Effective communication requires a team effort for the exchange of concise and relevant information. Team communication failures are, however, a frequent factor in malpractice claims. In a recent study of obstetric claims closed by The Doctors Company, nearly one quarter of all claims (24 percent) identified communication among providers as a cause of patient harm.
Because obstetrics is one of the higher-risk clinical areas from liability and patient safety perspectives, it is essential to implement a communication protocol to standardize the information exchange among obstetric caregivers.
SBAR, the acronym for situation, background, assessment, and recommendation, is an evidence-based communication protocol used for framing conversations—especially for any exchange that takes place during a situation requiring immediate attention and action.
The following are examples of obstetrical clinical situations, including those meeting maternal early warning signs (MEWS) criteria, that should be addressed using a standardized protocol, such as SBAR:
- Category II or III fetal heart rate (FHR) tracings.
- Systolic BP; mmHG <90 or >160
- Diastolic BP; mmHG >100
- Heart rate; bpm <50 or >120
- Respiratory rate; bpm <10 or >30
- Oxygen saturation; % <95
- Oliguria; ml/hr x 2 hr <35
- Temperature; degrees <35C/95F or >38C/100.4F
- Hypertension with headache, visual disturbances, nausea/vomiting, and/or epigastric pain.
- Agitation, confusion, or unresponsiveness.
- Vaginal bleeding.
- Suspected abnormal presentation.
- Decreased fetal movement.
A 40-year-old woman with a history of fertility treatment and in her first successful pregnancy arrived at the hospital labor and delivery unit at 7:30 AM and reported the onset of contractions and spontaneous rupture of the membranes at 3:00 AM that morning. The on-call attending physician arrived by 8:00 AM and performed an exam. An internal monitor was placed. The patient was 5–6 cm dilated, 90 percent effaced, and at 0 station. The fetal monitor reflected a rate of 120–130 with good variability.
At 9:30 AM, the anesthesiologist placed an epidural. The fetal monitor recorded a late deceleration to the 80s with a slow return to baseline of 120 after placement of the epidural. The patient was repositioned. The maternal blood pressure was recorded at 178/88. The anesthesiologist instructed the nurse to keep him and the attending physician advised of the maternal blood pressure.
At 10:07 AM, the nurse was called to assist with another patient. She reassured the patient that there was a centralized monitoring system in place. At 10:20 AM, she returned to the room. The patient’s contractions had increased in their frequency and intensity. The fetal monitor strip recorded a period of repetitive late decelerations with a return to a baseline of 100–110. The patient’s blood pressure was recorded at 180/100. The patient expressed a strong urge to push. The nurse repositioned the mother again, applied oxygen, and called the attending physician. The nurse reported to the attending physician that the mother’s blood pressure was “going up” and that the patient was feeling the urge to push. The nurse reported that the FHR demonstrated “some variability, but decelerations.” The attending physician said that she would be there “shortly.”
The attending physician arrived on the unit at 10:35 AM. She immediately noticed that the fetal monitor strip recorded a 12-minute period of late decelerations. An exam revealed that the patient was fully dilated, 100 percent effaced, and at +2 station. The mother was pushing, and the FHR baseline had dropped from 110 to the low 90s. A vaginal delivery was initiated, using vacuum assist and forceps attempts, but eventually converted to an emergency cesarean delivery.
The infant was fully resuscitated upon delivery and transferred to the NICU. She was eventually transferred to a children’s hospital for long-term care and was diagnosed with hypoxic ischemic encephalopathy.
This case study provides a good example of how a structured communication protocol between the provider and the nurse could have reduced or prevented the severity of the outcome. Here is how the SBAR model for communication could have been applied when the nurse contacted the attending obstetrician:
- Situation—What is the current situation: The nurse identifies herself and provides a concise statement of the problem.
Example: This is Nurse Jones from L/D. I am calling about Mrs. Taylor in Suite 1. The problem is a Category II to III FHR tracing and a blood pressure of 180/100.
- Background—Clinical background: The nurse briefly relays the patient’s history and any information related to what has occurred.
Example: She is Gravida 1 Para 0 at 40 weeks+ 1 day gestational age. Fetal monitor reflects late decelerations to the 90s with return to baseline of 100–110. The previous baseline was 125. The maternal BP is 180/100, and she has the urge to push.
- Assessment—Includes changes: The nurse conveys her clinical impression, assessment of the problem, and level of concern.
Example: I think labor is progressing, and I am concerned about fetal stress and maternal blood pressure.
- Recommendation—Action recommended: The nurse requests action.
Example: I would like some orders for the blood pressure, and I need you to come to see the patient immediately. When can you be here?
The implementation of SBAR and other standardized communication techniques facilitate a more consistent, complete, and concise exchange of information and play a key role in delivering safe patient care.
For further information, see the online teamwork education courses in our CME catalog. For information on our Team-Building INSIGHT for members, contact Patient Safety at 800.421.2368 or by email.