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The use of standardized communication protocol for patient handover in emergency department setting Koval, Valentyna 2015

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THE USE OF STANDARDIZED COMMUNICATION PROTOCOL FOR PATIENT HANDOVER IN EMERGENCY DEPARTMENT SETTING by  Valentyna Koval  M.D., Odessa State Medical University, 1999  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF ARTS in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Interdisciplinary Studies)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  March 2015  © Valentyna Koval, 2015 ii  Abstract  Patient handover has been recognized as a highly complex and dynamic process that relies heavily on effective communication. The lack of effective communication, particularly in an interprofessional Emergency Department (ER) setting, can compromise the quality of patient care. The goal of this project is to improve patient handover process by utilizing SBAR (Situation, Background, Assessment and Recommendation) technique to standardize interprofessional communication in the ER. It is hypothesized that the modified SBAR protocol will be well perceived by healthcare providers and will improve completeness and accuracy of the information transferred during ER patient handover between members of different professional groups. Three specific objectives guided the work of this project: 1) to modify the SBAR technique and adapt it for an interprofessional ER setting; 2) to study how the modified SBAR protocol is perceived by the students (Usability Study); 3) to design an experimental study to evaluate the effectiveness of the modified SBAR protocol (Effectiveness Study). Following the modification of the SBAR technique, 47 third-year medical students were invited to participate in the Usability Study. The students were randomly assigned into eight teams. One student from each team was randomly selected to verbalize the handover using the modified SBAR protocol, while the other students observed. The usability of the protocol was assessed using the following criteria: ease of learning; ease of use; perceived usefulness and satisfaction. Students found the protocol easy to learn (91%); simple to implement (85%); and useful during the handover (87%). Students were satisfied with the protocol, as it helps structure the iii  verbal report; promotes common language amongst team members and decreases confusion during the communication (83%). Nonequivalent groups post-test only design was developed to assess the effectiveness of the modified SBAR protocol on completeness and accuracy of the patient information transferred during ER patient handover between members of different professional groups. We anticipate that use of the modified SBAR protocol will significantly improve ER interprofessional communication by ensuring complete and accurate information transfer during the patient handover. Further studies are needed to support this claim. iv  Preface  This work is an original intellectual product of the author, Dr. V. Koval. All of the work presented in this paper was conducted at the Centre of Excellence for Simulation Education and Innovation (CESEI), Department of Surgery, the University of British Columbia (UBC).  The usability project presented in Chapter 2 was approved by the UBC Behavioural Research Ethics Board (certificate # H14-02020).  The electronic Platform for Education and Research (e-PER), utilized for educational purposes, is an intellectual product of CESEI. It was designed by Dr. Karim Qayumi, Director of CESEI and one of the supervisors for this Master’s thesis.  v  Table of Contents  Abstract .......................................................................................................................................... ii Preface ........................................................................................................................................... iv Table of Contents ...........................................................................................................................v List of Tables .............................................................................................................................. viii List of Figures ............................................................................................................................... ix List of Abbreviations .....................................................................................................................x Acknowledgements ..................................................................................................................... xii Dedication ................................................................................................................................... xiii Chapter 1: Introduction ................................................................................................................1 1.1 Problem ........................................................................................................................... 1 1.2 Handover Communication Issues in an Emergency Department Setting ....................... 3 1.3 Theoretical Model of ER Communication ...................................................................... 6 1.4 Standardized Communication During Patient Handover ................................................ 9 1.5 Hypothesis..................................................................................................................... 15 1.6 Project Objective ........................................................................................................... 15 1.6.1 Rationale ................................................................................................................... 15 Chapter 2: Materials and Methods. ...........................................................................................17 2.1 SBAR Technique Modification Process ....................................................................... 17 2.1.1 Getting Familiar with the Protocol/Education Program ........................................... 18 2.2 Usability Study.............................................................................................................. 19 2.2.1 Design and Educational/Physical Context of the Simulation ................................... 19 vi  2.2.1.1 Simulated ER Environment .............................................................................. 19 2.2.1.2 Simulators ......................................................................................................... 20 2.2.1.3 Scenarios ........................................................................................................... 20 2.2.1.4 Simulation Course ............................................................................................. 21 2.2.2 Participants ................................................................................................................ 21 2.2.3 Instruments and Variables......................................................................................... 22 2.2.4 Procedures ................................................................................................................. 23 2.2.5 Analyses .................................................................................................................... 23 2.3 Future Effectiveness Study. .......................................................................................... 24 2.3.1 Design and Educational/Physical Context of the Simulation ................................... 24 2.3.1.1.1 Simulated ER Environment ......................................................................... 24 2.3.1.2 Simulators ......................................................................................................... 24 2.3.1.3 Scenarios ........................................................................................................... 24 2.3.2 Participants ................................................................................................................ 25 2.3.3 Instruments and Variables......................................................................................... 26 2.3.4 Procedures ................................................................................................................. 28 2.3.5 Analyses .................................................................................................................... 29 Chapter 3: Results........................................................................................................................30 3.1 Results of Usability Study ............................................................................................ 30 3.2 Expected Results of Effectiveness Study ...................................................................... 32 3.2.1 Interpretation Framework of Effectiveness Study .................................................... 33 Chapter 4: Discussion and Conclusion ......................................................................................34 4.1 Future Plans .................................................................................................................. 38 vii  4.2 Limitations .................................................................................................................... 38 4.3 Summary ....................................................................................................................... 39 4.4 Conclusions ................................................................................................................... 40 References .....................................................................................................................................41 Appendices ....................................................................................................................................49 Appendix A SBAR-Based Communication Protocol ............................................................... 49 Appendix B Online Module “SBAR-Based Communication Protocol” .................................. 50 Appendix C Constructive Simulation (Scenario Development Template) ............................... 51 Appendix D Usability Questionnaire for SBAR-Based Communication Protocol .................. 53 Appendix E Acute Coronary Syndrome (ACS) Scenario ......................................................... 54 Appendix F Ischemic Stroke (Stroke) Scenario........................................................................ 57 Appendix G ACS Checklist ...................................................................................................... 