If documentation is a reflection of our care, does it show that nurses make a difference ?

1. If documentation is a reflection of our care, does it show that nurses make a difference?

2. Falls/Safety Documentation Changes – Why change? • Changing focus from repetitive screening for Falls Risk to a model that supports Falls Prevention • Historically for each new issue addressed, we’ve added a new section or Tab to HED – not sustainable and adds complexity to documentation • As we work toward a Culture of Safety, we need a framework that allows us to identify and address all safety risks efficiently and document all education in a compliant, simpler fashion

3. OBJECTIVES…. • Verbalize understanding of the changes in documentation and workflow associated with new Falls/Safety HED build • For your area, identify common Falls/Safety scenarios and how to address them Use a practice scenario to document Safety Assessment and Plan including: • Determine the Morse Falls Risk Score • Identify safety risk factors and safety problems; Start Safety Priority Problem, if warranted • Document Care Interventions, Patient/Family Teaching, and any Notifications & Care Coordination actions • Document response to safety interventions & shift goals/outcomes for Safety Priority Problems (if there is a Safety Priority Problem)

4. Disclaimer • We are starting training for Leaders who will implement this change during the week of the pilot in order to provide as much time as possible to train staff prior to rollout dates. Minor tweaks to what we see today are possible. We will update materials and share any modifications that we do make with you. • We will be adding training scenarios and other resources customized for the Psychiatric and Children’s Hospitals and these should be available by early next week. Today, we will use Adult scenarios.

5. Pilot: 9N September 18th • Pilot focuses on: • Falls Risk portion of new Safety Build • Other New features that will be addressed: • Role/Communication documentation • Changes in documentation of Patient/Family education & engagement • Changes in Restraint, CIWA, and some other safety-related documentation

6. Vision Statement Safety Documentation, including assessment, interventions, teaching, and notification, will result in a safer environment for our patients and will prevent or minimize injury. This will improve patient care and clearly define nursing’s contributions to patient care and the team.

7. Safety/Falls Section: What’s Changing? • Safety assessment on every patient, every shift. Also: • Adults: Morse Falls screen • Peds: Humpty Dumpty Falls • on admission & with change in status/condition (e.g. Transfer to different level of care, change in mental status, etc.) . No longer required every shift. • Streamlined documentation of Restraint Safety Care • Safety Problems(Injury Risk, Violence Risk, Substance Abuse, and others) will be identified. • If a safety problem will be a key driver of nursing care for that patient, also initiate as a Priority Problem • CIWA documentation will be available in HED for units that implement CIWA protocol • Safety Interventions will be documented – things you: • Assess/Monitor/Evaluate/Observe • Care/Perform/Provide/Assist • Teach/Educate/Instruct/Supervise • Manage/Refer/Contact/Notify

8. Education Tab: What’s Changing? • Caregivers’ contact information (“Care Contacts”) – will be documented in new Role/Communication section • Patient/Family Education & Engagement will be documented in a way that captures required elements more efficiently

9. What’s Not Changing • Plan of Care documentation • Priority Problems – continue to create and evaluate goals • Pathway, Nursing Summary, and Plan Priorities documentation in HED • Continue to assign e-docs pathway • Admission History • Continue to complete all sections (Contact Information will likely be removed in future)

10. What to Do & When • Admission • Falls Risk screen • Safety assessment as part of head-to-toe assessment; Identify problems & Plan Interventions; Start Priority Problem if warranted • Beginning of Shift • Safety assessment; Identify problems & Plan Interventions • Document expected Short Term Goals for Safety Priority Problems • Start/End Safety Priority Problems if warranted • Document Short Term Goal Status or outcome for Priority Problems • Document Response to all Safety Interventions • End of Shift • Falls Risk screen • Repeat Safety Assessment & Revise Planned Interventions as appropriate • Condition/ Status Change

11. PRACTICE SCENARIO – Admission • John Doe is an 85 year old male admitted for planned TURP for BPH. • Medical Conditions: COPD, Heart Disease, Hypertension, and migraine headaches. • Past Surgical Procedures: CABG (1987) Bilateral Knee Replacements (1997) shoulder surgeries (2002 & 2005). He has a history of falls with injury, resulting in rotator cuff tears and multiple rib fractures. • Medication History: 15 medications, some are anticonvulsants, Lortab for poorly controlled headaches, 2 antihypertensive, and Lasix. • Family/Support: His wife, the primary caregiver, shares that a lot of medications make him “dizzy” or “crazy”. She reports that he has stopped taking many medications because the side effects contributed to falls. • On admission: Mr. Doe has no IV, is alert and oriented x3 , and verbalizes awareness that he is very unsteady on his feet. He has Activity orders is to be OOB w/Assist and agrees to use the call light any time he needs to get out of bed. His wife is concerned that he may try to go to the bathroom without assistance because of urinary urgency and frequency associated with his prostate issues. His daughter will be secondary caretaker and will come on the weekends to relieve the wife.

