Joseph Ouslander, MD Florida Atlantic University

1. Putting the Tools to Work in Everyday Practice Joseph Ouslander, MD Florida Atlantic University Gerri Lamb, PhD, RN, FAAN Arizona State University Laurie Herndon, GNPMass Senior Care Ruth Tappen, EdD, RN, FAAN Florida Atlantic University Jo Taylor, RN, MPHThe Carolinas Center for Medical Excellence

2. Objectives Describe the purpose and use of: Stop and Watch SBAR Communication Form and Progress Note Decision Support Tools Change in Condition File Cards Care Paths Putting the Tools to Work in Everyday Practice

3. Putting the Tools to Work in Everyday Practice Do any of you use the Stop and Watch Tool? What is your experience?

4. Purpose of “Stop and Watch” To guide frontline staff through a brief review of early changes in the resident’s condition To improve communication between frontline staff and the nurse in charge Putting the Tools to Work in Everyday Practice

5. Putting the Tools to Work in Everyday Practice Video Clip Examples of poor communication between CNA and licensed nurse, and improved communication using the Stop and Watch Tool

6. Stop and Watch helps frontline staff identify important changes in the resident’s condition Who is frontline staff? CNA’s and other nursing staff, rehab therapists, dietary staff, housekeeping staff, activities staff and any staff member with directresident contact Family members may also contribute valuable observations Putting the Tools to Work in Everyday Practice

7. What early changes in condition should be reported? Putting the Tools to Work in Everyday Practice • Changes in mental status– sleepy, confused, agitated, anxious • Changes in physical status– problems with walking, transferring • Changes in function – problems with ADL’s • Changes in behavior – wandering, combative, yelling, verbal or physical aggression • Changes in pain level

8. Putting the Tools to Work in Everyday Practice Stop and Watchis the primary method for CNAs to alert the LPN/RNs of changes in the resident’s condition and for the nurse to hear what the CNAs have to say.

9. Recognizing Changes in Condition Putting the Tools to Work in Everyday Practice • Important changes to report are: • Actions or behaviors that are not part of the resident’s normal routine • A change from the resident’s usual condition

10. Your Eyes Are the Best Frontline staff: Know the resident best See changes in condition first Should identify important changes in the resident’s condition during their normal care routine Must be empowered to communicate what they know and see Putting the Tools to Work in Everyday Practice

11. “Stop and Watch” is a great way to communicate changes Putting the Tools to Work in Everyday Practice It helps … • The staff know what kinds of changes to report • The nurse understand what you have to say is important and when to take action

12. Putting the Tools to Work in Everyday Practice Unit nurses are busy giving medications and taking physician orders CNA’s are busy giving direct care “Stop and Watch” reporting can help close the gap!

13. Instructions for “Stop and Watch” If you have identified an important change while caring for a resident today, please circle the change and discuss it with the charge nurse before the end of your shift. More than one change may be marked on the same form Putting the Tools to Work in Everyday Practice

14. S eems different than usual Not their usual self? Change in personality or behavior? T alks or communicates less than usual Quieter? Drowsier? Confused? Altered speech? O verall needs more help than usual Needs more assistance? Changes in gait, transfer or balance? P articipated in activities less than usual Withdrawn? Decline in ADL’s? Change in normal routine? Putting the Tools to Work in Everyday Practice

15. Ate less than usual (Not because of dislike of food) N Drank less than usual Putting the Tools to Work in Everyday Practice

16. W eight change A gitated or nervous more than usual T ired, weak, confused or drowsy C hange in skin color or condition H elp with walking, transferring, toileting more than usual Putting the Tools to Work in Everyday Practice

17. Instructions: “Stop and Watch” Staff ____________________________ Reported to ______________________ Date __/__/__ Time ____________ Putting the Tools to Work in Everyday Practice

18. Putting the Tools to Work in Everyday Practice The SBARis a tool for LPNs and RNs to evaluate changes in the resident’s condition and communicate them to the MD/NP/PA and document them

