advanced sbar aka change of condition sbar-care paths and notification to physicians brief note on...

Advanced SBAR aka Change of ConditionSBAR-Care Paths and

Notification to Physicians

Brief Note on POSTL

Rhonda Anderson, RHIA, PresidentGayle Edell, RHIT, HI Consultant

Anderson Health Information Systems, Inc.

Regulatory Requirements

• Change of condition documentation is required by:– Federal Regulation– State Regulation– Standards of Practice for communication

with the physician and good quality of care in the facility

– SBAR process

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SBAR System – Clinical Care Paths

• SBAR System is the change of condition process, including Clinical Care Paths for Acute Mental Status, Congestive Heart Failure, Dehydration, Fever, Infections, Falls, etc.

• SBAR is an organized observation, examination and communication process with the physician.

• SBAR provides guidance on when to call the physician.

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Why Is SBAR Important To Your Resident And Facility?

• Represents the Resident and the facility in an accurate clinical presentation of the resident’s condition

• Presents the SITUATION to the physician – timely, completely

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Why Is SBAR Important To Your Resident And Facility? -2

• A communication tool with the community physicians that is similar to what the Acute Hospital uses

• A comfort zone for the community physician to know the observations/assessment of the resident is comprehensive before notification

• A Public Relations tool for the facility• Provides uniform guidance for

the Licensed Nursing Staff

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Review Of Highlights

• The following will review the highlights of SBAR, we will talk about the summary and documentation and then review the SBAR Clinical Care Paths, “A Guide for Nurses in the Skilled Nursing Facility”.

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What Is SBAR About?

• SITUATION – Introduction to the physician regarding the situation of the resident and the concern.

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What Is SBAR About? -2

• BACKGROUND – Provide the Background status re: the

resident.– Give the physician an immediate past

history, admission diagnosis– Describe recent laboratory work and key

medications/focus on medication for the condition or those with potential side effects that may impact the condition.

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What Is SBAR About? -3

• ASSESSMENT– Describe the observation points on

examining/observing the resident– Provide key information from the areas

observed/examined– Determine if a body system does not have

an abnormal sign/symptom.

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What Is SBAR About? -4

• Recommendations by the physician and follow up

• Follow up and notifications to the resident, family

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Change of Condition

• Let’s take a step back and look at the requirements mentioned previously related to Change of Condition

• The definition of C of C and the regulatory and good medical/nursing practices has not changed.

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Change of Condition -2

• F-157 §483.10(b) The facility must immediately inform the resident; consult with the resident's physician; and, if known, notify the resident’s legal representative or an interested family member when there is…– An accident resulting in injury or potential injury

requiring MD intervention– A significant change in physical, mental or

psychosocial status (i.e. deterioration in health)– A need to alter treatment

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Change of Condition -3

• Title XXII 72311(a)(2) – Nursing service shall notify the physician of:– (B) Any sudden and or marked change in

signs, symptoms or behavior exhibited by the patient

– (C) Any unusual occurrence involving a patient

– (D) Change in weight of 5 lbs. (or 5%) of more in 30 days*

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Change of Condition -4

• Title XXII 72311(a)(2) (con’t)– (E) Any untoward response to a medication

or treatment– (F) Any error in administration of a

medication or treatment– (G) All attempts to notify physicians shall be

noted in the patients record including the time, method of communication and the name of the person acknowledging contact (Using SBAR – on same form, otherwise in Lic. Nurse’s Notes)

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SBAR – “Change of Condition”

• The SBAR process will be used for all Change of Condition.

• There is an SBAR form to be used (see H.O. #1).

• If the form does not accommodate the change of condition, document in the Licensed Nurse Progress Notes and use the same process to describe the condition change, i.e., Situation/Presenting Problem, Vital Signs.

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SBAR – “Change of Condition” -2

• USE THE SBAR PROCESS & FORM (See H.O. #1)

• We will review the form/format a little later.

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SBAR – Clinical Care Paths

• When to call the M.D. for changes of condition

• A guide to nurses in the skilled nursing facility

• Review the clinical assessment

• Review the SBAR handout

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Acute Mental Status Clinical Care Path

• When making an assessment of the Mental Status of the resident, consider what affect many of the changes of conditions may also affect other areas besides Mental Status.

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Acute Mental Status Clinical Care Path -2

• Review the Care Path and the clinical decisions that are important for evaluation/observation and notification to the physician when it comes to Acute Mental Status and/or just the Mental Status and other conditions and how it may affect the other changes in condition.

