hospital stay. The MD who returns your page, may not be the attending MD. It could be a resident or the on-call physician. Don’t assume the physician knows the patient you are calling about. Know the patient’s admitting diagnosis, when they were admitted and any significant procedures that have been done, such as surgeries or diagnostics.
- Share your concerns with your resource nurse…this could be your preceptor if you’re new, or the charge RN.
- Take a quick peek at the most recent MD progress note and end-of-shift summary from the RN you received report from.
- Any specific data relevant to the current situation. For example, if you are calling about possible fluid overload, what is the patient’s I/O? What fluids are running? If you’re calling about blood in the patient’s stool, what is their hgb/hct?
- Have the chart open when you are talking with the MD so you can quickly find pertinent data such as: VS trends, allergies, lab results, current meds, code status, etc…
- Anticipate what the MD is going to want to know in order to make an informed decision and have that information ready.
Now it’s time to prepare our SBAR communication!
Sample SBAR scenarios
Let’s go through SBAR using an everyday scenario so that you can see how it generally works even if you have absolutely zero medical background. In this situation, you have been woken in the middle of the night by a huge crash. There’s a huge thunderstorm and when you walk into your guest bedroom, you see a large branch from your oak tree has fallen and broken the window. Wind and rain are coming into the room, soaking the carpet and generally ruining what had been a good night’s sleep.
|SITUATION||The guest room window is broken.|
|BACKGROUND||You are experiencing a severe thunderstorm with high winds; you’ve been wanting to get that tree trimmed for months but no one would listen 🙂|
|ASSESSMENT||Wind and rain are coming into the room, soaking the carpet.|
|RECOMMENDATION||Cover the window and call the window repair guy.|
Hopefully an everyday scenario like this helps you see a bit of how SBAR works. Ready to put it to the test?
Mr. Lee comes into the ED with shortness of breath, a sudden weight gain of 2kg in 24 hours and dependent edema. He is speaking in three word sentences and appears to be working hard to breathe.
What other information do you want to know about this patient before you update the MD? At this point, you’re thinking that Mr. Lee is having an issue with fluid volume overload.
- Any history of heart failure or renal disease
- Medications he takes at home
- VS (especially SpO2!)
- Physical assessment
After taking a closer look at Mr. Lee and his situation, you discover:
- Mr. Lee has CHF, but ran out of his diuretic four days ago and was unable to get to the pharmacy due to lack of transportation.
- Medications he takes at home are furosemide 20mg BID, (other meds for CHF).
- He has allergies to lisinopril, hydrocodone, sulfa antibiotics and morphine.
- VS (especially SpO2): HR 106, RR 26, SpO2 84% on RA; 93% on 15L NRB.
- Respiratory assessment reveals coarse lung sounds and the pt is displaying significant WOB with sternal retractions evident. You also note 3+ edema at bilateral lower extremities.
Now that we’ve anticipated the information the MD may want, we are ready to plan out our SBAR. Grab a piece of paper and take a moment to write out what you think you’d say…then we’ll go through it together. Remember, the components are SITUATION, BACKGROUND, ASSESSMENT and RECOMMENDATION. I’ll wait right here.
No peeking! Only scroll down when you’re ready!
Ready to give a quick SBAR to the emergency room MD?
|SITUATION||Mr. Lee in Bay 7 is in respiratory distress requiring 15L NRB to maintain an SpO2 of 93%.|
|BACKGROUND||He has a history of CHF and hasn’t taken his 20mg BID furosemide in four days. He’s noticed a 2kg increase in the past 24 hours.|
|ASSESSMENT||Lung sounds are coarse with 3+ edema at bilateral lower extremities. He’s speaking in 3-word sentences with sternal retractions. SpO2 on RA was 83%.|
|RECOMMENDATION||Would you like to put him on BiPAP and give furosemide?|
Summary: In this situation, Mr. Lee is fluid volume overloaded because he hasn’t taken his diuretic in several days. Like many patients, he will likely need furosemide to pull off fluid and BIPAP to support oxygenation while we wait for the diuretics to do their magic. The MD may also order a chest x-ray.
Two days later, Mr. Lee is complaining of feeling lightheaded when you stand him up to use the urinal before lunch. You check his blood pressure and it’s 83/44.
