An evaluation of the effectiveness of integrating an SBAR communication tool in a teaching hospital to improve patient safety in Taiwan
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For ensuring the patient safety without communication errors in hospitals, an effective communication skill within team members has been identified as a key point from literatures. It has also been proven in many occupational fields for crew members to effectively reduce the communication errors in their handoff. Situation-Background-Assessment-Recommendation (SBAR) is one of the most commonly used methods in the health care system. The health care system within a hospital is based on the teamwork provided by physicians, nurses, pharmacists, laboratory scientist, dietitians, and social workers etc… Not to be surprised, the caring quality of patient is the result of working effectiveness of team members and administrators. However, according to the statistic data shown, a lot of human errors happened during the handoff process especially in the field of communication within team members. Therefore the purpose of this study was to analyze the effectiveness of SBAR communication tool (the intervention) adapted in hospital handoff system. The effectiveness of the intervention was evaluated via the reported data (patient safety events, PSEs) to Taiwan Joint Commission on Hospital Accreditation (TJCHA). This data source was chosen as all PSEs that have occurred will be recorded by the TJCHA. A report (Taiwan Patient safety Report, TPSR) will be published annually after PSE have been gathered from participant hospitals nationwide. In this study, we used the quasi experimental design to eliminate the unknown background difference from control and experimental group via pre and post-tests. We also used pair t-test to eliminate health care system change over time elapse. The study period was from year 2006 to 2014, all the outcomes (or PSE), secondary data, obtained from TPSR were published by TJCHA annually. The intervention of this study adapted SBAR protocol to the handoff system in the experimental hospital from year 2010; meanwhile we observed the change of PSEs between control and experimental group. For the PSEs observation, we addressed them according to the TPSR classification. There are thirteen types of PSE to be classified as patient safety indicator (PSI) for the patient caring quality in a hospital. The injury degree in PSI are further classified by six levels such as death, extremely severe, severe, moderate, mild and no harm via severity assessment code (SAC) via root cause analysis (RCA). Two hospitals (the one named as control group without SBAR; the other one named as experimental group with SBAR intervention) conducted in this study were similar in hospital dimension, medical service, and employees. In the control group, there were 522 medical staffs including 114 clinicians and 310 nurses etc. to provide medical services. There were a total of 443 beds including 314 general beds and 129 special beds in this hospital. Seventeen specialties provided outpatient, inpatient, and emergency service which serviced a patient count of 514871, 11992, and 28325 patient/year respectively. In contrast to the control group, the experimental group adapted SBAR protocol since year 2010 and there were 543 staff providing medical services including 118 clinicians and 321 nurses etc. The experimental group owned 459 beds including 333 general beds and 126 special beds. Fifteen specialties provided outpatient, inpatient and emergency service which serviced a patient count of 445340, 10471, and 25733 patients/year respectively. We also used the nationwide data (TPSR dataset) to serve as a reference group for eliminating the bias from health management policy, health insurance payment, and hospital accreditation etc. In the control group, the initial PSEs were 110 events in 2006, and by the end of 2014, the final PSE increased up to 305 events, approximately a three times increase comparing to the initial year. In the experimental group, the PSEs also showed an increase from 100 events to 130 events in year 2006 to 2014. In the reference group (TPSR system), the PSEs increased from 8,176 to 60,559 events since year 2006 to 2014. Regarding the effectiveness analysis of SBAR in handoff system, student t-test and general estimation equation (GEE) was used to analyze the pre (year 2009) and post-test (year 2010, 2012, 2014) of control and experimental group. In 2009 and 2010 year, no significant difference was shown between the experimental and control group. After the implementation of SBAR in three and five years later, the PSIs showed a significant difference between the two groups. The experimental group have a decrease of 9 and 14.58 PSEs comparing to the control group on year 2012 and 2014 respectively. If we look at the change in experimental group independently, we found a significant difference between year 2009 and 2014, where the PSEs in the experimental group was significantly increased (p <0.05), meaning that the PSE increased over time. However, many causes such as policy requirement, hospital accreditation and health insurance payment can be the culprit of this increase than before. In contrast, the control group also showed a significant escalating trend over these years. However, via our analysis, the implementation of SBAR did effectively reduced the PSEs albeit the there was an increase in the total number of PSEs. The GEE test also showed the same results to the effectiveness by SBAR in the reduction of PSEs. Furthermore we analyzed the individual PSI affected by the intervention of SBAR. The results reveal the most effective reduction on PSEs were drug-related incidents (PSI 1), followed by falling incidents (PSI 2) and endo-tube incidents (PSI 9). If only communication error was placed into consideration, the endo-tube incidents and injurious behaviors were significantly reduced after year 2010. Lastly, we performed a study evaluating the harm level on patient injury by SAC. Compared to the control group, the experimental group showed that the injury degree induced by patient events falls mainly between the level of mild to moderate (lighter injury), occupying approximately 40% of the total events. Suggesting that through the intervention of SBAR tools, when events affect patient safety occurs, the harm level were limited and were not as evident Based on our results and finding, the intervention significantly improved the patient’s health and safety, but more time is required to verify the time series effectiveness. Therefore, we suggest that SBAR can bring a better patient safety environment, but requires time to develop and adapt. The alteration in communication processes is a re-learning procedure and thus a continuous education as well as training courses provided to the staff is necessary in the management of health care system. Introducing of SBAR to the handoff system is a critical and valuable method for improving patient’s health care quality.