Open access Research BMJ Open: first published as 10.1136/bmjopen-2018-022202 on 23 August 2018. Downloaded from Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review Martin Müller,1,2 Jonas Jürgens,2 Marcus Redaèlli,2 Karsten Klingberg,1 Wolf E Hautz,1 Stephanie Stock2 To cite: Müller M, Jürgens J, ABSTRACT Strengths and limitations of this study Redaèlli M, et al. Impact Objectives Communication breakdown is one of the main of the communication causes of adverse events in clinical routine, particularly ► This systematic review was conducted in accor- and patient hand-off tool in handover situations. The communication tool SBAR SBAR on patient safety: a dance with the Cochrane Collaboration standards (situation, background, assessment and recommendation) systematic review. BMJ Open using a validated tool for quality assessment of the was developed to increase handover quality and is widely 2018;8:e022202. doi:10.1136/ identified studies. assumed to increase patient safety. The objective of this bmjopen-2018-022202 ► Five well-known databases as well as the referenc- review is to summarise the impact of the implementation es of the included studies were searched using an ► Prepublication history and of SBAR on patient safety. open search strategy. additional material for this Design A systematic review of articles published on SBAR paper are available online. To ► Reliability of the study selection, data extraction and was performed in PUBMED, EMBASE, CINAHL, Cochrane view these files, please visit rating of the study quality was ensured using two Library and PsycINFO in January 2017. All original the journal online (http:// dx. doi. independent reviewers. research articles on SBAR fulfilling the following eligibility org/ 10. 1136/ bmjopen- 2018- ► Studies in which SBAR (situation, background, as- criteria were included: (1) SBAR was implemented into 022202). sessment and recommendation) was part of a larger clinical routine, (2) the investigation of SBAR was the quality improvement initiative and outcomes that did Received 17 February 2018 primary objective and (3) at least one patient outcome was not measure the incidence of adverse events were Revised 11 July 2018 reported. not included in this review. Accepted 26 July 2018 Setting A wide range of settings within primary and ► The heterogeneity of the studies impeded to test for secondary care and nursing homes. publication bias or to perform a meta-analysis. Participants A variety of heath professionals including nurses and physicians. http://bmjopen.bmj.com/ Primary and secondary outcome measures Aspects of patient safety (patient outcomes) defined as the defined by the World Alliance for Patient occurrence or incidence of adverse events. Safety of WHO as ‘the reduction of risk of Results Eight studies with a before–after design and unnecessary harm associated with healthcare 2 three controlled clinical trials performed in different clinical to an acceptable minimum’. To illustrate the settings met the inclusion criteria. The objectives of the impact of patient safety on healthcare quality, studies were to improve team communication, patient the incidence of adverse events is commonly hand-offs and communication in telephone calls from cited. Following the definition of Brennan et nurses to physicians. The studies were heterogeneous al,3 adverse events are injuries that are caused on September 29, 2021 by guest. Protected copyright. with regard to study characteristics, especially patient by medical conduct resulting in prolonged outcomes. In total, 26 different patient outcomes were hospitalisation and/or disability at the time measured, of which eight were reported to be significantly © Author(s) (or their of discharge. The Joint Commission reported improved. Eleven were described as improved but no employer(s)) 2018. Re-use that poor communication is a contributing permitted under CC BY-NC. No further statistical tests were reported, and six outcomes commercial re-use. See rights factor in more than 60% of all hospital did not change significantly. Only one study reported a 4 and permissions. Published by descriptive reduction in patient outcomes. adverse events they reviewed. Poor commu- BMJ. Conclusions This review found moderate evidence for nication is found in many different health- 1 Department of Emergency improved patient safety through SBAR implementation, care settings and is especially prominent in Medicine, Inselspital, Bern especially when used to structure communication over the patient hand-offs and settings where fast and University Hospital, University of phone. However, there is a lack of high-quality research on Bern, Bern, Switzerland effective management is indispensable. Such this widely used communication