How does an aviation cocktail taste
How does an SBAR taste?
Who doesn't know the scenario? You come to the start of your shift and there is a humming noise in every corner. The patient stretchers and loungers are full and there are no more chairs in the waiting area. There are patients in wheelchairs in the corridor and at least three red-white or yellow cars from the ambulance service park in front of the entrance. It's like being in a beehive and you can hardly find colleagues to take on the shift. Finally everyone gathers in front of a free computer terminal and the shift handover begins. You scroll through the patient files, occasionally call up laboratory results and X-rays and the current status is reported. Meanwhile the phone rings, the next patient is rolled in, the fire brigade wants to take a patient off, a medical consultant comes and asks where he can find a patient and why he should take care of it again now. Next, the boss calls, how can it be that another patient with dementia is waiting for more than three hours in the old people's unit, who had been brought to the rescue center after a fall ... After a few soothing words, I promise to ask about it immediately To take care of.
When I then sit down at the computer and look over the patient list, I can hardly think of anything that I should know about the patient. Where did the information go from the handover? So I go out, look for the patient who is waiting, take her to an examination room, read the emergency service log and realize that I still have no idea what this patient is about ...
In such a case, I would like to have the answers to four fundamental questions:
1.) What kind of patient do I have in front of me here? (Situation)
I want to know why the patient is here in the emergency room, what are her main complaints and how did she get here? Then at least I would have a picture under which I could classify the patient.
2.) What happened? (Background)
Has there been an accident or, for example, has the pain in the right shoulder been there for a long time? With a few details about the anamnesis, I could assess the urgency of the complaints and prioritize my work plan.
3.) What has been done so far? (Assessment = examinations)
Has there already been an X-ray, was an EKG done and what did the physical examination reveal? I would not have to look for or order these examinations again. And finally:
4.) What else should I do with this patient? (Recommendations)
Do you already have an idea for the basic admission or does the patient want to go home again?
We did something wrong with our handover.
The WHO and the DGAI recommend structuring handovers in medical settings. In particular, high-risk environments with a high level of temporal, spatial and personal uncertainty harbor the risk of errors that can easily increase so that patients can be harmed. This definitely applies to our central emergency room in #theHOSPITAL to! It is important to pay full attention to the handover process so that the information transfer can take place as completely as possible.
Young et al. looked at the handover process in medical settings from the perspective of cognitive load theory. This theory relates to learning processes and the transfer of learning content from working memory to long-term memory. To memorize, several data processing steps are carried out in the brain. We do not consciously take in and process information continuously through our senses, with visual and auditory signals being processed separately. Most of these signals are never conscious and are lost because they are not stored for a long time. If information comes to the consciousness, it appears in our short-term memory (or in the English "working memory"). It is important for us to transfer this information from the patient transfer from the short-term memory to the long-term memory, so that we can still have data on the patient at hand later in the day.
Unfortunately, the storage capacity of the "working memory" is limited - as a rule it can four up to seven information units are kept in the air at the same time (plus / minus two, Albert Einstein is said to have been able to process 12-15 information units at the same time ...). These data are lost again after about 30 seconds, unless they are repeated ... So this is our "cognitive load" or the load limit of remembering in a moment and the amount of data that can be transferred to long-term memory.
The data processing in the short-term memory and the transfer of the data into the long-term memory is therefore limited and, to put it simply, is determined by three factors: the information itself ("intrinsic load"), the design of the information ("extrinsic load") and the processing strategy ( "Germain load"). That sounds very complex, it is. But it can also be broken down into a light formula.
1.) An information unit must not contain too much information (i.e. 4 – 7 +/- 2), in order not to overload the "intrinsic load" and should be titrated (in chunks).
2.) An information unit at a handover should be designed in a standardized and structured manner, because then the receiving person knows what kind of process the handover will take (so that the “extrinsic load” can remain low).
3.) Understanding of the information unit should be checked by asking each other. Beginners in particular do not yet have a pronounced processing strategy ("germaine load") and must be supported by experienced people in the transfer processes.
Cognitive load theory and transfer in the model
I personally prefer to do the handover visit to the patient. This addresses auditory and visual data processing processes that can be processed separately (see above) and thus increase the "cognitive load" possibility. Other important points when handing over patients are the principle of the “sterile cockpit” (reduces the “extrinsic load”, since disruptive interference is reduced). This means that only patient-specific, professional communication takes place, without private conversations and without interruptions. Only one person speaks during the handover. Colleagues should encourage each other to adhere to the handover concept (“discussion discipline”). Inquiries about understanding are explicitly desired and improve remembering (strengthens the “germain load”). And then, if possible, everyone involved should be there from the beginning of the handover to avoid repetitions.
Why have I set out the whole cognitive load theory now? Oh, yes, I wanted to follow the structured handover SBAR come!
A structured patient handover after SBAR- Concept (recommendations of the DGAI and WHO) has led to a reduction in errors in scientific studies in the industrial and medical context, reduced unexpected deaths and increased patient safety. A structured handover reduces the "extrinsic load". Furthermore, the SBAR handover consists of random four (4!) Information units.
What does that mean in concrete terms?
S- "situation": I would like to have a catchphrase to be able to classify the patient immediately in my information processing strategy (eg "Demented geriatric patient with Zn fall"). This opens up a number of treatment paths for me in front of my inner eye and reduces my "germain load" .
B- "Backround": The background of the event (e.g. "Was found lying in the room by the nursing staff, falls frequently, has atrial fibrillation and takes ASA and beta blockers")
A- "Assessment": Physical Exam Status. (e.g. "ABC without pathology, D dementia, bruise mark right frontal, misalignment and pressure pain right upper arm, hyponatremia, cCT and X-ray upper arm / shoulder right registered)
R- "Recommendations": What is still to be done? (e.g. "Inpatient admission for recurrent falls and hyponatremia, still to be clarified whether geriatric, neurosurgical or trauma surgery based on the results of the imaging.")
SBAR concept. I wish that.
What has come of the demented old woman?
She has a complex fracture of the right humurus and no intracranial injuries. Conservative therapy is possible and the relatives with the power of attorney follow the patient's request for further outpatient treatment. Firstly, it turns out differently, secondly, than you think.
Where would you have the information with the power of attorney in the SBAR-Scheme should be passed?
Have fun using it.
John Q. Young et al. 2016 Unpacking the Complexity of Patient Handoffs Through the Lens of Cognitive Load Theory Journal Teaching and Learning in Medicine Volume 28
Dossow V et al. DGAinfo: Structured patient handover in the perioperative phase - the SBAR concept. Anästh Intensivmed 2016; 57: 88-90
Communication during patients hand-overs. WHO Patient Safety Solutions. Vol 1, solution 3 / May 2007
Starmer AJ et al: Changes in medical errors after implementation of a handoff program. NEJM 2014; 371: 1803-12
De Meester K et al: SBAR improves nurse physician communication and reduces unexpected death: a pre and postintervention study. Resuscitation 2013; 84: 1192-6
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