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Congestive Heart Failure

• Review the Clinical Care Path for Congestive Heart Failure symptoms and the clinical decisions that are important for evaluation/observation and notification of the physician.

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Fever

• Review of the Care Path for Fever of undetermined origin

• Evaluate the Mental Status, Functional Status, Respiratory, Gastrointestinal, Skin

• Is there a change in ability to eat or drink?

• New cough, lung sound changes, incontinence, pain, new skin condition

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Respiratory

• Review of the Respiratory Infection Care Path focuses on the following:– Vital signs and the normal vs. abnormal.– Consider any recent lab/X-rays– Review results of the recent labs/X-rays

and the positive/negative findings– If Antibiotic. Remember to complete the

Antibiotic sheet (H.O. #2)

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Urinary Tract Infection

• Review of Urinary Tract Infection Care Path

• Consider the Vital Signs, > temp, glucose• Lab Testing and any urinalysis maybe

already completed • Look at recent blood counts, persistent

nausea and vomiting, unstable VS• Dysuria, alone, Fever,

frequency, urgency

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New Form For C Of C….SBAR

• See H.O. #1 – SBAR ( C of C )

• See H.O. #2 – Use when there is an antibiotic given

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Advanced SBAR

• What is the Situation or Presenting Problem (see H.O. #1)– Be clear about who is calling and from which

facility, the name of the resident and the situation or concern about….

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Advanced SBAR -2

• BACKGROUND– Determine the background; provide

the physician with background information including admission dateand diagnosis, check this box.

– Provide recent lab, x-ray results, check this box.– Identify new medications ordered in the past

week, be prepared to provide medication and dosage, brief name of medication is all that is needed here.

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Advanced SBAR -3

• BACKGROUND (con’t)– Identify the medications currently impacting

the situation (be prepared to review any medications), identify here those that may have the most impact, i.e., an psychoactive drug and a fall (remember the definition of fall).

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Advanced SBAR -4

• Allergies of the resident

• Resident code status

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Advanced SBAR -5

• ASSESSMENT/OBSERVATION – On observing the situation, identify:– Your APPRAISAL of the problem is from

your observations, data gathering.– What the problem seems to be > refer to the

Nurses Guidelines from the “SBAR Guide For Nurses in Skilled Nursing Facilities”

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Advanced SBAR -6

• Vitals – take the vital signs and be ready to inform the physician. Note: the Care Paths for abnormal findings for each of the Care Paths; more information on those later.

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Advanced SBAR -7

• Determine the area that is presenting the primary problem for the resident; do not dismiss other body systems.

• Observation/evaluate and appraise the presenting problem and related conditions i.e., Mental Status – this area may be relevant to any number of conditions i.e., UTI, Falls, etc.

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Advanced SBAR -8

• Consider if the condition is a:

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Advanced SBAR -9

• Recommendations with and from the physician. Check those that apply.

• Do not repeat all the order changes, but reference order changes here.

• Indicate if call back is needed, any other directions, Dr’s name, and if they are the attending covering or consultant and method by phone, onsite, message left with????

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Advanced SBAR -10

• The Nurse must date, sign and include time, along with the Resident and Responsible party or representative that was called or discussed the condition and if no, why note.

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Advanced SBAR -11

• When there are other conditions not on Advanced SBAR form, use the Nurse Notes in addition to the Advanced SBAR form (see H.O. #1).

• If resident is placed on Oral Antibiotics, also use SNF form, Physician Oral Antibiotic Orders (see H.O. #2), in addition to the Advanced SBAR format as you are doing now – aside from your Nurses Notes.

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Q&As

• Questions and answers re: SBAR

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Change of Condition Monitor

• An integral part of– Daily Stand up will review residents w/ C of C

AKA “SBAR”– Ensures prompt follow up and complete

documentation for any change of condition including those identified by resident or family complaints or concerns

– Identifies trends or problems for prompt attention and possible follow up by the CQI Committee and Risk Management Program

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SBAR (C of C) – Fitting into the Big Picture

Quality Care & Review System

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Change In Condition-2

• If need additional space use the Nurses Notes, Enter, Date, Time. Continuation of SBAR dated:_________ (C of C) for (specify)_________________________.

• At any time if a nurses note is not complete before you start the Advanced SBAR form, draw a diagonal line through the page. Write “see SBAR”…..

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POLST

• A new policy for those facilities / areas using POLST (Admin #6007).

• Policy includes physician order part and the requirements.

• Flow chart of steps required from the facility included (see H.O. #3).

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Make It Happen!

It’s up to

you!41