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ISBAR for clear communication

Clinical communication for health employees

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Aim of ISBAR education is to help you to …

• further develop your communication skills• utilise these skills when making a telephone

referral• utilise questioning/prompting skills as necessary

when receiving a telephone referral • standardise the use of a common agreed tool

Telephone referral = any telephone conversation made by a clinician (medical, nursing, allied health) to another member of staff that relates to the immediate care of a patient

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Structure of session

• Introduction• Video viewing and critique (X2)• Explanation of ISBAR tool• Video viewing and critique (x1)• ISBAR activity in pairs• Conclusion / evaluation

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Why is this topic important?

• Patient care is dependant on effective communication - including telephone communication between all staff involved in the care of the patient

• Effective communication has become more important as healthcare has become more complex, highly specialised and team-based

• JCAHO & Southern Health statistics

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Why is it important to have a standard approach to telephone

communication?• It is a daily task • It is rarely explicitly taught • Telephone referrals can be a source of frustration

for both the ‘giver’ and the ‘receiver’• Ineffective telephone communication can

compromise patient care

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• How often do you make or receive a telephone referral?

• Generally, is making a telephone referral easy or difficult?

• What have you experienced?• If sometimes difficult, why?• What information would you like when receiving a

referral?

Some questions for you…

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Some of the challenges• People are busy and don’t want more work!• It can be difficult to summarise a complex case

succinctly• The person making the referral

– is often asked about things they have already said– may not get the help they were expecting

• The person receiving the referral may– interrupt mid-sentence– make assumptions about the capability of the person

making the referral

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What strategies do you already use to assist the process of

making or receiving a telephone referral?

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ISBAR• A tool used to help provide structure to

communication in a number of settings• Adapted from SBAR, a tool developed by the US

Navy to improve communication• We are proposing the use of ISBAR in relation to

making and receiving a telephone referral

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By the end of this session you will be able to…

• describe the use of the ISBAR tool in making a telephone referral

• prepare for a ‘mock’ referral • demonstrate the successful use of the ISBAR tool

to make a ‘mock’ referral• identify possible situations to use ISBAR in your

workplace

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Structure of session

• Introduction• Video viewing and critique (x2)

– all videos relate to the same case • Explanation of ISBAR tool• Video viewing and critique (x1)• ISBAR activity in pairs• Conclusion / evaluation

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What are your thoughts on this doctor’s attempt at making a referral?

What suggestions for improvement would you give him?

Video One

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Focused but not prepared• The doctor clearly states what he wants

– he wants the other doctor to come and see the patient• He checks he is talking to the right person

but …

• He doesn’t have important information at hand• The main problem is lack of preparation

– how long does it take to prepare? – what things should be prepared before picking up the

telephone?

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What are your thoughts on this doctor’s attempt at making a referral?

What suggestions for improvement would you give him?

Video Two

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Prepared but not focusedthis is an exaggerated vignette to make a point

• The person on the other end of the phone gave up because the information was neither concise nor organised

• All the relevant information was included, but …• The message was not clear

Note: the relevant information needs to be delivered slowly and simply with appropriate emphasis and repetition

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Structure of session

• Introduction• Video viewing and critique (x2)• Explanation of ISBAR tool• Video viewing and critique (x1)• ISBAR activity in pairs• Conclusion / evaluation

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ISBAR

• I - Identify• S - Situation• B - Background• A - Assessment• R - Request

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ISBAR

• Provides a standardised structure for communicating

• Helps prioritise information for both parties

• Decreases the chance of forgetting relevant information

• Helps to decrease assumptions by making the reason for the call obvious at the outset

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I - Identify

• Identify yourself - name, position, location• Identify the person you are talking to if not already

done• Identify the patient and unique ID number

“Hello. My name is Jasmine Sass, I’m a Division 1 RN working on Ward 2 at …. Hospital. Are you the medical registrar on for ward referrals today? … I didn’t catch your name?…I’m calling about a patient - Terry Jones - a 56 year old man in our surgical ward at ….. Hospital”

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I - Identify continued…• Why give your name?

– it is polite and professional to do so

• Why give your position?– helps the information receiver to know at what level to

pitch their response/advice

• Why state where you are calling from?– the information receiver may work at multiple sites

• Why identify the person you are speaking to?– to make sure it is the appropriate person

• Why do you need their name?– to document in the notes for future reference

• Why identify the patient - name, age, sex, location?– helps identify the patient and helps the receiver to

develop a mental picture of the patient

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S - Situation

• Explanation of WHY you are calling“I am calling you about a patient, Mr Jones*. He is a 56 year old man, 2 days post hernia repair who has developed new atrial fibrillation with a blood pressure of 105/66. He looks pale and feels unwell. I would like you to come and assess this patient please”

• If urgent, make this clear at the start“Mr Jones is a 56 year old man who is 2 days post hernia repair. He has gone into atrial fibrillation. He is stable at present with a blood pressure of 105/66 but he is normally hypertensive. He looks pale and feels unwell. I am concerned about him and would appreciate it if you could come and help us to stabilise him”

*No need to repeat patient’s name age and sex if already included in IDENTIFY

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S - Situation Continued

• Stating the purpose of the call at the start of the conversation helps the receiver focus their attention appropriately when listening to the story

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B - Background• Tell the story

“I’ll tell you the story…”“I’ll give you the background information…”

• Provide RELEVANT information only. Deciding what is relevant is a skill that comes with experience

• Don’t forget ‘less is often more’– you may get the message across better with less

information

• Include aspects of history, examination, investigations and management where relevant

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B - Background Continued…

• The volume of information will depend on the situation– Less

• if the receiver will see the patient themselves shortly. No background may be quite appropriate in this situation.

