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3/24/2013
1
Joseph G. Ouslander, M.D.
Professor and Senior Associate Dean for Geriatric Programs
Charles E. Schmidt College of Biomedical Science
Professor (Courtesy) Christine E. Lynn College of Nursing
Florida Atlantic University
Executive Editor, Journal of the American Geriatrics Society
INTERACT
Communication Tools
http://interact2.net
The INTERACT
Version 3.0 tools are
meant to be used
together in your daily
work in the nursing
home
Using the INTERACT Early Warning Tool:
Stop and Watch
3/24/2013
2
Video Clip:
Early Identification of and Communication
About Acute Changes in Condition
Available in the Medline INTERACT eCurriculum
Using the INTERACT Early Warning Tool:
Stop and Watch
Using the INTERACT Early Warning Tool:
Stop and Watch
If you have identified a change
while caring for or observing a
resident, please circle the change
and notify a nurse. Either give the
nurse a copy of this tool or review
it with her/him as soon as you can.
More than one change may be
marked on the same form
Stop and Watch is a
clinical alert
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1. Purpose
To guide direct care staff through a brief review of early changes in resident’s condition
To improve communication between frontline staff and the nurse in charge about early changes in condition
Using the INTERACT Early Warning Tool:
Stop and Watch
2. Target audience
Frontline workers
CNA’s and other nursing staff, rehabilitation therapists, dietary staff, housekeeping staff, activities staff , laundry staff, and any staff member with direct resident contact on a routine basis
Others
Family and close friends with regular direct contact
Using the INTERACT Early Warning Tool:
Stop and Watch
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3. Relevant changes in condition Actions or behaviors that are not part
of the resident’s normal routine
A change from the resident’s baseline
Using the INTERACT Early Warning Tool:
Stop and Watch
Changes in mental status
Changes in physical status
Changes in function
Changes in behavior
Changes in pain level
When in doubt, fill it out!
4. Methods of Use When to Report Changes
During the shift in which the change occurs
Part of daily routine care
Using the INTERACT Early Warning Tool:
Stop and Watch
3/24/2013
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STOP
Seems different than usual Not their usual self? Change in personality or behavior?
Talks or communicates less Quieter? Drowsier? Confused? Change in speech?
Overall needs more help Needs more assistance? Changes in gait, transfer or
balance?
Pain level new or worsening
Participated less in activities Withdrawn? Decline in ADL’s? Change in normal routine?
AND
Ate less
(Not because of dislike of food)
No bowel movement in 3 days;
or diarrhea
Drank less
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WATCH
Weight change
Agitated or nervous more than usual
Tired, weak, confused, or drowsy
Change in skin color or condition
Help with walking, transferring, toileting
more than usual
Examples of Use • CNA notices an early change in mental status during AM care and
reports that the resident is more confused than normal.
• CNA reports that his resident was up 3 times during the night shift
because of increased agitation and anxiety.
• The housekeeper notices and reports that a resident slept most of
the morning and did not respond when she said hello.
• The physical therapy assistant reports that the resident’s strength
and coordination was much less on Friday than it was on
Wednesday.
• The daughter reports that her father’s memory loss has changed
since her visit the day before and that even long term memory is
impaired for the first time.
Using the INTERACT Early Warning Tool:
Stop and Watch
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5. Barriers to Success Inconsistent assignment (CNA/nurse); turnover
Unit nurse with insufficient resident knowledge
Broken relationships and communication nurse /CNA and
between CNA/CNA
Resistance to change; verbal method of notification
Used alone without comprehensive INTERACT program
Lack of leadership from clinical champion and unit nurses
Using the INTERACT Early Warning Tool:
Stop and Watch
6. Methods to improve use
Keep tools for frontline workers to access easily (e.g.,
pocket card, nurses station, front desk, therapy)
Translate into necessary languages
Teach, follow-up, monitor, role model, mentor
Ensure consistent assignment
Improve culture and communication patterns (i.e., shift
report process, unit based team huddles, relational
coordination)
Using the INTERACT Early Warning Tool:
Stop and Watch
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Step One: Who does the CNA report it to?
Step Two: Who completes the nurse
assessment?
Unit nurse
Supervisor
DON, ADON
Step Three: Who gets back to the CNA?
Close the Loop
Using the INTERACT Early Warning Tool:
Stop and Watch
Close the Loop
CNA reports
to unit nurse
Unit nurse communicates to supervisor
Appropriate response
(SBAR)
Feedback to CNA
Using the INTERACT Early Warning Tool:
Stop and Watch
3/24/2013
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Ways to Sustain
1. Clinical champion monitors frontline staff use
Number, staff, shift, unit, etc.
