interact communication tools - aic learn · interact communication tools the interact ... •...

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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

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Video Clip:

Early Identification of and Communication

About Acute Changes in Condition

Available in the Medline INTERACT eCurriculum


Stop and Watch


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


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


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


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


Stop and Watch

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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.


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


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)


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


Stop and Watch

Close the Loop

CNA reports

to unit nurse

Unit nurse communicates to supervisor

Appropriate response

(SBAR)

Feedback to CNA


Stop and Watch

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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


Stop and Watch

© Florida Atlantic University 2011


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

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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


and Progress Note

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The SBAR: One Section At a Time


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• 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


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?



and Progress Note

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Let’s Try It!


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!


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

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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


and Progress Note


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Let’s Try It!


• Diagnoses include multi-infarct dementia and hypothyroidism

• Nursing assistant uses Stop and Watch to Report: Fatigue



• Nurse noted that urinary frequency started today



• Vital signs:

• BP 124/72

• Pulse 76

• RR 18

• Temp 100.9 po

• O2 saturation 94% on room air

Mrs. Susan Dunn


• Needs more assistance than

usual getting in to bed

• Agitated

• Abdominal exam shows no

tenderness

Mrs. Susan Dunn

Let’s Try It!

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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

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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


Putting the Tools to Work in

Everyday Practice

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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



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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.



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



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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


Change in Condition File Cards and Care Paths

The real story behind the Cards:

Mrs. Sadie Schwartz



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The case of

Mama O (See “Transitions of

a Medical Mama” for

the full story)





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


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and Progress Note









• Vital signs:

• BP 124/72

• Pulse 76

• RR 18

• Temp 100.9 po


Mrs. Susan Dunn

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and Progress Note









• Vital signs:

• BP 124/72

• Pulse 76

• RR 18

• Temp 100.9 po


Mrs. Susan Dunn


and Progress Note









• Vital signs:

• BP 124/72

• Pulse 76

• RR 18

• Temp 100.9 po


Mrs. Susan Dunn

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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




Audience Response

Does the clinician on call

need to be notified

immediately?

Yes

No



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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



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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



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




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Audience Response


need to be notified

immediately?

Yes

No





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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




need to be notified

immediately?

1. Yes

2. No





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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




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need to be notified

immediately?

Yes

No







Refer also to the CHF and

Lower Respiratory Infection

Care Paths

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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



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




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need to be notified

immediately?

Yes

No







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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



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



Key Points (2)

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Questions?

Comments?

Suggestions?

The INTERACT Program

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