SBAR 1

[admin]

MRCS Part B – Communication Station (SBAR Handover)

Time allowed: Reading time: 9 minutes
Interaction time: 9 minutes

Candidate Instructions
You are a S.H.O. admitting patients in the Emergency Department.

A patient, Ms Jane Doe, a 62-year-old woman, has just arrived with neurological symptoms. The initial assessment and CT head have now been completed. You have reviewed the notes provided.
Your task is to make a telephone call to the on-call Neurosurgical Registrar to hand over the case and request appropriate further management.

You must use the SBAR framework to structure your handover.
During the station, the examiner will play the role of the on-call neurosurgical registrar and may ask questions about the case or your clinical reasoning.

You should:
Identify yourself clearly at the start of the call.
Provide relevant clinical information succinctly.
Highlight any immediate concerns.
State clearly what you are requesting.
Answer any questions asked.
Demonstrate safe clinical judgement and prioritisation.

You should NOT physically examine the examiner or role player.
You should NOT take a history from the patient.

At the end of the interaction, close the call appropriately.
Who you are calling
On-call Neurosurgical Registrar
The examiner will play this role.

You should assume the neurosurgical registrar is based at the regional neurosurgical centre.
CT imaging is available on PACS for them to review.
Information available to you
Patient notes including initial assessment, observations, drug history, CT result, and ED management (provided on the reading sheet).
You may refer to these notes during the station.
You do not have access to electronic records, except for what is included.
Your Objective
By the end of the call, you should have:
Provided a clear, structured SBAR handover.
Communicated the urgent issues (ICH, high BP, anticoagulation on warfarin).
Requested an urgent neurosurgical review.
Demonstrated awareness of immediate management priorities (BP control, reversal of anticoagulation, level of care).
Shown safe communication, escalation, and closing.

[admin]

DETAILED PATIENT NOTE (9-minute read)
Patient identifiers
Name: Jane Doe
DOB: 15/04/1963 (62 years)
Hospital number: 0123456
Location: ED resus bay 2 — arrived 15 minutes ago (time of arrival 09:10)

A. Presenting complaint & history of presenting illness
Onset: Sudden collapse at home 30 minutes prior to arrival; family say acute severe headache then progressive left-sided weakness and slurred speech.
Symptoms on arrival: Severe occipital/temporal headache, left facial droop, left arm and leg weakness, mild dysarthria. No seizure reported. No loss of consciousness for >5 minutes; was drowsy but responsive.
Timeline: Symptom onset ~09:00, ambulance called, arrived ED 09:10, CT performed 09:25, reviewed by ED at 09:30.

B. Past medical history
Atrial fibrillation (CHA₂DS₂-VASc 3) — on warfarin.
Hypertension (longstanding).
Hypercholesterolaemia.
No previous stroke/TIA. No diabetes.
C. Drug history / allergies
Regular medications: Warfarin 5 mg od, amlodipine 5 mg od, atorvastatin 20 mg od.
Allergies: None documented.
D. Social / background
Lives with husband; independent. Non-smoker, minimal alcohol. Next of kin: Mr Doe (husband) present in ED.
E. Examination (documented at 09:20 on arrival)
GCS: 13/15 (E4 V4 M5) — intermittently drowsy, follows commands.
Observations: HR 88 bpm regular; BP 210/112 mmHg; RR 18/min; SpO₂ 97% on room air; Temp 36.8°C.
Neurological exam:
Pupils equal and reactive, no obvious gaze palsy.
Cranial nerves: left lower facial weakness (upper face spared).
Power: right side normal (5/5). Left upper limb 2/5, left lower limb 2/5.
Tone: increased on left (mild).
Sensation: reduced to light touch on left side.
Coordination: limited by weakness.
No meningism.

Other exam: cardiovascular and respiratory exam unremarkable.

F. Investigations / results so far
CT head (non-contrast) 09:25: Acute intraparenchymal haemorrhage in the left basal ganglia measuring approximately 3.2 cm maximal diameter; intraventricular extension into left lateral ventricle; no radiological acute obstructive hydrocephalus; no subdural/epidural component. (Radiology report on PACS; images reviewed.)
Blood tests: (samples taken, results pending) — FBC, U&E, LFT, clotting (INR), Group & Save sent.
Point of care: INR from ED point-of-care 3.2 (lab confirmation pending).
ECG: AF with controlled ventricular rate ~85 bpm.

G. Treatment given in ED (so far)
Airway: talking, airway patent. NBM.
Breathing: SpO₂ 97% RA; oxygen 2 L/min via nasal cannula started for safety.
Circulation: IV access x2 cannulae in place.
BP: IV labetalol 20 mg given once at 09:18 — BP now 200/106 (recheck needed). Plan to target systolic BP <140 mmHg if tolerated per acute ICH guidance. Consider IV infusion (nicardipine) if persistent.
Coagulation: Warfarinised — requirement for immediate reversal (prothrombin complex concentrate (PCC) + IV vitamin K) discussed; awaiting prescription/consent.
Analgesia/antiemetic: Paracetamol 1 g PO given (if safe), ondansetron 4 mg IV for headache/nausea PRN.
Monitoring: Continuous cardiac and blood pressure monitoring; neurological observations hourly or sooner.

