Dealing with difficult docs using SBAR

SBAR

Before I start an “us” vs. “them” war, let me start off by saying that I cannot imagine the pressure that physicians are under these days. They go for long stretches with no days off, work very long hours, have tremendous responsibility and, basically, have a job that I would never ever ever want. So, with that said, it is understandable that you will, at times, deal with a difficult or demanding physician. These tips about SBAR and effective communication should help!

Be ready for rounds

Some units have set times for rounds, others don’t. So, one of the first things you want to do at the start of your shift is create a “problem list” and a “wish list.” What problems is your patient facing? And, what orders would you like to receive to help alleviate those problems? This is also the time to foresee potential problems your patient might have, so you can get all (or most) of your routine orders out of the way and avoid having to page the MD mid-shift.

For formal rounds, your unit may have a set routine it follows…this was how we did things in the MICU. The entire huge team (MD, NP, social worker, dietician, ICU pharmacist, ICU physical therapist, respiratory therapist and charge nurse) would gather outside the patient’s room, and the nurse would then launch into a brief overview of the patient and then go through a list of pre-determined topics (number of days on the ventilator, VTE prophylaxis, stress ulcer prophylaxis, I/Os, current gtts, etc…). At the end of the spiel we would propose our “wish list” and get a lot of routine orders done all at once. Where I work now, there are no formalized rounds. The docs come when they can (which is basically when they’re not in surgery) and we don’t go through a formalized list of topics. In cases like this, the best thing to do is just be ready with your wish list and a brief summary of any issues the MD needs to be aware of so s/he can take care of them in the moment (and avoid getting paged later).

Paging the doc: gather your data

So it’s 3am and your patient’s urine output has decreased over the last two hours and now they’re febrile and hypotensive. As much as  you don’t want to…you gotta call the MD. Regardless of the time of day, check with your coworkers to see if anybody else needs to talk to the doc…that way, you’re just sending out one page for the two or three nurses who need things, rather than a bunch of individual pages that might put your MD over the edge.

Before you make that call, gather your data. Know exactly WHY you’re calling and be ready with any supporting data  you may need. In the case of our patient whose urine output is decreasing here’s what else the MD may want to know:

  • Admitting diagnosis and any significant events (the MD you call may know NOTHING about this patient, so a brief summary may be needed).
  • Urine output trends
  • Current blood pressure and trends over the last few hours
  • Bladder scan results (tells you if there’s urine sitting in the bladder)
  • Fluid balance overall
  • Current fluids running (how many ml/hr)
  • BUN, creatinine, chemistry and CBC results
  • Any history of renal impairment
  • Any periods of hypotension prior to this one
  • EBL from surgery (if applicable)
  • Did the patient recently receive contrast dye? (it can cause renal impairment).
  • Any nephrotoxic medications?
  • Do they take Lasix at home? How much? Have they received Lasix in the hospital? Did they respond to it?
  • Current ejection fraction if known….especially if it’s abnormal
  • Any other signs/symptoms of sepsis

Now, you don’t need to go into a huge spiel and cover all this in your SBAR to the doc. But be ready with the pertinent info so you can answer questions as they come up. For example…let’s say you’ve gone through this list of things to consider and thought about how you’d answer:

  • Admitting diagnosis and any significant events (the MD you call may know NOTHING about this patient, so a brief summary may be needed).
    • Pt was admitted for abdominal pain and had an exploratory laparotomy yesterday for a perforated viscous, which was repaired.
  • Urine output trends
    • 75 per hour for first 4 hours of shift, then 25 in the next hour, 20 in the next and 12 in this past hour.
  • Current blood pressure and trends over the last few hours
    • Current BP is 95/47; prior BP ranges 135-144 systolic
  • Bladder scan results (tells you if there’s urine sitting in the bladder)
    • Bladder scan revealed no urine in the bladder
  • Fluid balance overall
    • The patient is 2 liters positive overall
  • Current fluids running (how many ml/hr)
    • NS at 75 ml/hr
  • BUN, creatinine, chemistry and CBC results
    • BUN is normal, creatinine was slightly elevated this morning, K is 4.9, and Hgb is 9.0
  • Any history of renal impairment
    • Stage 1 renal disease, never been on dialysis
  • Any periods of hypotension prior to this one
    • Hypotensive in ED with BP 82/36. Given fluid bolus 2 liters.
  • EBL from surgery (if applicable)
    • EBL 500; no blood given as BP and O2 saturation was stable in surgery
  • Did the patient recently receive contrast dye? Dye can cause renal impairment.
    • Yes…pt had an abdominal CT upon admit yesterday
  • Any nephrotoxic medications?
    • None
  • Do they take Lasix at home? How much? Have they received Lasix in the hospital? Did they respond to it?
    • Pt takes 20mg of Lasix daily; has not received any this admission
  • Current ejection fraction if known….especially if it’s abnormal
    • Unknown; no signs of CHF
  • Any other signs/symptoms of sepsis
    • Febrile, altered mental status

Paging the doc: do your SBAR like a boss

So you’ve paged the doc and now you’re waiting for a call back. You want to take the data that you’ve gathered and put it into a succinct SBAR report. Remember the letters refer to Situation, Background, Assessment and Recommendation. Here’s how it might look:

SITUATION: Hi Dr. Espejo, I’m calling about your patient Oliver Truman. I’m concerned that he’s showing signs of sepsis. His urine output has decreased, he’s febrile and hypotensive.