60 Appendix H Stroke Checklist ................................................................................................... 61  viii  List of Tables  Table 1 Ease of Learning Category .............................................................................................. 30 Table 2 Ease of Use Category ....................................................................................................... 31 Table 3 Usefulness Category ........................................................................................................ 31 Table 4 Satisfaction Category ....................................................................................................... 32  ix  List of Figures  Figure 1 ER Communication Model (Information Flow. Influence of “Environmental” and “Human” Factors) ........................................................................................................................... 8  x  List of Abbreviations  ACS Acute Coronary Syndrome ALL Allergy Basic TEAM-SIM Basic Trauma Evaluation and Management BP Blood Pressure CESEI Centre of Excellence for Simulation Education and Innovation CPSI Canadian Patient Safety Institute  EDTR Emergency Department Trauma Room EMS Emergency Medical Service e-PER Electronic Platform for Education and Research ER Emergency Department FHX Family History GCS Glasgow Coma Scale GR Geriatric HR Heart Rate ICU Intensive Care Unit MEDS Medications METI Man Medical Education Technology, Inc. Mannequin  MSK Musculoskeletal OR Operating Room xi  PICU Post-Intensive Care Unit PMH Past Medical History RR Respiratory Rate SBAR Situation Background Assessment Recommendation  SBAR-CCE Situation Background Assessment Recommendation- Collaborative Communication Education  SpO2 Peripheral capillary oxygen saturation Stroke Ischemic Stroke UBC University of British Columbia USE Usefulness, Satisfaction and Ease of Use xii  Acknowledgements  First I would like to thank Dr. Karim Qayumi and Dr. George Pachev for their invaluable contribution as my supervisors. Their suggestions, insights, feedback and advice added to my knowledge and experience in the fields of research and medical education.  My deep gratitude goes out to Marlene Woschee (Administration Manager at the Centre of Excellence for Simulation Education and Innovation (CESEI)) and Dr. Karim Qayumi (Director of CESEI) for their outstanding moral and financial support during all these challenging years. I would also like to thank Dr. Geoffrey Blair (Director of Undergraduate Surgical Education at the University of British Columbia (UBC)) and the UBC Department of Surgery for their support during the simulation study conducted with 3rd year medical students. My appreciation to all UBC medical students who participated in the simulation study. My most grateful thanks to my dear mother, Nadiya Koval, who is always praying for me; and my family, my dear daughter Anna and my dear husband Oleg, for always being there for me through my good times and bad. Thank you for your support and love!  xiii  Dedication      To my mother Nadiya Koval, my daughter Anna and my husband Oleg Mazurenko.  1  Chapter 1: Introduction The goal of this project is to improve the patient handover process in Emergency Department (ER) settings by standardizing interprofessional communication between healthcare providers. 1.1 Problem Patient handover refers to the “transfer of professional responsibility and accountability for some or all aspects of care for a patient, or groups of patients, to another person or professional group on a temporary or permanent basis” (British Medical Association, National Patient Safety Agency, NHS Modernization Agency, 2005). Handover can occur at shift changes, when clinicians take breaks, when patients are transferred within and between hospitals and during admission, referral or discharge. In this process, the healthcare providers are looking for any warning signs or symptoms that can help in making a correct diagnosis and starting treatment earlier. The ability to collect and transfer complete patient information during patient handover is of paramount importance in medicine. In recent patient safety literature there is increasing agreement that effective patient handover is critical to patient safety by ensuring appropriate coordination among health-care providers and continuity of care (Manser & Foster, 2011). Any information loss or failure to obtain information completely and accurately will compromise the effectiveness of the handover process, leading to incorrect clinical decisions and adversely affecting patient outcomes. Researchers who aimed to investigate the handover in different clinical settings found this process to be highly complex and often unreliable. In addition, patient handover has been recognized internationally as a high risk area for patient safety (Joint Commission on Accreditation of Healthcare Organizations, 2007).  2  Patient handover consists of various actions and tasks and is mainly described as complex communication activity. It is therefore not surprising that communication issues are the most frequent contributory factors to adverse events identified in patient handover. Suresh et al. (2004) developed a specialty-based, voluntary, anonymous, Internet-based reporting system for medical errors. Health professionals (n = 739) from 54 hospitals in the Vermont Oxford network received access to a secure Internet site for anonymous reporting of errors. Of 1230 reports, researchers were able to identify a broad range of medical errors in neonatal intensive care. Communication problems were one of the most frequent contributory factors (22%). Another study, conducted by Lingard et al. (2004), found that communication failures are a commonly exhibited set of problems in operating rooms (OR). Trained observers recorded 90 hours of observation during 48 surgical procedures. Ninety-four team members participated from anesthesia (16 staff, 6 fellows, 3 residents), surgery (14 staff, 8 fellows, 13 residents, 3 clerks) and nursing (31 staff). Field notes, recording procedurally relevant communication events, were analyzed using a framework which considered the content, audience, purpose, and occasion of each communication exchange. 421 communication events were noted, of which 129 were categorized as communication failures. 36.4% of failures resulted in visible effects on system processes including inefficiency, team tension, resource waste, workaround, delay, patient inconvenience and procedural error. These data describe the worrisome fact of large numbers of communication failures and their jeopardizing effects on patient safety.  Communication becomes even more challenging when it is conducted within interprofessional and multidisciplinary teams. Teamwork within the health care system is a highly complex and dynamic process, relying heavily on interpersonal communication across varying levels of experience, knowledge and roles. Pronovost et al. (2006), in a prospective 3  cohort study of incidents reported from adult and pediatric intensive care units (ICUs) in the United States, analyzed 2075 incidents from 23 ICUs. Harm was reported in 42% of incidents with 18 deaths. Teamwork issues contributed to 325 of all reported incidents.  Similar findings came from an observational study conducted by Wiegmann, ELBardissi, Dearani, Daly and Sundt III (2007). Surgical errors and their relationship to surgical flow disruptions were studied during 31 observed and recorded cardiac surgical operations over a 3-week period. Disruptions in surgical flow associated with problems in teamwork accounted for the greatest percentage of these events (n = 178; 52%). Regression analysis revealed a strong association between teamwork-related disruptions and surgical errors (r = 0.67, P < .001). These recent studies demonstrate the importance of effective communication for safe patient care. At the same time, they reveal a lack of effective communication in the interprofessional and interdisciplinary setting of current medical practice. Patient information loss and failure to transfer information completely and accurately is causing incorrect patient management, compromising continuity of patient care and jeopardizing patient safety. The extremely important process of patient handover, if not done properly, will cause errors in management and harm to patients. 1.2 Handover Communication Issues in an Emergency Department Setting As has been proven by recent studies, handover relies heavily on effective communication (Beach, Croskerry & Shapiro, 2003; Cook, Render & Woods, 2000). In some settings, such as in the ER, the handover communications between healthcare providers and representing emergency medical service (EMS) personnel may hold more potential difficulties due to the unique operating characteristics of ER settings, as described in the following list:  interprofessional nature of communication; 4   interdisciplinary nature of communication;  differing levels of adherence to standards;  an extraordinary range of situations;  time pressure;  transitions in staff;  many verbal reporting formats;  assumptions made in oral communication;  lack of clarity in written communication. Researchers who investigated the patient handover process between ambulance and ER staff found significant problems that require special attention. Scott, Brice, Baker and Shen (2003) measured the verbal communication between paramedics and physicians in an Emergency Department Trauma Room (EDTR). Forty-three paramedics’ verbal reports were audio-recorded over a 12-week period in the EDTR. Participants included 59 paramedics and 31 physicians. It was found that the physicians accurately recalled paramedic verbal report information 36% of the time. The physicians incorrectly recalled what the paramedic stated 4% of the time. The physicians did not recall what was stated by the paramedics 47% of the time. Finally, the physician gave extraneous information, or information that was never verbalized by the paramedics 12% of the time. In summary, ER staff recall just over one-third (36%) of an ambulance verbal report, with important information like patient vitals and preexisting health conditions being lost. Talbot and Bleetman (2007) evaluated current handover processes in two large ERs (Birmingham Heartlands Hospital and The Royal London Hospital) to assess the accuracy of the ER staff’s recall of patient information communicated during the ambulance handover. Ten 5  ambulance handovers were observed and recorded with a dictation machine. After recording, sending (ambulance) personnel and receiving (ER staff) personnel were asked to complete a short questionnaire. This sought to identify retention and accuracy of information recall from the verbal handover. Overall, this study demonstrated that only 56.6% of the information given at verbal handover by ambulance crews was accurately retained by ER staff.  