The Effect of an Electronic SBAR Communication Tool on Documentation of Acute Events in the Pediatric Intensive Care Unit

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1 553263AJMXXX.77/ American Journal of Medical QualityPanesar et al research-article24 Article The Effect of an Electronic SBAR Communication Tool on Documentation of Acute Events in the Pediatric Intensive Care Unit American Journal of Medical Quality 26, Vol. 3() The Author(s) 24 Reprints and permissions: sagepub.com/journalspermissions.nav DOI:.77/ ajmq.sagepub.com Rahul S. Panesar, MD, Ben Albert, MD, Catherine Messina, PhD 2, and Margaret Parker, MD Abstract The Situation, Background, Assessment, Recommendation (SBAR) handoff tool is designed to improve communication. The effects of integrating an electronic medical record (EMR) with a SBAR template are unclear. The research team hypothesizes that an electronic SBAR template improves documentation and communication between nurses and physicians. In all, 84 patient events were recorded from 542 admissions to the pediatric intensive care unit. Three time periods were studied: (a) paper documentation only, (b) electronic documentation, and (c) electronic documentation with an SBAR template. Documentation quality was assessed using a 4-point scoring system. The frequency of event notes increased progressively during the 3 study periods. Mean quality scores improved significantly from paper documentation to EMR free-text notes and to electronic SBAR-template notes, as did nurse and attending physician notification. The implementation of an electronic SBAR note is associated with more complete documentation and increased frequency of documentation of communication among nurses and physicians. Keywords SBAR, electronic medical record, communication tool, pediatric One of the Joint Commission National Patient Safety goals issued in 26 was to implement a standardized approach to hand off communications for residents and health care staff.,2 In response, health care institutions have devised a variety of methods to improve communication in attempts to decrease communication-related errors associated with incomplete or inaccurate information. 3 The Situation, Background, Assessment, Recommendation (SBAR) model was designed as a tool for organizing information in a clear and concise format to facilitate collaborative communication among health care providers. 4 A systematic review of handoff mnemonic literature reported SBAR is now the most frequently utilized handoff tool, cited in 36 out of 42 articles (69.6%). 3 Concurrently, the Health Information Technology for Economic and Clinical Health Act of 29 includes legislation incentivizing incorporation of the electronic medical record (EMR) into the health information infrastructure with the goal of improving meaningful use by providers. 5 More recently, hospitals have integrated the EMR and physician communication, but sign-out practices, even within a single institution, can remain varied and lack key clinical information. 6 Moreover, to date there is no published literature examining the use of an electronic SBAR template to provide vital clinical information during acute changes in a patient s condition that require immediate attention by house and nursing staff and the attending physician. Therefore, this study aimed to describe the impact of integrating an EMR with a structured SBAR note on these crucial communications among clinicians. Specifically, this study examined the frequency of notes written and the completeness of the documentation based on set scoring criteria. Also evaluated were any changes that occurred in documentation of communication among health care providers. Stony Brook Children s Hospital, Stony Brook, NY 2 Stony Brook University Hospital, Stony Brook, NY Corresponding Author: Rahul S. Panesar, MD, Department of Pediatrics, Stony Brook Long Island Children s Hospital, HSC L-, Suite 4, Stony Brook, NY rahul.panesar@stonybrookmedicine.edu

2 Panesar et al 65 Table. Pediatric SBAR Guidelines for Attending Notification. Acute life-, limb-, or organ-threatening event Unexpected episodes of hypotension New-onset bradycardia or tachycardia New unexplained acidosis ph <7.25 Emergent intubation Acute change in mental status Unexpected oliguria or anuria New-onset sustained hypertension Unexpected critical lab value(s) Indication for antiarrhythmic, pressors, or inotropes PEWS score of orange or red New-onset tachypnea or significant change in respiratory rate/pattern/saturations Need for transfusion of blood or blood products if not planned in advance Unexpected seizure activity New-onset unexplained pain requiring the use of narcotics New-onset fever in an immunocompromised patient Abbreviations: PEWS, Pediatric Early Warning Score; SBAR, Situation, Methods This study was conducted at a 2-bed pediatric intensive care unit (PICU) in a university children s hospital. The study was approved by the university hospital institutional review board. Consent was waived for this study. There were no screening methods or exclusion criteria