12. Falls Risk screen • Safety assessment as part of head-to-toe assessment; Identify problems & Plan Interventions; Start Priority Problem if warranted Admission • Click on HED Train tab and select the Safety Falls/ Risk tab • Locate and complete the Morse Falls Risk Section

13. Morse Falls Risk screen • Safety assessment as part of head-to-toe assessment; Identify problems & Plan Interventions; Start Priority Problem if warranted Admission • How would you assess the patient’s: • Ambulation aid • Gait

14. Morse Falls Risk screen • Safety assessment as part of head-to-toe assessment; Identify problems & Plan Interventions; Start Priority Problem if warranted Admission • Document the Safety Assessment on admission and identify at least one safety problem and 2-3 interventions to address the problem. • Would “Falls Risk” likely be a Priority Problem for this patient? • Click on the Education tab and document contact information for primary and secondary caregiver

15. Safety assessment; Identify problems & Plan Interventions • Document expected Short Term Goals for Safety Priority Problems Would you need to document another Morse Falls Risk Screening at the beginning of every shift? What safety interventions might you document for this patient? Beginning of Shift

16. End of Shift • Start/End Safety Priority Problems if warranted • Document Short Term Goal Status or outcome for Priority Problems • Document Response to all Safety Interventions What are some examples of patient responses to Safety Interventions you might document for this patient?

17. PRACTICE SCENARIO – Status Change Mr. Doe returns from the OR on IV antibiotics receiving bladder irrigation with a 3-way foley catheter in place for the next 48 hrs. He is confused and keeps trying to pull out his foley despite numerous interventions from family members and staff. Restraints are ordered to protect him from injuring himself.

18. Morse Falls Risk screen • Repeat other Safety Assessment & Revise Planned Interventions as appropriate • Condition/ Status Change • Now with this change in status, go back to the Safety/Falls tab. • Complete a Morse screening and new Safety Assessment

19. Morse Falls Risk screen • Repeat other Safety Assessment & Revise Planned Interventions as appropriate • Condition/ Status Change • Mr. Doe’s IV, GU irrigant, and foley are discontinued. He experiences bladder spasms and urinary urgency at intervals throughout the day. He is ambulating short distances with 2 assisting using a walker. He is oriented to pre-surgery level. A pharmacy consult was completed to discuss his medication side effects and they have recommended some changes that have been ordered. Discharge teaching is done with Mr. Doe & his primary and secondary caregivers. They request and are provided with information on how to make his home environment safer and a Home Health PT consult is ordered to do an environmental assessment and recommend improvements. Fall Safety education is provided, including a video, printed materials, and verbal instruction. Patient and both caregivers verbalize overall understanding but you notify Home Health Agency to reinforce education post discharge.

20. Morse Falls Risk screen • Repeat other Safety Assessment & Revise Planned Interventions as appropriate • Condition/ Status Change • Where & how would you document the referrals to Pharmacy and Home Health PT? • Where & how would you document the patient/caregiver education?

21. What to Do & When • Admission • Falls Risk screen • Safety assessment as part of head-to-toe assessment; Identify problems & Plan Interventions; Start Priority Problem if warranted • Beginning of Shift • Safety assessment; Identify problems & Plan Interventions • Document expected Short Term Goals for Safety Priority Problems • Start/End Safety Priority Problems if warranted • Document Short Term Goal Status or outcome for Priority Problems • Document Response to all Safety Interventions • End of Shift • Falls Risk screen • Repeat Safety Assessment & Revise Planned Interventions as appropriate • Condition/ Status Change

22. Second Scenario • When the patient’s condition deteriorates 2 hrs. after she arrives on your unit, does the Morse Falls Risk screen need to be repeated? Why? • Will she have a Safety Priority Problem started? Why? • How will the Care Contact information change from day of surgery to day of discharge? • What education and notifications will you document on day of discharge?

23. Common Questions Answer No, only with changes in condition/status Yes, but you now document a single checkbox instead of multiple checkboxes Sometimes but not all Safety issues rise to that level. Question • Do I have to document a Falls Screen every shift? • Do I still need to do Restraint documentation every 2 hrs. ? • Will safety issues still be Priority Problems?

24. GO LIVE DAY VUH – Oct. 16 VPH – Oct. 23 VCH – Oct. 30 New Safety/Fall Risk section will replace the old Falls Risk section in Assessment/Interventions tab New content will appear in Education tab Restraints tab will be removed Past data will be viewable for the Restraintsand Fall Risksections of Assessments/Intervention Tab but will not contain charting boxes.

25. Training and Implementation Plan • Resources: • Provided by SSS: • All resource materials will be accessible from Systems Support Services Web Site by Sept. 25 • CAPS will partner with Unit-Based Resources to complete education & will provide support • Provided by Unit: • Super-Users/ Educator • Need enough super-users for each shift Go Live week • Implementation Support • Super-user: 9a-5p and 9pm to 5am • SSS: 9a-5pm and 9pm to 5am (Night Shift will support multiple units concurrently; rounding schedule to be posted)

26. Unit Leader TO DO LIST • Meet with CAPS person to formulate specific plan for our unit • Review the documents provided (posted on SSS website) • Complete Unit-Specific Implementation Plan (including recruiting Super-users) and use that Plan and Implementation Checklist to track progress through implementation process • Identify Super-users and best way to do training for your unit ASK QUESTIONS