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Adding an I to SBAR: A new twist on communicating patient emergencies

Case study

This case report of a rapid-response activation at the authors’ workplace shows how to use ISBAR during a clinical event, underscoring the importance of structured communication during an emergency. (All names in scenarios are fictitious.)

Stephen Coates, age 55, is admitted to the outpatient clinic for a transesophageal echocardiogram to investigate mitral valve stenosis. The rapid response team (RRT) is activated when his arterial oxygen saturation (Spo2) drops to 82% despite supplemental oxygen via a nonrebreather mask. Methemoglobinemia is diagnosed from the patient’s history and arterial blood gas (ABG) results. Mr. Coates is treated successfully with methylene blue and transferred to the intensive care unit for closer monitoring.


Nurses in many practice settings manage patients with respiratory distress. In our workplace, respiratory distress is the most frequent reason for activating the RRT. You may be well versed in providing appropriate interventions, such as giving supplemental oxygen, elevating the head of the bed, obtaining an ABG sample, and administering other therapies. Although methemoglobinemia warrants supplemental oxygen therapy and elevating the head of the bed, correcting the disorder necessitates methylene blue administration. In a situation like Mr. Coates’, using ISBAR to convey pertinent information helps ensure all healthcare team members are on the same page so the patient receives prompt, appropriate treatment. (See Using ISBAR below.)


Like SBAR, ISBAR provides a structured format that helps you organize your thoughts and communicate essential information concisely to other healthcare team members. However, it includes an additional step at the beginning to introduce or identify yourself.

I: Introduction or identification This is Nurse John Wells. I’m the rapid response nurse responding to patient Stephen Coates. He is currently located in the heart station.
S: Situation I’m concerned about him because he is desaturating.
B: Background Mr. Coates began to desaturate after a transesophogeal echocardiogram, which prompted RRT activation. Before the echo, he received benzocaine spray to numb his throat.
A: Assessment His Sp02 is 82% on a nonrebreather oxygen mask. His respirations are even and unlabored. His lung sounds are clear throughout. He has no complaints of shortness of breath and is talking in full sentences. His nail beds are cyanotic. Results of his previously ordered ABG tests are pH, 7.48; Pac02, 29; Pa02, 319; and Hc03– 22. His methemoglobin level is 44.5% and his arterial blood appears chocolate brown.
R: Recommendation or request I suspect Mr. Coates has methemoglobinemia from the benzocaine he received, and may require methylene blue I.V. immediately. Also, he may need to be transferred to the ICU for a higher level of care and monitoring for harmful effects of methemoglobinemia. Can you come to the patient’s bedside urgently? Do you have further recommendations for interventions to take while you’re en route?

Recommendations for practice

Incorporating the following recommendations into your practice will help you promote positive patient outcomes:

  • Learn about medications and toxins that can cause methemoglobinemia. If your patient develops sudden respiratory distress shortly after exposure to such an agent, suspect possible methemoglobinemia. At our workplace, availability of benzocaine spray (a common precipitant of methemoglobinemia) is limited to a unit-dose (single spray or application) product to reduce the risk of overapplication and subsequent methemoglobinemia.
  • Use ISBAR to promote standardized effective communication in the workplace. Practice using this technique so you’ll be well prepared when you need it. In a patient emergency, ISBAR can be especially useful for identifying a problem quickly and starting targeted recommendations that may save the patient’s life.

In early 2015, our workplace transitioned to using ISBAR for communication about patients between nurses and other healthcare providers. All nurse clinicians have been educated on the rationale and use of ISBAR, and flowsheet rows have been built into our electronic health record to document clinician communication using this technique.

The authors work at the University of Texas Medical Branch in Galveston. Odette Y. Comeau is an adult critical care clinical nurse specialist. Scott A. Woodby is a nurse clinician in the medical ICU/cardiac care unit.

Selected references
Compton J, Copeland K, Flanders S, et al. Implementing SBAR across a large multihospital health system. Jt Comm J Qual Patient Saf. 2012;38(6):261-8.

Cornell P, Gervis MT, Yates L, Vardaman JM. Improving shift report focus and consistency with the situation, background, assessment, recommendation protocol. J Nurs Adm. 2013;43(7-8):422-8.

De Meester K, Verspuy M, Monsieurs KG, Van Bogaert P. SBAR improves nurse-physician communication and reduces unexpected death: a pre and post intervention study. Resuscitation. 2013;84(9):1192-6.

Denshaw-Burke M. Methemoglobinemia. emedicine.medscape.com/article/204178-overview#a1

Institute for Healthcare Improvement. ISBAR Trip Tick. www.ihi.org/resources/Pages/Tools/ISBARTripTick.aspx

Institute for Healthcare Improvement. WIHI: SBAR: structured communication and psychological safety in health care. January 30, 2014. www.ihi.org/resources/Pages/AudioandVideo/WIHISBARStructuredCommunicationandPsychologicalSafetyinHealthCare.aspx

Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine; 2000.

Labson M. SBAR – a powerful tool to help improve communication! @ Home with The Joint Commission. November 19, 2013. www.jointcommission.org/at_home_with_the_joint_commission/sbar_%E2%80%93_a_powerful_tool_to_help_improve_communication/

Prchal JT. Clinical features, diagnosis, and treatment of methemoglobinemia. UpToDate. Updated July 28, 2015. www.uptodate.com/contents/clinical-features-diagnosis-and-treatment-of-methemoglobinemia?source=search_result&search=methemoglobinemia&selectedTitle=1%7E150

Safer Healthcare. Why is SBAR communication so critical?

Steinberg MH. Hemoglobins with altered oxygen affinity, unstable hemoglobins, M-hemoglobins, and dyshemoglobinemias. In: Greer JP, Arber DA, Glader B, et al., eds. Wintrobe’s Clinical Hematology. 13th ed. Philadelphia: Lippincott Williams & Wilkins; 2014: 914-26.

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