Further investigations were done to assess the prevalence of situations with information loss and the effect on patient outcomes. In the study conducted by Stiell, Forster, Stiell and van Walraven (2003), 1002 visits to the ER made by 983 patients were recorded and assessed for information gaps. At least 1 information gap was identified in 323 (32.2%) of the 1002 visits (95% confidence interval 29.4 – 35.2%), which is one-third of all recorded visits. Information gaps were associated with severity of illness, being significantly more common in: patients who had serious chronic illnesses; patients who arrived by ambulance; those who had visited the emergency department or had been in hospital recently; patients in monitored areas in the emergency department; and older patients. Information gaps most commonly comprised medical history (58%) and laboratory test results (23.3%) and were felt to be essential to patient care in 47.8% of the cases. In addition, information gaps were associated with prolonged stay in the emergency department: patients with information gaps stayed 1.2 hours longer on average which led to increase in direct costs of patient care, patient dissatisfaction and overcrowding. A study by Carter, Davis, Evans and Cone (2009) aimed at determining the degree to which information presented during the handover is degraded. The researchers recorded and evaluated 96 handovers during full trauma responses. The video recordings were evaluated for the presence of important data points appropriate to the case, checking off whether the data points were verbally transmitted by ambulance workers and whether the same elements were 6  received by the ER trauma team. In 96 patient handovers, a total of 473 elements were transmitted, of which 329 were received (69.6%). In the average handover, 72.9% of the items transmitted were received (95% CI 69.0% -76.8%), but the variability from one element to another was significant (range 33.3% - 100%, median 75%). Information about prehospital hypotension was received in only 10 of the 28 times it was transmitted (35.7%). Prehospital Glasgow Coma Scale (GCS) scores were received in 10 out of 22 times (45.5%); pulse rates 13 out of 49 times (26.5%). The study found significant variability between transmitted and received information elements known to have an impact on outcomes, even in the controlled setting of a single-patient handover with direct verbal communication between ambulance and ER staff.  These studies demonstrated significant patient information loss and failure to transfer information completely and accurately while managing acutely ill patients in the ER. These findings cannot be ignored and require detailed studying of the communication model in ER settings, as well as improvement of the handover process in order to prevent negative outcomes for patients. 1.3 Theoretical Model of ER Communication According to the Shannon-Weaver model (Foulger, 2004), communication is a process wherein information flows between the communicators, message receivers and message senders, via communication channels. Based on Foulger and Barnlund’s theory (Foulger, 2004), each communicator in the communication chain plays two roles, creator and consumer, that are embodied interchangeably. Message receivers consume the information and transform it into the message that has to be communicated to the next person in the communication chain, becoming message creators. Every time the information enters the communicator, whether it is receiver or 7  sender, it gets changed according to communicators’ roles, experience and knowledge. These changes can cause significant variability in what has been transferred between the communicators. In the ER, information is transferred between various healthcare providers. In addition to being processed by message consumers and creators, the information transferred in the ER undergoes multiple transformations due to the interprofessional and interdisciplinary nature of communication. The information obtained at the scene is optimized by ambulance personnel in order to be transferred to the ER staff, nurses and physicians. ER staff will interpret the information within the context of their perspectives on and relationship with the creators of the message, ambulance personnel. In turn, ER nurses will optimize the received information in order to transfer it to ER physicians. All messages will be created within the context of the providers’ roles, experience and knowledge.  Several studies have been conducted to identify various factors that enable and constrain effective communication in the ER during patient handover (Carter et al., 2009; Scott et al., 2003; Talbot & Bleetman, 2007). Communication effectiveness was examined from the perspectives of message “creators” and “consumers”. The factors that led to errors in what was “created” were related to: lack in language skills; stressful nature of job; increased level of frustration; feeling ignored. The factors that led to errors in what was “consumed” were related to: multitasking by “doing” and “listening” at the same time; multiple interactions; social/professional hierarchy; difference in training; difficulties in understanding and creating a shared picture. In the communication model presented by Reason (1997), these factors were identified as “environmental” and” human” factors that have potential to create the error-provoking conditions leading to communication failures. 8  Our current understanding of the communication model in the ER, and the latest findings on factors that enable and constrain communication, lead to the conclusion that ER communications are highly variable in completeness and accuracy of information transferred during handover.  All messages in the ER are created and consumed under the influence of “environmental” and “human” factors, within the context of the providers’ roles, experience, knowledge, perspectives and relationships with each other. When the communication consumers receive the information they become creators, as they change the information according to their roles, experience and knowledge. The information X receives from the source will transform into information X5  after being processed by all involved communicators (Figure 1). The Shannon-Weaver communication model (Foulger, 2004), was adapted for ER communication by adding multiple transfer points between members of different professional groups, and demonstrating the influence of the “environmental” and “human” factors on the information flow chart.   Figure 1 ER Communication Model (Information Flow. Influence of “Environmental” and “Human” Factors)  9  These changes can be seen as positive if they add to and quicken the decision making process, or negative if they change the accuracy and completeness of the transferred information. The statement that “ER personnel, representing the distinct categories of healthcare professional, are expected to communicate dynamically, interdependently and adaptively towards a common goal” becomes anecdotal based on the growing empirical evidence that patient information transfer processes in all healthcare settings are highly complex and often unreliable. The transferred information requires some kind of protection screen to bounce back from the strong influence of environmental and human factors and prevent the significant variability in the completeness and accuracy of the transferred information. Lately, many authors recommend reducing the information variability through standardization (Catchpole 2007; McFetridge, Gillespie, Goode & Melby, 2007; Riesenberg, Leitzsch & Little, 2009; Ye, McD Taylor, Knott, Dent & MacBean, 2007). A primary focus of the standardization is defining and ordering the content of information transferred between healthcare providers during patient handover. Standardization becomes a protection screen to prevent the influence of the “environmental” and “human” factors on the completeness and accuracy of the transferred information. Overall, the interprofessional and interdisciplinary setting of the ER, with its multiple transfers, can significantly impact patient handover and cause deterioration in the completeness and accuracy of the transferred information. The standardization method has been proposed in the literature as a method to diminish the significant variability of the transferred information and improve its completeness and accuracy. 1.4 Standardized Communication During Patient Handover In the current literature there are two commonly used approaches to the standardization of handover communication (Manser & Foster, 2011). The first approach defines specific 10  information content and the order in which this information must be handed over. Catchpole et al. (2007), for example, developed a specific handover protocol using Formula 1 pit-stop and aviation models to support patient handover in setting ranging from the operating theatre to the cardiac intensive care unit. This protocol includes the handover preparation, the clinical handover tasks to be completed before the verbal handover (e.g., connecting monitoring equipment, ventilator and so on), and defines the order in which the verbal handover is conducted. Similarly, Berkenstadt et al. (2008) introduced a checklist/protocol for the handoff containing specific items of information to be handed over during shift change in a medical step-down unit.  The second approach to handover standardization does not define the exact content, but the topics to be covered and their order. This approach frequently suggests the use of handover mnemonics. In a recent systematic review conducted by Reisenberg et al. (2009), 46 articles describing handover mnemonics were reviewed and 24 handover mnemonics aimed to improve the process were identified.  The flexible mnemonic approach to communication standardization appears to be more suitable for an ER setting, rather than the structured checklists. Instead of defining the exact content to be communicated, it suggests the possible topics or categories and the order to be used by ER personnel while communicating adaptively towards a common goal. However, for research purposes, the detailed case-specific checklist should be developed to identify information that is expected to be transferred and collected within each category of the used mnemonic.   