SBAR improves nurse–physician communication and reduces unexpected death: A pre and post intervention study

The aim of this study was to determine the effect of SBAR (situation, background, assessment, recommendation) on the incidence of serious adverse events (SAE’s) in hospital wards.

Resuscitation 84 (2013) 1192–1196
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Resuscitation
j o u r n a lh o m e p a g e :w w w . e l s e v i e r . c o m / l o c a t e / r e s u s c i t a t i o n
Clinical paper
SBAR improves nurse–physician communication and reduces unexpected death:
A pre and post intervention study夽
K. De Meestera,b,∗, M. Verspuyb, K.G. Monsieursa,c, P. Van Bogaerta,b
a Antwerp University Hospital, Wilrijkstraat 10, 2650 Edegem, Belgium
b Faculty of Medicine and Health Sciences, Division of Nursing and Midwifery Sciences, University of Antwerp, Universiteitsplein 1, 2610 Wilrijk, Belgium
c Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610 Wilrijk, Belgium
a r t i c l e i n f o
Article history:
Received 20 December 2012
Received in revised form 8 March 2013
Accepted 17 March 2013
Keywords:
Rapid response system
Inter-professional communication
SBAR
Un-expected death
Serious adverse event
Unplanned intensive care unit admission
a b s t r a c t
Background: The Joint Commission International Patient Safety Goal 2 states that effective communication
between health care workers needs to improve. The aim of this study was to determine the effect of SBAR
(situation, background, assessment, recommendation) on the incidence of serious adverse events (SAE’s)
in hospital wards.
Method: In 16 hospital wards nurses were trained to use SBAR to communicate with physicians in cases
of deteriorating patients. A pre (July 2010 and April 2011) and post (June 2011 and March 2012) inter-
vention study was performed.Patient records were checked for SBAR items up to 48 h before a SAE.A
questionnaire was used to measure nurse–physician communication and collaboration.
Results: During 37,239 admissions 207 SAE’s occurred and were checked for SBAR items,425 nurses
were questioned. Post intervention all four SBAR elements were notated more frequently in patient
records in case of a SAE (from 4% to 35%; p < 0.001), total score on the questionnaire increased in nurses
(from 58 (range 31–97) to 64 (range 25–97); p < 0.001),the number of unplanned intensive care unit
(ICU) admissions increased (from 13.1/1000 to 14.8/1000 admissions; relative risk ratio (RRR) = 50%;
95% CI 30–64; p = 0.001) and unexpected deaths decreased (from 0.99/1000 to 0.34/1000 admissions;
RRR = −227%; 95% CI −793 to −20; NNT 1656; p < 0.001). There was no difference in the number of cardiac
arrest team calls.
Conclusion: After introducing SBAR we found increased perception of effective communication and col-
laboration in nurses, an increase in unplanned ICU admissions and a decrease in unexpected deaths.
© 2013 Elsevier Ireland Ltd. All rights reserved.
1. Introduction
The Joint Commission International Patient Safety Goal num-
ber 2 (Standard IPSG 2) states that effective communication among
health care workers has to improve.1 According to the Institute
of Medicine the six aims in the 21st-century health care system
are: safe, effective, patient-centred, timely, efficient and equitable.2
Many potential barriers have been reported in nurse–physician
communication such as lack of structure, hierarchy, language, cul-
ture, sex and difference in communication style.3–5 Nurses tend to
be more detailed in their communications whereas physicians use
more brief statements.4 In the context of critical events, nurses and
夽 A Spanish translated version of the abstract of this article appears as Appendix
in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2013.03.016.
∗ Corresponding author at: Antwerp University Hospital,Wilrijkstraat 10, 2650
Edegem, Belgium.
E-mail addresses: [e-mail],
[e-mail] (K. De Meester).
