553263

research-article2014
AJMXXX10.1177/1062860614553263American Journal of Medical QualityPanesar et al

Article
American Journal of Medical Quality

The Effect of an Electronic SBAR

2016, Vol. 31(1) 64­–68
© The Author(s) 2014
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DOI: 10.1177/1062860614553263

Documentation of Acute Events in ajmq.sagepub.com

the Pediatric Intensive Care Unit

Rahul S. Panesar, MD1, Ben Albert, MD1, Catherine Messina, PhD2,

and Margaret Parker, MD1

Abstract
The Situation, Background, Assessment, Recommendation (SBAR) handoff tool is designed to improve communication.
The effects of integrating an electronic medical record (EMR) with a SBAR template are unclear. The research team
hypothesizes that an electronic SBAR template improves documentation and communication between nurses and
physicians. In all, 84 patient events were recorded from 542 admissions to the pediatric intensive care unit. Three time
periods were studied: (a) paper documentation only, (b) electronic documentation, and (c) electronic documentation
with an SBAR template. Documentation quality was assessed using a 4-point scoring system. The frequency of event
notes increased progressively during the 3 study periods. Mean quality scores improved significantly from paper
documentation to EMR free-text notes and to electronic SBAR-template notes, as did nurse and attending physician
notification. The implementation of an electronic SBAR note is associated with more complete documentation and
increased frequency of documentation of communication among nurses and physicians.

Keywords
SBAR, electronic medical record, communication tool, pediatric

One of the Joint Commission National Patient Safety goals
issued in 2006 was to “implement a standardized approach
to ‘hand off’ communications” for residents and health
care staff.1,2 In response, health care institutions have
devised a variety of methods to improve communication in
attempts to decrease communication-related errors associ-
ated with incomplete or inaccurate information.3
The Situation, Background, Assessment, Recommen-
dation (SBAR) model was designed as a tool for organizing
information in a clear and concise format to facilitate col-
laborative communication among health care providers.4 A
systematic review of handoff mnemonic literature reported
SBAR is now the most frequently utilized handoff tool, cited
in 36 out of 42 articles (69.6%).3
Concurrently, the Health Information Technology for
Economic and Clinical Health Act of 2009 includes legis-
lation incentivizing incorporation of the electronic medi-
cal record (EMR) into the health information infrastructure
with the goal of improving meaningful use by providers.5
More recently, hospitals have integrated the EMR and
physician communication, but sign-out practices, even
within a single institution, can remain varied and lack key
clinical information.6
Moreover, to date there is no published literature
examining the use of an electronic SBAR template to pro-
vide vital clinical information during acute changes in a
patient’s condition that require immediate attention by
house and nursing staff and the attending physician.
Therefore, this study aimed to describe the impact of inte-
grating an EMR with a structured SBAR note on these
crucial communications among clinicians. Specifically,
this study examined the frequency of notes written and
the completeness of the documentation based on set scor-
ing criteria. Also evaluated were any changes that
occurred in documentation of communication among
health care providers.
1
Stony Brook Children’s Hospital, Stony Brook, NY
2
Stony Brook University Hospital, Stony Brook, NY
Corresponding Author:
Rahul S. Panesar, MD, Department of Pediatrics, Stony Brook Long
Island Children’s Hospital, HSC L-11, Suite 040, Stony Brook, NY
11794-8111.
Email: rahul.panesar@stonybrookmedicine.edu
Panesar et al 65
Table 1.  Pediatric SBAR Guidelines for Attending Notification.
•• Acute life-, limb-, or organ-threatening event
•• Unexpected episodes of hypotension
•• New-onset bradycardia or tachycardia
•• New unexplained acidosis pH <7.25
•• Emergent intubation
•• Acute change in mental status
•• Unexpected oliguria or anuria
•• New-onset sustained hypertension
•• Unexpected critical lab value(s)
•• Indication for antiarrhythmic, pressors, or inotropes
•• PEWS score of orange or red
•• New-onset tachypnea or significant change in respiratory rate/pattern/saturations
•• Need for transfusion of blood or blood products if not planned in advance
•• Unexpected seizure activity
•• New-onset unexplained pain requiring the use of narcotics
•• New-onset fever in an immunocompromised patient
Abbreviations: PEWS, Pediatric Early Warning Score; SBAR, Situation, Background, Assessment, Recommendation.
Methods
This study was conducted at a 12-bed pediatric intensive
care unit (PICU) in a university children’s hospital. The
study was approved by the university hospital institu-
tional review board. Consent was waived for this study.
There were no screening methods or exclusion criteria
implemented, and all children admitted to the PICU dur-
ing the specified time periods were included in the study.
Data included in event notes, either on paper or in elec-
tronic form, were analyzed.
Medical records of children admitted to the PICU
were reviewed during 3 distinct phases, including paper
chart documentation (December 2010 to February 2011),
EMR free-text event notes (June 2011 to August 2011),
and electronic SBAR note documentation (April 2012 to
June 2012). Each study period began 3 months after the
implementation of each modality (ie, electronic health
record, electronic SBAR communication note). This
allowed for a period of time during which staff were pro-
vided education on the use of the documentation tool.
After this 3-month buffer period allowing incorporation
into routine workflows, data were collected for 3 consec-
utive months.
Prior to implementation of the EMR, the Pediatric
Critical Care Division had established guidelines for
attending notification of critical patient events. This
model included predefined criteria in which pediatric
residents were required to notify the attending physi-
cian using an SBAR format (Table 1). An orange
sticker with sections for each SBAR component, which
was designed to allow for easily identifiable documen-
tation in the paper-based progress notes, was com-
pleted freehand.
In March 2011, the PICU converted to the EMR with
full physician documentation using Cerner PowerChart
(Cerner Corp, Kansas City, Missouri). During this period,
pediatric residents were instructed to document critical
patient events using the SBAR criteria as before and to
notify the attending physician, similarly using a free-text
format, which now was a blank electronic note. This note
had greater accessibility to multiple users on the health
care team because it was available via any hospital com-
puter terminal with EMR access, but it did not provide a
structured template for data entry. Therefore, residents
were allowed to enter as much or as little information as
they deemed necessary.
The Department of Pediatrics adopted an electronic
SBAR communication note by the end of 2011. This pro-
vided a data entry structure prompting the resident to
document each of the 4 components of SBAR as well as
a checkbox for each of the attending physician notifica-
tion criteria. These fields were not required to be checked
off or completed before signing the note. However, they
served as reminders to the resident to provide a detailed
and complete record of what acutely changed in the
patient’s condition. A data field on the SBAR note
prompted documentation of who was the attending physi-
cian of record, which was designed to alert the author to
document closed-loop communication between the resi-
dent and the covering attending physician. Finally, an
additional data field was included in the SBAR template
to document the nurse caring for the patient, also designed
to prompt closed-loop communication with the nurse at
the bedside.
Prior to signing the note, the resident was given a final
prompt by the EMR to identify an endorsing attending
physician to whom the note would be sent. The attending
66 American Journal of Medical Quality 31(1)

Table 2.  SBAR Scoring Criteria.

25
Scoring Criteria Point Scale
19.8
Situation: Current condition, working 1 20
diagnosis, were SBAR criteria met?
Background: History of presenting illness, 1

Percentage (%)
15 14.2
past medical history, medications 12.7
Assessment: Examiner’s evaluation and 1 Frequency
assessment of the disease or condition 10
Recommendation: Plan of care, anticipated 1
changes in condition or treatment
5

Abbreviation: SBAR, Situation, Background, Assessment,

Recommendation.
0
Paper Notes Free-text EHR Free-text + SBAR

would receive the note in his/her electronic inbox in the

EMR and was instructed to attest to the note within 24 Figure 1.  Frequency of documentation.
hours. After completing the note, the resident was Abbreviations: EHR, electronic health record; SBAR, Situation,
instructed to notify the nurse assigned to the patient so he/ Background, Assessment, Recommendation.
she could add an attestation of the event and sign the note
before the end of the shift. This portion of the process for
attendings and nurses could not be made mandatory in the
electronic system, but both faculty and nursing staff were
strongly advised to complete this piece of the documenta-
tion. All residents were instructed to verbally discuss the
event with both the attending and the nurse before elec-
tronically writing, signing, or sending the note for any
attestation.
A scoring system was constructed to assess complete-
ness of documentation (Table 2). One point was given for
any documentation within each of the 4 components of
the situation, background, assessment, or recommenda-
tion. The accuracy of the resident’s documentation was
not assessed. Any documentation that fulfilled each of the
4 SBAR components was given 1 point, totaling a possi- Figure 2.  Completeness of documentation.
ble 4 points for each event note reviewed. For example, Abbreviations: EHR, electronic health record; SBAR, Situation,
Background, Assessment, Recommendation.
any documentation that included the situation of the
patient event, background information of the patient’s ill-
ness, a clinical assessment of the disease or condition, period (Figure 1). During the electronic SBAR documen-
and a plan of care would receive a total of 4 points. tation, 34 of 172 patients had event notes documented.
After removal of all patient identifiers, data were This yielded a nonsignificant increase of documentation
entered into a secure spreadsheet for statistical review (P = .07) in the PICU during the study period.
using analysis of variance and χ2 analysis. A P value <.05 The completeness of documented event notes is shown
was considered statistically significant. in Figure 2. Mean scores of completeness were tabulated
using the 4-point scoring system as outlined in Table 2.
During the third time period, not all event notes had tran-
Results sitioned to the electronic SBAR note; some residents
A total of 542 patients were admitted to the PICU during were still using the free-text EMR note. Subset analysis
the 3 time periods studied, including 173 patients in paper of the EMR-SBAR note alone (n = 15) during this time
chart documentation, 197 patients in free-text EMR doc- period showed a mean score of 4 points when only the
umentation, and 172 patients in the electronic SBAR electronic SBAR note was used (P < .0001).
documentation. Documentation of multidisciplinary communication is
During paper chart documentation, a total of 22 of 173 shown in Figure 3. During paper chart documentation, the
patients had event notes documented; 28 of 197 patients nurse caring for the patient was never identified in the
had event notes documented during the free-text EMR event note, and the attending physician was documented
Panesar et al 67
120
100
100100
79.4
80
Percentage (%)
Nurse Notification
60 53.6
Physician Notification
44.1
40
20
18.2
7.1
0
0 The data show that documentation of attending physi-
Paper Notes Free-Text Free-text + SBAR Only
EHR SBAR
Figure 3.  Multidisciplinary communication.
Abbreviations: EHR, electronic health record; SBAR, Situation,
Background, Assessment, Recommendation.
to be notified less than 20% of the time. After transition-
ing to free-text EMR documentation, identification of the
nurse increased by about 7% and identification of the
attending physician increased by about 35%. After initia-
tion of the electronic SBAR note identification of the
nurse increased by an additional 37% and identification of
the attending physician increased by an additional 26%.
Subset analysis of this last time period of the electronic
SBAR notes alone demonstrated 100% documented noti-
fication of both nurse and attending physician (P = .0001).
Discussion
Electronic documentation tools have been used in several
modalities such as described by Stockwell et al, using a
computerized checklist to standardize documentation for
neurological determination of brain death.7 The present
article describes an electronic SBAR communication
tool, which was associated with more complete docu-
mentation of critical pediatric patient events and with an
increase in documentation of attending physician and
nursing notification.
The use of the electronic SBAR note suggests an asso-
ciation with an increased frequency of documented event
notes among patients in the PICU, although the differ-
ence was not statistically significant (P = .07). The
research team hypothesizes that greater accessibility of
any electronic note could have contributed to the
increased number of documented events. With the ability
to write a note anywhere on any hospital computer that
has access to the EMR, users may have been more apt to
use the electronic free-text notes and subsequently the
SBAR template more often.
By having predefined fields prompting residents to
document important aspects of an event within the elec-
tronic SBAR note, the completeness of documentation
improved compared to blank free-text notes, even though
it was not mandatory to complete these fields in order to
sign the note. Completeness of charted events increased