In the review conducted by Reisenberg et al. (2009), one handover mnemonic, SBAR (Situation, Background, Assessment, Recommendation), was recommended most frequently; 11  almost 70% of the time SBAR was suggested to be useful. Originally developed in the armed forces and then refined by the aviation industry to reduce the risks associated with the transfer of inaccurate and incomplete information (Leonard, Graham, & Bonacum, 2004), SBAR provides a framework for communication between health care providers about a patient’s condition by defining categories of information that need to be communicated and their order. Categorization provides clarity and prevents the confusion that can happen when using a check list. The person conducting communication in the SBAR format starts by stating what is happening right now (Situation); moves on to the context (Background); provides a problem assessment (Assessment) and suggests a solution (Recommendation).  The successful implementation of SBAR in healthcare has been demonstrated in high-risk, urgent settings that rely predominantly on verbal communication due to time pressure and lack of clarity in written communications. Following SBAR implementation in nurse-to-nurse and nurse-to-physician communications, improvements were seen in staff and patient satisfaction, clinical outcomes, team communication and patient safety culture in Perinatal Care, OR, ICU and Post-Intensive Care Unit (PICU) (Beckett & Kipnis, 2009; Haig, Sutton & Whittington, 2006; Pope, Rodzen & Spross, 2008; Rodgers, 2007).  In 2009, Beckett and Kipnis evaluated the SBAR technique in large scale urgent hospital settings. The researchers developed and implemented an SBAR-based Collaborative Communication Education (SBAR-CCE) intervention for 215 staff working in pediatric/perinatal services departments in a 271-bed community hospital located in northern Arizona. The participants were asked to complete pre/post intervention surveys to determine the effectiveness of the intervention and its influence on teamwork, communication, and patient safety outcomes. Out of a possible 215 staff, 212 staff participated in the SBAR-CCE intervention. There were 12  141 completed pre-intervention surveys (group 1) and 71 completed post-intervention surveys (group 2). For the purpose of this study, the “Safety Attitude Questionnaire: Teamwork and Safety Climate Survey” was administered before and 3 months after the SBAR-CCE intervention. The survey was comprised of 27 items. The first 14 items are specific to the teamwork climate, and the final 13 items are focused on the safety climate. As a result of the SBAR-CCE implementation, the improvements were found in participants’ perception of: team coordination, interprofessional collaboration, conflict resolution, ability to speak up, opportunity to report safety concerns and learn from the errors; support from other healthcare providers. The qualitative data from observations and interviews themed the SBAR-CCE intervention as “positive communication” described as a “good framework”, “strong foundation for communication”, and that it “increases awareness.” Recently, SBAR was tested in a small scale interprofessional setting different from the urgent setting of Rehabilitation and Complex Continuing Care (Andreoli et al., 2010; Boaro, Fancott, Baker, Velji & Andreoli, 2010). Andreoli et al implemented and adapted the SBAR tool for use on two interprofessional rehabilitation teams [geriatric (GR) and musculoskeletal (MSK)] for the specific priority issues of fall prevention and management. A total of 91% of the GR (50/55) and 70% of MSK rehabilitation units (35/50) participated in this demonstration project. A series of didactic and interactive workshops were offered to medical staff in order to implement the SBAR tool. The study outcomes were measured using a pre/post intervention design. Surveys, confidential forms, face-to-face interviews and focus group discussions were utilized for research purposes. After implementation of the SBAR tool, both teams (GR and MSK) showed clinically meaningful improvements in their perceptions of communication, teamwork ability and patient handovers. GR and MSK rehabilitation units’ staff found the tool 13  useful in better communicating relevant and succinct information, and “closing the loop” by providing recommendations and accountabilities for action. The SBAR technique has been implemented in both large and small scale settings that share a number of characteristics with the ER: their interprofessional and interdisciplinary nature; differing degrees of adherence to standards; predominance of verbal communication, and time pressure.  Woodhall, Vertacnik and McLaughlin (2008) supported the appropriateness of SBAR use in ER settings during shift changes and patient transfer. Physicians and nursing staff were surveyed regarding effective communication. Based on the results of the initial survey, the SBAR technique was introduced hospital-wide in an effort to standardize the transfer of information. All of the nursing units were required to make reports using the SBAR technique, including the ER. In one year, the same hospital areas were surveyed again to evaluate the perceived efficacy of SBAR. Dramatic improvements were found in the perception of all areas of communication. Both nursing staff and physicians appreciated abbreviated, concise and to-the-point communications supported by the technique. It was not, however, clear if physicians went through the same SBAR training and whether they were required to use the SBAR technique during their communication as were the nursing group. Therefore, one can question if the SBAR technique is equally useful to all members of an interprofessional ER team. In addition, perceived efficacy was the only measured outcome and it was unclear whether participants were gaining in the amount and quality of transmitted information.  As we can see, the previous implementation of the SBAR technique lacked in objective assessments and focused mostly on the subjectivity of the participants’ perceptions of the handover effectiveness. In 2012, Tews, Liu and Treat conducted a quantitative study to evaluate 14  the feasibility of using SBAR tools to teach inter-physician communication skills to first-year ER residents during patient handover. All residents were evaluated with pre/post intervention simulated cases conducted as two separate sessions with an interval of 4 months. A 17-item SBAR checklist, including items/information expected to be conveyed during patient handover, was utilized for evaluation purposes. One point was given for each correctly presented item by residents during the simulated cases. The findings showed a statistically significant improvement in residents’ post-intervention versus pre-intervention scores (mean, 15; SD, 1.6 versus mean, 10.2; SD, 2.7; P = .001) during the first session; and (mean, 14.4; SD, 2.2 versus mean 16.3; SD, 1 .6; P = .001) during the second session. There was no statistically significant difference between post-intervention first session and pre-intervention second session (P = .34), suggesting retention of the use of the SBAR tool. In addition, residents completed a survey to rate their perceptions of the training and potential clinical utility of the SBAR tool. The survey results yielded good reliability for both sessions (Cronbach alpha = 0.87 and 0.89, respectively) and demonstrated statistically significant increase for the perceived quality of training, presentation comfort level, and the use of the SBAR tool (P = .001). In summary, SBAR was acceptable to first-year ER residents, with improvements in both the ability to apply SBAR to simulated case presentations and retention at a follow-up session. Although, the researchers used the objective measurements of correctly transferred information on the check list, the SBAR technique was implemented for one professional group, missing the important interprofessional component of communication in the ER. After we explored the existing protocols for communication standardization, we found SBAR’s, flexible mnemonic communication technique to be more suitable for the interprofessional and interdisciplinary setting of the ER. The previous implementation of SBAR 15  in various clinical settings proved its usefulness in supporting the communication process between healthcare providers.  We modified the SBAR technique and implemented it in the simulated ER setting in order to improve the ER patient handover process and achieve the goal of this project. 1.5 Hypothesis It is hypothesized that the modified SBAR protocol will be well perceived by healthcare providers and will improve completeness and accuracy of information transferred during ER patient handover between members of different professional groups. 1.6 Project Objective The specific objectives of the project are threefold: 1. To modify the SBAR technique and adapt it for an interprpofessional ER setting 2. To study how the modified SBAR protocol is perceived by the students (Usability Study) 3. To design an experimental study to evaluate the effectiveness of the modified SBAR protocol (Effectiveness Study) 1.6.1 Rationale  Firstly, the SBAR technique was modified in order to adapt it to an interprofessional ER setting. The flexible mnemonic approach of SBAR suggests possible categories and the order for each to be used by EMS providers when communicating patient information. Considering the overwhelming amount of information in the ER, we specified some general elements to be communicated under each category. For research purposes, the elements were further expanded into scenario-specific checklists.  16  Secondly, we believed it was important to implement and evaluate the usability of the protocol before conducting any further assessment. Usability is usually defined as “the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use” (International Organization for Standardization, 1998). Although usability refers to subjective experience, it captures the important aspects of instituting a process: learning the necessary steps, implementing the steps in practice, and completing the process. The evaluation of usability is an increasingly important part of the communication protocol development process. The Usability Study, conducted in the simulated ER setting amongst 3rd year medical students, would help identify deficiencies in the protocol and possible solutions for the improvement of the protocol. Thirdly, the Effectiveness Study was identified as an important step in the protocol evaluation for addressing the deficiencies of previously conducted research. In particular, our Effectiveness Study aimed at implementing the SBAR-based communication protocol across various professions representing EMS, and objectively assessing its effectiveness. For the purpose of the Effectiveness Study, two simulated clinical scenarios with detailed case-specific checklists for each were developed and tested. Taking into account the complexity of the project and the time available for its completion, the supervising committee approved our bid to conduct the study, collect data for the Usability report and limit the Effectiveness Study to creating the design and completing the preparatory work for future research. Therefore, there will be no Effectiveness Study results included in this paper.   17  Chapter 2: Materials and Methods. 2.1 SBAR Technique Modification Process In order to standardize communication between healthcare providers, the SBAR technique was modified for an interprofessional ER setting. The four main categories of the SBAR technique, Situation (S), Background (B), Assessment (A), and Recommendation (R), were used as a core structure for the “SBAR-based communication protocol”. S-B-A-R defines the information categories and the order they should be used by ER personnel while communicating patient information. However, the overwhelming amount of information transferred during ER handovers requires more detailed specification of the information elements that are expected to be transferred within each SBAR category. Also, the specification of the information elements helps to standardize the information transferred between members of different professions and minimizes the differences related to providers’ roles, experience and knowledge. We conducted field observations in the ER and interviews in a focus group format with experienced ambulance providers and ER staff (physicians and nurses), in order to define appropriate information elements expected to be transmitted during the handover. We tried to create a protocol that could be used for any clinical situation, therefore, the elements were not case-specific and were comprised of more general information (e.g. patient’s age, vital signs, results of physical exam, etc.). The defined information elements were organized into the SBAR format (Appendix A). Five elements under “Situation” category: 1. Identify self 2. Identify patient (name, age, gender) 18  3. Chief complaints/ reason(s) for admission (Mechanism, Injury, Symptoms) 4. Time of onset 5. Additional complaints  Four elements under “Background” category: 1. What has been done for management so far (Treatment) 2. Vital signs (BP, HR, RR, SpO2, t) 3. Physical Exam is significant for (list the findings): - Neurological deficit - Respiratory status - Cardiovascular status - Gastrointestinal status - Psychiatric status 4. Other relevant History (PMH, FHX, Social, ALL, MEDS) One element under “Assessment” category: 1.  Patient Status/Problem/Issue Two elements under “Recommendation” category: 1.  Indicate your management plan  2.  State your concerns  2.1.1 Getting Familiar with the Protocol/Education Program An educational online module was developed to familiarize health professionals with the SBAR-based communication protocol (Appendix B). The module was based on the electronic Platform for Education and Research (e-PER). e-PER offers a standardized curriculum development template that has been effectively used in medical education and previously 19  evaluated in several studies (Garett & Van der Wal, 2007; Vanderhoeven, Callaghan, Savard & Qayumi, 2007). In addition, e-PER offers individual and time-flexible access for the participants, as well as the opportunity for data collection. The on-line module consists of didactic materials, videos and a discussion forum in a virtual classroom. Students were given individual access for opening, working and completing the module. Upon completion, the students were expected to be able to utilize the protocol in a simulated ER situation of patient transfer. 2.2 Usability Study In order to assess the usability of the SBAR-based communication protocol, it was implemented in the simulated ER setting amongst 3rd year medical students. The students were expected to utilize the protocol during the simulated ER patient handover and assess its usability using the “Usability Questionnaire”. 2.2.1 Design and Educational/Physical Context of the Simulation 2.2.1.1  Simulated ER Environment The SBAR-based communication protocol requires an environment where it can be implemented and tested without compromising patient safety. A working ER is a very intense and highly dynamic environment where the implementation and testing of a new communication protocol would be very difficult to accomplish. For our research purposes, medical simulation was used to mimic a real ER setting, allowing proper implementation and testing of the SBAR-based communication protocol. Over the past few decades, simulation has become an integral part of medical education and research (Bradley & Postlethwaite, 2003; De Ponti et al., 2011; Moorthy, Vincent & Darzi, 2005; Qayumi et al., 2004; Qayumi, 2006; Steadman et al., 2006; Ziv, Wolpe, Small & Glick, 2003). First, simulation offers a safe and realistic environment in which healthcare providers’ 20  skills and knowledge can be evaluated without direct contact with the patients (Salas, Bowers & Rhodenizer, 1998). Second, it has been proven that simulators play an important role in studying communication process, allowing for the recording and measuring of observable behaviors of team members in dynamic, time-critical emergencies (Bond & Spillane, 2002; Harrison, Manser, Howard & Gaba, 2006; Lane & Rollnick, 2007). Simulation also allows for interprofessional and interdisciplinary training that is essential for the ER setting (Bond & Spillane, 2004; Sica, Barron, Blum, Frenna & Raemer, 1999; Fiedor 2004; Curran, Aziz, O’Young & Bessell, 2004; Lee et al., 2003). Finally, simulation permits standardization of clinical situations, which is essential for the research. 2.2.1.2 Simulators ER clinical scenarios were recreated using advanced human patient simulators. For the purpose of this simulation study, two Medical Education Technology, Inc. Mannequins (METI Man) and two Laerdal (3G and Essential) simulators were used. The simulators are computer-model-driven, full-sized mannequins that have characteristics of real patients and allow for a physical examination, patient monitoring and medical interventions. Using specialized software, four clinical scenarios were programmed to allow the simulation of the patient handover. 2.2.1.3 Scenarios For the purpose of this study, four clinical scenarios were simulated. Musculoskeletal injury, Head and Spine injury, Chest injury, and Abdominal injury scenarios were selected for the following reasons: 1) common clinical entities that are in the scope of third year medical students’ competence; 2) acute clinical conditions that require effective utilization of knowledge and communication skills during the patient handover. Simulated clinical scenarios were developed using a constructive simulation scenario development template (Appendix C). Each 21  scenario consisted of three stages to allow information transfer within the team and from the team leader to the instructor at the end. Each stage in the scenario represents the conditions of the simulated patient at the given moment, and serves as the source of the information elements that are expected to be communicated using the SBAR-based communication protocol. The scenarios were reviewed by the teaching faculty and suggested changes were implemented. 2.2.1.4 Simulation Course All four simulated scenarios were delivered during the Basic Trauma Evaluation and Management (Basic TEAM-SIM) course offered as a part of the academic day for 3rd year medical students. The Basic TEAM-SIM course is conducted at the Centre of Excellence for Simulation Education and Innovation (CESEI), an internationally recognized multi-disciplinary academic centre. CESEI offers conditions for effective teaching using innovative and highly interactive technology. A controlled and fully equipped emergency environment was simulated at CESEI, using advanced human patient simulators to allow the implementation of the SBAR-based communication protocol during the ER patient handover. 2.2.2 Participants Following Ethics Board approval, 47 participants were recruited from the 3rd year medical class at the University of British Columbia (UBC) to participate in the study. Inclusion criteria included: undergraduate third-year level of study; familiarity with the principles of acute management and resuscitation essential for the ER setting. While all students participated in the simulation course as a part of their academic day, only students who consented to be study- participants were included in the study. Eight teams of six participants each were formed through random assignment. One student was absent on the day of the simulation course. The students were asked to participate in the simulation training and complete the questionnaire. Although all 22  students participated in the simulation, only half of the students had a chance to communicate patient handover information while performing the role of the team leader, while the rest of the team observed the handover communication. The students were informed that the questionnaire, with no identifiers (neither individuals nor teams), would be used to assess the usability of the SBAR-based communication protocol utilized during the patient handover.  2.2.3 Instruments and Variables The usability of the SBAR-based communication protocol was measured with a questionnaire requiring participants to rate different usability characteristics. The usability characteristics were defined based on the literature and previously used usability evaluation methods (Quesenbery, 2001; Sauro, 2011). There are a variety of usability evaluation methods, with the majority being used to evaluate technology (Hom, 1998). We adapted a method based on the previously utilized “Usefulness, Satisfaction and Ease of Use” (USE) where “Ease of Learning” or “Learnability” defines how easy it is for users to become familiar with the protocol and learn its design; “Ease of Use” defines how quickly the users can implement the protocol; “Usefulness” is users’ ability to perform their job while utilizing the protocol; and “Satisfaction” defines how pleasant is it to use the design. The adapted “Usability Questionnaire” consisted of four categories: Ease of Learning, Ease of Use, Usefulness, and Satisfaction (Appendix D). Each category included items collected from previous internal studies, literature and focus group discussions with ER personnel. Each item formed a question, allowing students’ responses on a five point scale, where “1” is strongly disagree and “5” is strongly agree. Overall, there are twenty five questions/ constructs in the questionnaire. Ease of Learning questions address how quickly the protocol can be learned, memorized, and how easy it is to become skillful with it. Ease of Use questions target participants’ ability to apply the protocol to different situations and 23  reveal any inconsistencies. Usefulness indicates how practical the protocol is in assisting with patient management and handover, as well as helping to accomplish the tasks faster and easier. The Satisfaction questions indicate if the protocol can be used as a tool to promote effective communication through the ability to “speak up”, and structuring the verbal reports. 