'There ain't no party like an SBAR party'

Case Based Learning - 'The single biggest problem in communication is the illusion that is has taken place ' 

George Bernard Shaw

In an attempt to keep the shared learning coming, I am going to try something new in this post.  Rather than pull a series of cases together and combine the learning I am going to share some of the 'SBAR Incident Alerts' I produce for my ED and hospital. Again theses are ALL real incidents. The errors are genuine, and I suspect will be recognisable to all experienced EM clinicians.

The SBAR (Situation, Background, Assessment, Recommendation ) format is one that will also  be familiar to many. It was originally derived from military use and is a really useful tool to aide clear communication.
 

  Where I work we have introduced SBAR type notification as our standard form of documentation for information coming into the ED, be that paramedic alerts or abnormal investigation results.

We have also introduced it to our ED Notes as a summary page to aide handover between clinical teams and in our Clinical Decisions Unit at the end of protocols so that the referring clinicians can clearly outline their expectations for the patient

Used correctly and aye there lies the rub, SBAR use help delivers safer patient care and also protects clinicians.

I HIGHLY recommend considering using it.

Information about SBAR can be found here- NHS Institute for Innovation and Improvement on SBAR

Situation

Missed C2 Fracture

Background

An elderly patient attended from his Nursing Home having fallen on to his face on concrete sustaining significant bruises to his face and head. He had quite marked dementia which made assessment difficult but he seemed to have good neck movement and complained of no localised pain there.

X-rays were taken of his mandible which was deemed to be normal before a plan to admit to Med Eld was made.  The following day he was seen on the ward round and again had no neck pain and was deemed fit for discharge.

He returned to the ED 3 days later as the nursing home staff felt he was more confused than normal.  He was noted to have no ‘neck tenderness’ before being sent for a CT of his head and brain.

The CT confirmed facial fractures, small intra-cerebral haematomas and also showed an off ended PEG (C2) fracture with cord impingement.

He was fitted in an Aspen Collar before transfer to Med Eld for conservative treatment

Assessment

The ED teams initial failure to diagnose the C2 fracture caused no serious harm to the patient however it certainly exposed him to risk and despite repeated ‘no neck pain documentations’ must have caused some him some additional discomfort

Assessing any patient with decreased ability to communicate makes it harder to get things right first time, be that extremes of age, language barriers, intoxication or dementia

Frail elderly people break more easily than you think.

A fall banging the forehead /face is a classic mechanism for PEG fractures (hyperextension of the neck)

They are VERY easily missed

Neck Radiology 

Recommendation

Remember ‘the head bone is connected to the neck bone’  so any facial injury puts the neck at risk

Have a lower threshold than normal for CT imaging of the neck in patients with the right history and decreased communication abilities

 NICE CT Neck Algorithm

College of EM- Neck Imaging 2010 

Remember ’Steel’s rule of thirds’- at the level of C1 the spinal canal consists of 1/3 Cord, 1/3 Bone (peg of C2) and 1/3 space- so there may be no neurological signs (fortunately)

Also remember Central Cord Syndrome can occur late in this group, even without a fracture CC Syndrome

Remember to give good discharge advice with ‘triggers to return’ for patients or their carers

Situation

Opiate Overdose

Background

A 50 yr old lady was found face down on a golf course having apparently taken 200mg of oramorph . Paramedics gave her IM Naloxone on scene and on the way in (800mcg and 400mcg). On arrival at ED her GCS was 15 with normal observations but she did de-saturate off Oxygen

She was seen immediately by a senior doctor and moved to a visible cubicle next to the nurses’ station on a monitor where she chatted to her family. The doctor was drawn into to resus to deal with other patients but came back approximately thirty minutes later to perform an Arterial Blood Gas (ABG). In that 30 minutes the pt had been cannulated, an ECG performed and was conversant with staff and relatives. The doctor noted that the pt was now very drowsy, with an ABG showing a pH of 7.2, CO2 of 8.38 and O2 of 12 (kPa on high flow oxygen)

She was taken to resus where a naloxone infusion was commenced and BiPAP started before transfer to critical Care. She made an uncomplicated recovery and was discharged the following day.

The case was reported as a potential SI in view of the patient’s deterioration, but subsequently downgraded on review of her care records

Assessment

There are many elements of good care;

Good recording of pre-hospital SBAR

Good nursing assessment with immediate discussion with a senior doctor

Immediate review by the senior doctor

Placement of the patient in a highly visible cubicle on cardiac monitoring

What could have been done better?

The treating doctor did not notice the first dose of Naloxone given by the paramedics was 800mcg

Had they done so they may have considered starting an IV Infusion earlier or further bolus doses

Recommendation

Opiate overdoses should be cared for in a monitored highly visible environment with regular documented obs

If obs cannot be measured regularly on a team the patient should be moved to resus

Always read and document what treatment the patient has had BEFORE arrival. It can influence what you need to do

BEWARE of re- narcotisation

Naloxone has a much shorter half-life (30 to 80 minutes) than most opiates especially methadone (4- 8 hours analgesia, 8-59 hours elimination)

Consider a naloxone infusion (BNF- 10mg (25 vials!)in 50mls of 5%dex)