Posts Tagged ICU

Critical Communication — SBAR

submarineThe U.S. Navy Submarine Service is attributed with the development of a communication technique for critical situations.  The technique is to standardize a message from one person to another in the order of Situation, Background, Assessment and Recommendation.  For example in a submarine:

  • Situation:  Captain this is #1, we are having difficulty maintaining our speed
  • Background:  We are near a fishing fleet
  • Assessment:  I think we may be entangled in a fishing net
  • Recommendation:  I recommend we surface and cut away the netting

The captain says “make it so” or perhaps he says “no, all stop, send out divers”

 

About 15 years ago the method came to the attention of patient safety experts.  It had several great features:  1) The person on the front line (like an ER doctor or nurse) could make a report quickly  2) the method was easy to learn and was consistent even when emotions were running high  3) It leveled the hierarchy so the person on the front line made a recommendation with situational awareness that the person receiving the message might not have.  In a medical situation SBAR might sound like:

  • Situation:  Doctor this is the ICU nurse, your patient John Doe has become comatose and is breathing very slowly.
  • Background:  He has lung disease and was just admitted 2 hours ago
  • Assessment:  I think he is in respiratory failure
  • Recommendation:  I recommend we intubate as soon as possible.

The critical care doctor says: “Get me a scope and a tube, I will be right there”

 

Those health care professionals who embraced the method found it very helpful and it is still being used at many institutions.  But, the idea has not had universal success for reasons that were not clear at the outset:

  1. Fear.  Recommendations might be rejected.
  2. License:  Some felt their license did not allow an assessment which was the equivalent of a diagnosis.
  3. Semantics:  The word assessment means physical exam to nurses but it means diagnosis to physicians.
  4. Litigation risk:  Some felt if a recommendation was followed and later proved to be an error they would be blamed and possibly sued.

 

Improved communication in critical health care situations is very important to the patient in distress, in fact, poor communication is responsible for many in-hospital errors.  The SBAR technique is more difficult than one might think.  And, implementing it requires more than just saying “wow, this is great, do it”.  Techniques for implementation include some of the following:

  1. Audio or video recordings of the technique in use
  2. Practice sessions including both doctors and nurses.
  3. Role playing — the doctor giving the nurse a report and visa versa.
  4. Explanation of why the technique works
  5. Examples of errors in communication and how patients might suffer
  6. Emphasis on teamwork and not blame.  A single negative comment by a physician or supervisor can take a great deal of effort to correct.
  7. Understand a critical assessment is not a final diagnosis but just a step in the right direction.  The assessment is made at the training level of the person stating it.  Some might say “breathing difficulty” some might say “respiratory failure”.
  8. Continued education and reinforcement.  All new members of a medical team need to be instructed.  This is an ongoing process.

 

Good communication improves patient safety especially when quick action is needed.  SBAR is a framework for communication.  Other methods may do the same thing but the history and success so far suggest it has wide applicability.  Users of the technique express satisfaction (1).  Communication always involves two parties — both must be accepting and well trained to use the technique.  The World Health Organization has included SBAR in some of its publications (2) so wider use of the technique is expected.

References:

Personal experience with SBAR

(1) Beckett, C. D. and Kipnis, G. (2009), Collaborative Communication: Integrating SBAR to Improve Quality/Patient Safety Outcomes. Journal for Healthcare Quality, 31: 19–28. doi: 10.1111/j.1945-1474.2009.00043.x

http://onlinelibrary.wiley.com/doi/10.1111/j.1945-1474.2009.00043.x/abstract

(2) Haig, K. M., Sutton, S., & Whittington, J. (2006). SBAR: A shared mental model for improving communication between clinicians. Journal on Quality and Patient Safety, 32 (3), 167–175.

http://www.ncbi.nlm.nih.gov/pubmed/16617948

(3) Anonymous (2007) Communication During Patient Hand-Overs.  WHO Collaborating Centre for Patient Safety Solutions,Patient Safety Solutions,volume 1, solution 3, May 2007

http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution3.pdf

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Medical Futility — drawing the line

icuToday’s medical futility is tomorrow’s routine care.   A very hopeful thought.  However, in the present consider a modern intensive care unit.  A treatment area in most hospitals where a month of care could easily cost half a million dollars.   That’s a big bill for any individual, hospital or insurance company and there is mounting pressure to use technology more wisely.

Cost is the most important factor to consider in a discussion of medical futility.  Futility means doing something that will fail.  Of course, our modern definition is doing something that will likely fail but might not if we spend enough money.  If there is only one treatment for a horrible disease and it only costs a penny — we would spend it instantly, even if the treatment is futile.  But,  if it costs ten million pennies …  we think about futility.

American medicine has been plagued with the problem of implementing treatments before they are affordable or even proven.   Nobody asks a medical innovator “could you work on the invention a little more to make it less expensive”.  Nobody asks a surgeon if a surgical procedure is proven — coronary bypass surgery is a good example, since the proof of effectiveness came 20 years later — turns out it’s not for every patient, just a select few.

The same question of effectiveness exists for intensive care.  It’s clearly not for every patient,  just a select few.  But, how are doctors identifying  those select few?

Critical illness is fraught with uncertainty.  We have lots of expensive treatments but where do we draw the line.  Deploy the technology or let nature take it’s course?   Ethicists and theologians suggest they know the answers.

Yet, patients and families seek a pragmatic solution:  grandpa was in great health but now his aneurysm has ruptured — he looks bad, should he have surgery?

Research shows critical care doctors actually predict outcome fairly well in this sea of uncertainty.   They tend to favor using their skills to “give it a try” and make money doing so.  But, if they say the chance of meaningful survival is less than 10% — absolutely do not go down that road.  The road is often a dead end — the end may be after weeks in the ICU, or weeks in rehabilitation, or months in a nursing home.

Critical care is extremely stressful to the body.  Research has shown that persons over 65 who survive an illness but who spend a week connected to a mechanical ventilator only have a 50% chance of living 6 months.  So, even walking out of the hospital after critical illness is not a guaranteed success.

Back to the question of futility.  Severe illness does not provide the luxury of time, time to check the internet, or time to go to the best doctor.  This is when going to a hospital with a high quality score is important.   There are always media splashes about miracle cures or soap opera dramas — the reality is patients and families do not want futile care.  This is one time “ask your doctor” is exactly the right thing to do — listen carefully.

 

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