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Military Health System

Airman uses SBAR to improve COVID-19 swab technique

Image of Military personnel in full PPE at a car window demonstrating a swabbing technique. U.S. Air Force Tech. Sgt. Steve Zavala, 422nd Medical Squadron medical operations flight chief and trusted care champion, demonstrates COVID-19 testing procedures at RAF Croughton, England, August 3, 2020. Zavala discovered a COVID-19 testing technique that needed to be changed, so he elevated the concern and impacted testing procedures across the Department of Defense. (U.S. Air Force photo by Airman 1st Class Jennifer Zima).

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Recently, an Air Force medical technician at RAF Croughton in England uncovered a COVID-19 testing technique that needed to be changed, so he elevated the concern and impacted testing procedures across the entire Department of Defense (DOD).

Air Force Tech. Sgt. Steve Zavala, 422nd Medical Squadron medical operations flight chief and trusted care champion, along with three fellow medical technicians, have been testing patients for COVID-19 at the 422nd MDS using the same testing procedure used for the seasonal flu.

“The particular method to collect the COVID-19 swabs is called the nasopharyngeal swab,” said Zavala. “The training that we received is dictated down from DHA [Defense Health Agency]. The DOD Global Respiratory Pathogen Surveillance questionnaire lays out step by step how to do a nasopharyngeal swab.”

One of the steps when collecting a sample, is to first have the patient blow their nose into a tissue. However, while watching COVID-19 testing on the news, Zavala noticed other medical professionals were not having their patients blow their noses before collecting samples.

“I was pretty confident we were doing something wrong here, something just didn’t seem right to me.” said Zavala. “I did some research and finally came across a step-by-step guideline according to the CDC [Centers for Disease Control and Prevention] on what you should do for nasopharyngeal swabs.”

Zavala noticed there were no recommendations stating that patients have to blow their noses. He then searched the Air Force Medical Service Knowledge Exchange COVID-19 page but didn’t find any recommendations for this there as well.

“There’s this big push for medical Trusted Care, not only in the Air Force but across DOD,” said Zavala. “We’re trying to mirror the reliability that the nuclear industry and commercial aircrafts have. Let’s take the naval aircraft carriers for instance. You have jets landing and taking off all the time on these little precise aircraft carriers, and how many times do we hear accidents happening with that? It’s few and far between that stuff happens in the airline and the nuclear industries. Medical has been trying to adopt the principles that those industries have, and we call it Trusted Care.”

Trusted Care is not a program, but a type of culture focused on improved communication.

“It took us three years to get to the point where we’re starting to see some of the positives from doing all of the Trusted Care work. Every department has their own daily huddle. That’s the time to bring up any safety concerns – it’s all safety driven. Every meeting that we have starts with safety moments and safety stories. It’s hard for people sometimes. They just fix things on the fly – they don’t think of things as a safety moment. The way that people learn the best is from stories. It’s to get people to look at things in a different way and maybe it will trigger that story in their mind when they see something else. In a hospital anyone can find something that can be a huge issue.

A Situation, Background, Assessment, Recommendation (SBAR) report is part of Trusted Care. It’s a technique used in healthcare to facilitate in communicating recommendations to improve patient care.

“You’re recommending an action be taken,” said Zavala. “You’re not just complaining about something wrong, but you’re recommending up to the highest levels.”

Zavala sent an SBAR report to his leadership, explained the situation and asked for clearer guidance on testing procedures in order to have more accurate results. They sent the SBAR, and the recommendations to discontinue nose-blowing, to the U.S. Air Forces in Europe Trusted Care Regional and head laboratories. From there, the report gained Air Force level attention.

“The form that is DOD-wide is going to be changed to match the CDC,” said Zavala.

“Speak up if you see something that doesn’t jive with what you’ve been taught,” said Zavala. “A big thing in Trusted Care is to exercise a questioning attitude. It’s always good to ask people for a cross check ‘hey, does this seem right to you?’ It ties into our core value of excellence in all we do. Why are we taking the time to do this, if you feel it’s not the best method?”

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