Implementation of a Patient Triage Communication Tool to Improve Nurse-Provider Communication and Promote Patient Safety in the Outpatient Clinic

Purpose: Ineffective handoff communication is a critical patient safety problem resulting in delays in treatment, adverse events, increased cost, and inefficiency from redundant work. The purpose of this evidence-based practice (EBP) quality improvement project is to facilitate nurse-provider communication through the implementation and evaluation of a patient triage communication tool based upon situation, background, assessment, and recommendation (SBAR) methodology in the hospital-based outpatient clinic of a large academic medical center on the East Coast.

Description: Patients, caregivers, and providers utilize the outpatient clinic phone system as a primary point of contact for the acute care provider teams, leading to approximately 1500 incoming calls per month. A retrospective review of the electronic triage call logs demonstrated a lack of a structured communication method resulting in triage nurse to provider communications that were misunderstood or lacked valuable information. Additionally, the electronic medical record did not incorporate a triage documentation module. Interviews with leadership and staff as well, as observation of the triage process, identified the need for changes in key structures and processes to improve communication. A literature review focused on the applicability of the situation, background, assessment, and recommendation (SBAR) methodology to support the implementation of a communication tool. Findings demonstrated that SBAR methodology is an evidence-based communication tool that enhances nurse-provider communication by creating a common language for key patient information. A communication tool was adapted using SBAR methodology and uploaded into the electronic medical record by the clinic leadership. The EBP project was approved by the University of Maryland Baltimore (UMB) Institutional Review Board (IRB) for a non-human subject research determination. The target population was patients under the care of trauma teams A, B, C, D, and acute care emergency surgery. An implementation plan to address changes in structure and processes included a safety attitudes questionnaire to measure team culture, staff education, and weekly meetings to support the staff in the practice change.

Evaluation/outcome: Data collection occurred over a 12-week time frame to identify trends to improve process outcomes. Pre-implementation evaluation included the safety attitude questionnaire, a 36-item questionnaire addressing teamwork climate, safety climate, job satisfaction, stress recognition, unit management, hospital management, and working conditions. Questionnaire data (n=10) demonstrated a lack of teamwork (60%) and communication breakdowns (70%). A one-month retrospective chart analysis (n=100) demonstrated the number of nurse-to-provider (mean 1.91), provider-to-nurse (0.97), and nurse-to-patient communication (1.05) to close a telephone encounter. Additional retrospective analysis revealed the median length of time from triage nurse to encounter closure was 235.45 minutes (3.92 hours). Project data will evaluate the median length of time from routing the message to encounter closure and mean of each point in communication. Post-implementation, the safety attitude questionnaire will be re-administered to the triage staff. The implementation of the communication tool resulted in documentation changes within electronic medical record. The clinic leadership has expressed interest in implementing the tool for additional services to improve communication and patient safety.