from 2.23 points with paper chart documentation to 2.57
points with EMR documentation. With the addition of the
electronic SBAR communication note, the completeness
of documentation increased to 4.0 points. This suggests
that the SBAR note, which was readily available in the
EMR, likely made documentation more accessible and
prompted the author to be more complete in the docu-
mentation of events.
cian and bedside nurse notification reached 100% when
the resident used the electronic SBAR note for charting,
thereby improving documentation of multidisciplinary
communication. During this portion of the study, the on-
call attending physician was required to attest to all event
notes on their patients within a 24-hour period. Therefore,
the resident needed to complete and send the note soon
after the event, which was delivered electronically to the
attending for attestation. This change in workflow with
the electronic SBAR note was associated with an
increased rate of documented attending notification from
53.6% to 79.4%, from the electronic free-text note to the
electronic SBAR note time frames.
The multiple data fields built into the electronic SBAR
note that prompted documentation of the attending and
nurse of record prior to signing the note proved to be
advantageous over the EMR free-text note. In this study,
100% documentation of nurse and attending physician
communication was achieved when the electronic SBAR
note was used. Interestingly, although 100% of nurses
attested to the SBAR event notes, they did not have an
electronic inbox to receive the notes, as attending staff
did. The nurse would only become aware of the note once
the resident discussed the note with them. This high level
of attestation rates with the SBAR note supports the notion
that there was increased communication between the resi-
dents, attending physicians, and nurses. Additionally, it
can be argued that the ability to write an attestation to a
note in which he or she was named empowered the nurse
to include his or her independent account of findings lead-
ing up to and including the critical event. This feature may
have allowed a greater opportunity for nursing staff to col-
laborate with residents, ultimately improving the details
of the documentation.
This study has several limitations. This study was con-
ducted in a single institution and may not be representa-
tive of the workflow of other institutions. The study only
reviewed notes written in the PICU and a larger data set
including other wards and/or facilities might have shown
more significant changes in the frequency of notes writ-
ten in each phase of the study. The study institution had
adopted EMR documentation in phases during this
study, and the implementation of each phase, including
68 American Journal of Medical Quality 31(1)
the electronic free-text note and the electronic SBAR
note, varied. However, the 3-month study period after
implementation was consistent. The subset analysis of
completeness and communication also had a smaller pool
of patients. Furthermore, not all resident physicians had
converted to use of the electronic SBAR note by the last
phase of the study. Residents during this last time frame
still had the option of writing free-text notes after the
SBAR templates were made available. Therefore, sub-
group analysis within this time frame was used to sepa-
rate the different forms of documentation used. However,
the subgroup of SBAR-only notes also may reflect a
cohort of residents who accepted the SBAR system more
readily and who were more thorough with their documen-
tation than users of free-text notes. Additionally, it is pos-
sible that not all events were recorded on paper or the
EMR, but there was no definitive way of verifying this.
Although nursing staff were usually notified by residents
about the SBAR note, it may have been possible that a
nurse would be aware of an event and would find the
event note in the EMR and attest to it without communi-
cating with the resident. Also, the accuracy of documen-
tation could not be verified because this was a retrospective
study. Finally, mortality in the PICU is so low that study-
ing the effect of these changes on outcomes is difficult.
Future work would involve a prospective study
reviewing nursing documentation at the time an elec-
tronic SBAR note is written and cross-checking it with
residents’ documentation in an attempt to assess the qual-
ity of documentation during critical patient events.
Additionally, adding forcing functions to the SBAR note
with mandatory fields instead of prompts alone may fur-
ther improve completeness and documentation of com-
munication between all health care providers. Ultimately,
the goal of improved documentation would be to serve as
a surrogate marker for improved patient safety in the hos-
pital setting.
Conclusion
The implementation of an electronic SBAR note provides
a template for more complete documentation. This elec-
tronic SBAR note was associated with an increase in the
frequency of documentation of communication among
residents, nurses, and attending physicians caring for
patients in the PICU.
Acknowledgments
We acknowledge Seoungju Won, RN, MS, Senior Instructional
Support Specialist, Clinical Informatics, and Gerald Kelly, DO,
Associate Professor, Chief Medical Information Officer, for
their assistance in implementing the SBAR template in the elec-
tronic medical record.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The authors received no financial support for the research,
authorship, and/or publication of this article.
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