implemented, and all children admitted to the PICU during the specified time periods were included in the study. Data included in event notes, either on paper or in electronic form, were analyzed. Medical records of children admitted to the PICU were reviewed during 3 distinct phases, including paper chart documentation (December 2 to February 2), EMR free-text event notes (June 2 to August 2), and electronic SBAR note documentation (April 22 to June 22). Each study period began 3 months after the implementation of each modality (ie, electronic health record, electronic SBAR communication note). This allowed for a period of time during which staff were provided education on the use of the documentation tool. After this 3-month buffer period allowing incorporation into routine workflows, data were collected for 3 consecutive months. Prior to implementation of the EMR, the Pediatric Critical Care Division had established guidelines for attending notification of critical patient events. This model included predefined criteria in which pediatric residents were required to notify the attending physician using an SBAR format (Table ). An orange sticker with sections for each SBAR component, which was designed to allow for easily identifiable documentation in the paper-based progress notes, was completed freehand. In March 2, the PICU converted to the EMR with full physician documentation using Cerner PowerChart (Cerner Corp, Kansas City, Missouri). During this period, pediatric residents were instructed to document critical patient events using the SBAR criteria as before and to notify the attending physician, similarly using a free-text format, which now was a blank electronic note. This note had greater accessibility to multiple users on the health care team because it was available via any hospital computer terminal with EMR access, but it did not provide a structured template for data entry. Therefore, residents were allowed to enter as much or as little information as they deemed necessary. The Department of Pediatrics adopted an electronic SBAR communication note by the end of 2. This provided a data entry structure prompting the resident to document each of the 4 components of SBAR as well as a checkbox for each of the attending physician notification criteria. These fields were not required to be checked off or completed before signing the note. However, they served as reminders to the resident to provide a detailed and complete record of what acutely changed in the patient s condition. A data field on the SBAR note prompted documentation of who was the attending physician of record, which was designed to alert the author to document closed-loop communication between the resident and the covering attending physician. Finally, an additional data field was included in the SBAR template to document the nurse caring for the patient, also designed to prompt closed-loop communication with the nurse at the bedside. Prior to signing the note, the resident was given a final prompt by the EMR to identify an endorsing attending physician to whom the note would be sent. The attending

3 66 American Journal of Medical Quality 3() Table 2. SBAR Scoring Criteria. Scoring Criteria Situation: Current condition, working diagnosis, were SBAR criteria met? Background: History of presenting illness, past medical history, medications Assessment: Examiner s evaluation and assessment of the disease or condition Recommendation: Plan of care, anticipated changes in condition or treatment Abbreviation: SBAR, Situation, Background, Assessment, Recommendation. would receive the note in his/her electronic inbox in the EMR and was instructed to attest to the note within 24 hours. After completing the note, the resident was instructed to notify the nurse assigned to the patient so he/ she could add an attestation of the event and sign the note before the end of the shift. This portion of the process for attendings and nurses could not be made mandatory in the electronic system, but both faculty and nursing staff were strongly advised to complete this piece of the documentation. All residents were instructed to verbally discuss the event with both the attending and the nurse before electronically writing, signing, or sending the note for any attestation. A scoring system was constructed to assess completeness of documentation (Table 2). One point was given for any documentation within each of the 4 components of the situation, background, assessment, or recommendation. The accuracy of the resident s documentation was not assessed. Any documentation that fulfilled each of the 4 SBAR components was given point, totaling a possible 4 points for each event note reviewed. For example, any documentation that included the situation of the patient event, background information of the patient s illness, a clinical assessment of the disease or condition, and a plan of care would receive a total of 4 points. After removal of all patient identifiers, data were entered into a secure spreadsheet for statistical review using analysis of variance and χ 2 analysis. A P value <.5 was considered statistically significant. Results Point Scale A total of 542 patients were admitted to the PICU during the 3 time periods studied, including 73 patients in paper chart documentation, 97 patients in free-text EMR documentation, and 72 patients in the electronic SBAR documentation. During paper chart documentation, a total of 22 of 73 patients had event notes documented; 28 of 97 patients had event notes documented during the free-text EMR Percentage (%) period (Figure ). During the electronic SBAR documentation, 34 of 72 patients had event notes documented. This yielded a nonsignificant increase of documentation (P =.7) in the PICU during the study period. The completeness of documented event notes is shown in Figure 2. Mean scores of completeness were tabulated using the 4-point scoring system as outlined in Table 2. During the third time period, not all event notes had transitioned to the electronic SBAR note; some residents were still using the free-text EMR note. Subset analysis of the EMR-SBAR note alone (n = 5) during this time period showed a mean score of 4 points when only the electronic SBAR note was used (P <.). Documentation of multidisciplinary communication is shown in Figure 3. During paper chart documentation, the nurse caring for the patient was never identified in the event note, and the attending physician was documented 9.8 Paper Notes Free-text EHR Free-text + SBAR Frequency Figure. Frequency of documentation. Figure 2. Completeness of documentation.

4 Panesar et al 67 Percentage (%) to be notified less than 2% of the time. After transitioning to free-text EMR documentation, identification of the nurse increased by about 7% and identification of the attending physician increased by about 35%. After initiation of the electronic SBAR note identification of the nurse increased by an additional 37% and identification of the attending physician increased by an additional 26%. Subset analysis of this last time period of the electronic SBAR notes alone demonstrated % documented notification of both nurse and attending physician (P =.). Discussion Paper Notes Free-Text EHR Free-text + SBAR Only SBAR Nurse Notification Physician Notification Figure 3. Multidisciplinary communication. Electronic documentation tools have been used in several modalities such as described by Stockwell et al, using a computerized checklist to standardize documentation for neurological determination of brain death. 7 The present article describes an electronic SBAR communication tool, which was associated with more complete documentation of critical pediatric patient events and with an increase in documentation of attending physician and nursing notification. The use of the electronic SBAR note suggests an association with an increased frequency of documented event notes among patients in the PICU, although the difference was not statistically significant (P =.7). The research team hypothesizes that greater accessibility of any electronic note could have contributed to the increased number of documented events. With the ability to write a note anywhere on any hospital computer that has access to the EMR, users may have been more apt to use the electronic free-text notes and subsequently the SBAR template more often. By having predefined fields prompting residents to document important aspects of an event within the electronic SBAR note, the completeness of documentation improved compared to blank free-text notes, even though it was not mandatory to complete these fields in order to sign the note. Completeness of charted events increased from 2.23 points with paper chart documentation to 2.57 points with EMR documentation. With the addition of the electronic SBAR communication note, the completeness of documentation increased to 4. points. This suggests that the SBAR note, which was readily available in the EMR, likely made documentation more accessible and prompted the author to be more complete in the documentation of events. The data show that documentation of attending physician and bedside nurse notification reached % when the resident used the electronic SBAR note for charting, thereby improving documentation of multidisciplinary communication. During this portion of the study, the oncall attending physician was required to attest to all event notes on their patients within a 24-hour period. Therefore, the resident needed to complete and send the note soon after the event, which was delivered electronically to the attending for attestation. This change in workflow with the electronic SBAR note was associated with an increased rate of documented attending notification from 53.6% to 79.4%, from the electronic free-text note to the electronic SBAR note time frames. The multiple data fields built into the electronic SBAR note that prompted documentation of the attending and nurse of record prior to signing the note proved to be advantageous over the EMR free-text note. In this study, % documentation of nurse and attending physician communication was achieved when the electronic SBAR note was used. Interestingly, although % of nurses attested to the SBAR event notes, they did not have an electronic inbox to receive the notes, as attending staff did. The nurse would only become aware of the note once the resident discussed the note with them. This high level of attestation rates with the SBAR note supports the notion that there was increased communication between the residents, attending physicians, and nurses. Additionally, it can be argued that the ability to write an attestation to a note in which he or she was named empowered the nurse to include his or her independent account of findings leading up to and including the critical event. This feature may have allowed a greater opportunity for nursing staff to collaborate with residents, ultimately improving the details of the documentation. This study has several limitations. This study was conducted in a single institution and may not be representative of the workflow of other institutions. The study only reviewed notes written in the PICU and a larger data set including other wards and/or facilities might have shown more significant changes in the frequency of notes written in each phase of the study. The study institution had adopted EMR documentation in phases during this study, and the implementation of each phase, including

5 68 American Journal of Medical Quality 3() the electronic free-text note and the electronic SBAR note, varied. However, the 3-month study period after implementation was consistent. The subset analysis of completeness and communication also had a smaller pool of patients. Furthermore, not all resident physicians had converted to use of the electronic SBAR note by the last phase of the study. Residents during this last time frame still had the option of writing free-text notes after the SBAR templates were made available. Therefore, subgroup analysis within this time frame was used to separate the different forms of documentation used. However, the subgroup of SBAR-only notes also may reflect a cohort of residents who accepted the SBAR system more readily and who were more thorough with their documentation than users of free-text notes. Additionally, it is possible that not all events were recorded on paper or the EMR, but there was no definitive way of verifying this. Although nursing staff were usually notified by residents about the SBAR note, it may have been possible that a nurse would be aware of an event and would find the event note in the EMR and attest to it without communicating with the resident. Also, the accuracy of documentation could not be verified because this was a retrospective study. Finally, mortality in the PICU is so low that studying the effect of these changes on outcomes is difficult. Future work would involve a prospective study reviewing nursing documentation at the time an electronic SBAR note is written and cross-checking it with residents documentation in an attempt to assess the quality of documentation during critical patient events. Additionally, adding forcing functions to the SBAR note with mandatory fields instead of prompts alone may further improve completeness and documentation of communication between all health care providers. Ultimately, the goal of improved documentation would be to serve as a surrogate marker for improved patient safety in the hospital setting. Conclusion The implementation of an electronic SBAR note provides a template for more complete documentation. This electronic SBAR note was associated with an increase in the frequency of documentation of communication among residents, nurses, and attending physicians caring for patients in the PICU. Acknowledgments We acknowledge Seoungju Won, RN, MS, Senior Instructional Support Specialist, Clinical Informatics, and Gerald Kelly, DO, Associate Professor, Chief Medical Information Officer, for their assistance in implementing the SBAR template in the electronic medical record. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The authors received no financial support for the research, authorship, and/or publication of this article. References. Kitch BT, Cooper JB, Zapol WM, et al. Handoffs causing patient harm: a survey of medical and surgical house staff. Jt Comm J Qual Patient Saf. 28;34: Revere A, Eldridge N. Joint Commission National Patient Safety Goals for docs/tips/tips_janfeb8.pdf. Accessed September 8, Riesenberg LA, Leitzsch J, Little BW. Systematic review of handoff mnemonics literature. Am J Med Qual. 29;24: Beckett CD, Kipnis G. Collaborative communication: integrating SBAR to improve quality/patient safety outcomes. J Healthc Qual. 29;3(5): Blumenthal D, Tavenner M. The meaningful use regulation for electronic health records. N Engl J Med. 2;363: Schoenfeld AR, Salim Al-Damluji M, Horwitz LI. Sign-out snapshot: cross-sectional evaluation of written sign-outs among specialties. BMJ Qual Saf. 24;23: Stockwell JA, Pham N, Fortenberry JD. Impact of a computerized note template/checklist on documented adherence to institutional criteria for determination of neurologic death in a pediatric intensive care unit. Pediatr Crit Care Med. 2;2: