Improving Communication in Nursing Homes Using Plan-Do-Study-Act Cycles of an SBAR Training Program

Abstract

Background

Incomplete communication between staff and providers may cause adverse outcomes for nursing home residents. The Situation-Background-Assessment-Recommendation (SBAR) tool is designed to improve communication around changes in condition (CIC). An adapted SBAR was developed for the Centers for Medicare and Medicaid Services demonstration project, OPTIMISTIC, to increase its use during a resident CIC and to improve documentation.

Methods

Four Plan-Do-Study-Act (PDSA) cycles to develop and refine successive protocol implementation of the OPTIMISTIC SBAR were deployed in four Indiana nursing homes. Use of SBAR, documentation quality, and participant surveys were assessed pre- and post-intervention implementation.

Results

OPTIMISTIC SBAR use and documentation quality improved in three of the four buildings. Participants reported improved collaboration between nurses and providers after SBAR intervention.

Conclusion

Successive PDSA cycles implementing changes in an OPTIMISTIC SBAR protocol for resident CIC led to an increase in SBAR use, improved documentation, and better collaboration between nursing staff and providers.

Keywords

SBAR PDSA nursing home quality improvement

What this paper adds

• Iterative PDSA cycles can improve implementation of SBAR into nursing home clinical care routines

• Targeted nurse training increases adherence of SBAR tool use to assess and communicate about resident changes in condition

• SBAR use enhances communication and collaboration between nursing home providers and nursing staff

Applications of study findings

• Use of SBAR tool in nursing homes to streamline communication during a resident change in condition

• SBAR implementation improves documentation in nursing homes

• Nurse champions are instrumental in promoting nursing home SBAR use

Introduction

Avoidable Hospitalizations

Up to half of Emergency Department (ED) transfers of nursing home residents are potentially unnecessary and often lead to subsequent hospitalizations (Burke et al., 2015). To address risks associated with unnecessary hospitalizations for nursing home residents, the Centers for Medicare and Medicaid Services (CMS) launched the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents in 2012 (CMS, 2016). Associated programs were implemented in seven states and all the clinical demonstration projects were tasked with reducing potentially avoidable hospital transfers of nursing home residents enrolled at their sites (CMS, 2016; Ingber et al., 2017). All sites were instructed in the use of tools from the Interventions to Reduce Acute Care Transfers, or INTERACT, a program developed to reduce nursing home resident transfers (Ingber et al., 2017; Ouslander et al., 2014; Unroe et al., 2015). The Optimizing Patient Transfers, Impacting Medical quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) is the Indiana-based site of the national demonstration project and successfully reduced hospitalizations of long-stay residents (>100 days in the facility) by evaluating and targeting causes of hospital transfers (Blackburn et al., 2020; Ingber et al., 2017; Unroe et al., 2015). The OPTIMISTIC model has embedded geriatric and palliative care trained registered nurses and nurse practitioners who assist nursing facility staff in improving early recognition of condition changes, transitions to and from the hospital, and advanced care planning (Hickman et al., 2020; Unroe et al., 2015, 2018). Phase I of the project (2012–2016) evaluated avoidable hospitalizations in 19 central Indiana nursing facilities; Phase II (2016–2020) added Medicare billing codes to reimburse for care of acutely ill residents in 40 nursing facilities throughout Indiana (Hickman et al., 2020; Unroe et al., 2018).

According to Ouslander et al., 67% of hospital transfers of nursing home residents were probably or definitely avoidable (Ouslander et al., 2010). Transfers may be considered avoidable if the clinical condition triggering the patient transfer can be managed safely in the nursing home care setting (McAndrew et al., 2016). Some commonly included conditions are pneumonia, congestive heart failure, urinary tract infections, and chronic obstructive lung disease among others and account for up to 78% of potentially avoidable hospitalizations of nursing home residents (Muench et al., 2019; Walsh et al., 2012). Unnecessary hospital transfers can adversely impact nursing home resident outcomes because they increase risk of delirium, falls, and pressure ulcers; lead to functional decline; decrease quality of life; and increase mortality (Dwyer et al., 2014; Hwang & Morrison, 2007; Wang et al., 2011). ED visits even without hospital admission can cause adverse events such as unnecessary testing, invasive procedures, new infections, and administration of potentially inappropriate medications (Budnitz et al., 2011; Burke et al., 2015; Quach et al., 2012; Wang et al., 2011; Beers criteria).

Communication about Hospital Transfers

Poor communication is a common barrier to quality care (Ingber et al., 2017; Ouslander et al., 2010; Young et al., 2010; Young et al., 2011). High rates of hospital transfers from nursing facilities are attributed to inadequate ability to quickly obtain resident medical record information by physicians, little financial incentive to keep residents in facilities, and poor communication between nurses and physicians (Kane et al., 2017; Mor et al., 2010; Young et al., 2010). High staff turnover rates, averaging 140% for registered nurses and 129% for certified nursing assistants, led to increased hospitalizations due to unfamiliarity with facility residents and policies (Gandhi, Huizi, & Grabowski, 2021). Decisions about next steps when there is an acute change in condition are often made over the phone with covering physicians whom may not know the resident in question. Hospital transfers ordered by covering physicians as opposed to the primary physician have been associated with preventable hospitalizations (Ouslander et al., 2016). In addition to communication barriers, lack of adequate bedside assessments, superficial knowledge of a patient’s medical history, time constraints, and feeling hurried by the physician all contribute to potentially avoidable hospital transfers (Renz et al., 2013; Tjia et al., 2009; Young et al., 2010). Facility staffs play a pivotal part in assessing and informing providers about residents when there is possible need for hospital transfer (O’Neil, Dwyer, Reid-Searl, & Parkingson, 2018). Therefore, clear and effective communication is crucial to providing the best care for nursing home residents.

Intro to SBAR/SBAR History

The SBAR (Situation-Background-Assessment-Recommendation) is a standardized tool intended to help improve clinical communication and empower nurses to make recommendations based on assessments and patient background. Initially developed by the US military, SBAR has become a staple of nursing education (Lim and Pajarillo, 2016; Joint Commission https://e-handoff.com/wp-content/uploads/2017/09/Joint-Commision-Handoff-Communication-Alert.pdf). Because communication is an important deficiency, SBAR use has been adopted in investigations of patient safety and has led to a reduction of safety incidents in surgical, obstetric, and ICU settings (Leonard et al., 2004; Narayan, 2013). In other clinical settings, SBAR provides a standardized protocol for communication, allowing critical patient information to be conveyed in an organized and consistent manner (Leonard et al., 2004; McFerran et al., 2005; Velji et al., 2008).

Situation-Background-Assessment-Recommendation-Related Studies

Given its use, the SBAR tool has now been adopted by numerous healthcare organizations to improve structured communication. The tool has been used to bolster both intra- and inter-disciplinary communication (Achrekar et al., 2016; Demeester, Verspuy, Monsieurs, & Van Bogaert, 2013; Field et al., 2011; Leonard et al., 2004). Results have shown improvement in patient outcomes for anticoagulant drug monitoring (Field et al., 2011), reduction in hospital readmissions (Kane et al., 2017; Leonard et al., 2004), decline in unexpected deaths in the hospital setting (Demeester, Verspuy, Monsieurs, & Van Bogaert, 2013), improvement in hospital hand hygiene (McLean et al., 2017), and increased protocol adherence (Harrison & Lyerla, 2012). In a large study of over 230 nursing facilities, 95% reported a new policy or procedure to implement a standardized communication tool with SBAR being the second most common quality improvement intervention (Daras et al., 2017).

The INTERACT program developed a version of the SBAR for changes in condition in nursing homes (Ouslander et al., 2014). INTERACT’s four-page SBAR served as a model for the two-page OPTIMISTIC SBAR that was developed in 2017 for use by the project staff to facilitate communication during a resident change in condition (Appendix 1).

Research that examines the implementation and effect of SBAR use in long-term care facilities is limited. Thus, the primary goal of this study was to implement a program to determine the efficacy of Plan-Do-Study-Act (PDSA) cycles in improving utilization of the OPTIMISTIC SBAR when there is a resident change in condition through structured and targeted training. The secondary goal was to improve nursing documentation.

Methods

Design

Optimistic SBAR

This was a prospective quality improvement project embedded within a CMS demonstration project. The OPTIMISTIC SBAR (Appendix 1) was designed to be an efficient paper-based tool used in real-time to facilitate data collection and communication between nursing staff and providers when a resident is experiencing a change in condition. The two-page document consists of four standardized sections: Situation (resident name, age, symptom), Background (resident medical history, allergies, code status), Assessment (vital signs, pertinent physical exam, review of systems), and Review/Recommendations (final decision to keep the resident in house or send to the hospital, additional orders).

