Structured SBAR Handover

Hi, my name’s Gilly and I’m an intensive care registrar in south east Scotland. We’re going to spend the next couple of minutes talking about structured referrals. Referrals are something that we all do as health care professionals on a day to day basis. At their essence, they’re a communication tool that direct patients to the appropriate specialists for either advice, assessment, or admission. Most of our patients come to critical care through a critical care referral. We do know that if a referral is inappropriate, it’s delayed, or if it’s unsuccessful, that has an adverse effect on that patient’s outcome. So, if we can do it well, we can improve patient safety.

The World Health Organisation advocate the use of the SBAR structured referral tool, which is Situation, Background, Assessment, and Recommendation. Firstly, you should describe the situation you’re in. You should identify who you are and where you’re calling from. You should identify the patient and the relevant identifiers, including their date of birth and where they are in the hospital. You should say, “I need you– I’m in a situation; I need you to come and help with this patient”. From a background point of view, you should start by giving a short summary of why the patient is in hospital. They were iden–, for example, they were admitted two days ago with a community-acquired pneumonia.

At this point, you should also explain the patient’s past medical history, and if you can, give some information about their relevant functional status. And that’s particularly important in critical care referrals, when we’re thinking about the appropriateness of escalation of care. From an assessment point of view, you want to give the patient’s observations, so their respiratory, their blood pressure, their saturations, and their level of consciousness, along with any other relevant observations, including BMs. And you might want to say any treatment that you’ve introduced at that point, so “I’ve placed the patient on 15 litres of oxygen.” Or if you’ve clearly identified what the issue is, say that. Say, I think the problem is acute pulmonary edoema.

And then from a recommendation point of view, this is what you’re asking of your– the person you’re referring to. So “I need you to come and see this patient”, and ideally, I would add a frame into that, to say “within the next five minutes”, “within the next half hour”, or “at some point during the day”. At this point, it’s also useful to say, “Is there anything else I could be doing at this point that could be helpful?” and the referrer might be able to direct you to some things over the phone.

Now, we’re going to look at two examples of referrals, one of which makes use of a structured communication tool such as SBAR, and one of which does not. Compare and contrast the two referrals and reflect on which you think is more successful in efficiently portraying the person and clinical information.

Hello? [PHONE RINGING] Hi, it’s Gilly, the intensive care registrar. How can I help? Hi, this is Emma. I’m one of the doctors, and I work in the– sorry, work in the acute medical unit. I was just phoning just to see– I’ve been asked to phone you by my consultant about one of our patients. Is that OK? OK, just give me one sec.

So the patient’s name is John Bride, and I think he’s– I think he’s 50. He’s in his 50s, anyway. And he’s on– he’s in the acute medical unit in bed 7. Oh, sorry, I don’t have his date of birth. I can try and get that for you just now. OK, OK, well, I’ll just tell you about him, then. So he’s this guy, and he’s– I think he’s been in for quite a while, actually. Oh, no– yeah, maybe– yeah, it’s the acute medical unit, so yeah, he’s probably only be in for a couple of days. But he’s– we think he’s– he’s got problems with breathing anyway, and he’s really short of breath.

So I was wondering if I could just ask you about that? Oh, I don’t really know about his past medical history. I think he said he maybe had a heart attack before. Yeah, yeah, I think he’s– I think he’s had a heart attack, but I think there’s other things in his history, but I’m not really sure. I’ve not got his notes here right now, no, sorry. I can– I’ll phone you back with that if that’s OK. So he’s got some sort of heart problem, and at the moment, he’s really short of breath. And we’ve needed to put him on more oxygen, and he’s really struggling. And I don’t really know what else to do.

I think his blood pressure’s OK. I’m really sorry, I don’t have– I don’t have his chart here, but I’ll– yeah, his blood pressure was OK, and it was all breathing problems, like his SATs and his respiratory rate. OK, yeah, I’ll put him on to 15 litres of oxygen. Can you come as soon as you can? Thank you. OK, bye.

[PHONE RINGING] Hi, it’s Gilly, the intensive care registrar. How can I help? Hello, is this the ITE registrar? Hi, my name’s Emma. I’m one of the FY1s in the acute medical unit. I was wondering if I could refer to you a patient that we have here for critical care. His name’s Mr. Jones, and he’s a 54-year-old male. Would you like his CHI number? OK, I’ll give that to you. So the story is, he’s come in with respiratory failure. He was admitted two days ago, and on a chest X-ray, showed a right lower lobe pneumonia. We’ve treated him with antibiotics, and there’s been some micro sent in a sputum sample, but we haven’t got anything back from that yet.

He’s got a background of ischemic heart disease, and he also has hypertension. He’s a relatively fit man. He works as a joiner, and he’s quite physically active with that, obviously. And he can climb two flights of stairs without having to stop due to shortness of breath or anything. At the moment, in terms of his assessment, his saturations are 90% on a 60% venturi mask, and his heart rate’s 122 beats per minute, which is a sinus tachy on an ECG that we’ve just done. His blood pressure’s 150 over 59 and his respiratory rate’s 35.

I’ve increased his oxygen up to 15 litres on a non-rebreathe mask, but we’d really appreciate a critical care review as soon as possible just to see whether he would maybe benefit from high flow oxygen or whether he needs to be intubated. OK, thanks, Emma. you’ve done the right thing in calling us. That’s really helpful information. I’ll be along in the next five or ten minutes. In that time, I’d really appreciate if we could have an ABG, so if you do that, that would be really helpful. I’ll see you shortly. Thanks very much. For the last few minutes, we’ve talked about some of the things that make a successful referral.

I hope you learned something you can take forward into your own clinical practise. What we know is that if you use structured communication tools, such as SBAR, you’re more likely to have a successful referral and to positively impact patient care.