SBAR Handover in patient safety: advantages and disadvantages

 

SBAR is a general mnemonic used to guide focused conversations between healthcare practitioners, particularly in critical situations. SBAR provides a simple structure that ensures that salient points are covered in ways that rely less on practitioner preferences and context.

In this article we take a critical look at this tool and its near cousins ISBAR and ISBAR3. We discuss some of the advantages and disadvantages of SBAR and how this may relate to clinical handover

Situation background assessment recommendation

SBAR was developed initially at Kaiser Permanenty in Colorado in 2002 by Doug Bonacum and colleagues to help nurses communicate with doctors in a way that helped overcome hierarchical barriers. Bonacum explains that this was partly informed by his experience in the US Navy. SBAR caught-on and spread widely. It is now arguably the most common mnemonic in healthcare.

SBAR stands for:

1)    Situation: a summary of the patient’s current condition or problem

2)    Background: brief points explaining how the patient may have come to this point, 

3)    Assessment: A summary of options or opinion on the situation

4)    Recommendation: What tasks or actions may be necessary 

SBAR Handover example

Before SBAR, a telephone conversation between ward staff and on-call doctor might start:

 “Oh, hello doctor, do you know Mr Jones? He came in a few days ago and was put on oxygen by one of night doctors. He’s one of Dr Peter’s patients. The ward manager asked me to ring you  ….” 

SBAR insists on providing a more concrete problem statement early on:

“Hello Doctor, I’m calling about the patient in Ward 20, bed 3, Mr Jones. He is having breathing difficulties and increasing chest pain” (Situation)

”He came in with cellulitis, but is known to have COPD, his saturations dropped from 91% to 85% on 3l of O2 over the last few hours.” (Background)

“I think he is having a critical deterioration” (Assessment)

“Please could you come to assess him immediately” (Recommendation)

Using SBAR Handover to improve patient safety

The intention of SBAR is therefore to structure the information in this way will prompt more appropriate action to ensure that critical information is not lost (a phenomenon known in journalism as ‘burying the lead’).

SBAR ensures that staff don’t ‘bury the lead’ when trying to communicate important information, especially in stressful situations. It also improves speed of decision-making.

The intention here is to ensure that patients get the right level of attention as quickly as possible so that potentially dangerous delays are avoided.

Improving patient outcomes

The intention, therefore, is to improve patient outcomes. However, the evidence, is not overwhelming. A 2018 study published in BMJOpen found only moderate evidence of improved safety and that was mainly for its use in telephone communication.

The authors also state that that there was a lack of high quality evidence to support safety improvements and therefore in patient outcomes.

Advantages and disadvantages of SBAR

The reason SBAR has gained in popularity and become widespread in healthcare is largely because of it has some clear advantages.

SBAR Advantages

1)    Simplicity. SBAR has the advantage of simplicity and ease of memorisation. Mnemonics such as this are clearly less easy to remember the longer the acronym.

2)    Flexibility: the generic nature of SBAR means that it is a mnemonic that can be applied in any clinical situation (Bonacum mentions the mnemonic was being used to structure emails).

3)    Recognition: as it has rapidly gained favour SBAR is now well understood at many levels and has been widely taught.

SBAR Disadvantages

However, some of these advantages can themselves cause problems.

1)    Over-simplification. Many clinical scenarios are complex and require more granular or nuanced descriptions of situations than are accounted-for in a four-word mnemonic. SBAR may not necessarily force the right content.

2)    Rigidity: although being flexible in application, the SBAR also constrains the format of discussions. This has resulted, as discussed below, in further extension of SBAR to include ISBAR and ISBAR3.

3)    Context dependency: the effectiveness of is subject to cultural factors  and qualitative issues. 

These disadvantages are discussed more fully in a Dutch paper from 20202

SBAR communication tools and NICE guidelines

Since its widespread adoption in healthcare, SBAR tools have been further developed and promoted, notably by  the Institute of Healthcare Improvement (IHI) in the USA and in the UK from NHS Improvement. Tools and associated training materials are also available to improve the quality of SBAR communications.

NICE has strongly recommended SBAR for structured patient handovers, an area which warrants further discussion.

SBAR in handover – using ISBAR, ISBAR3 

SBAR, in its original form is not really a handover tool. As a result, it has been enhanced and and expanded, gathering more letters. SBAR has suffered, it could be said, from mission creep and has spawned offspring: ISBAR and ISBARRR (also known as ISBAR3).

It’s worth stressing that handover must be ast least a two-way discussion not simply a broadcast of information. If broadcast were sufficient, then all handover could be safely written down. That doesn’t happen, for a reason. The receiver needs to understand context, quiz the giver and clarify any ambiguities.

What is ISBAR?