Participants

Study participants consisted of facility staff including the following: Certified Nursing Assistants (CNAs), Licensed Practice Nurses (LPNs), Registered Nurses (RNs), Nurse Practitioners (NPs), and physicians. Participants were recruited in the facility and all on a voluntary basis. Verbal consent was obtained from all participants. Information on nursing facility residents was taken from the Minimum Data Set information obtained closest to the intervention period at each facility.

Setting

Focused SBAR training was implemented at four OPTIMISTIC nursing facilities in central Indiana, referred to as Buildings A, B, C, and D through a series of Plan-Do-Study-Act, or PDSA, cycles. The cycles occurred at successive buildings over a total of 22 months. Training on SBAR use was initiated at Building A in May 2017. SBAR training at Building B started in November 2017 and data was collected through February 2018. Training at Buildings C and D began in October 2018 and data collection occurred until March 2019. (Figure 1) Data on change in condition events for nursing facility residents was collected and analyzed regularly for SBAR use, SBAR documentation, and electronic medical record (EMR) documentation for buildings B–D. No information on change in condition, SBAR completion percentage, SBAR scoring, or EMR scoring pre- and post-pilot was collected in Building A.

Figure 1.

SBAR Cycles Timeline.

The included facilities were buildings that had OPTIMISTIC project nurses embedded in the facility and where management expressed an interest in participating in the SBAR quality improvement project. At each building, the OPTIMISTIC project nurse trained facility nursing staff on SBAR usage highlighting the SBAR’s utility in facilitating meaningful staff communication. Both formal and informal education were provided, and facility leadership championed the efforts.

Nursing home characteristics were obtained from the Nursing Home Compare Provider Files and the CMS data set. This study was approved by the Institutional Review Board (IRB, 1303010822).

Plan-Do-Study-Act Cycles

This study deployed multiple PDSA cycles to develop and refine implementation of the OPTIMISTIC SBAR in participating nursing homes. The PDSA cycle is a method of quality improvement rooted in the scientific method that incorporates small tests of change with subsequent analysis of the test and modifications to the plan tested (IHI). In order to achieve this, each cycle of the PDSA model utilizes four steps: (1) Plan-develop a procedure to test a change, (2) Do-implement the plan, (3) Study-analyze the results and areas of possible improvement, and (4) Act-make modifications to the plan (Agency for Healthcare Research and Quality). PDSA uses an audit and feedback-type model to allow real-time identification of needed modifications to be applied in the next cycle, (Ivers et al., 2012; McLean et al., 2017). In this study, OPTIMISTIC staff and nursing facility staff examined feedback and SBAR use information collected at each nursing home. Protocols were then updated, iterative feedback was given to the facility staff on SBAR usage, and the study was re-deployed at another facility which served as the next round of the four PDSA cycles as detailed below (Figure 1).

Plan-Do-Study-Act Cycle 1-All Phase I Optimistic Facilities

The first PDSA cycle occurred when the INTERACT SBAR was introduced to project nurses in the entire OPTIMISTIC network of Phase 1 (Figure 1). When OPTIMISTIC was launched, all OPTIMISTIC nurses were trained in use of the INTERACT tools including the INTERACT SBAR. Early during Phase 2, which occurred four years into the program, the OPTIMISTIC SBAR was developed as a condensed two-page tool partially adapted from the INTERACT SBAR. Project nurses were trained in its use to facilitate communication for acute changes in condition occurring within the facility.

Plan-Do-Study-Act Cycle 2-Building A

The second cycle took place when the OPTIMISTIC SBAR was introduced into the electronic medical record of Building A as there was little uptake of the paper version of the tool (Figure 1). SBAR use was mandated in this building. The OPTIMISTIC program nurse served as a resource for facility nurses using the SBAR for communication and provided printed copies of the OPTIMISTIC SBAR for the facility nurses to use in real time during an acute change in resident condition.

Plan-Do-Study-Act Cycle 3-Building B

The third PDSA cycle occurred when Building B implemented a new protocol with the OPTIMISTIC SBAR (Figure 1). After reviewing the Building A roll-out, the decision was made to implement the OPTIMISTIC SBAR in a building without mandated use of an electronic SBAR. Building B nurses were provided paper copies of the OPTIMISTIC SBAR at all wings and nursing stations to facilitate use of the SBAR. Three in-service training sessions were provided to licensed nursing staff; sessions focused on the purpose of the OPTIMISTIC SBAR, introduction of pilot protocol, pilot expectations, and practice case scenarios. One-on-one education was provided for nursing staff after in-services on an as needed basis. Unit reminders were posted at nursing stations with brief educational messages in SBAR use.