tool. 5 2Institute of Health Economics settings include the perioperative period, the 6 and Clinical Epidemiology, Trial registration none intensive care unit (ICU) and the emergency University Hospital of Cologne, department.7 The components and processes Cologne, Germany of communications are complex and prone 8 Correspondence to INTRODUCTIOn to misunderstanding. To overcome these Dr Martin Müller; Patient safety is crucial for the delivery of barriers, communication strategies are desir- martin. mueller2@ insel. ch effective, high-quality healthcare1 and is able, which take little time and effort to Müller M, et al. BMJ Open 2018;8:e022202. doi:10.1136/bmjopen-2018-022202 1 Open access BMJ Open: first published as 10.1136/bmjopen-2018-022202 on 23 August 2018. Downloaded from Table 1 SBAR communication technique, adapted table 16 18 63 64 Questions Description Example S Situation What is going on First, the speaker presents the situation, by ‘Dr Preston, I’m calling with the patient? identifying himself, stating the patient’s name and about Mr Lakewood, who’s What is the situation briefly describing the problem having trouble breathing’ you are calling/ communicate about? B Background What is the The speaker then provides the background, such ‘He’s a 54 year old man background or as the patient’s diagnosis or reason for admission, with chronic lung disease context on this medical status and relevant history. The patient’s who has been sliding patient? chart is reviewed and questions the other care downhill, and now he’s provider may have are anticipated acutely worse’ A Assessment What is the Then specific information on vital signs, recent ‘I don’t hear any breath problem? laboratories and other quantitative or qualitative sounds in his right data related to the patient’s current state are chest. I think he has a provided. This section can include a provisional pneumothorax’ diagnosis or clinical impression R Recommendation What is the An informed suggestion for the continued care ‘I need you to see him right next step in the of the patient has to be made by the speaker. now. I think he needs a management of the The immediate need is explained clearly and chest tube’ patient? specifically, including what is necessary to address the problem The tool is available for download from the website of the Institute for Healthcare Improvement.9 complete, deliver comprehensive information efficiently, However, the actual effect of SBAR on patient outcome encourage interprofessional collaboration and limit is unclear. The wide adoption of SBAR (or any other the probability of error.9–11 The SBAR (situation, back- communication strategy) without proven benefit may ground, assessment, recommendation) instrument (see paradoxically limit improvements because a problem table 1) and its derivatives ISBAR, SBAR-R, ISBARR and presumably solved will be less addressed. Thus, the ISOBAR fulfil this need and are widely used in different purpose of this systematic review is to summarise the avail- healthcare facilities as a communication and hand-off able evidence for and evaluate the impact of the imple- http://bmjopen.bmj.com/ tool both intraprofessionally and interprofessionaly.12–15 mentation of SBAR in clinical settings on patient safety as By virtue of a clear structure, SBAR calls for the provi- measured by the incidence of adverse events. sion of all relevant information, organised in a logical fashion.16 Furthermore, it enables a preparation before the communication process,16 17 and because sender and METHODS receiver share the same mental model, understanding Search strategy 18 and awareness are expected to be higher. Besides, it A systematic search for articles published on SBAR was reduces inhibitions especially in hierarchical context by performed in PUBMED, EMBASE, CINAHL, Cochrane on September 29, 2021 by guest. Protected copyright. encouraging the sender to provide a personal assessment Library and PsycINFO via OvidSP. The search was 19 and suggestion of the situation (‘Recommendation’). conducted in January 2017. It was augmented by a review The SBAR tool is regarded as a communication technique of the references of all articles included. Search terms used that increases patient safety and is current ‘best practice’ in all electronic medical databases were SBAR, ISBAR, 16 20 to deliver information in critical situations. SBAR-R, ISBARR and ISOBAR (combined as text words A number of studies have investigated ‘soft’ outcomes with the Boolean operator ‘OR’). The detailed search 21 22 such as employee satisfaction and interdisciplinary strategy is provided in online supplementary appendix A. 19 23 communication in relation to SBAR. Positive reso- No restrictions were applied in terms of time, language