2. DON/clinical champion reviews nurse response to Stop
and Watch tool
Who responded, what was done, communication loop closed
3. Resident outcome and role of tool
Using the INTERACT Early Warning Tool:
Stop and Watch
© Florida Atlantic University 2011
http://interact2.net
Putting the Tools to Work in
Everyday Practice
The INTERACT
Version 3.0 tools are
meant to be used
together in your daily
work in the nursing
home
3/24/2013
10
Video Clip:
Effective Nurse – Primary Care Clinician
Communication About Acute Changes in
Condition
Available in the Medline INTERACT eCurriculum
The SBAR Communication Form
and Progress Note
Improve communication
Consistent language
Standardized criteria
Clear guidelines
Communication that is
efficient
Communication that is
effective
The Purpose of the SBAR
The SBAR Communication Form
and Progress Note
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The SBAR: One Section At a Time
The SBAR: One Section At a Time
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The SBAR: One Section At a Time
The SBAR: One Section At a Time
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• The SBAR: One Section At a Time
The SBAR: One Section At a Time
The SBAR: One Section At a Time
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1. “This is going to take so long”
2. “What about the “A” section?
…LPNs, are not allowed to
assess?”
3. “Do I have to do an SBAR for
EVERYTHING?”
What comment will you hear first?
Audience Response Question
The SBAR Communication Form
and Progress Note
1. They guide the nursing assessment
2. They help further structure nurse-primary
care clinician communications
3. They reduce potential for illegible notes
4. They are important for electronic health
records
5. All of the above
Why all the checkboxes?
Audience Response Question
The SBAR Communication Form
and Progress Note
3/24/2013
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Let’s Try It!
The SBAR Communication Form
and Progress Note
• 92 year-old long-term care resident
• Diagnoses include multi-infarct dementia
and hypothyroidism
• Nursing assistant uses Stop and Watch
to Report:
Fatigue
Mental status change
Poor intake at lunch
• Nurse noted that urinary frequency
started today
• Family concerned
• Recent treatment for UTI
Mrs. Susan Dunn
Let’s Try It!
The SBAR Communication Form
and Progress Note
Mrs. Susan Dunn
• Vital signs:
• BP 124/72
• Pulse 76
• RR 18
• Temp 100.9 po
• O2 saturation 94% on
room air
3/24/2013
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• Needs more assistance
than usual getting in to bed
• Agitated
• Abdominal exam shows no
tenderness
Let’s Try It!
Mrs. Susan Dunn
The SBAR Communication Form
and Progress Note
The SBAR: One Section At a Time
3/24/2013
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The SBAR: One Section At a Time
Let’s Try It!
• 92 year-old long-term care resident
• Diagnoses include multi-infarct dementia and hypothyroidism
• Nursing assistant uses Stop and Watch to Report: Fatigue
Mental status change
Poor intake at lunch
• Nurse noted that urinary frequency started today
• Family concerned
• Recent treatment for UTI
• Vital signs:
• BP 124/72
• Pulse 76
• RR 18
• Temp 100.9 po
• O2 saturation 94% on room air
Mrs. Susan Dunn
The SBAR: One Section At a Time
• Needs more assistance than
usual getting in to bed
• Agitated
• Abdominal exam shows no
tenderness
Mrs. Susan Dunn
Let’s Try It!
3/24/2013
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The SBAR: One Section At a Time
Let’s Try It!
Mrs. Susan Dunn
• How would you complete
these sections?
Use of the SBAR Form and Progress Note:
• Provides guidance on how to complete and document a
comprehensive nursing evaluation
• Improves communication
– Between staff in the nursing home
– With primary care clinicians
– With hospital partners
• Structured and standard approach consistent with best practices
• Improved care for residents
Using the INTERACT SBAR Communication
Form/Change in Condition Progress Note
Key Points
3/24/2013
19
Questions?
Comments?
Suggestions?
The INTERACT Program
The INTERACT Version
3.0 Tools are meant to be
used together in your daily
work in the nursing home
http://interact2.net
Putting the Tools to Work in
Everyday Practice
3/24/2013
20
These tools help guide decisions about:
Further evaluation of changes in resident condition
When to communicate with the primary care clinician (physician, NP, or PA)
When to consider transfer to the hospital
How to manage some conditions in the facility
INTERACT Decision Support Tools:
Care Paths and Change in Condition File Cards
The INTERACT and Change in Condition
File Cards and Care Paths are consistent
with established clinical guidelines published
by several national professional
organizations
Most are based on expert opinion as opposed to
definitive scientific clinical trials
INTERACT Decision Support Tools:
Care Paths and Change in Condition File Cards
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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 medical director and primary care clinicians must review and approve these tools in order for them to be effective in everyday care.