Prior to nursing staff education, the OPTIMISTIC nurse trainers at this building graded both use of the OPTIMISTIC SBAR and EMR documentation for resident change in condition using a standardized protocol, referred to as pre-pilot results. The SBAR documentation quality score was based on a standardized ten-point scale developed by the project RN. Point breakdown is as follows: Situation—one point, Background—two points, Vital Signs—two points, Assessment—three points, Orders—two points. EMR documentation scoring was also assessed using a ten-point scale developed by the project RN. The same measures were collected again at week twelve, referred to as post-pilot results. The goal was improvement in SBAR and EMR scores after SBAR protocol implementation as higher scores, closer to ten, implied better documentation. OPTIMISTIC nurses performed all scoring. All SBAR data was collected in a tracking tool.

The reason for change in condition, listed as one of twenty symptom categories, experienced by a resident was also inputted in the tracking tool. This information was collected to assess for trends in conditions prompting further evaluation by providers. However, it was not a main endpoint of the current study. Advanced care providers conducted daily tracking of overall communication progress with nursing staff about changes in condition as well. Weekly meetings were held between OPTIMISTIC RNs and providers to review change in condition communication.

Plan-Do-Study-Act Cycle 4-Buildings C and D

The fourth PDSA cycle occurred with an enhanced protocol launched in Buildings C and D simultaneously (Figure 1). SBAR use and quality, EMR documentation, and category of change in condition were assessed in Buildings C and D at week one (pre-pilot) and week twelve (post-pilot) as was done in Building B. The decision was also made to survey both the nursing staff and providers, which included physicians and nurse practitioners, to gain more insight into communication between the two groups. The surveys were adopted from the Institute for Healthcare Improvement Nurse and Physician Attitudes about Communication and Collaboration surveys (available at http://www.ihi.org/resources/Pages/Tools/SurveysNursePhysicianAttitudesCommunicationCollaboration.aspx). The questions were answered with a Likert scale (Table 3). Overall, higher scores on the surveys indicated better perception of communication and collaboration amongst nurses and practitioners. Pre-pilot surveys were performed prior to nursing staff education and post-pilot surveys were completed twelve weeks later. Both surveys captured facility staff working first and second shifts at survey capture times. Surveys were distributed in person or via email if the participant could not be reached in person.

Results

All Facilities

Nursing facility resident characteristics were obtained from each building (Table 1). In Building A, residents’ average age was 72.5 and most residents were white and female (91.5% and 62.8%, respectively). In Building B, average resident age was 79.3, most were female (60.8%), and a greater majority were black (51.6%). In Building C, mean age was 65.7, more residents were male (53.7%), and most residents were black (73.9%). In Building D, average age was 80.2, most residents were female (68.7%), and the majority of residents were black (53.4%). For all four facilities, most residents were not married, hypertension was the most common chronic medical condition, approximately half had a diagnosis of Alzheimer’s or another type of dementia, and combined Medicare/Medicaid was the typical payer source.

Table 1.

Characteristics of Nursing Facility Residents in Buildings A, B, C, and D.