physicians often communicate over the phone which makes these
communications error-prone.6 Up to 65% of serious adverse events
(SAEs) include communication as a contributing factor.7 Root cause
analysis of SAEs on wards reveals failure in three domains.8 First,
no observations are made for a prolonged period and/or changes
in vital signs are not detected. Second, despite the recording of
vital signs, clinical deterioration is not recognized and/or no action
is taken. Finally, when deterioration is recognized and assistance
sought, medical attention is delayed. This delay in receiving medical
attention can originate from sub-optimal nurse–physician com-
munication or collaboration.8 In answer to these three domains
of failure, rapid response systems (RRSs) have been widely intro-
duced although they are not supported by a high level of evidence.9
It remains uncertain which elements of RRSs contribute most
to patient outcome but there is growing awareness that the
effect depends on the different components such as the ability
to detect and interpret deterioration, to communicate clearly and
to start the correct response without delay.10 By implementing
a standard observation protocol incorporating the modified early
warning score (MEWS), better and accurate patient observation and
0300-9572/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.resuscitation.2013.03.016

K. De Meester et al. / Resuscitation 84 (2013) 1192–1196 1193
interpretation of abnormal vital signs was achieved in our
hospital.11 The components “detection” and “interpretation” were
improved. It remained unclear whether in cases of patient deterio-
ration the nurse–physician communication was clear and provided
the best information to optimize collaboration so physicians
could respond without delay. Dr. Michael Leonard, physician-
leader at Kaizer Permanente in Denver introduced standardised
communication with the SBAR (situation, background, assess-
ment, and recommendation) structure to optimize effective
communication.12,13 By using the SBAR tool nurses could be
empowered to formulate a recommendation to a physician. This is
only possible after formal assessment of the patient and knowing
the situation and the background of the patient. We hypothesized
that if nurses are better prepared before calling a physician and
by structuring the communication, physicians should be better
informed and able to prioritise in their work, give the best orders
and take the right actions.
The aim of this study was to determine the effect of standard
SBAR communication in deteriorating patients on the perception
of effective communication and collaboration between nurses and
physicians and on the incidence of SAEs in adult hospital wards.
2. Method
2.1. Design, setting and participants
We investigated SAEs and conducted a questionnaire for nurses
pre and post the introduction of SBAR in the Antwerp University
Hospital (AUH). AUH is the tertiary referral hospital of the Univer-
sity of Antwerp and has one campus of 573 beds. AUH provides
all medical and surgical specialties but has no beds for chronic or
psychiatric hospitalization. In the research period there were 244
beds on nine medical wards including a 10-bed cardiac care unit,
205 beds on seven surgical wards including eight beds for medium
care and 45 beds on five intensive care units (ICUs). Of the 16 med-
ical and surgical wards nine have one nurse and seven have two
nurses during the night shift. A mobile team of two nurses and one
nursing aid support these nurses each night shift. The hospital has a
physician-led cardiac arrest team 24 h a day, seven days a week. No
additional rapid response team is available.The pre intervention
period was 10 months between July 2010 and April 2011, and the
post intervention period was 10 months between May 2011 and
March 2012. To measure perception of effective nurse–physician
communication and collaboration, nurses and physicians were
asked to respond to the “Communication,Collaboration and Crit-
ical Thinking Quality Patient Outcomes Survey Tool” (CCCT Tool)
questionnaire by Vazirani et al. pre and post intervention.14 The
participants for this questionnaire were all nurses involved in the
direct care for patients on medical and surgical wards. The face
validity of the Dutch translation of the CCCT Tool was verified by a
staff nurse, one director of nursing and two physicians. Consensus
on wording was achieved. The translation was then back-translated
into English for validation by an academic qualified expert. The
hospital admission and discharge registration system and the hos-
pital registration for emergency calls were used to detect cases of
SAEs. This included all patients older than 16 years without do
not attempt resuscitation (DNAR) order who stayed for at least
one night on a medical or surgical nursing unit during the study
period. Patients with a DNAR code were excluded from the study
because the outcome indicator “unexpected death” was defined as
“death without pre-existing DNAR code”.15 The Ethics Committee
of the hospital approved the study (EC Nr 11/43/316) registered
in Belgium under number B300201112705.Informed consent for
patients was waived as no therapeutic intervention was scheduled
or influenced by the trial. Nurses participating in the questionnaire
signed for informed consent.
2.2. Intervention
The intervention was the second step in the introduction of the
afferent limb of a RRS.9 The afferent limb of a RRS has the follow-
ing components: patient observation, measurement of vital signs,
patient assessment,recognition of clinical deterioration, call cri-
teria for triggering a response and a policy to communicate with
the health care workers of the efferent limb of the RRS.The first
step was introduced on 1 November 2009 and consisted of the
introduction of a standardised nurse observation protocol includ-
ing the MEWS and a coloured graphical observation chart.11 The
MEWS includes 6 vital signs: heart rate, respiratory rate,oxygen
saturation, consciousness (AVPU = alert, voice, pain, and unrespon-
sive), systolic blood pressure and temperature.16 This second step
focused on better communication, collaboration and critical think-
ing in cases of clinical emergencies on medical and surgical wards.
Nurses were educated and instructed to use the SBAR tool for han-
dover communication between nursing shifts and to use SBAR in
cases of deteriorating patients when calling a physician. Physicians
were not instructed because the aim of this study was to use SBAR
only in the communication of nurses calling physicians.First, for
each ward one or two reference nurses received a two-day course
in SBAR by discussing the problem of communication-related errors
and the need for standard communication in clinical emergencies,
explaining the use of SBAR and training in using SBAR by role-play.