H. Working diagnosis
Acute spontaneous intracerebral haemorrhage (left basal ganglia) on warfarin with intraventricular extension.
I. Clinical concerns / clinical deterioration triggers
Drop in GCS ≥2 points, airway compromise, uncontrolled hypertension, expanding haematoma on repeat CT, rising INR, new hydrocephalus, worsening focal deficit, new seizure.

J. Questions / actions requested of the on-call team (what you want from the reviewer)
Urgent neurosurgical review to assess for possible surgical intervention (external ventricular drain if hydrocephalus, or decompression if indicated) and consideration of transfer to neurosurgical centre.
Immediate reversal of anticoagulation: administer PCC (dose per weight/INR) and IV vitamin K — please authorise and arrange.
Blood pressure strategy: advice on agent and target (recommend systolic 130–140 mmHg if safe). Consider starting nicardipine infusion if unable to control with bolus labetalol.
Ongoing level of care: discuss HDU/ITU admission vs ward-level care; escalation plan and ceilings of care.
If operative: obtain consent discussion with next of kin; arrange CT neurosurgery protocol (repeat CT timing) and transfer pathway.

K. Contact details
Caller: Dr David (junior doctor, ED) — bleep 321, mobile 07XXXX. Located ED Resus Bay 2. Next of kin in ED (husband). CT images available on PACS.

[admin]

Model answer

Spoiler

C — SCRIPTED SBAR PHONE CALL (9-minute phone station — candidate lines)
(Opening / identification)
“Hello, I’m Dr X, a SHO from the Emergency Department. May I ask who I’m speaking to? … I’m calling about a patient called Jane Doe, DOB 15/04/1963, hospital number 0123456 — a 62-year-old lady who arrived 15 minutes ago with a suspected intracerebral haemorrhage. I’d like you to review the patient.”

Spoiler

S — Situation (short)
“She has an acute left basal ganglia intracerebral haemorrhage on CT with intraventricular extension. She arrived 15 minutes ago and is currently in ED resus bay 2.”

Spoiler

B — Background (brief relevant items)
“Key background: Atrial fibrillation on warfarin. Hypertension. Allergies none. On arrival her GCS is 13 (E4 V4 M5), left-sided weakness with power 2/5 in left arm and leg, blood pressure 210/112 mmHg, SpO₂ 97% on air. Point-of-care INR 3.2.”

Spoiler

A — Assessment (clinical status & investigations)
“CT head performed shows a ~3.2 cm left basal ganglia bleed with intraventricular extension; no acute hydrocephalus on initial CT. We’ve given IV labetalol 20 mg once and started oxygen 2 L/min. IV access established, bloods including clotting and group & save sent. She is NBM and being monitored. I’m concerned about ongoing anticoagulation (INR 3.2) and the high blood pressure.”

Spoiler

R — Recommendation (what you want them to do)
“I would like urgent neurosurgical review to assess for surgical intervention/need for transfer. I also recommend immediate reversal of warfarin with PCC and IV vitamin K — could you authorise this or come see? Please advise BP target and agent; if agreeable we plan to target systolic <140 mmHg. Finally, please advise level of care (HDU/ITU) and whether you want a CT repeat and timing. I can send you the CT images to review on PACS and have the patient ready for review now in resus bay 2 — can you come to ED or should we arrange transfer?”

Close

“Thank you — I’m able to give you further information or bring the patient to the neurosurgical unit if advised. My contact is bleep 321. Do you need any additional details now?”

D — Examiner / Marking tips & likely questions to expect

Key points examiners look for (communication and clinical content):

Clear identification and succinct SBAR structure.

Immediate recognition of reversible causes and time-sensitive actions: urgent reversal of warfarin (PCC + vitamin K) and BP control.

Clear request for neurosurgical review and suggestion of level of care (HDU/ITU).

Safe airway plan (NBM, prepare for decline), monitoring plan and clear escalation triggers.

Appropriate documentation: CT findings, GCS, observations, anticoagulant status and INR.

Likely follow-up questions the examiner/onsite consultant may ask (prepare short answers):

“What is the exact CT finding?” → Left basal ganglia ICH ~3.2 cm with intraventricular extension; no acute hydrocephalus.

“What’s her INR and when was last warfarin dose?” → INR 3.2 (POC); husband reports she took warfarin that morning.

“What have you given already?” → IV labetalol 20 mg once; oxygen; analgesia; IV access; bloods sent.

“What BP target do you propose?” → Target systolic 130–140 mmHg if tolerated; recommend nicardipine infusion if boluses fail.

“Is she a surgical candidate?” → Unsure — needs neurosurgical assessment; size and intraventricular extension raise concern; recommend urgent neurosurgical review for EVD/consider decompression/transfer.

Pitfalls to avoid in the station

Missing anticoagulation status.

Forgetting to ask for neurosurgery.

Not naming a BP target or asking for specific reversal agents.

Failing to document GCS or a change in GCS as an escalation trigger.