	Building A (N = 129)	Building B (N = 130)	Building C (N = 121)	Building D (N = 147)	Total (N = 527)
Age at MDS assessment
Mean (SD)	72.5 (15.0)	79.3 (11.5)	65.7 (14.4)	80.2 (11.3)	74.8 (14.3)
Median (Q1, Q3)	74.0 (62.0, 84.0)	81.0 (69.0, 88.0)	66.0 (57.0, 75.0)	82.0 (73.0, 89.0)	76.0 (65.0, 86.0)
Range	28.0–96.0	57.0–105.0	26.0–94.0	49.0–103.0	26.0–105.0
Gender
Male	48 (37.2%)	51 (39.2%)	65 (53.7%)	46 (31.3%)	210 (39.8%)
Female	81 (62.8%)	79 (60.8%)	56 (46.3%)	101 (68.7%)	317 (60.2%)
Race
Hispanic	0 (0.0%)	1 (0.8%)	2 (1.7%)	1 (0.7%)	4 (0.8%)
Black	10 (8.5%)	66 (51.6%)	85 (73.9%)	78 (53.4%)	239 (47.2%)
White	107 (91.5%)	61 (47.7%)	28 (24.3%)	67 (45.9%)	263 (52.0%)
Other	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
N-Miss	12	2	6	1	21
Marital status
Never married	14 (10.9%)	24 (18.5%)	35 (28.9%)	20 (13.6%)	93 (17.6%)
Married	21 (16.3%)	21 (16.2%)	15 (12.4%)	25 (17.0%)	82 (15.6%)
Widowed	24 (18.6%)	56 (43.1%)	15 (12.4%)	56 (38.1%)	151 (28.7%)
Separated	1 (0.8%)	3 (2.3%)	1 (0.8%)	1 (0.7%)	6 (1.1%)
Divorced	17 (13.2%)	26 (20.0%)	24 (19.8%)	27 (18.4%)	94 (17.8%)
Unknown	52 (40.3%)	0 (0.0%)	31 (25.6%)	18 (12.2%)	101 (19.2%)
CHF	24 (18.6%)	26 (20.0%)	18 (14.9%)	32 (21.8%)	100 (19.0%)
COPD	31 (24.0%)	31 (23.8%)	25 (20.7%)	17 (11.6%)	104 (19.7%)
Diabetes	38 (29.5%)	65 (50.0%)	49 (40.5%)	49 (33.3%)	201 (38.1%)
CVA/stroke	1 (0.8%)	10 (7.7%)	36 (29.8%)	10 (6.8%)	57 (10.8%)
Hypertension	98 (76.0%)	101 (77.7%)	81 (66.9%)	109 (74.1%)	389 (73.8%)
Cancer	1 (0.8%)	7 (5.4%)	7 (5.8%)	3 (2.1%)	18 (3.4%)
Depression	11 (8.5%)	66 (50.8%)	46 (38.0%)	50 (34.0%)	173 (32.8%)
Alzheimer’s disease or other dementia	75 (58.1%)	70 (53.8%)	47 (38.8%)	92 (62.6%)	284 (53.9%)
ADL function score
Mean (SD)	18.0 (3.5)	19.0 (4.3)	19.7 (2.5)	19.4 (2.1)	19.1 (3.2)
Median (Q1, Q3)	19.0 (16.0, 21.0)	20.0 (18.0, 21.0)	19.0 (18.0, 21.0)	20.0 (19.0, 21.0)	20.0 (18.0, 21.0)
Range	7.0–21.0	4.0–28.0	12.0–27.0	9.0–23.0	4.0–28.0
**Does the resident have a condition or chronic disease
that may result in a life expectancy of less than 6 months?**
Yes	3 (2.3%)	0 (0.0%)	2 (1.7%)	2 (1.4%)	7 (1.3%)
No	126 (97.7%)	130 (100.0%)	119 (98.3%)	145 (98.6%)	520 (98.7%)
Pay source eligibility
Medicare/Medicaid	96 (74.4%)	111 (85.4%)	85 (70.2%)	102 (69.4%)	394 (74.8%)
Medicaid only	20 (15.5%)	5 (3.8%)	31 (25.6%)	18 (12.2%)	74 (14.0%)
Medicare only	8 (6.2%)	12 (9.2%)	5 (4.1%)	23 (15.6%)	48 (9.1%)
Unknown	4 (3.1%)	0 (0.0%)	0 (0.0%)	4 (2.7%)	8 (1.5%)
Other	1 (0.8%)	2 (1.5%)	0 (0.0%)	0 (0.0%)	3 (0.6%)
Mortality risk score
Mean (SD)	4.0 (2.3)	5.1 (2.4)	3.8 (2.2)	4.4 (1.9)	4.3 (2.2)
Median (Q1, Q3)	4.0 (2.0, 5.0)	5.0 (3.2, 7.0)	4.0 (2.0, 5.0)	4.0 (3.0, 6.0)	4.0 (3.0, 6.0)
Range	1.0–12.0	1.0–15.0	1.0–10.0	1.0–10.0	1.0–15.0
Eligible days in 6 months before SBAR
Mean (SD)	110.4 (81.3)	113.3 (82.3)	107.8 (82.4)	93.3 (81.3)	105.8 (82.0)
Median (Q1, Q3)	175.0 (0.0, 181.0)	184.0 (1.0, 184.0)	157.0 (0.0, 183.0)	107.0 (0.0, 183.0)	145.0 (0.0, 183.0)
Range	0.0–181.0	0.0–184.0	0.0–183.0	0.0–183.0	0.0–184.0
Eligible days in 6 months after SBAR
Mean (SD)	119.8 (76.7)	107.7 (81.2)	110.4 (83.4)	112.6 (82.4)	112.6 (80.9)
Median (Q1, Q3)	184.0 (36.0, 184.0)	144.0 (5.0, 184.0)	165.0 (0.0, 183.0)	183.0 (0.0, 183.0)	168.0 (3.5, 183.0)
Range	0.0–184.0	0.0–184.0	0.0–183.0	0.0–183.0	0.0–184.0

