Implementing Patient Triage Communication, Improving Nurse-Provider Communication and Promoting Safety

Abstract

Problem & Purpose: Ineffective handoff communication is a critical patient safety problem resulting in delays in treatment and adverse events. At a large, hospital-based outpatient clinic of a large East Coast academic medical center, the lack of a standardized communication tool resulted in messages that were misunderstood or lacked valuable information. The purpose of this evidence-based quality improvement project was to facilitate nurse-provider communication through the implementation and evaluation of a patient triage communication tool based upon situation, background, assessment, recommendation (SBAR) methodology. Methods: This DNP project was guided by Lewin's Change Theory. A retrospective electronic health record (EHR) review demonstrated a lack of a structured communication method resulting in communication breakdowns. A literature review demonstrated that SBAR methodology creates a common language for nurse-provider communication. An adapted SBAR methodology communication tool was uploaded into the EMR. Over nine weeks, triage nurses and providers from trauma general surgery teams A, B, C, D, and ACES utilized the communication tool for every patient call. Weekly chart audits evaluated the median time at each point in communication and length of time to close the call encounter. Safety Attitude Questionnaire (SAQ) evaluated teamwork and safety climate pre-implementation and post-implementation. Results: Compliance with the standard communication tool ranged from 83% to 100% (average 95%). The reason for the lack of use in week one of implementation was electronic health record coding issues within the communication tool. Comparing data 1-month pre-implementation through 9 weeks of implementation: SAQ demonstrated the lack of teamwork remained steady at 60%, and communication breakdowns decreased from 70% to 40%; time cycling demonstrated: nurse to provider communication response mean decreased from 1.91 to 1, provider to nurse communication response mean decreased from 0.97 to 0.84 and nurse to patient communication response mean decreased from 1.05 to 0.86. The median length of time from the initial call to the encounter closure decreased from 245.5 (4.09 hours) to 155 (2.58 hours). Process cycling revealed that the triage process could not be standardized under the defined steps as it did not account for variability in nursing practice or quality of the voice messaging system. Conclusions: The standardization of triage documentation impacted the time from the initial call to encounter closure as well as the number of responses between nurses and providers. While the time benchmark of 120 minutes (2 hours) was not met, the improved response times have led to leadership support for sustainability and spread to the remaining four trauma specialty surgery teams.