2.2.4 Procedures Third year medical students at the University of British Columbia were invited to attend the simulation course as a part of their academic half-day during the general surgery clerkship. One week before the actual simulation, the students were provided with online access to the educational module and asked to complete it in order to become familiar with the SBAR-based communication protocol. After the completion of the online module, the students were randomly assigned into four teams. Each team included six students. On the assigned day the students rotated through four simulation stations: Musculoskeletal injury; Head and Spine injury; Chest injury and Abdominal injury. The students were asked to manage the simulated patients as a team. At the end of each simulation, team leaders were expected to handover the patient information to the instructor utilizing the SBAR-based communication protocol, while the rest of the team observed the handover. At the end of the simulation course, all students completed the questionnaire to assess the usability of the communication protocol. 2.2.5 Analyses Responses to each question were summarized by the percentage of choices of each response option (five options - from strongly disagree (1) to strongly agree (5)). In addition, we calculated the combined “agree” and “strongly agree” percentages as an index of favorable responses for each item.  24  2.3 Future Effectiveness Study.  The design of the future study was created in order to assess the usability and the effect of the SBAR-based communication protocol on completeness and accuracy of patient information transferred during ER patient handover between members of different professional groups. A future study with nonequivalent groups and a post-test-only design will be discussed in this chapter.  2.3.1 Design and Educational/Physical Context of the Simulation 2.3.1.1.1 Simulated ER Environment For the purpose of this study, the entire process of the ER patient handover will be recreated using advanced human patient technology at CESEI (for more information refer to Chapter 2.2.4). 2.3.1.2 Simulators The portable human patient simulators (METI Man and Laerdal 3G) previously utilized for the protocol usability evaluation amongst 3rd year medical students will be used to simulate patient handover in the dynamic and time-sensitive mode of the ER (for more information refer to Chapter 2.2.2). 2.3.1.3 Scenarios Two clinical scenarios will be used to simulate patient handover in the ER: Acute Coronary Syndrome (ACS) and Ischemic Stroke (Stroke), selected for the following reasons: 1) high frequency in ED; 2) arrival to ED by ambulance; and 3) significant impact of pre-hospital information on outcomes (Carter et al., 2009; Rajajee & Saver, 2005). Each clinical scenario will be simulated using a constructive simulation scenario development template (Appendix C). Each scenario, ACS (Appendix E) and Stroke (Appendix F), will consist of three phases to allow three 25  points of information collection (during the “Initial Assessment”, “Case Progression” and the “Final Handover”) and two information transfer points (“Ambulance-to-ER Nurse” and “ER Nurse-to-ER Physician”). Each phase in the scenario will represent the conditions of the simulated patient at the given moment, and serve as a source of the information elements that are expected to be collected and communicated by the participants during the patient handover.  The ACS scenario simulates a 60-year-old male, Mr. C, who was brought to the ER by ambulance. Mr. C presents with a history of two hours of retrosternal chest pain and difficulty breathing. He never experienced a similar pain previously. He has a history of hypertension and hypercholesterolemia. During the “Initial Assessment” phase, simulated patient Mr. C will present with the symptoms of acute myocardial infarction. The symptoms will get progressively worse, developing cardiogenic shock in the “Case Progression” phase. The “Final Handover” phase requires patient’s transfer to cardiac catheterization laboratory for final management and treatment. The Stroke scenario will simulate a 66-year-old male, Mr. S, who was brought to the ER by ambulance. Mr. S complains of a generalized headache that became worse two hours ago. Patient also complains of blurred vision, numbness over the left side of the face, difficulties moving left arm, nausea and dizziness. During the “Initial Assessment” phase, simulated patient Mr. S, will present with the symptoms of ischemic stroke. The initial management will continue into “Case Progression”. The “Final Handover” will require a neurology consult for final management and treatment. 2.3.2 Participants Following Ethics Board approval, participants will be recruited from volunteers representing three professional groups (ambulance personnel, ER Nurses and ER Physicians). 26  These professional groups are usually involved in ER patient handover and represent the EMS. One representative from each professional group will be invited to form EMS teams and participate in the simulated ER patient handover. For the purpose of sample size calculation, the literature on similar measures was reviewed. We found that for a set of 16 information elements, 10.21 are transferred on average with a standard deviation of 3.5 (Talbot & Bleetman, 2007). Assuming an effect size of 1(that is 3.5 elements or 21% out of the 16 items) and an alpha level of 0.05, we found that 10 teams are needed in each condition (control and study), in order to reach a power of 0.70 of the independent samples comparisons (Cohen, 1969). Twenty representatives from each professional group will be chosen. In order to form 20 EMS teams, one representative from each professional group will be randomly assigned into the EMS team. Overall, 60 participants (20 ambulance providers, 20 ER Nurses and 20 ER Physicians), meeting eligibility criteria, will be recruited and included in the study upon their consent. The participants will be expected to meet the following inclusion criteria: 1) experience working in the EMS; 2) currently practicing as healthcare providers; 3) fluent English. Each EMS team will be randomly assigned into one of the two conditions: Study Group (Group A) consisted of 10 EMS teams expected to utilize the SBAR-based communication protocol; and Control Group (Group B), consisted of 10 EMS teams not utilizing the protocol. 2.3.3 Instruments and Variables The effect of the SBAR-based communication protocol on the completeness and accuracy of patient information transferred during ER handover was evaluated on the basis of checklists developed specifically for the purpose of this study. Each checklist consists of case-specific information elements that are important to convey during the clinical situation. The information 27  elements were defined based on literature review (Arbabi et al., 2004; Carter et al., 2009; Gropen et al., 2006) and the interviews with EMS providers, representing different professional groups; and composed into checklists specific to either ACS scenario (Appendix G) or Stroke scenario (Appendix H). There are 28 elements in each checklist. The elements are organized, according to the SBAR format, into four categories (Situation, Background, Assessment and Recommendation): nine elements under “Situation”; sixteen elements under “Background”; two elements under “Assessment” and one element under “Recommendation”. The checklists will serve as the “gold standard” for the information elements that need to be transferred between healthcare providers during the handover. Two experimenters blinded to the group-membership will collect information elements while observing the simulated patient handover within the EMS teams. The elements will be collected from two information transfers. To ensure that all elements have been collected, the simulated handovers will be audio/video recorded using the advanced automated audio-recording system that clearly captures everyone talking in the room and is capable of exporting the recorded information to multiple formats for analyses. The sources mentioned above will yield a list of information elements communicated during each information transfer. This list will be compared against the gold standard. The completeness measure was calculated as the percent of all recalled elements. For accuracy, the list of the elements communicated at each transfer will be compared against the gold standard on whether the information was recalled correctly (1) or not (0). The accuracy measure was calculated as the percent of correctly recalled elements. The usability of the SBAR-based communication protocol will be measured with the “Usability Questionnaire” previously utilized during the simulation study with the 3rd year 28  medical students. (Please refer to Chapter 2.2.3 for the details on the instrument development and application).   2.3.4 Procedures In order to study the effect of the SBAR-based communication protocol on the completeness and accuracy of the information transferred between healthcare providers, the participants previously assigned into two groups are asked to participate in the simulated patient handover as the EMS teams. Group A participants will be expected to complete the online educational module to become familiar with the SBAR-based communication protocol. Group B participants will not be aware of the protocol during the study period. After completing the study, Group B participants will also be offered the opportunity to learn the SBAR-based communication protocol.  On the assigned day, participants are expected to complete the two simulated patient handovers, ACS and Stroke. The order of the simulation scenarios will be randomized. Participants from each EMS team will be expected to act as they presently do in the similar life-situations, accordingly to their duties and responsibilities. During the simulation the participants will be asked to manage the simulated patient and convey the important patient information between team members at each output point (“Ambulance-to-ER Nurse” and “ER Nurse-to-ER Physician”). Group A participants will be expected to utilize the SBAR-based communication protocol while transferring the patient information. Two observers will be collecting the information elements communicated by the participants at each transfer using the checklists. At the end of the simulated handover the participants will be asked to complete the Usability Questionnaire to assess ease of learning; ease of use; usefulness; and satisfaction of the SBAR-based communication protocol. 