Number of beds in the facility ranged from 123–150. The star rating range at the midpoint of Phase II data collection was one to four. Average resident hours per day ranged from 3.6 to 4.6. All but one of the facilities was county government owned; the other was non-profit owned. While county ownership of nursing facilities is not common nationally, in the state of Indiana the majority of nursing homes are county owned but may be managed by a variety of companies.

Plan-Do-Study-Act Cycle 2-Building A

Building A embedded the OPTIMISTIC SBAR within their electronic health record for use by all the facility nurses when there was an acute change in condition to facilitate use of the tool. Although SBAR use was mandated, the electronic OPTIMISTIC SBAR was typically filled out after the change in condition resolved to meet facility documentation requirements rather than being used as a real-time tool to facilitate communication. Therefore, minimal quantitative data was collected from Building A as it served as a model to test and refine the SBAR protocol to improve implementation in the next buildings.

Plan-Do-Study-Act Cycle 3-Building B

At Building B, the most common change in condition was cough/cold symptoms (26.8%) followed by gastrointestinal/genitourinary symptoms (17.1%; Supplemental table). Pre-pilot, SBAR completion was 60% for all changes in condition; completion increased to 72% post-pilot (Table 2). The average SBAR quality score improved from 7 pre-pilot to the maximum score of 10 post-pilot indicating improved SBAR documentation. EMR scores worsened over the 12-week period; score at week one was 7.5 and at week twelve was 4.5, although at week 11 the average score was 9.5.

Table 2.

Results of SBAR completion, SBAR Score, and EMR Score Pre-Pilot and Post-Pilot in Buildings B, C, and D.

	Bldg B	Bldg C	Bldg D
SBAR completion
Pre (week 1)	60%	4%	0%
Post (week 12)	72%	67%	44%
SBAR score (-/10)
Pre (week 1)	7.0	7.4	—
Post (week 12)	10.0	8.4	8.9
EMR score (-/10)
Pre (week 1)	7.5	4.8	4.1
Post (week 12)	4.5	6.4	5.6

Plan-Do-Study-Act Cycle 4-Builidings C and D

The most common changes in condition in Building C pre-pilot were gastrointestinal/genitourinary symptoms (35.1%) and signs/symptoms of infection (20.8%); post-pilot, the most common change in condition was gastrointestinal/genitourinary symptoms (40.8%) followed by cough/cold symptoms (12.2%; Supplemental table). Initially, Building C had an OPTIMISTIC SBAR completion rate of 4%; post-intervention, 67% of all changes in condition had a completed OPTIMISTIC SBAR (Table 2). For the limited SBARs completed pre-intervention, the average score was 7.4; post-intervention, the average SBAR score improved to 8.4 demonstrating better SBAR documentation. The average EMR documentation score increased from 4.8 to 6.4 points after pilot implementation in Building C.

In Building D, the top two changes in condition pre-pilot were cough/cold symptoms (24.2%) followed by change in mental status (10.5%) and post-pilot, they were gastrointestinal/genitourinary symptoms (15.9%) and edema/volume overload (15.9%; Supplemental table). No OPTIMISTIC SBAR tools were utilized for a resident change in condition prior to the intervention; pilot outcomes revealed 44% of changes in condition had an associated OPTIMSITIC SBAR (Table 2). The pilot revealed an average SBAR score of 8.9 (there was no SBAR score for comparison as no pre-intervention OPTMIISTIC SBARs were completed). The average EMR documentation score increased from 4.1 to 5.6 points in Building D.

Pre-post surveys were administered to both nursing staff and providers (physicians and nurse practitioners). In Building C, seventeen nurses and one provider completed the pre-pilot survey and twelve nurses and one provider completed the post-pilot study. Nurse and provider scores increased in every area on the post-survey compared to the pre-survey. Increased reported use of the SBAR was stated by both nurses and providers; pre-pilot 89% reported SBAR use and 100% reported use post-pilot intervention (Table 3). Pre-pilot, one provider commented, “I am encouraged by the implementation of the new SBAR; it should improve communication quality.”