ISBAR stands for:

1)    Identify: clarity on of who is talking, who is receiving and which patient is being discussed

2)    Situation: a summary of the patient’s current condition or problem

3)    Background: brief points explaining how the patient may have come to this point, 

4)    Assessment: A summary of options or opinion on the situation

5)    Recommendation: What tasks or actions may be necessary 

The addition of this “Identity” section is to ensure that someone using SBAR doesn’t launch into a conversation where the receiver is the wrong person or they don’t know who is talking.

In the example above, ISBAR might sound like this:

“Hello is that the Doctor Greenl?  … Great. I’m nurse Smith from Ward 20. I want to talk to you about Mr Jones in Bed 3” (I)

“Mr Jones is having breathing difficulties and increasing chest pain” (S)

”He came in with cellulitis, but is known to have COPD, his saturations dropped from 91% to 85% on 3l of O2 over the last hour” (B)

“I think he is having a critical deterioration” (A)

“Please could you come to assess him immediately” (R)

The “I” in ISBAR makes more certain which Nurse, Doctor and the Patient are in the discussion.

What is ISBAR3?

ISBAR3 stands for:

1)    Identify: clarity on of who is talking, who is receiving, and which patient is being discussed

2)    Situation: a summary of the patient’s current condition or problem

3)    Background: brief points explaining how the patient may have come to this point, 

4)    Assessment: A summary of options or opinion on the situation

5)    Recommendation: What tasks or actions may be necessary 

6)    Read-back: A chance for the recipient to acknowledge what they have heard

7)    Risk: a summary of any safety risks

The addition of this “Identity” section is to ensure that someone using SBAR doesn’t launch into a conversation where the receiver is the wrong person, or if it’s not clear who is talking.

In the example above, ISBAR3 might sound like this:

Nurse Smith

“Hello is that the Doctor Green?  … Great. I’m nurse Smith from Ward 20. I want to talk to you about Mr Jones in Bed 3” (Identify)

“Mr Jones is having breathing difficulties and increasing chest pain” (Situation)

”He came in with cellulitis, but is known to have COPD, his saturations dropped from 91% to 85% on 3l of O2 over the last hour” (Background)

“I think he is having a critical deterioration” (Assessment)

“Please could you come to assess him immediately” (Recommendation)

Doctor Green

“Thank you Nurse Smith. I understand that Mr Jones in Bed 3 having an acute deterioration with falling saturations, chest pain and breathing difficulties.” (Read-back)

How soon do you think I need to come?” (Risk)

Nurse Smith

“I think that he is in a critical condition. You should come immediately” (Risk)

SBAR Handover tools

With the addition of the additional “R”s – Read-back and Risk Assessment – SBAR has entered the territory of a more complex interaction. Rather than simply a structured form of information giving the mnemonic is now being used to help structure handover conversation.

As a result, tools that store and reproduce patient information in ISBAR3 format have been developed.

A handover tool might therefore include:

·      I — patient demographics

·      S — Current diagnosis

·      B — Past medical history

·      A — Clinical Summary

·      R — Jobs list

Again, this moves us further away from the original use of SBAR to structure information-giving into the realm of handover structure

The use of structured communication tools and SBAR tools, especially for nurses, moves users further away from the original use of SBAR to structure information-giving into the realm of handover discussions.

Advantages and Disadvantages of ISBAR tools

As mentioned above in relation to SBAR, the use of ISBAR and ISBAR3 tools can help with simplicity, flexibility and recognition. And they are also easily programmed or entered into a spreadsheet or word document, or indeed used to structure an entry in the medical record.

However, in the same vein, the SBAR mnemonic lacks depth and granularity and specificity. Many handover tools, including forms that should be filled-in prior to handover disucssions, SBAR are used more as ‘subject headings’ which require much more detailed and structured information in each section. See for instance images in Katheryn Stewards 2016 review. These forms are no longer simple mnemonics, they are chapter headings.

One of the most obvious areas in which such tools are inadequoate is in the management of tasks. Handover must – and does – include task-level handover and this is a serious gap in ISBAR as a handover tool.

So glaring is this omission, there may be an argument for promoting ISBAR-T, to include “Tasks”.

While they may aim to improve professional communication skills, the evidence from a 2019 survey in Irelandin a paediatric hospital found that it was used consistently (Risk, was the most commonly omitted part of IBAR3). This is despite the Irish government recommending ISBAR3 in 2015 as part of their patient safety strategy.

Summary

In conclusion, SBAR is a widespread professional structured communication tool intended to improve the efficient delivery of comprehensive clinical information in crucial situations.

It has evolved, including to become ISBAR and ISBAR3, and to subsume the structure of complex handover forms. The evidence that SBAR and its cousins increases patient safety and patient outcomes is varied. It is nonetheless a readily recognisable mnemonic in widespread use in many clinical settings and with many electronic and manual tools.