29  2.3.5 Analyses Usability results will be summarized and described by the frequencies of choosing each response option and the percentage of favorable ratings (combined “agree” and “strongly agree” responses on the 5-point, strongly disagree – strongly agree scale).   We will seek evidence of effectiveness by comparing the performance of the experimental and control groups in the context of two-way within-between analyses of variance for each of the dependent variables (completeness and accuracy). Group membership will be the between-factor (experimental vs. control), and transfer (padamedic to nurse vs. nurse to physician) as the within-factor. 30  Chapter 3: Results 3.1 Results of Usability Study A two-way t-test was conducted to compare how the usability items were rated by the students, who verbalized the handover information by using the SBAR protocol (team leaders) and students, who just observed the handover (observers). Means ranged from 3.92 to 4.33 for team leaders and between 3.82 and 4.14 for observers on “ease of learning” items. For “ease of use” items, the ranges were 3.60 – 4.28 and 3.68 -4.00, for leaders and observers, respectively. Item-means for “usefulness” ranged between 3.72 and 3.92 for leaders, and 3.67 and 3.86 for observers. For “satisfaction” items, the ranges were 3.58 – 4.04 and 3.86 -4.09. There were no statistically significant differences between the two groups on any of the individual items or scale-combinations of items. Students found the protocol easy to learn (91%, M=4.23, SD=0.60) and easy to memorize (89%, M=4.13, SD=0.65) (Table 1). Table 1 Ease of Learning Category  Ease of learning   Percent choice of response-options  % N 1 2 3 4 5 I learned to use the protocol quickly 47 0 0 9 60 32 91 I easily remember how to use the protocol 47 0 2 9 64 26 89 It is easy to learn to use it 46 0 2 2 67 28 96 I can use the protocol without written instructions 46 0 2 7 70 22 91 I quickly became skillful with it 47 0 4 15 70 11 81  The students found that the protocol was easy to use (85%, M=4.09, SD=0.75), however, they gave less favorable ratings to the flexibility of the protocol to adjust to different clinical 31  situations (72%, M=3.74, SD=0.64) and to be used successfully in any situation (68%, M=3.68, SD=0.69) (Table 2). Table 2 Ease of Use Category  Ease of use   Percent choice of response-options  % N 1 2 3 4 5 The protocol is easy to use 47 0 4 11 57 28 85 The protocol is simple to use 47 0 4 6 60 30 89 The protocol is easily adjusted to different clinical situations 47 0 4 23 66 6 72 I don't notice any inconsistencies as I use it 47 0 4 19 72 4 77 Both occasional and regular users would like it 47 0 2 19 70 9 79 I can use the protocol successfully every time 47 0 6 26 62 6 68  The majority of the students (87%) found the SBAR-based communication protocol useful during the patient handover, as it helped them to be more effective and productive with patients’ management; gave more control over communication; made things easier to get done and saved time (Table 3). Table 3 Usefulness Category  Usefulness   Percent choice of response-options  % N 1 2 3 4 5 The protocol helps me be more effective with patient management 47 0 4 19 74 2 77 The protocol helps me be more productive with patient management 47 0 4 23 70 2 72 The protocol is useful during the patient handover 47 0 2 11 83 4 87 The protocol gives me more control over the communication during the patient handover 45 0 2 18 73 7 80 The use of protocol makes the things I want to accomplish easier to get done 46 0 2 20 78 0 78 The protocol saves me time when I use it 46 0 2 17 78 2 80 The protocol meets my needs 46 0 2 17 78 2 80  32  Overall, the students were satisfied using the protocol (83%, M=3.96, SD=0.63), as it helps structuring the verbal report (89%, M=4.07, SD=0.53); promotes common language amongst team members (85%, M=3.98, SD=0.54); and decreases confusion during communication (85%, M=3.93, SD=0.65) (Table 4). Table 4 Satisfaction Category  Satisfaction   Percent choice of response-options  % N 1 2 3 4 5 The protocol helped me to be open minded when listening to the recommendations 46 0 1 14 28 3 67 The protocol helped me to “speak up” 46 0 2 9 31 4 76 The protocol decreases confusions during the communication 46 0 2 5 33 6 85 The protocol helps structuring the verbal report 46 0 0 5 33 8 89 The protocol promotes common language amongst team members 46 0 0 7 33 6 85 The protocol works the way I want it to work 46 0 1 9 30 6 78 I am satisfied with the protocol 46 0 1 7 31 7 83 3.2 Expected Results of Effectiveness Study We expect some deterioration in the completeness and accuracy of information between transfers, and that the degree of the deterioration will be significantly greater in the control group. We believe that use of the SBAR-based communication protocol will help preserve the essential information elements during transfers, creating a framework to organize and communicate the available information.  We also expect that the protocol will be well-received by EMS health professionals due to its ease of learning, simplicity in implementation, and usefulness during the handovers. 33  3.2.1 Interpretation Framework of Effectiveness Study According to the literature, only 53% of all information that is expected to be transferred is completely recalled, with accuracy at about 36%. The effect of the SBAR-based communication protocol can be considered significant if we achieve at least 75% in completeness and accuracy. In other words, a 22% increase in completeness and 39% increase in accuracy.  34  Chapter 4: Discussion and Conclusion The overall goal of this project was to improve Emergency Department (ER) patient handover process, specifically information transfer and interprofessional communication between healthcare providers. A standardization method was selected to improve the completeness and accuracy of the transferred information (Catchpole et al., 2007; Manser & Foster, 2011; McFetridge et. al., 2007; Riesenberg et al., 2009; Ye et al., 2007). Amongst all existing protocols for communication standardization, the SBAR (Situation, Background, Assessment and Recommendation) technique was found to be useful in various settings, including the ER (Reisenberg et al., 2009). Previous implementations of SBAR have relied on subjective assessment of effectiveness and have been often limited to a single professional group (Tews et al., 2012; Woodhall et al., 2008).  Three specific objectives guided the work of this project. The first objective was to modify the SBAR technique in order to adapt it to the interprofessional ER setting. SBAR is a flexible mnemonic approach that organizes the information into categories and defines the order in which the information should be communicated. The overwhelming amount of information being transferred during ER handovers requires more detailed organization and specification of what needs to be transferred under each category. The need to modify and adapt the SBAR to specific settings has also been demonstrated in a project conducted by Boaro et al. (2010) who implemented the SBAR technique in rehabilitation and complex continuing care setting.  Previous implementations of SBAR proved the importance of training on how to use the technique prior to its utilization (Beckett & Kipnis, 2009; Boaro et al., 2010). In this project, the electronic Platform for Education and Research (e-PER) template was used to develop online curriculum for the purposes of familiarization with the protocol (Garett & Van der Wal, 2007; 35  Vanderhoeven et al., 2007). e-PER allows individual and time-flexible access, and provides the opportunity to track participants’ activity level.    Field observations in the ER and group interviews with emergency medical service (EMS) providers, representing different professional groups, were conducted in order to specify the information elements that are expected to be communicated within each category of SBAR. In addition, we tried to create a protocol that can be used by different professions in various clinical situations. Therefore, the elements were not case-specific and included more general information (e.g. patient’s age, vital signs, results of physical exam, etc.). The defined information elements were organized into the four categories forming the “SBAR-based communication protocol”.  The second objective was to conduct a study on how the modified SBAR protocol is perceived by students (Usability Study). Usability was considered an important parameter to study. The importance of studying usability has been emphasized by the International Organization for Standardization (1998): the ability to learn the protocol, memorize it and easily implement it plays an important role and might compromise the effect of the protocol on the quality of the transferred information. It also defines the extent to which the protocol can be used by healthcare providers from different professional groups. Previous studies of SBAR implementations have lacked a proper usability assessment or have limited its assessment to one or two usability aspects (Tews et al., 2012; Woodhall et al., 2008).  For the purpose of the Usability Study, patient handover was simulated using advanced human patient simulation technology (METI Man, Laerdal 3G and Laerdal Essential). Simulation has been proven a useful educational and research tool, especially to mimic the intense and highly dynamic environment of the ER (Bradley & Postlethwaite, 2003; Moorthy et 36  al., 2005; Qayumi, 2006; Ziv et al., 2003). Forty seven third year medical students formed eight teams and participated in the simulated patient handover. Upon completion of the simulation, students evaluated how easy the SBAR protocol was to learn, use, and the extent to which it was useful and satisfactory. The homogeneous sample from the 3rd year medical school students can be seen as an important feature of the study, as it helped to diminish the differences in students’ protocol perceptions, which might be related to their prior knowledge and experience with the material. In addition, in finding no difference in the perceptions of the protocol between students who verbalized the handover and the students who just observed, we demonstrated that the protocol is readily acceptable and simple to use. The protocol structures the information verbalized by the message senders, as well as the information processed by the message receivers, as it prompts the latter to ask for information that is missing. Students found the protocol easy to learn (91% agreed or strongly agreed); simple to implement (85%); and useful during the handover (87%). The students were satisfied with the protocol (83%), as it helps structuring the verbal report (89%). The protocol was found to promote common language amongst team members (85%); and decreases confusion during the communication (85%). Overall, the results of the Usability Study indicated students’ favorable perception of the protocol usability, including ease of learning, implementation and satisfaction.   