Table 3.

Nurse and Provider Survey Scores Pre-Pilot and Post-Pilot in Buildings C and D.

	Bldg C		Bldg D
	Pre-pilot (N = 18)	Post-pilot (N = 13)	Pre-pilot (N = 15)	Post-pilot (N = 8)
Q1 - Do nurses and physicians share in decision making?
	3.39	3.46	3.07	3.25
Q2 - Do nurses and physicians cooperate in decisions?
	3.22	3.46	3.33	3.5
Q3 - Do nurses and physicians plan together before making decisions?
	3	3.31	2.87	3.13
Q4 - Is there open communication between nurses and physicians in making decisions?
	3.5	3.54	3.27	3.63
Q5 - I get relevant information on patient status from nurses/physicians
	3.72	4.15	4.07	4.13
Q6 - There are no delays in relaying information regarding patient care
	3.5	3.85	3.47	3.63
Q7 - Nurses/physicians return calls in a timely manner
	4.17	4.46	3.8	3.63
Q8 - I receive correct information from nurses/physicians
	4.28	4.62	4.2	4.25
Q9 - I have good communication with nurses/physicians
	4.22	4.54	4.13	4.5
Q10 - I feel certain about accuracy of information from nurses/physicians
	4.17	4.62	3.93	4.25
Q11 - I enjoy collaborating with nurses/physicians
	4.38	4.62	4.27	4.38
Q12 - It is easy to ask the nurses/physicians questions
	4.17	4.54	4.13	4.13
Q13 - Do you use the SBAR?
Yes	88.89%	100%	60.00%	87.50%
No	0%	0%	40%	12.50%
N/A	11.11%	0%	0.00%	0%
Q14 - If yes to #13, is it the OPTIMISTIC SBAR?
Yes	44.44%	100%	13.33%	87.50%
No	38.89%	0%	60.00%	0%
N/A	11.11%	0%	26.67%	12.50%

In Building D, twelve nurses and three providers filled out the pre-pilot survey and five nurses and three providers completed the post-pilot survey. For both nurses and providers, scores improved in a majority of categories. Nurses once again did tend to initially score communication and collaboration higher than the providers as was seen in Building C. Nurses and providers also indicated increased reported use of SBAR for change in resident condition after pilot initiation; pre-pilot SBAR use was 60% compared to 87.5% after SBAR intervention (Table 3). In Building C, one provider post-pilot noted, “Some nurses are good at collecting necessary data and communication it. Some are not,” perhaps indicating motivation as a barrier to SBAR use.

Discussion

Plan-Do-Study-Act Cycles

The use of Plan-Do-Study-Act cycles in this study allowed for continued improvement in successful implementation of the OPTIMISTIC SBAR tool. Small modifications to the SBAR protocol at each subsequent nursing home resulted in more frequent use of the tool for acute changes in resident condition, better documentation of the change in condition, and enhanced views of communication among nursing facility staff. Having embedded OPTIMISTIC nursing staff in the facilities were key to identifying needed protocol changes. This is consistent with another study that used a similar time series project model to improve hand hygiene and was able to induce immediate and sustained quality improvement (McClean, Carriker, & Bordley, 2017).

SBAR Use/Documentation

For resident changes in condition, OPTIMISTIC SBAR use and quality of SBAR documentation improved in Buildings B–D after targeted training was employed. A study performed at a large long-term care facility in suburban Pennsylvania employing a similar SBAR protocol with nurse training on the protocol revealed an increased compliance rate of SBAR use in addition to improved post-intervention use (Renz et al., 2013). A key component of the study’s improved SBAR adherence was having embedded champions in the nursing home; nursing supervisors received additional training to monitor and promote SBAR use similar to the OPTIMISTIC nurses in our study. Another study also successfully utilized champions to reinforce SBAR use for urgent and non-urgent patient situations to improve safety in a rehab facility setting (Velji et al., 2008).

