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Abstract

Introduction: There is limited literature evaluating the integration of the electronic health record (EHR) to a structured communication template such as the SBAR (Situation, Background, Assessment, and Recommendation) model to improve physician documentation of significant in-patient events. Hypothesis: We hypothesized that an electronic SBAR template within the EHR would improve interdisciplinary communication with more frequent, higher quality physician documentation compared to traditional paper charting. Methods: We reviewed 542 PICU admissions over 9 months, collecting 84 documented patient events. Three time periods were studied: 1) paper chart documentation only, 2) only electronic free-text notes after EHR implementation, and 3) electronic documentation with an SBAR template option. Each event note was scored to assess quality by allotting 1 point for each completed element of the SBAR, totaling 4 points. Documentation pre- and post- implementation of the EHR and SBAR template note was examined using ANOVA and chi-square analysis to assess quality and frequency, respectively. Results: The frequency of event notes showed an increasing trend from paper documentation (12.7%), to EHR free-text notes (14.2%), and greater after instituting the electronic SBAR note (19.8%, p = 0.071). Mean scores assessing quality were 2.23 points (95% CI = 1.96-2.50) with paper documentation, 2.57 pts (95% CI 2.17 -2.97) with EHR free-text notes, 3.24 pts (95 CI = 2.90 – 3.57) after initiation of the SBAR template note, and 4.0 pts when only the SBAR template was used (p<0.0001). Nurses were never identified (0%) with paper documentation, identified 7.1% with free-text EHR and 44.1% post-SBAR template note (p<0.0001). Analysis of the SBAR notes alone showed 100% identification (p = 0.006). The attending physician was notified 18.2% with paper documentation, 53.6 % with EHR free-text note, 79.4% post- SBAR template (p<0.0001) and 100% notified when only the SBAR template note was used (p < 0.0001). Conclusions: The implementation of an SBAR template within the EHR resulted in higher frequency and higher quality documentation of significant patient events, with increased multidisciplinary communication.