aspects of bowel and bladder care using a spinal cord...

Aspects of Bowel and Bladder Care Using aSpinal Cord Injury Activity of Daily Living Nursing Note

Ron Spencer, MS, RN, CRRNStaff Development CoordinatorRichmond VAMC

Disclosure

Ronald Spencer, RN has no interest to disclose

PEGS and PVA staff have no interest to disclose.

This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with PVA. PEGS, PVA and all accrediting organizations do not support or endorse any product or service mentioned in this activity.

Aim

Optimize CPRS documentation and improve communication within the IDT of bowel and bladder care using standardized language

Objectives1. Explain process involved in a Performance Improvement Project,

(PI).

2. Recognize the importance of developing an easy-to-use3. survey tool to keep staff engaged during a change in practice

2. Plan for and expect barriers when implementing changes in documentation practices

3. Compare current Nursing ADL note to the SCI Specific ADL note for potential integration into various facilities charting requirements

How it all Started…Quality on Parade – PI Summary Registration Form – Poster (11/14)

Description of Measure, (brief explanation)Justification of Measure, (why it is being

measured)Contact info and poster authors

Weekly IDT ConferencesNurses were inconsistently using FIM, the universal language used in rehab settings, to communicate patient’s changes among group members.

The current ADL noteFailed at capturing usable, detailed information to be shared among members.

Formal PI Project

Service SupervisorPI Project Title

Mandate or Directive (if applicable)

Start Date

Deadline Status

Richmond PI ModelMeasure – Documentation of care delivered was not reflected in ADL Note

Change - Develop a pilot note with input from the entire team capture specific information regarding bowel and bladder aspects of care, likened to the ratings scored in FIM. Implement the new and revised SCI Specific ADL note into CPRS.

Measure – assess satisfaction with revised note and determine the consistent use of standard rehab language when discussing patient concerns in IDT Meetings.

Current ADL Note

Nutrition

Elimination (Bowel / Bladder)

Hygiene (Bed Bath vs Shower)

Mobility

Sleep

Safety

GU

MEASURE

Charge Nurses were given a printed copy of the CPRS note and asked to work with key staff, on designated shifts, to determine what changes they would like to see with the bowel / bladder aspects of the ADL Note.

Numerous edits were recommended to the note to improve all 7 aspects of care: NPO, Aspiration Precautions, Adaptive Equipment, Sitting Protocol, Enteric Precautions, etc., etc.,

It’s important to note is that staff performing the care recognized the need to improve documentation

Functional Independence Measures, FIM®

Measures patients functional abilities

Statement

“Care will be delivered by engaged, collaborative teams in an integrated environment that supports learning, discovery and continuous improvement.”

Functional Independence MeasuresFIM®It is the most widely used disability measure in rehabilitation medicine.

(SCI Clinical Practice Guideline: Outcome)100% of the following staff are FIM Certified for 2016:

MDs, RNs, Therapists, Psychologists and SW’s

CARF Certification 9/15 – 9/18

Functional Independence Measures, FIM®

Measures patients functional abilities

Statement:

“Care will be delivered by engaged, collaborative teams in an integrated environment that supports learning, discovery and continuous improvement.”

Bowel Care

BOWEL CARE RESULTS on Current NoteVarious DescriptionsScheduled vs Unscheduled Bowel Movements –“It was unscheduled, but it was not an accident”

Orders were sometimes absent

No mention of use of assisted aids with bowel program

Text boxes in Template dependent on training and skill of staff – “What is large to you might be small to me.”

What is a rectal tube anyway?

16 different descriptions for appearance of stool

Bristol Stool Scale Explained

An ideal poo is likely to be type 3 or 4, easy to pass without being too watery.

A person with type 1 or 2 probably has constipation.

Types 5-7 usually indicate a tendency towards diarrhea.

If you are concerned about how your poo looks, seek medical advice. It may help to refer to the number on the Bristol Stool Scale.

Urinary Management

Non-Standard Terms

16 Characteristics of Urine

Vagaries, - “kick-off,” “triggered”

Failed to consistently and accurately capture patients current management protocol

Redundant

Strategy and Micro Actions

Alerted all staff that changes were being considered to improve the ADL Note in CPRS and evaluations of the changes could be anticipated

Submitted request for New / Revised Template, (MCM 136, Attachment B)

Informal networking among stakeholders to advance requested changes

CHANGE

With constructed agendas, 3 specific meetings were held with key team members to outline specific changes need to make the note more meaningful for dedicated SCI patients.

Non-agenda items were not discussed during these meetings.