Second, the other nurses were educated and instructed by the ref-
erence nurse of their ward in a 2-h training session. Additionally, a
4-h lesson on early detection, the ABCDE algorithm (airway, breath-
ing, circulation, disability, and exposure), critical thinking and SBAR
communication for all nurses was part of the intervention.17,18
Nurses were instructed to be better prepared before calling for
help by taking every step in the early warning process: frequent
patient observation and measuring six vital signs at the same time
according to the standardised nurse observation protocol, calcula-
tion of MEWS, assessing the patient by using the ABCDE algorithm
and notating their findings in the patient record according the SBAR
structure. No instruction was given about writing down and reading
back the verbal orders given by physicians.
2.3. Main outcome measures
2.3.1. The questionnaire
The perception of effective communication was measured by
the CCCT Tool.13 Twelve questions were postulated for nurses about
physicians. A 4-point Likert scale was used scoring each ques-
tion in the same direction: “strongly agree (4 points)”,“agree (3
points)”, “disagree (2 points)”,and “strongly disagree (1 point)”.
Three dimensions were deducted: collaboration,communication
between nurses and physicians and perception of communication.
2.3.2. Cases of a SAE
Patient records with identified SAEs were checked by an investi-
gator for a period of 48 h before the SAE for SBAR items according to
the SBAR form of the Kaiser Permanente Centre for Health Research
(1) to investigate if nurses prepared their communication accord-
ing to the SBAR protocol, (2) to analyze the type and frequency
of vital signs noted in the patient record. SAE’s were defined as:
unexpected deaths (=deaths without do not attempt resuscitation
code), unplanned admission to an ICU and cardiac arrest team
calls.19,20

1194 K. De Meester et al. / Resuscitation 84 (2013) 1192–1196
Table 1
Demographics of “Communication, Collaboration and Critical Thinking Quality Patient Outcomes Survey Tool” questionnaire participants.
Total Pre intervention period Post intervention period
Nurses Number 425 245 180
Gender (male) % 10.6 9.1 12.9
Age in years Mean (range) 40.0 (21–64) 40.5 (21–64) 39.51 (21–63)
Medical nursing unit % 42.9 46.9 37.3*
Surgical nursing unit % 57.1 53.1 62.7*
Experience in years Mean (range) 15.4 (0–44) 15.4 (0–44) 15.4 (0–37)
Years in the nursing unit Mean (range) 12.0 (0–32) 11.3 (0–32) 13.2 (1–32)
p-Values: independent samples t-test, Pearsons’ chi-square, Mann–Whitney U-test not significant.
* Pearsons’ chi-square = p < 0.05.
2.4. Statistical analysis
Descriptive analysis of the study population was performed
comparing the characteristics of the pre and post intervention
population. Independent sample t-test, Pearsons’ chi-square, Fish-
ers’ exact test and Cronbachs alfa were performed. In cases of
non-normally distributed continuous variables the non-parametric
Mann–Whitney U-test was used. The relative risk ratio (RRR) and
number needed to treat (NNT = ((1/ARR) × 100)) were calculated.
For data analysis we used SPSS®, version 20.0 (IBM, Chicago, IL,
USA) and statistical significance was set at p < 0.05.21
2.4.1. The questionnaire
The total score on the CCCT Tool ranges from 12 to 48. We
transformed this to a 0–100 scale by using the formula: ((total
score − lowest possible score)/range of total score) × 100 for clar-
ity reasons. Mean values are reported. The three dimensions were:
“collaboration” (questions 1, 2, 3 and 4), “overall perception of com-
munication” (questions 5, 6, 7), “communication between physicians
and nurses” (questions 8, 9, 10, 11 and 12).
2.4.2. Patient record analysis
Wards were divided according to medical and surgical specialty.
Length of stay (LOS) was coded in days. The variable SBAR was
scored “1” if all 4 elements of SBAR were found in the patient
record and all other possible combinations were scored “0” as not
compliant with the SBAR protocol.
3. Results
3.1. The questionnaire
The questionnaire was completed by 425 nurses. Nurses’
response rate in the pre intervention period was 72% (n = 245) and
53% in the post intervention period (n = 180). For questionnaire par-
ticipants there were no demographic differences between pre and
post intervention group (Table 1). The mean age of the respondents
was 40 years, they were mainly female (90%) of Belgian nation-
ality (92%) and worked as a nurse for 15 years. Sixty percent of
the nurses had a bachelor degree. Nurses’ total score on the CCCT
Tool increased from 58 (range 31–97; Cronbach’s alpha = 0.883) in
the pre intervention period to 64 (range 25–97; p < 0.001; Cron-
bach’s alpha = 0.843) in the post intervention period. The subscales
for nurse–physician communication and for collaboration changed
in the same direction (Table 2).
