joseph ouslander, md florida atlantic university

© 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


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




Do any of you use the Stop and Watch Tool? What is

your experience?


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



Video Clip

Examples of poor communication between CNA and licensed nurse, and improved

communication using the Stop and Watch Tool



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



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?



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.



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



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



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



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!



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



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?



Ate less than usual

(Not because of dislike of food)

NDrank less than usual



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



Instructions: “Stop and Watch”

Staff ____________________________

Reported to ______________________

Date __/__/__ Time ____________



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



Video Clip

Example of how good evaluation and communication using SBAR can prevent an

acute care transfer and hospitalization



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



Getting a comprehensive history: Who to involve

CNAs Social Workers Rehab, Activities, Dietary Other staff Family members



Progress Note



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




Do any of you use the SBAR? What is your experience?


INTERACT Decision Support Tools:Care Paths and Change in Condition File Cards



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



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



Who Uses the INTERACT Decision Support Tools?

RN’s LPN’s Nurse supervisors Nurse educators MDs, NPs, PAs



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



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



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



The INTERACT Change in Condition File Cards include recommendations

Immediate vs. non-immediate notification for specific:

Vital signs Lab results Symptoms and signs



The INTERACT Change in Condition File Cards:

The case of Mrs. S: a classic case that illustrates their purpose



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



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



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



Questions? Comments? Suggestions?

[email protected]


joseph ouslander, md florida atlantic university

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