Anticipated Barriers and Considerations

Lukewarm participation support and ownership by leaders

Varying expectations from stakeholders

“Something new” for staff to do

Opposition from labor partners

BarriersLet the Games Begin…

Physician Desires - Competing agendas

Therapist Desires - Is patient meeting goals?Nursing Desires – competes with duties, unpleasant, Nursing Administration

Forms and follow-thruIT Desires: Skills and Personalities--------------------------------

Imagine yourself as a fulcrum working to improve patient care…

Pilot Template

Developed Pilot template from key staff as previously mentioned

Pilot Template

LOCAL TITLE: NURSING ADL NOTE (S) STANDARD TITLE: NURSING INPATIENT NOTE DATE OF NOTE: MAY 15, 2016@23:01 ENTRY DATE: MAY 15,

2016@23:01:39 AUTHOR: BURNS,RACHEL L EXP COSIGNER: URGENCY: STATUS: COMPLETED

NUTRITION: Meal: dinner (%) 100 Functional Status: needs maximum assist

ELIMINATION:

Bowel Management Techniques:

Date of last BM: May 15 2016

Methodology: Descriptive Quantitative and Qualitative Study…StepsDeveloped a Pilot Progress Note – IDT Direct

Involvement

Identified an IT Specialist for inclusion to make modifications into existing template

Developed survey tool with narrative questions to retrieve information on the level of satisfaction with pilot note

Developed a spreadsheet to collate responsesSample Size: 140 folk asked to complete survey. Meetings conducted to educate staff and

keep them engaged with potential improvements forthcoming

Survey Tool1. Importance of using standard rehabilitation language to document elimination concerns for SCI patients.

2. Education regarding anticipated revisions of the note prior to implementation

3. The availability of assistance to complete the notes when uncertainty with documentation was an issue

4. Opportunities to evaluate and offer suggestions for improvements in the revised note during the 30 day pilot period.

5. Various bowel management techniques are now included in the note

6. The Bristol Stool Scale provides adequate description of bowel movements.

7. Management of various urinary devices can be documented consistently with outputs noted in the chart

8. The SCI specific note captures detailed information about the patients functional capabilities with bowel and bladder aspects of care

9. As a result of the revised note, I am now able to provide comprehensive reports of patients elimination concerns during Interdisciplinary Team, (IDT), meetings

10. Patient goals can be captured and measured allowing the team to be more focused and collaborative in targeted care delivered

Satisfaction Survey LimitationsLikert Scale, focused on level of interest in capturing and measuring current delivery of care; while focusing on improving the level of care.

Comments Sectionallowed for expression of unmeasured items and suggestions / concerns not mentioned in the tool

Statistical models; validity, reliability and standard deviationwere minimal considerations in this study

Survey Results

Participants: 24 /140

Response Rate: 17%+

Many members collaborated in the comments section of the survey to reflect satisfaction or desires with the note making the response rate as undetermined.

Dominant responses were excellent / good in all areas being measured

Evaluation Survey ResultsExcellent Good Fair Poor Not Applicable

Standard language 4 12 2 2 2

Education 2 13 4 3 1

Assistance 2 8 7 1 3

Offer Suggestions 3 11 4 3 1

Bowel Techniques 4 11 4 0 1

Bristol Stool Scale 3 7 7 3 1

Urinary Devices 1 11 7 1 1

Detailed Information 4 9 9 4 1

IDT Meetings 3 9 5 3 3

Patient Goals 2 10 4 3 3

Optics

0

2

4

6

8

10

12

14

Excellent

Good

Fair

Poor

Not Applicable

Comments Section

Dislikes:Delete

RedundancyResults are subjective

Unable to quickly determine if patient had BM on shift

Variety of language to mean same thing: spontaneous, unscheduled, accident

Bristol Stool Scale - No Credit to developerTakes too much time to check all boxes in the note

Requested ChangesIf independent with bowel care remained of note should be unnecessaryIf no BM this shift, then remainder of note should be unnecessaryDecrease number of mandatory fieldsAdd Color to stools; i.e., tan, black tarry, yellow, blood tinged, mucousAdd box for Excess FlatusAdd and reposition the following two (2) Boxes:

Independent with Bowel Care

Independent with Ostomy

Il t

Execution Plan

Work closely with IT staff during each phase of the development and trial the note before implementation

Develop a schedule to train staff on using the revised note

Final Meeting with key stakeholders seeking input and informing them of changes to the pilot note

Recommendations to IDT for permanent changes to note

Alert staff of target implementation date

Training Schedule5/11 7:30A 1U Conference Rm.

8:00a 1W Conference Rm5/11 3:30p 1U Conference Rm.5/11 4:00p 1W Conference Rm.5/12 6a 1U Conference Rm.

6:30a 1W Conference Rm.7:30a 1U Conference Rm.8:00a 1WConference Rm.3:30p 1U Conference Rm.4:00p 1W Conference Rm.7:00p 1U Conference Rm.8:00p 1W Conference Rm.

5/13 6a 1U Conference Rm.7:30a 1W Conference Rm.8:00a 1U Conference Rm.3:30p 1W Conference Rm.4:00p 1U Conference Rm.7:00p 1W Conference Rm.8:00p 1W Conference Rm.

Accessing the Revised Note1. Go to ADL Template

2. All 7 domains of ADL are still assessed3. The change occurs when you click on

ELIMINATION4. Question: Is this a Spinal Cord Injury patient?5. Two Options:

___No___ Yes

6. When YES is clicked, Radio Buttons and Text Boxes become active.

7. Remainder of ADL note remains unchanged

Actual Note #1

ELIMINATION:


Date of last BM: Jul 13,2016

Patient had 0 scheduled and 0 unscheduled

bowel movement(s) on this shift.