3.2. Patient record analysis
The SBAR items were notated more frequently in patient records
from mean 32% in the pre intervention period to 56% (p < 0.005)
post intervention. Pre intervention only 4% of the SAE’s all 4 SBAR
elements were notated in the patient records and in the post inter-
vention period this increased to 35% (p < 0.001).
3.3. Patient outcome
During the research periods with 210,074 inpatient days and
37,239 admissions there were 207 SAE’s of which 81 (4.4/1000
admissions) in the pre intervention period and 126 (6.7/1000
admissions) in the post intervention period.Of the patients with
SAE’s 35% had a previous ICU episode during the same hospital
stay. Compared to the pre intervention period patients with a SAE
episode in the post intervention period were younger (from mean
68 to 63 years) and stayed shorter in the hospital (from mean
32 days to 46 days) (Table 3). Patients with SAE episodes were
mainly male (54%) and were admitted to medical wards in 73%.
In 88% of the SAE’s vital signs were found in the patient record up
to 8 h prior to the event.The number of unplanned ICU-transfers
increased from 51 (13.1/1000 admissions) in the pre interven-
tion period to 105 (14.8/1000 admissions) in the post intervention
period (RRR = 50%, 95% CI = 30–64; p = 0.001). There was no signifi-
cant difference in Cardiac Arrest Team calls (Table 3). The number
of unexpected deaths decreased from 16 (0.99/1000 admissions) in
the pre intervention period to 5 (0.34/1000 admissions) in the post
intervention period (RRR = −227%, 95% CI = −793 to −20, NNT 1656;
p < 0.001).
Table 2
Results of the “Communication, Collaboration and Critical Thinking Quality Patient Outcomes Survey Tool” questionnaire.
Pre intervention
N = 245
Post intervention
N = 18
p Cronbach’s alphaa
Nurses
Total score (48b) 58.6 (31–97) 63.9 (25–97) <0.001c 0.871
Subscales
Collaboration (16b) 56.2 (0–100) 62.2 (17–100) <0.001c 0.795
Communication with physician (20b 62.9 (20–100) 68.9 (13–100) <0.001c 0.872
Overall perception of communication (12b) 55.3 (0–89) 58.4 (0–100) 0.042c 0.769
a Cronbach’s alpha for the whole population.
b Independent samples t-test.
c Scores corrected to a 0–100 scale.

K. De Meester et al. / Resuscitation 84 (2013) 1192–1196 1195
Table 3
Demographics of pre and post intervention period population and cases of SAE’s.
Total Pre intervention period Post intervention period
Included medical and surgical nursing units
Admissions n 37,239 18,405 18,834
In-patient days n 210,074 105,694 104,380
Hospital length of stay in days Mean 5.64 5.74 5.54
Mortality /1000 admissions 10.45 10.29 10.60
SAE’s n 207 81 126*
Unexpected death /1000 admissions 0.66 0.99 0.34#
Cardiac arrest team calls /1000 admissions 3.06 3.15 2.97
Unplanned ICU admissions /1000 admissions 13.99 13.13 14.85#
Severity of illness
Level 1 % 37.5 37.8 37.2
Level 2 % 42.7 42.9 42.4
Level 3 % 13.7 13.4 14.3
Level 4 % 6.0 6.0 6.1
Risk of mortality
Level 1 % 65.9 66.7 64.8
Level 2 % 18.0 17.5 18.6
Level 3 % 11.4 11.2 11.7
Level 4 % 4.7 4.6 4.8
In cases of a SAE
Age Mean (range) 65.1 (18–92) 68.2 (24–92) 63.1 (18–90)
Gender (male) % 53.6 53.1 54.0
Hospital length of stay in days Mean (range) 37.9 (1–212) 46.2 (1–212) 31.7 (2–124)
Hospital length of stay up to SAE in days Mean (range) 10.5 (0–125) 13.0 (0–125) 8.8 (0–63)
Medical nursing unit % 72.5 65.4 77.0
Surgical nursing unit % 27.5 34.6 23.0
Previous ICU admission before SAE % 35.3 34.6 35.7
Vital signs measurement in the 8 h before SAE % 88.4 85.2 90.5
* Pearsons’ chi-square = p < 0.05.
# Fishers’ exact test = p < 0.05.
§ Independent sample t-test = p < 0.05.