What other information do you want to know about this patient before you call the MD?
- Admitting diagnosis
- BP trends
- Fluid volume status
- Any culprit medications (such as diuretics, opioids, antihypertensives).
- Respiratory assessment
- Hgb/hct if any potential for bleeding
So, you go through the chart and obtain the following information for the MD so you can be ready for any questions:
- Admitting diagnosis: CHF exacerbation
- BP trends: 128/83 at midnight; 107/78 at 4am; 95/61 at 8am; 83/44 at 12pm
- Fluid volume status: In the last 12 hours, intake has been 500 ml, output 3 liters
- Any culprit medications (such as diuretics, opioids, antihypertensives). Furosemide 40mg BID. Last dose 0900.
- VS: Heart rate 115, O2 saturation 96% on RA, RR 14
- Respiratory assessment: no complaints of SOB, no increased WOB, lung sounds clear.
- Hgb/hct if any potential for bleeding: Hgb 14.8
It’s time to plan out what we are going to say to the MD…fill out your SBAR!
Scroll down when you’re ready to call the doc!
Here’s one way you could explain the situation to the MD:
|SITUATION||It’s Mo from CCU. I’m calling about patient Lee in room 4210. He’s hypotensive with a BP of 83/44 and complaining of feeling dizzy.|
|BACKGROUND||He was admitted for CHF exacerbation on the 30th and has received 40mg furosemide BID since admission. His home dose is 20mg BID. His I/O for the past 12 hours is negative 2.5 liters.|
|ASSESSMENT||HR is 115 and he became very dizzy when he stood at the side of the bed to urinate. Lung sounds are clear, O2 saturation is 96% on RA with no complaints of SOB.|
|RECOMMENDATION||Do you want to adjust the lasix and provide some fluids?|
Summary: In this situation, you have Mr. Lee becoming hypotensive because we over-medicated him with a diuretic. As a result, he lost too much volume and became hypotensive.
That night Mr Lee falls while trying to get to the bathroom and bangs his elbow pretty good. X-ray shows a hairline fracture and there’s nothing to be done except immobilization with an arm sling while it heals. However, it hurts like heck. After you fill out all the appropriate patient safety paperwork, Mr. Lee complains of intense pain in his elbow. You plan to call the MD to ask for something for his pain.
What information do you anticipate the MD needed before she can make that determination?
- Pain level
- Allergies if any
After a quick look through the chart, you learn:
- Pain level: 8 out of 10
- Allergies if any: Mr. Lee is allergic to morphine and hydrocodone
- VS: HR 116, BP 92/53, RR 22, SpO2 98% on RA
Ready to plan out your SBAR so you can call the resident and wake him up from his nap? Scroll down when you’re ready!
No peeking, keep scrolling!
Ok…how’d you do?
|SITUATION||I’m calling about Mr. Lee. He’s complaining of 8 out of 10 pain in his left elbow.|
|BACKGROUND||He fell around 2am, x-ray showed hairline fracture. Arm is immobilized in a sling and pain is not relieved by acetaminophen. He’s allergic to morphine and hydrocodone.|
|ASSESSMENT||Vital signs correlate with acute pain. HR is 116, RR is 22. Elbow is tender to the touch. However, BP is borderline hypotensive at 92/53.|
|RECOMMENDATION||Can you prescribe something additional for pain management?|
Summary: In this situation, Mr. Lee has an acute problem (pain) but also has allergies which have to be taken into consideration. We also want to make sure the MD knows about the blood pressure as it may too low for an opioid. Good job!
So there you have it…your basic guide to using SBAR in the clinical setting. Remember, keep it concise, keep it relevant and anticipate the questions that will be asked. If you do all that, you’ll be using SBAR like a pro!
Go through this again on audio in episode 147 of the Straight A Nursing podcast. Tune in here or wherever you get your podcast fix.
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De Meester, K., Verspuy, M., Monsieurs, K. G., & Van Bogaert, P. (2013). SBAR improves nurse–physician communication and reduces unexpected death: A pre and post intervention study. Resuscitation, 84(9), 1192–1196. http://dsue.bol.ucla.edu/Handoff/SBAR%20article.pdf
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