Attitudes about Communication

Our study found that after implementation of a required SBAR for resident change in condition, the overall survey scores among both nursing staff and providers improved in Buildings C and D. The increases in scoring signify improvement in perceptions about communication and collaboration after implementation of the SBAR. This is consistent with the Renz et al study showing improved satisfaction with communication between nurses and providers after the INTERACT II SBAR tool was utilized at a long-term care facility during changes in resident condition (2013). A similar study performed across sixteen hospital wards also found that after implementation of SBAR for use in declining patient conditions, nurses scored communication and collaboration higher as they felt more prepared to discuss concerns about patients (DeMeester et al, 2013). Formal interventions that serve to improve nurse-provider communication tend to have a positive effect on perceived collaboration and communication by streamlining and structuring pertinent patient information. Nurses feel more prepared when alerting providers about acute changes in patient condition in turn leading to more prompt responses and faster interventions.

Study Limitations

Given the use of PDSA cycles to implement successive change, it is difficult to define which specific intervention had the largest impact on SBAR use. However, targeted nursing training and embedded champions likely played a large role given their benefit in other studies (Renz et al., 2013; Velji et al., 2008). No long-term monitoring of SBAR use compliance was collected so long term impact of the SBAR protocol was not assessed but would be beneficial in future studies.

It is also important to note that data on resident outcomes pre- and post-SBAR pilot was not directly assessed in this study. We did not assess the impact of the SBAR tool on reducing avoidable hospitalizations given implementation of the SBAR tool was inconsistent across buildings with some championing the tool and others unable to implement more sustained use. The main goal of this study was to improve SBAR tool use when a resident experienced a change in condition. However, tracking outcomes of residents after implementation of a communication tool like the OPTIMISTIC SBAR is an important next step for future studies, especially because we know that SBAR use in this study, improved communication which is key to reducing the transfer of nursing home residents during a change in condition.

In addition, reasons for change in condition pre- and post-SBAR pilot was not an outcome that was further explored either (Supplemental table). Although SBARs triggered by signs of infection decreased post intervention, this could be due to multiple resident and facility factors versus the SBAR intervention alone. More investigation is needed to determine how the SBAR can affect certain changes in condition.

The number of advanced practice providers surveyed was limited and survey results were reported as overall change in communication/collaboration perceptions for both nurses and providers. Assessing nurse and provider perceptions separately would be a good next step for future studies. There was a decrease in survey participation in both Buildings C and D as well. And, the same group of nurses and providers were not surveyed pre- and post-intervention leading to a possible under or over estimate of collaboration and communication perceptions after SBAR implementation.

Conclusion

This project demonstrates successful short-term implementation of a project specific SBAR into a subset of OPTIMISTIC nursing homes when a resident experienced an acute change in condition. Using PDSA cycles allowed for protocol changes at successive facilities with embedded OPTIMISTIC staff championing the efforts to overcome barriers identified at the previous facility. This resulted in increased use of the OPTIMISTIC SBAR and improved documentation on the SBAR as well as EMR documentation as demonstrated in Buildings B–D. Furthermore, SBAR use led to improved impressions of collaboration and communication among nursing staff and facility practitioners. The OPTIMISTIC SBAR is a useful tool to improve communication in the nursing home setting but requires significant support for implementation into the clinical workflow.

Supplemental Material

Supplemental Material - Improving Communication in Nursing Homes Using Plan-Do-Study-Act Cycles of an SBAR Training Program

Supplemental Material for Improving Communication in Nursing Homes Using Plan-Do-Study-Act Cycles of an SBAR Training Program by Samantha Kay, Kathleen T. Unroe, Kristi M. Lieb, Ellen W. Kaehr, Justin Blackburn, Timothy E. Stump, Russell Evans, Sarah Klepfer, and Jennifer L. Carna in Journal of Applied Gerontology

Footnotes

Acknowledgments

The authors would like to thank Danielle Patten, RN, who helped with the development and implementation of the SBAR program.

Declaration of conflicting interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Kathleen Unroe is the founder and a consultant and Russell Evans and Sarah Klepfer are employees of Probari, Inc, a healthcare start-up founded to disseminate the OPTIMISTIC clinical care model.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Dr. Carnahan was supported by the National Institute On Aging Division of the National Institutes of Health [grant K23AG062797]. OPTIMISTIC was supported by the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) [grant 1E1CMS331488]. The contents are those of the author9s0 and do not necessarily represent the official views of, nor an endorsement by, CMS, HHS, or the U.S. Government.

Ethical Approval

1303010822, Institutional Review Board (IRB) of Indiana University

ORCID iD

Samantha Kay

Supplemental Material

Supplemental material for this article is available online.

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