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

Am J Med Qual. 2016 Jan-Feb;31(1):64-8. doi: 10.1177/1062860614553263. Epub 2014 Oct 1.

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; communication tool; electronic medical record; pediatric.

MeSH terms

  • Communication
  • Continuity of Patient Care
  • Documentation / methods*
  • Documentation / standards
  • Electronic Health Records
  • Hospitals, Pediatric / organization & administration
  • Humans
  • Intensive Care Units, Pediatric / organization & administration*
  • Intensive Care Units, Pediatric / standards
  • Interdisciplinary Communication*
  • Medical Staff, Hospital
  • Nursing Staff, Hospital
  • Patient Handoff / organization & administration*
  • Patient Handoff / standards