19. Putting the Tools to Work in Everyday Practice Video Clip Example of how good evaluation and communication using SBAR can prevent an acute care transfer and hospitalization

20. Putting the Tools to Work in Everyday Practice Purpose of the SBAR Communication Form and Progress Note • Improve communication • Standardized evaluation • Consistent language • Communication that is efficient and effective • Documentation that is thorough and focused

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23. Getting a comprehensive history: Who to involve Putting the Tools to Work in Everyday Practice • CNAs • Social Workers • Rehab, Activities, Dietary • Other staff • Family members

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27. Putting the Tools to Work in Everyday Practice Progress Note

28. Making the Case for SBAR Putting the Tools to Work in Everyday Practice • Assists nurses in organizing their evaluation • Improves communication with MDs/NPs/PAs • Improves shift to shift communication • Alerts all providers about a change in condition • Enhances documentation • Can be copied and sent to ER with resident

29. Putting the Tools to Work in Everyday Practice Do any of you use the SBAR? What is your experience?

30. Putting the Tools to Work in Everyday Practice INTERACT Decision Support Tools:Care Paths and Change in Condition File Cards

31. Putting the Tools to Work in Everyday Practice • The INTERACT Care Paths and Change in Condition File Cards are decision support tools • Available for guidance when changes in status or specific symptoms and signs occur

32. Putting the Tools to Work in Everyday Practice • The Change in Condition File Cards and Care Pathshelp guide decisions about: • Further evaluation of changes in condition • When to communicate with the MD/NP/PA • When to consider transfer to the hospital • How to manage some conditions in the NH

33. Putting the Tools to Work in Everyday Practice Who Uses the INTERACT Decision Support Tools? • RN’s • LPN’s • Nurse supervisors • Nurse educators • MDs, NPs, PAs

34. Putting the Tools to Work in Everyday Practice • The Care Paths and Change in Condition File Cardsare meant to be used with other tools • The change in condition or new symptom or sign may have been noted using the Stop and Watch Tool • Nurses should consider completing an SBAR Form and Progress Note using guidance from these tools

35. Putting the Tools to Work in Everyday Practice • The INTERACT decision support tools are based on established clinical guidelines published by several national professional organizations • Most are based on expert opinion because we lack definitive scientific clinical trials

36. Putting the Tools to Work in Everyday Practice • Recommendations in the INTERACT Care Paths and Change in Condition File Cards are not fixed in stone • They are meant to guide decision making, not dictate it • Your clinical team may choose to modify specific recommendations • The systematic, clearly defined approach to symptoms and signs is more important than the specific recommendations

37. Putting the Tools to Work in Everyday Practice • The INTERACT Change in Condition File Cards include recommendations • Immediate vs. non-immediate notification for specific: • Vital signs • Lab results • Symptoms and signs

38. Putting the Tools to Work in Everyday Practice • The INTERACT Change in Condition File Cards: • The case of Mrs. S: a classic case that illustrates their purpose

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42. Putting the Tools to Work in Everyday Practice Using the Change in Condition File Cards • Staff education to develop critical thinking skills • Nurse educators and managers use Change of Condition File Cards when teaching staff nurses who are assessing a resident’s change in condition • Strategies • 5-minute huddle on the unit • Morning stand-up meeting • Report between shifts

43. Putting the Tools to Work in Everyday Practice • The INTERACT Care Paths focus on 6 conditions that are: • Common reasons for hospital transfer • Often manageable in the nursing home • Frequent causes of potentially avoidable and preventable transfers or hospitalizations • The INTERACT Care Paths : • Acute mental status change • Fever • Dehydration • Symptoms of CHF • Symptoms of Lower Respiratory Illness • Symptoms of UTI

44. Putting the Tools to Work in Everyday Practice INTERACTCare Paths • All structured the same way • Provide guidance on when to notify the MD/NP/PA consistent with File Cards • Suggest evaluation strategies • Provide recommendations for management and monitoring in the facility

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