9n safety/falls pilot – sss guide
DESCRIPTION
9N Safety/Falls Pilot – SSS guide . Falls/Safety Documentation Changes – Why change?. Changing focus from repetitive screening for Falls Risk to a model that supports Falls Prevention - PowerPoint PPT PresentationTRANSCRIPT
9N Safety/Falls Pilot – SSS guide
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
Framework developed to identify and address all safety risks efficiently
Falls/Safety Documentation Changes – Why change?
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
Pilot: 9N September 18th
RNs complete hands-on check off on documentation and workflow associated with new Falls/Safety HED build
Practice Scenario: o Determine the Morse Falls Risk Score
o Identify safety risk factors and safety problems ; Start Safety or Restraints Priority
Problem, if warranted
o Document, Care Interventions, Patient/Family Teaching, and any Notifications &
Care Coordination
o Document shift goals/outcomes for Safety Priority Problems & response to safety
interventions
TRAINING
1. Assess2. Care3. Educate 4. Notify
Safety Risk AssessmentSafety PlanResponse to Interventions
Safety Risk Assessment Tab
Morse Falls Risk Screen
Education Tab Role Communication Section
(caregiver contact info)- nurses to document caregivers contact info once and if any phone number changes
Education Categories – categorized in similar fashion to Priority Problems
9N Pilot: What’s Changing Safety assessment on every patient every shift. Alsoo 9N: Morse Falls screen on admission & with change in status/condition (e.g.
Transfer to different level of care, change in mental status, etc.)
o 6A/B: PEWS screen documented q4h (will be moved from Falls/Safety Tab at conclusion of pilot before VCH-wide rollout)
Safety Problems (Injury Risk, Violence Risk, Substance Abuse, and others ) will be identified. o If they are a priority, also initiate this as a Priority Problem
Safety Interventions will be documented – things you: o Assess/Monitor/Evaluate/Observeo Care/Perform/Provide/Assisto Teach/Educate/Instruct/Supervise o Manage/Refer/Contact/Notify
New Education Tab:
Caregivers’ contact information (“Care Contacts”) – will be documented
in new Role/Communication section
Patient/Family Education & Engagement
Some other Safety documentation (eg. Restraints) streamlined.
9N Pilot: What’s 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
Education Record tab still visible for pilot until further discussion as to whether to
blend the new Education tab with current one
Admission History documentation of substance screening and caregiver
contact information will still be recorded until further evaluation with pilot
What’s NOT Changing
Admission
• Morse 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
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
Condition/ Status
Change
• Morse Falls Risk screen• Repeat other Safety Assessment & Revise Planned Interventions as
appropriate
What to Do & When
Admission
• Morse Falls Risk screen • Safety assessment as part of head-to-toe assessment; Identify problems
& Plan Interventions; Start Priority Problem if warranted
Click on HED Train tab and select the Safety Falls/ Risk tab
Locate and complete the Morse Falls Risk Section – bottom of screen
Complete Safety Risk Assessment
Admission
• Morse Falls Risk screen • Safety assessment as part of head-to-toe assessment; Identify problems
& Plan Interventions; Start Priority Problem if warranted
How would you assess the patient’s:◦ Ambulation aid◦ Gait
Hover over boxes with HED Upgrade on many fields
Continue to document:◦ Nursing Summary, Plan Priorities, and Goal Status
Include from Safety/Falls tab end of shift documentation on: ◦ Response to Safety Interventions
• 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
Re-Assessment of Morse Falls Risk Screen and Safety Assessment with:
◦ Change in level of care (unit-to-unit)
◦ Status Change
◦ Fall or injury
◦ Increased monitoring of patient’s condition due to status
change
Condition/ Status
Change
• Morse Falls Risk screen• Repeat other Safety Assessment & Revise Planned Interventions as
appropriate
Day of go-live
also9N Go Live – Sept 18th
New Safety/Fall Risk tab will replace the old Falls Risk section in
assessment tabs
New Education tab will appear- old Education Record tab will still be visible
Restraints documentation moved from Restraints tab to Safety/Fall Risk tab
Past data will be viewable for the Restraints tab, and Fall Risk section but
will not contain charting boxes.
CIWA tab released
Resources:◦Super Users – in-staffing◦Educator◦Unit Resource Manual- contains issue log, pocket aides, staff& support schedule, and pocket aides
Implementation Support◦ SuperUsers◦ SSS/CAPS: 9a-5pm and 9pm to 5am, Sept. 18, 19, 20, 21st ◦ Issues Log on unit
Training and Implementation Plan