• if the receiver already knows the patient– More

• if you are wanting management advice over the phone without the receiver seeing the patient

• The receiver can always fill any important gaps in your story with questions

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A - Assessment

• State what you think is going on. Give your interpretation of the situation

• Don’t leave the receiver to guess what you are thinking - tell them

• Stating the obvious is helpful here• Include your degree of certainty

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A - Assessment cont…

• “… the patient is febrile and I can’t find a source of infection”

• “The patient has improved but I am concerned they have had a pulmonary embolus”

• “The patient has acute coronary syndrome”

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R - Request• State what you want from them

“We would be grateful for your opinion regarding the need for surgery”

“I need help urgently, are you able to come now? … If not, who should I call?”

• Ask questions“What would be the most appropriate antibiotic in this situation?”

“What are the priority tasks for me while you are on your way?”

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Additional points…

• NB: What you say for Situation may be a concise summary of what you say for Assessment and Request. This repetition is helpful as it emphasises the key purpose of the referral

• Sometimes the receiver will lead the conversation – you can still use ISBAR as a guide– Don’t forget, the receiver may not be familiar with ISBAR

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Preparation for the call• Preparation is vital - use ISBAR to prepare• Make sure YOU are clear on the reason for referral

before calling• Write down your questions• Document a written referral in the notes if this is

the practice for formal referrals in your hospital or include in nursing notes

• Gather relevant patient details, notes, charts, ECGs, observations etc before making the call

• Have pen and paper on hand to write down names, numbers and instructions

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Structure of session

• Introduction• Video viewing and critique (x2)• Explanation of ISBAR tool• Video viewing and critique (x1)• ISBAR activity in pairs• Conclusion / evaluation

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What are your thoughts on this attempt at making a referral?

This is an example of ISBAR in action…

Video Three

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ISBAR can be done briefly - 1• I - “Hi, I’m Joe, an intern in ED”• S - “I would like to refer a 66 year old man with

pneumonia”• B - “He has been on oral antibiotics for 1 week

with no improvement. He is stable and we have commenced IV antibiotics”

• A - “His presentation of pneumonia is classic”• R - “Are you able to see him with a view to

admission?”

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ISBAR can be done briefly - 2• I - “Hi, I’m Sue, an ANUM on Ward 2”• S - “I would like you to come and see a 21 year old

man who has had a significant skin reaction to an IV antibiotic”

• B - “He was admitted this morning for treatment of an appendicectomy wound infection. He is a type 1 diabetic. He has just had his first dose of Gentamicin, Metronidazole and Ampicillin”

• A - “He is anxious and appears flushed with an erythemous rash on his chest and arms. His blood pressure is normal”

• R - “Are you able to see him urgently?” “What would you like me to do in the

meantime?”

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If you are receiving the referral

• Don’t forget you can help– Are we using the ISBAR format?– Can you give this to me in ISBAR format?– Can you please identify ….?

patient’s name, location

– What is the Situation?– What is the Background?– What is your Assessment?– What do you think needs to happen?

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Structure of session

• Introduction• Video viewing and critique (x2)• Explanation of ISBAR tool• Video viewing and critique (x1)• ISBAR activity in pairs• Conclusion / evaluation

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Other applications of ISBAR

• Making a written referral• Presenting a case on a ‘ward round’• Handing over a complicated patient to covering

staff• When transferring or receiving a patient from ED• ‘Standardised Forms’ development

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Structure of session

• Introduction• Video viewing and critique (x2)• Explanation of ISBAR tool• Video viewing and critique (x1)• ISBAR activity in pairs• Conclusion / evaluation

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Conclusion• ISBAR is a simple tool that enables a standardised

approach to telephone referrals• 7001 Medical Nursing & Allied Health staff trained at

Southern Health• 4760 attended sessions, 2813 evaluations completed

94.08% worthwhile,91.66% relevant to them 93.85% relevant to colleagues

ISBAR in Practice Diagnostic Imaging: reduction in error

(Interim results - Southern Health 2009 )

Reduced inpatient misidentification: 9% to 2 %Reduced incorrect procedure verification: 30% to 4%Reduced incorrect side and site verification: 55% to 5%Referrer Audit: improved compliance. Clinical details provided 100% of timeContact details: non conformance reduced:15% to 2%

ISBAR forms

• Emergency Dept to ward transfer form • Emergency surgery booking form• Medical Referral Form• Pain Consultancy Request Form

New ISBAR forms discovered during evaluation1. Birth Suite record of telephone contact2.Wound Assessment Request

ISBAR in practice

• Simulation Centre Study : Medical students assessed in SIM Centre. ISBAR trainees outperformed non trainees each time. 88% of Junior Staff using ISBAR tool six months laterMarshall et all Qual Saf Health care 2009,18(2):137-40

There is leading evidence that ISBAR promotes improved patient safety and outcomes

Questions?

Thank you for supporting the use of ISBAR in our organisation

ISBAR tools (2010) – developed by Southern Health in partnership with the VMIA