5.20.2010

ICS SBAR SOAP CUS? Medical Communications...

Communications

Communication is one of the most important tools in the medical profession. The better the communication, the better care the patient is going to receive.

It is especially important for those in EMS. We are the eyes and ears of the doctors and definitives care. Moreover, what we are told prior to arrival is often wrong or inaccurate. It is our job to communicate with the patient, with each other and with higher levels of care. Failure to communicate effectively can lead to a failure in the patient's care.

There are a couple models of communication that have become useful in Emergency Medicine. 

SBAR

Situation - What is going on. (Example. I have an elderly man with chest pain that started about 20 minutes ago.)
Background - History and relevant findings (he had a heart attack two years ago with stents placed. He took three nitro with no relief before calling 911)
Assessment - What's Happening (He may be having a heart attack. His 12 lead states acute mycardial infarction with ST elevation)
Recommendation - What needs to happen (He needs 02, IV, Cardiac monitor, ALS and rapid transport to a cath lab. I have a full set of vitals and a list of meds and allergies.)

We should be using the SBAR model every time we tell a new person about a patient. The first responder is going to use SBAR to communicate to the Ambulance crew, the Ambulance crew needs to communicate to the Paramedic and the Paramedic is going to use it to communicate to the hospital (via HEAR report) and to the doctor or nurse at bedside. SBAR is our tool in updating the team one where things stand and what needs to happen next. 

Here's an example of an SBAR given by a first responder to the arriving ambulance crew:

(S) "Martha here is having a hard time breathing and her son called 911 because she can only speak one word at a time. (B) She has a history of Congestive Heart Failure and had a heart attack two years ago. No history of lung disease. She's been feeling tired and weak for the past 4 days. (A) She can only breathe sitting straight up, her room air 02 sats are 90 %, she's pale and breathing rapidly. Her feet are swollen. Even with a oxygen mask she's only sat-ing at 93%. (R) We need to call ALS and get her to a hospital quickly. She'll need a 12 lead and to be placed on the monitor. Grab the stair chair and the lifepack. Her son is looking for a med and allergy list as well as a copy of her DNR."

Note that you don't have to convey every set of vitals or every part of the SAMPLE history. This is the MOST IMPORTANT STUFF in your clinical understanding. Other stuff can be communicated after the important stuff gets done. Don't be surprised if the patient gets asked the same questions more than once. Sometimes it is important to ask patients questions over and over again in different ways -- whether it is to assess their mentation, or to get a better picture of their medical history. For example, some people deny they have high blood pressure because it's controlled by their blood pressure medication. 
  
Don't confuse SBAR with SOAP charting. They are similar in that the separate information that is all jumbled together in our minds, but one is much more detailed -- even redundant. 

SOAP

Subjective - Stuff people have said -( the call was for a 43 year old woman not feeling well. Patient states she "feels tired and like she's going to throw up" Denies pain but says "it feels like there is an elephant sitting on my chest.")
Objective - Stuff you see and observe - (arrive to find cool, pale, sweating female with her hand on her chest. BP 186/40, HR 175 and irregular)
Assessment - What you think is happening - (patient maybe having an acute cardiac event.)
Plan - What you did and how it went- (IV, 02, 12 lead, ALS. pain relieved with 3 nitro. )

SOAP charting is for charting only and sometimes it is redundant. Sometimes what people tell you and what you yourself observe are the same things. Often in the world of EMS they are not. It is important to chart both. 

Incident Command

It is important for someone to be in charge on the scene of any emergency. Things are chaotic and often times well trained individuals can lack focus without direction. It is important for one person to step back and look at the big picture of what resources are needed, what is getting done and what needs to get done.  This all sounds more impressive than it is. For a small department like ours, incident command can be as simple as one person telling the other units where to park or to bring in a stair chair rather than a stretcher. Maybe if we used the term traffic control that would be less intimidating. In any case there are a few ways we can systematically integrate incident command principles into our everyday response.

First Person on scene - if someone responds to a call by private vehicle, that person is going to have a better idea of what is needed. As soon as possible they should give a quick seen size up report to other responding units and make sure the proper resources are enroute. (This is 384 on scene. I have an elderly man here having chest pain, not abdominal pain and we are going to need to get ALS enroute. He's upstairs in a small room, so 310 we'll need the stair chair and lifepack when you come in.) 

When other units arrive that first responder can remain incident command -- stepping back and letting others take over patient care -- or they can can remain primary caregiver. What they can't do is make assumptions. It has to be handed off to someone else. We can do this by protocol (senior officer assumes IC on arrival) or by verbally handing it off. (Ed, I'll do patient care and you can direct the other units as they arrive.) When we do this, we need to make sure that this shift is communicated effectively to everyone involved. (Okay, I'll take IC you keep doing patient care. Cathlamet 310 will be incident command.) 

Now if there is just one ambulance and three people, you don't need to call over the radio and say  "I'm in charge!" However, you still need to decide who is going to do what on scene.

Closed Loop Communication

So on scene, how should we communicate?

Studies have shown the best method is closed loop communication. In this system:

  • A command is given for a task -- it's best if a person is assigned this task. If you give an open command out in the air, no one will do it, everyone will assume the other person is taking care of it. (Jack, we need 02 15 liters via mask)
  • A response to the command is given to make sure it is understood. (Okay, I'm getting a nonrebreather mask for 02 at 15 liters)
  • The loop is closed when the task is completed (Okay I've got oxygen going and it looks like Sats are improving.)

Assertive

The other thing that's required is assertive speech no soft speech. Soft speech is suggestive and respectful. Often we see soft speech in a situation where there are different ranks involved or one person with more experience than the other. In those situations the less experienced person may know something's wrong but they don't know how to come right out and say it. Instead, the try to hint at the looming danger. After a plane crashed when the co-pilot used "soft speech" and was unable to warn the pilot of error, airline training schools created "critical language" training. This involves the use of words that are designed to get the other team member's attention. 

Concerned - Uncomfortable - Scared

These words tell people to PAY ATTENTION to what they are saying. If you hear these yellow-flag words, it means for the team leader to stop and listen to me. Here's an example.

Team Leader: Okay, let's get this guy on the stretcher
EMT: I'm CONCERNED that this patient has neck pain and was in a car accident, yet we haven't put a C-collar on him.
The team leader doesn't listen to this first yellow flag so the EMT tries again:
EMT I'm UNCOMFORTABLE moving this patient without c-spine immobilization. 
If there is still no response from the team the EMT states:
EMT: I'm SCARED that we may injure this patient if we don't c-spine him.

Situational Awareness

This is away of reviewing what's been done and where things stand. It is a way of getting everyone on the same page. People need to know why they are doing what they are being asked to do.  Situational Awareness makes everyone move forward together and keeps things slow and calm. It also allows a forum for team members to give input on what to do next. Here's an example:

"Okay, we've got a good airway with an OPA and Jack is providing good ventilation with the bag valve mask. We have pulses after two shocks but the patient is not breathing. So let's keep bagging him and what else should we be doing. "

1 comment:

Darrell said...

One of the most useful lists I've ever seen. If these measures were widely practiced hundreds of thousands of lives would be saved