4. Discussion
To our knowledge, this is the first study to show a significant
reduction in unexpected deaths after the introduction of SBAR.22–34
A systematic review of the literature on nursing handoff com-
munication concluded that negative consequences of inadequate
nursing handoffs are well-known but that little research has been
done to identify best practices.35 The current study confirmed
the Joint Commission Patient Safety Goal 2 (IPSG 2) statement
regarding better effective communication in the context of deteri-
orating patients.1 Because AUH is a teaching hospital, it is common
that junior doctors and nurses have responsibility over hospi-
tal nursing unit patients. When on call, junior doctors need to
make decisions about patients unknown to them and in special-
ties they are less familiar with.To help nurses in the use of SBAR
they were educated in critical thinking in order to become more
confident in the assessment of a patients’ condition and in the
formulation of a recommendation for treatment to a doctor.This
education could in itself have contributed to the improvement in
our study and it is a necessary step in our intervention. It has
been shown that nurses sometimes are reluctant to call a doc-
tor because they are uncertain or afraid of “looking stupid”.36 We
found that SBAR helped nurses in this respect. Patient records
showed that nurses were better prepared before calling a doctor
and they scored higher on the perception of communication and
collaboration in the post intervention period after the introduc-
tion of SBAR. In a previous study we showed that a standardised
nurse observation protocol including MEWS after ICU discharge
had a positive effect on observation frequency, and yielded an abso-
lute risk reduction for SAE’s within 120 h after ICU discharge. 11
In the current study,by introducing SBAR,we improved effective
inter-professional communication and collaboration. Additionally
this study shows an increase in unplanned ICU transfers and a
decrease in unexpected deaths. RRS’s aim to shift patient outcome
from “unexpected death” over “cardiac arrest” and “unplanned
transfer to ICU” to “planned transfer ICU” or “stabilized on the
nursing unit”.20 To interpret our results we assume a shift from
unexpected deaths to unplanned ICU admissions,because nurses
detected patients earlier in the deterioration process and alerted
actions of a higher level of care to rescue them. Therefore, patients
could be treated on the nursing ward but if necessary they were
transferred to an ICU. If this transfer happened in a timely man-
ner it could be called a more predicted and controlled “unplanned
ICU admission”, if too late it is more a sudden and less con-
trolled “unplanned ICU admission“. The aim of this study was
not to reduce LOS. However a relatively shorter LOS in the post
intervention period may suggest improved care for deteriorating
patients.In a recent study Shearer et al.found local informal cul-
tural rules within the clinical environment and intra-professional
hierarchies in clinical areas as the main contributing factor for fail-
ure to activate the RRS.37 We believe that by introducing SBAR
these factors can be neutralized to prevent failure to activate
the RRS. Using SBAR, nurses are better prepared before call-
ing a physician and to formulate a recommendation based on
solid assessment. Nurses are more confident in their judgment
and have better chances to convince the physician on call about
the severity of the situation, that physicians will give orders
promptly and that they come and see the patient as required.
Our current study contributes to the debate of afferent limb
failure. By using SBAR we believe that “lack of appreciation of
urgency”,“lack of calling for assistance” and “lack of insight into
own limitations” can be tackled because better inter-professional
communication and collaboration in deteriorating patients is
achieved.38,39

1196 K. De Meester et al. / Resuscitation 84 (2013) 1192–1196
4.1. Study limitations
The study design had the limitations of similar cohort studies
with historical controls, it reflects only a single centre, and we can-
not conclude that the effect solely resulted from our intervention.
Therefore the results cannot be generalised. No conversations were
recorded or analysed to verify if SBAR was really used. There was
a drop in nurse survey participation.Doctors were not instructed
or educated neither in the use of SBAR nor in critical thinking. This
should be the next step for improvement and has to be investigated.
In addition, we recommend future studies to clarify the factors that
support the shift to more predicted and controlled “unplanned ICU
admissions” and the effect on patient outcome.
5. Conclusion
The introduction of SBAR communication in our tertiary uni-
versity referral hospital increased the perception of effective
communication and collaboration in nurses. Nurses were better
prepared to call a doctor after the introduction of SBAR by using
SBAR items in patient records. The number of unplanned ICU admis-
sions increased in the post intervention period and the number of
unexpected deaths decreased. The number of Cardiac Arrest Team
calls stayed the same. This means a shift in the direction of earlier
detection, trigger and response potentially attributable to SBAR.
Conflict of interest statement
No conflicts of interest to declare.
Appendix A. Supplementary data
Supplementary data associated with this article can be
found, in the online version, at http://dx.doi.org/10.1016/
j.resuscitation.2013.03.016.
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