Bristol Stool Scale: No BM this shift

Color of stool:

Bladder Management:

Patient:

Actual Note #2

ELIMINATION:



Patient wears incontinence briefs? No

Patient has a colostomy? No

Patient Refused Bowel Care? No

Reason refused:

Bowel care ordered? Yes



Patient had bowel movement this shift with medium

results.

Bristol Stool Scale: Type 6-Fluffy pieces with ragged edges, a mushy

stool

Color of stool:

Actual Note #3

ELIMINATION:



Patient wears incontinence briefs? No



Patient had * scheduled and * unscheduled


Patient had bowel movement this shift with medium

results.

Level of assistance:

Total assistance

Bowel Care performed during this shift with good results.

Performed by nursing staff

Bristol Stool Scale: Type 6-Fluffy pieces with ragged edges, a mushy stool

ELIMINATION:



Patient wears incontinence briefs? Yes


Patient Refused Bowel Care? No

Reason refused:




Patient had bowel movement this shift with X-large

results.

Level of assistance:

Total assistance

Bowel Care performed during this shift with good results.

ELIMINATION:


Patient wears incontinence briefs? Yes

Bristol Stool Scale: No BM this shift

Color of stool:

Bladder Management:

Patient:

Has a condom catheter - 50 ml.

External came off? No

Suprapubic tube: 250 ml.

Urine appears: Hazy, Yellow

Measure Informal, 3 WEEKS AFTER IMPLEMENTATION

Some remaining jokes about the Bristol Stool Scale

Some staff continued to use the former ADL Note without SCI revisions

Most folk expressed satisfaction with the new note

Staff Expressions

LIKES:

“Helps me understand my patient’s better.”

Pulled staff – “I wish we had a note like this in our area.”

“I can now give accurate reports to the team about specific patients.”

DISLIKES:

“It takes longer to complete the note, its now more about the care that I have to consider.”

“That new description of stool is disgusting.”

FENCE-SITTERS:

“Now if we can just get staff to complete the note…”

“Can we go back to the was it was before?”

LESSONS LEARNEDWhen birthing a new idea / practice realize that you may be alone, initially…

Don’t hesitate to involve new staff into PI projects

Measure buy-in from others and negotiate pathways to success, (leaders, peers and labor partners)

Avoid temptation to make major system changes or deviate from stated goals

Momentum - Follow-up – Maintenance, (behavioral / educational / resistance concerns)

Other Services, i.e., CLC, may request assistance in improving documentation in their areas

Desired Outcomes and Benefits

Consistency with documentation of elimination concerns

Decreased LOS

Easy to use

Standardized language

Team Building with a shared sense of accomplishment

Provide information about the injury, treatment needs, possible and preventable complications

Agreement with Clinical Practice Guidelines

TimeLine

11/14 Quality on Parade

5/18/15 Note was created and inserted into existing template

5/18/15 – 5/31/15 Pilot period

6/1/15 – 6/4/15 Survey for evaluation of changes and satisfaction with note

6/5/16 – 6/9/15 Requested changes made to note

6/18/15 Permanent SCI ADL note incorporated into CPRS

Looking head…opportunities for the future improvements

Documentation of I&O’s in SCI specific ADL Note

Level of Injury; UMN / LMN

Clinical Warnings

Calorie Counts added…, etc.,

Review of Objectives

1. Explain process involved in a Performance Improvement Project, (PI).

2. Recognize the importance of developing an easy-to-use survey tool to keep staff engaged during a change in practice

2. Plan for and expect barriers when implementing changes in documentation or any other clinical practiceissue

3. Compare current Nursing ADL note to the SCI Specific ADL note for potential integration into various facilities charting requirements

Sources and References

Bhimani, Rozina, DNP, PhD, CNP, CNE, “Understanding work related musculoskeletal injuries in rehabilitation from a nursing perspective.” Rehabilitation Nursing. March / April, 2016, p.91 – 100, 2016.

Chumney, Douglas, et., al. “Ability of Functional Independence Measures to accurately predict functional outcome of stroke dependent population: Systemic Review. “ The Journal of Rehabilitation Research and Development. 47 (1), 17 – 30.

Consortium for Spinal Cord Medicine. “Clinical Practice Guideline: Outcomes Following Traumatic Spinal Cord Injury:” Clinical Practice Guidelines for Health-Care Professionals. 1999.

Joint Commission of Accreditation of Healthcare Organizations. Oakbrook Ter., Illinois. October 2011.

Lewis, Stephen, MD, and Ken Heaton, MD; “The Bristol Stool Scale.” Scandinavian Journal of Gastroenterology, 1997.

“Rating the FIM Instrument for the FIM System.” Uniform Data Systems for Medical Rehabilitation. A division of UB Foundation Activities, Inc. (UBFA) . ® 5.2, 2009

VAMC Policy, MCM 136, Attachment B Request for new /revised template, 2014.

CE / CME Credit

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