The third objective was to design an experimental study to assess the effect of the SBAR-based communication protocol on completeness and accuracy of the patient information transferred during ER patient handover between members of different professional groups (Effectiveness Study). An Effectiveness Study is a necessary step for objective evaluation of the SBAR protocol and would add to the evidence of information transfer optimization. Different criteria can be used to assess the effectiveness: time to treatment, time to final diagnosis, time to 37  transfer, completeness of the transferred information, and accuracy of the transferred information. Time to treatment, time to final diagnosis and time to transfer (Carter et al., 2009; Rajajee & Saver, 2005) are outcome-based measure that should be assessed in a real clinical environment. The latter might compromise patient safety as a result of the new protocol implementation. Assessing completeness and accuracy of the transferred information, on the other hand, requires standardization of the checklist for the clinical context or situation, which is impossible to achieve due to the variety of the clinical situations in the ER. Both conditions, patient safety and standardization of clinical situations, can be achieved in the simulated setting only. Therefore, information completeness and accuracy were selected as the criteria to evaluate the effectiveness of the SBAR-based communication protocol in a simulated ER setting (Carter et al., 2009; Scott et al., 2003; Stiell et al., 2003; Talbot et al., 2007). For the purpose of the Effectiveness Study, two clinical simulation scenarios with detailed case-specific checklists for both scenarios were developed and tested. Another important feature of the Effectiveness Study is the involvement of healthcare professionals representing real EMS personnel (ambulance, ER Nurses, ER Physicians). Participants from different groups will be expected to assess and manage simulated patients, and utilize the modified SBAR protocol during patient handover.  Nonequivalent groups post-test-only design was developed to assess the effect of the SBAR protocol on completeness and accuracy of information transferred during ER patient handovers. This design of the future Effectiveness Study would allow for assessing differences in the completeness and accuracy of transferred information between teams utilizing the modified SBAR protocol and teams that are not. The case-specific check lists, developed on the basis of 38  the simulation scenarios used in this study, would help precisely capture and easily quantify the transferred information elements and their accuracy.  We expect that the use of the SBAR-based communication protocol will help optimize the transfer of patient information by improving its completeness and accuracy. We also expect that the protocol will be well-perceived by EMS health professionals for its being easy to learn and simple to implement. 4.1 Future Plans In the long-term, the usability and effect of the SBAR-based communication protocol should be tested in a real clinical environment. This might be more difficult to accomplish due to the complexity of the ER and the involvement of seriously ill patients.   4.2 Limitations This project also has limitations that might prevent researchers from replicating similar results in real-life settings.  First, the simulation environment used for the Usability and Effectiveness studies to mimic a real ER setting might compromise the ecological validity of the studies. The simulated patients may not adequately recreate the actual handover experience. Although the simulators are capable of mimicking the real experience, there are some aspects of simulation that make it artificial and less realistic. In particular, the stress levels that are increased by crowdedness, multiple admissions, large workloads and long working hours in real life might be different in simulation settings, affecting the usability of the protocol. Second, the usability of the protocol was evaluated by medical students who might not be able to recognize the challenges faced in real ER setting. This might be related to the lack of their clinical experience, knowledge gaps, and communication ability.  39  The Effectiveness Study can address the limitations of the Usability Study by involving healthcare professionals representing real EMS services (ambulance personnel, ER Nurses and ER Physicians). However, there are other professions in the chain of communication who deal with ER patients (dispatchers, triage nurses, accepting floor nurses and specialists) and who could not be included in this study due to recruitment challenges. In addition, the post-test only design won’t allow us to detect any baseline differences between participants. The possibility of assessing participants’ knowledge in a pre-test should be considered. Another significant limitation is imposed by the recruitment of volunteers. It has been previously shown that volunteers have certain characteristics that can make a difference, especially in research involving communication and teamwork (Rosenthal & Rosnow, 1975). Volunteers tend to be better educated, more sociable and less authoritarian than non-volunteers. Therefore, we might expect better communication and teamwork with our volunteer participants in comparison to the real-life experience. Furthermore, there will be only two clinical scenarios simulated during the Effectiveness Study, limiting the generalizability of the results over different clinical conditions. This can be addressed by future studies involving different clinical situations. 4.3 Summary The SBAR-based communication protocol was identified as one of the ways to optimize the transfer of information during ER patient handovers. The protocol organizes the information into categories and defines the order of the categories during information transfer. For the ER setting, we found that it was important to add more specific information elements under each category in order to minimize differences related to providers’ roles, experience and knowledge. 40  Our usability study findings, along with findings of previous research (Tews et al., 2012; Woodhall et al., 2008), indicate that the SBAR protocol is easy to learn, easy to use and that users generally perceive it as useful for ensuring completeness and accuracy of the transferred patient information. Thus, study participants evaluated the protocol as a tool that promotes effective teamwork environment and reduces differences in roles, experience and knowledge between healthcare providers representing different professional groups.  The Usability study, however, addresses only perceptions of protocol effectiveness. It is not clear if the use of the protocol would help preserve the completeness and accuracy of transferred patient information. To address this question, we created the design and developed data acquisition tools for a simulation-based study of patient handover with key members of the EMS team. The potential findings of the Effectiveness study can help promote interprofessional communication and reduce errors related to poor communication and multiple information transfers. Further studies will be needed however to draw conclusions about the effectiveness of the SBAR-based communication protocol in real clinical settings. 4.4 Conclusions Upon the completion of this project, the following conclusions were made: 1. The SBAR technique was successfully modified and adapted for the interprofessional setting 2. The modified SBAR protocol was perceived as an easy to learn, easy to use and useful 3. Experiemental design for the evaluation of the SBAR protocol effectiveness is complete. 41  References Arbabi, S., Jurkovich, G. J., Wahl, W. L., Franklin, G. A., Hemmila, M. R., Taheri, P. A., & Maier, R. V. (2004). A comparison of prehospital and hospital data in trauma patients. The Journal of Trauma and Acute Care Surgery, 56(5), 1029-1032. Andreoli, A., Fancott, C., Velji, K., Baker, G. R., Solway, S., Aimone, E., & Tardif, G. (2010). Using SBAR to communicate falls risk and management in inter-professional rehabilitation teams. 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Implementation of the SBAR communication technique in a tertiary center. Journal of Emergency Nursing, 34(4), 314-317. Ye, K., McD Taylor, D., Knott, J. C., Dent, A., & MacBean, C. E. (2007). Handover in the emergency department: deficiencies and adverse effects. Emergency Medicine Australasia, 19(5), 433-441. Ziv, A., Wolpe, P. R., Small, S. D., & Glick, S. (2003). Simulation‐based medical education: an ethical imperative. Academic Medicine, 78(8 49  Appendices Appendix A  SBAR-Based Communication Protocol  S Situation – State what is going on  1. Identify self 2. Identify patient (name, age, gender) 3. Chief Complaints/reason(s) for admission (Mechanism, Injury, Symptoms) 4. Time of Onset 5. Additional complaints B Background 1. What has been done for management so far (Treatment) 2. Vital signs (BP, HR, RR, SpO2, t) 3. Physical Exam is significant for (list the findings): - Neurological deficit - Respiratory status - Cardiovascular status - Gastrointestinal status - Psychiatric status 4. Other relevant History (PMH, FHX, Social, ALL, MEDS) A Assessment:  1. Patient Status/Problem/Issue - Stable/Unstable/may get worse  - The problem seems to be…..                     or -- I am not sure what the problem is but the patient is deteriorating R Reflection (Recommendation): 1. Indicate your management plan or what should be done next 2. State what your concerns are 50  Appendix B  Online Module “SBAR-Based Communication Protocol” 51  Appendix C  Constructive Simulation (Scenario Development Template)  52   53  Appendix D  Usability Questionnaire for SBAR-Based Communication Protocol  54  Appendix E  Acute Coronary Syndrome (ACS) Scenario  55    56    57  Appendix F  Ischemic Stroke (Stroke) Scenario  58    59    60  Appendix G  ACS Checklist  61  Appendix H  Stroke Checklist  

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