Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review

Summary of main results

The present systematic review assesses the effect of the implementation of the widely adopted communication strategy SBAR on patient-related outcomes. Because communication breakdowns have been repeatedly identified as a major source of adverse events and medical error,4 58 59 implementation of a strategy such as SBAR seems a valid remediation approach.

Eleven studies, eight with a before–after design and three controlled trials, met the inclusion criteria. SBAR was implemented through different strategies in three different clinical settings (hospitals, rehabilitation centre and nursing homes) and with a broad range of objectives to improve (1) team communication in general, (2) intradisciplinary and interdisciplinary patient hand-offs, and (3) communication in telephone calls from nurses to physicians. In total, 26 different patient outcomes were measured. Eight significantly improved, 11 were described as improving (but no further statistical test were reported), six outcomes did not change significantly and one study reported a descriptive reduction in patient outcomes. Study outcomes with statistical evidence for improvement included INR values within the target range49 and unplanned transfers to hospitals57 in nursing homes, as well as CIRS events due to communication errors,37 patient falls,54 unexpected death and ICU admissions55 in hospitals. The overall study quality was high or moderate in two studies only; all other studies showed a weak study quality.

Quality of the evidence

The strongest evidence identified in our review comes from a single RCT investigating the effect of SBAR implementation in nursing homes on anticoagulation management of patients under warfarin.27 However, because warfarin is increasingly substituted by direct oral anticoagulants less difficult to dose,60 the relevance of this finding may cease over time. Furthermore, adverse events related to warfarin therapy, the primary outcome parameter in this study, did not differ significantly between the intervention and control group. We found further evidence that the use of SBAR in telephone communication to inform the physician of a deteriorating patient leads to (1) a significant decrease in unexpected death22 and (2) a significant reduction in transfers to hospitals, 30-day readmissions and avoidable hospitalisations from nursing homes.21 Therefore, SBAR implementation in telephone communication seems to positively affect patient outcome. However, one study conducted in a similar setting56 (nursing home, unplanned hospital admission) but with a longer study period could not find any significant difference between the preimplementation and postimplementation phase in the patient outcomes. One explanation for the differences in the findings might be that the use of SBAR (not reported in the two studies) decreased over time, thus the effect vanished.

Study periods were short at least in two trials50 54 (2 months only). As a consequence, only one sentinel event in one controlled clinical trial50 over the study period was reported.

Power calculations were missing in all studies. Thus, the lack of significant differences between the groups in these studies could not be interpreted adequately. Furthermore, in almost half of the reported outcomes, no statistical tests were performed. Notably, no study in our review found a significant increase in the occurrence of adverse events after to the implementation of SBAR, but Andreoli et al 52 descriptively reported an increase in fall incidence while the fall severity was reduced at the same time. This study’s findings illustrate the difficulty with most of the studies findings included in the review. Some might argue that the implementation of SBAR in patient fall reporting has just led to an increased awareness regarding patient falls. Consequently, the reporting of patient falls and especially of less severe falls increased, resulting in a decrease of the patient fall severity overall.

It has been previously argued that downstream targets of educational interventions (such as the implementation of a specific communication strategy) are often difficult to assess due to possible dilution of the effect of any intervention.61 62 Indeed, implementation of SBAR may only directly affect communication among health professionals, which in turn may or may not affect healthcare conduct, which then may result in altered patient outcome. Arguably, there are many other effective agents along this path that may dilute the effect of SBAR implementation on patient outcome. We would argue that because it has been possible in the past to relate adverse events to communication breakdowns,7 58 59 it should just as well be possible to demonstrate the effect on patient safety of interventions targeted at remediating such communication breakdowns.

One reason for the current failure to demonstrate such effects may be that studies investigating the effect of SBAR on patient outcome are mostly of limited quality and yield heterogeneous results. Many studies identified were before–after studies. It is thus difficult to differentiate between changes attributed to the implementation of SBAR and changes attributable to other factors that had changed over time, such as increased awareness. Process measures in regard to parameters of communication were not measured in any of the included studies, but several not included studies suggest an improvement of communication through the implementation of SBAR.34–40 The lack of process measures within the included studies reduces internal validity and impedes the interpretation of the present results with regard to causation. Consequently, the unreflected adoption of SBAR may paradoxically limit improvements in healthcare communication because once a problem appears to be solved, less research will be conducted on it.

Limitations

This systematic review has some limitations. Efforts were undertaken to identify all relevant trials to evaluate the impact of SBAR implementation in clinical practice on patient safety. Five well-known databases as well as the references of the studies that met the inclusion criteria were searched using an open search strategy. No grey literature was searched, thus trials could have been missed. Further, we did not contact any author to ask for raw data to perform additional statistical analysis. Publication bias could not be assessed leading to an important source of bias. The heterogeneity of the data impeded a meta-analysis. This systematic review was conducted in accordance with the Cochrane Collaboration standards using a validated tool for quality assessment of the identified studies. Reliability of the study selection, data extraction and rating of the study quality was ensured using two independent reviewers. We did not differentiate the broad range of adverse events or sentinel events, but subsume them under patient safety/outcome in order to provide a first insight into the relationship between SBAR and patient safety. The inclusion criteria were restricted to trials that reported at least one ‘hard’ patient outcome parameter to evaluate SBAR’s impact on patient safety. Evidence of improvement of potentially ‘soft’ outcomes such as an increase in employee satisfaction21 22 and interdisciplinary communication19 23 with improvements of the communication perception, interdisciplinary teamwork,29–33 completeness41–44 and efficiency40 42 45 of the communication were not reported in this review. Last, trials in which SBAR was a minor component of a complex intervention only were not included in this review. These trials may contain potential evidence for an improvement of patient safety through the implementation of SBAR.

Implications for practice and research

Five of the studies37 49 54 55 57 including the two moderate/high-quality studies found significantly improved patient safety outcomes. Four other before–after studies41 51–53 reported descriptive improved patient outcomes. On the one hand, these findings emphasise the potential importance of implementation of SBAR in the clinical practice to improve (1) telephone communication from nurse to doctors in critical situations, (2) general patient hand-off as well as (3) team communication in general. However, the quality of the evidence is low and four studies49 50 55 56 reported no significant changes of other relevant outcomes and even a descriptive increase of patient falls also.52 Best evidence was found in telephone communication between nurses and physicians. This should raise awareness and demands future high-quality research as the unreflected adoption of SBAR may paradoxically limit improvements in healthcare communication because once a problem appears to be solved, less research will be conducted on it.