BACKGROUND: Mr. Truman had an ex-lap yesterday morning for a perfed viscous. He was hypotensive upon arrival to the ED but responded to a 2 L fluid bolus.

ASSESSMENT: For the past two hours, he’s put out 32 ml urine. Baseline BP has been 120s-140s currently 95 systolic. He’s more somnolent and has spiked a temp of 102.3. He currently has NS running at 75ml/hr.

RECOMMENDATION: Can we try a fluid bolus and pan culture him?

Most likely at this point the doc will say yes and then ask a few more questions…hopefully the ones you’ve anticipated! Have the patient’s chart open so you can look up any data on the fly, just in case. Go you!

P.S. “Pan culture” means to do all the cultures…blood, urine and sputum.

Paging the doc: never ever ever apologize

Unless you’ve made an actual mistake, NEVER ever ever ever ever apologize for calling the doc. It is your job to speak up for your patients, regardless of the time of day or night. I cringe every time I hear a nurse say, “Sorry to bother you, but….” You are not BOTHERING the doc and you are NOT sorry…you are updating him/her on important changes in the patient’s condition. You are doing YOUR job and you are helping the MD do his/her job. Period.

Now, if you’ve actually made a mistake…like accidentally pulled a JP drain, given heparin instead of levaquin (yes, I saw this once), then yeah…you can apologize. But for updates on patient condition when you are advocating for your patient? THIS DOES NOT WARRANT AN APOLOGY! Ok, there…I’ve said it.

Paging the doc: be professional and polite

It goes without saying that you should always approach communications with your coworkers in a polite and professional way. Even if the doc is a total jerk to you, doesn’t mean that you should respond in kind. When they go low, we go high…remember that? If a doc is rude, don’t take it personally and don’t get defensive. At the end of the call, I always say “thank you for your help” and leave it at that..even if I’d rather say something not so kind. We are all on the same team…keep it focused on the patient and you’ll be fine.

When the doc is a total jerk

Sometimes docs are jerks…after all, they’re people, too. And some people are just straight up doctorsunpleasant. So if you are dealing with a jerk doc, the best advice I can give is to try not to take it personally. Keep your motivations focused on doing what’s best for the patient and, most importantly, DO NOT let a fear of a doc’s outburst keep you from advocating for your patient. I’ve seen lots of nurses avoid calling the doc because they’re afraid of getting yelled at. How does that help your patient? It does not…working in a hostile environment such as this is a patient safety issue and you should definitely bring it to the attention of your supervisor.

So what do you do if a doc totally goes off on you? If they’ll listen, then state your case as succinctly as possible and walk away from the situation. You do not have to stand there and take abuse from anyone. If your doc is yelling/cursing at your for any reason, throwing things, bullying you or insulting you…you need to move things up the chain of command. This is unacceptable in the workplace and needs to be addressed. Alert your charge nurse so s/he is aware of the situation and can help facilitate you getting what you need for your patient.

Also, Let your unit manager know exactly what was said/done before you leave for the day. If there’s an issue with a doc bullying or abusing the nursing staff, then your manager definitely needs to know about it. And finally, don’t internalize…talk it through with your coworkers so you can get back to focusing on your patient with a clear head. And, if this kind of behavior is common practice in your unit…you might want to look for another job. I wholeheartedly agree that docs who bully the staff present a clear danger to the patients…the nurses are hesitant to speak up and things get missed. Plus, you worked your tail off to get your license…you deserve to work somewhere where you are appreciated and team members treat one another with respect. It’s that simple.

Taking telephone/verbal orders

In a perfect world, the docs put in their own orders but this isn’t always possible. The doc you talk to might be at home, in surgery or simply too busy to stop at a computer. When you get your orders, always clarify who will be putting the orders in (“will you be putting those in, or would you like me to?” is what i usually say.) If the doc wants you to put the orders in, make sure you get all the information you need. For example, let’s say you’re getting orders for Mannitol to decrease your patient’s ICP (like in this post). Here’s what you need to know:

  • Dose
  • Frequency
  • Scheduled or prn (if prn you need the indication…in this case it’s typically ICP > 20)
  • Hold parameters (serum osmolality > 320 is typical)
  • Any associated labs (in this case, serum osmol)

If the doc is ordering a narcotic,  you might want to also ask for benadryl and zofran since opioids can cause itching and nausea. Get all the info/orders you need at once so you don’t have to keep calling back. It will be appreciated.

And, of course, any time you take a telephone/verbal order…repeat the entire order back to the MD to ensure you heard it correctly. And, before you hang up, I always ask “Is there anything else?” and then I thank them for their help. What can I say…I try to be the change I want to see in the world…haha.

Advocate advocate advocate

Remember that the docs only see their patients for a few minutes each day. You are the eyes, hands and ears of the doc…and you are the voice of the patient. Always. With these tips I hope you feel more confident speaking up for your patients and getting what you need from the docs.

And try to remember, if you think your job is tough (and it is!), then the physician’s job is even harder…the hours, the commitment and the stress are enormous. Be kind and understanding, but also stand up for yourself (and, of course, your patient!)

Got any tips for dealing effectively with the medical staff? Let us know in the comments below! And be safe out there!

 

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