Contextualizing the Content of Clinical Communications: A Learning Point

Suboptimal communication or inadequate exchange of important clinical information can be peculiarly perilous in subspecialties like cardiac anesthesia that are characterized by a highly predisposed working environment.¹, ², ³ While the fraternity acknowledges an effective communication to be at the cornerstone of minimizing the susceptibility to avoidable perioperative critical events, as George Bernard Shaw aptly puts it: the major problem with communication is precisely the illusion that it has taken place.¹, ⁴

The diversity in the experience of the communicating clinical workforce and the subjectivity of the communication mode compound the matter furthermore. Withstanding the above-mentioned fact, refinement of the objective communication skills of the young trainees continues to be an area of active interest. In this respect, the UK National Health Service (NHS) endorsed: Situation, Background, Assessment, Recommendation (SBAR) classifies as the most frequently cited tool for clinical communications.¹ Devised by Doug Bonacum, the origins of the SBAR tool are linked to the US Navy with its implementation aimed at effectively communicating critical mission information regardless of the hierarchical factors.⁵

Despite inconsistencies in the literature on SBAR application, partly owing to issues like compliance and physician-dependence of the information transfer in heterogeneous settings, it is expected to enhance the completeness of the patient-related communication during face-to-face handovers among clinicians.¹, ⁵ This is heralded by the fact that the informative content needs to be closely backed by the contextual component wherein a SBAR approach can be of particular assistance. The former can be explained in the light of the following SBAR-based handoff of a patient manifesting a state of hemodynamic compromise:

• Situation: Difficulty in maintenance of hemodynamic stability while weaning from cardiopulmonary bypass (CPB) in a 2-year-old patient who has undergone a ventricular septal defect (VSD) closure.

• Background: The patient had a documented severe preoperative pulmonary artery hypertension (PAH, associated with a large VSD) and a prolonged aortic cross clamp and CPB time.

• Assessment: Hypotension with high right atrial pressures, desaturation amid an unexplained high airway pressure, and tachycardia with ischemic changes in right-sided leads suggest a setting of PAH crisis as the cause of hemodynamic instability. Assessment for the presence of PAH aggravating factors (acidosis, hypoxia, hypercarbia, and pain) accompanied by an echocardiographic assessment of PAH and concomitant right ventricular (RV) function.

• Recommendation: To break the vicious cycle of PAH-(hypoxia, acidosis, hypercarbia)-PAH by augmenting the fractional inspired oxygenation, ensuring an adequate minute ventilation and correcting metabolic acidosis. Inotropic-pulmonary vasodilator infusions, like adrenaline and milrinone, to support the RV function and alleviate PAH. In refractory cases, call for team-help to initiate inhaled nitric oxide or extracorporeal membrane oxygenation.

While the SBAR model can prove to be instrumental in a structured communication between specialists, the need for a succinct nonspecialist based “go-between” communication to seek requisite clinical assistance can also not be undermined. MacDougall-Davis et al propose a traffic-light color-coded tool to flag the urgency of the clinical situation to minimize the possibility of the situational gravity from being lost-in-translation in a “go-between” communication.¹

With the availability of lucid patient handover checklist tools like SBAR, there are ever-increasing viable options to provide an accurate, concise, consistent, and effective patient care transfer. Alongside the institutionalization of the protocols and practices, the standardization of the communication within the clinical framework is the need of the hour. The notion is strengthened by the literature on the role of organizational factors in influencing the patient safety.⁶ Moreover, this paradigm shift can be further perpetuated in the information technology age by supporting the development, incorporation, and operationalization of the computerized patient handover applications as a component of the electronic clinical record systems.⁷