INTERACT Decision Support Tools:
Care Paths and Change in Condition File Cards
How to Use the Tools Must be readily available and visible in order
to be used effectively
They will not be used if they are in a
notebook on a shelf
The Change in Condition File Cards should
be kept at the nurses station near the phone,
and/or hanging on medication carts to be at
nurses’ fingertips
Examples of the Care Paths should be used
as posters to remind nurses and primary care
clinicians of their availability
Pocket size booklets containing all of the File
Cards and Care Paths can be effective
These tools can be ordered in these formats
through links on the INTERACT website
INTERACT Decision Support Tools:
Care Paths and Change in Condition File Cards
3/24/2013
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The INTERACT Change in
Condition File Cards are meant
to be visible and sit next to the
phone for quick reference
Originated at the LA JHA,
published in a letter to JAGS,
then in Medical Care in the
Nursing Home
New version based on AMDA
Clinical Practice Guideline
INTERACT Decision Support Tools:
Change in Condition File Cards and Care Paths
The real story behind the Cards:
Mrs. Sadie Schwartz
INTERACT Decision Support Tools:
Change in Condition File Cards and Care Paths
3/24/2013
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The case of
Mama O (See “Transitions of
a Medical Mama” for
the full story)
INTERACT Decision Support Tools:
Change in Condition File Cards and Care Paths
INTERACT Decision Support Tools:
Change in Condition File Cards and Care Paths
How many nurses in
the room have called
an on-call physician at
1:30 am for an
abnormal Mean
Corpuscular Volume
(MCV) on a CBC?
1. Yes
2. No
Audience Response Question
3/24/2013
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INTERACT Decision Support Tools:
Change in Condition File Cards and Care Paths
The SBAR Communication Form
and Progress Note
• 92 year-old long-term care resident
• Diagnoses include multi-infarct dementia and hypothyroidism
• Nursing assistant uses Stop and Watch to Report: Fatigue
Mental status change
Poor intake at lunch
• Nurse noted that urinary frequency started today
• Family concerned
• Recent treatment for UTI
• Vital signs:
• BP 124/72
• Pulse 76
• RR 18
• Temp 100.9 po
• O2 saturation 94% on room air
Mrs. Susan Dunn
3/24/2013
25
The SBAR Communication Form
and Progress Note
• 92 year-old long-term care resident
• Diagnoses include multi-infarct dementia and hypothyroidism
• Nursing assistant uses Stop and Watch to Report: Fatigue
Mental status change
Poor intake at lunch
• Nurse noted that urinary frequency started today
• Family concerned
• Recent treatment for UTI
• Vital signs:
• BP 124/72
• Pulse 76
• RR 18
• Temp 100.9 po
• O2 saturation 94% on room air
Mrs. Susan Dunn
The SBAR Communication Form
and Progress Note
• 92 year-old long-term care resident
• Diagnoses include multi-infarct dementia and hypothyroidism
• Nursing assistant uses Stop and Watch to Report: Fatigue
Mental status change
Poor intake at lunch
• Nurse noted that urinary frequency started today
• Family concerned
• Recent treatment for UTI
• Vital signs:
• BP 124/72
• Pulse 76
• RR 18
• Temp 100.9 po
• O2 saturation 94% on room air
Mrs. Susan Dunn
3/24/2013
26
At 10:30 pm, complains moderate
diffuse abdominal pain since yesterday
No fever, nausea, or vomiting
Afebrile, abdomen mildly tender with
decreased bowel sounds
Recently begun on narcotic for arthritis
unresponsive to PT and acetominophen
Sol An 89 year old long-stay NH resident
INTERACT Decision Support Tools:
Change in Condition File Cards and Care Paths
Sol An 89 year old long-stay NH resident
Audience Response
Does the clinician on call
need to be notified
immediately?
