joseph ouslander, md florida atlantic university
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Putting the Tools to Work in Everyday Practice. Joseph Ouslander, MD Florida Atlantic University Gerri Lamb, PhD, RN, FAAN Arizona State University Laurie Herndon, GNP Mass Senior Care Ruth Tappen, EdD, RN, FAAN Florida Atlantic University - PowerPoint PPT PresentationTRANSCRIPT
© Florida Atlantic University 2011
Joseph Ouslander, MD Florida Atlantic University
Gerri Lamb, PhD, RN, FAAN Arizona State University
Laurie Herndon, GNP Mass Senior Care
Ruth Tappen, EdD, RN, FAAN Florida Atlantic University
Jo Taylor, RN, MPH The Carolinas Center for Medical Excellence
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
Do any of you use the Stop and Watch Tool? What is
your experience?
© Florida Atlantic University 2011
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
© Florida Atlantic University 2011
Video Clip
Examples of poor communication between CNA and licensed nurse, and improved
communication using the Stop and Watch Tool
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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 direct resident contact
Family members may also contribute valuable observations
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
What early changes in condition should be reported?
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Stop and Watch is the primary method forCNAs to alert the LPN/RNs of changes in the resident’s conditionand for the nurse to hear what the CNAs have to say.
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
Recognizing Changes in Condition
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
© Florida Atlantic University 2011
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
“Stop and Watch” is a great way to communicate changes
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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!
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
© Florida Atlantic University 2011
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
© Florida Atlantic University 2011
Ate less than usual
(Not because of dislike of food)
NDrank less than usual
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
© Florida Atlantic University 2011
Instructions: “Stop and Watch”
Staff ____________________________
Reported to ______________________
Date __/__/__ Time ____________
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
The SBAR is 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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Video Clip
Example of how good evaluation and communication using SBAR can prevent an
acute care transfer and hospitalization
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Getting a comprehensive history: Who to involve
CNAs Social Workers Rehab, Activities, Dietary Other staff Family members
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Progress Note
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Making the Case for SBAR 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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
Do any of you use the SBAR? What is your experience?
© Florida Atlantic University 2011
INTERACT Decision Support Tools:Care Paths and Change in Condition File Cards
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
The Change in Condition File Cards and Care Paths help 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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Who Uses the INTERACT Decision Support Tools?
RN’s LPN’s Nurse supervisors Nurse educators MDs, NPs, PAs
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
The Care Paths and Change in Condition File Cards are 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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
The INTERACT Change in Condition File Cards include recommendations
Immediate vs. non-immediate notification for specific:
Vital signs Lab results Symptoms and signs
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
The INTERACT Change in Condition File Cards:
The case of Mrs. S: a classic case that illustrates their purpose
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
INTERACT Care 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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Questions? Comments? Suggestions?
Putting the Tools to Work in Everyday Practice