Yes
No
INTERACT Decision Support Tools:
Change in Condition File Cards and Care Paths
3/24/2013
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INTERACT Decision Support Tools:
Change in Condition File Cards and Care Paths
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
Educational tools
Recommended as posters
Use for case-based learning
INTERACT Decision Support Tools:
Change in Condition File Cards and Care Paths
3/24/2013
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INTERACT Care Paths Acute Mental Status Change
Change in Behavior: New or Worsening
Behavioral Symptoms
Dehydration
Fever
GI Symptoms – nausea, vomiting,
diarrhea
Shortness of Breath
Symptoms of CHF
Symptoms of Lower Respiratory Illness
Symptoms of UTI
INTERACT Decision Support Tools:
Change in Condition File Cards and Care Paths
After a dose of Pepto Bismol and Milk
of Magnesia Sol is no better
He had two episodes of vomiting over
night
The morning nurse exams him and
finds moderate abdominal tenderness
and no bowel sounds
His temperature is 100.9 F
Sol An 89 year old long-stay NH resident
INTERACT Decision Support Tools:
Change in Condition File Cards and Care Paths
3/24/2013
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Sol An 89 year old long-stay NH resident
Audience Response
Does the clinician on call
need to be notified
immediately?
Yes
No
INTERACT Decision Support Tools:
Change in Condition File Cards and Care Paths
INTERACT Decision Support Tools:
Change in Condition File Cards and Care Paths
3/24/2013
30
Rose has a history of COPD and CAD
and had an acute MI 6 months ago
At 8 pm she complains of increased
shortness of breath after an upsetting
phone call with her daughter
Her RR is 26, and her O2 sat is 92%,
both unchanged from her baseline
The nurse finds no abnormal lung
sounds on exam
Rose A 92 year old long-stay NH resident
INTERACT Decision Support Tools:
Change in Condition File Cards and Care Paths
Does the clinician on call
need to be notified
immediately?
1. Yes
2. No
Rose A 92 year old long-stay NH resident
INTERACT Decision Support Tools:
Change in Condition File Cards and Care Paths
Audience Response Question
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INTERACT Decision Support Tools:
Change in Condition File Cards and Care Paths
Two days later, the nurse notes that
Rose’s breathing is a little more
labored.
Her RR is 30, and her O2 sat is 89 %,
and she has faint wheezes on lung
exam
She also has the new onset of pedal
edema
Rose A 92 year old long-stay NH resident
INTERACT Decision Support Tools:
Change in Condition File Cards and Care Paths
3/24/2013
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Does the clinician on call
need to be notified
immediately?
Yes
No
Rose A 92 year old long-stay NH resident
INTERACT Decision Support Tools:
Change in Condition File Cards and Care Paths
Audience Response Question
INTERACT Decision Support Tools:
Change in Condition File Cards and Care Paths
Refer also to the CHF and
Lower Respiratory Infection
Care Paths
3/24/2013
33
David has a 10-year history of multi-
infarct dementia
Only other problems are HTN, arthritis,
and osteoporosis
As the nursing assistant is taking him to
the shower, he starts yelling and
scratches her hand
He has not had similar behavioral
symptoms in over a year
David An 88 year old long-stay NH resident
INTERACT Decision Support Tools:
Change in Condition File Cards and Care Paths
The nurse comes to evaluate him and
finds him more confused than usual
and that he was incontinent of urine–
a new symptom for him
His BP is 96/70, Apical HR 140 and
irregular
RR and O2 sat are normal, and he is
afebrile
David An 88 year old long-stay NH resident
INTERACT Decision Support Tools:
Change in Condition File Cards and Care Paths
3/24/2013
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Does the clinician on call
need to be notified
immediately?
Yes
No
David An 88 year old long-stay NH resident
INTERACT Decision Support Tools:
Change in Condition File Cards and Care Paths
Audience Response Question
INTERACT Decision Support Tools:
Change in Condition File Cards and Care Paths
3/24/2013
35
Key Points (1)
The INTERACT Decision Support Tools help guide
decisions about:
Further evaluation of changes in resident condition
When to communicate with the primary care clinician
When to consider transfer to the hospital
How to manage some conditions in the facility
In order to be effective in everyday care the tools must be:
Reviewed and have buy-in from the medical director and primary
care clinicians
Visible and accessible for nursing staff and primary care clinicians
Used in case-based education
INTERACT Decision Support Tools:
Change in Condition File Cards and Care Paths
The recommendations in the Tools are:
Consistent with established clinical guidelines published by
several national professional organizations
Not fixed in stone
Meant to guide decision making, not dictate it
The systematic, clearly defined approach to symptoms
and signs in the Change in Condition File Cards and the
Care Paths is more important than the specific
recommendations
Your clinical team may choose to modify specific
recommendations and incorporate these changes into facility
policies and procedures
INTERACT Decision Support Tools:
Change in Condition File Cards and Care Paths
Key Points (2)
3/24/2013
36
Questions?
Comments?
Suggestions?
The INTERACT Program
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