Session 3 Using the INTERACT Early Warning Tool: Stop and Watch This session is designed for:

Session 3Using the INTERACT Early Warning Tool:

Stop and Watch

This session is designed for:

• Certified nursing assistants (CNAs)• All non-nursing staff with regular

direct resident contact such as those working in activities, dietary, and environmental services departments

The development and evaluation of the INTERACT quality improvement program have been supported by grants from The Commonwealth Fund

and the Retirement Research Foundation.

•Project champion•DON•RNs •LPNs• Rehabilitation Therapists

The INTERACT Interdisciplinary Team

Joseph Ouslander, MD Florida Atlantic UniversityRuth Tappen, EdD, RN, FAAN Florida Atlantic UniversityJill Shutes, GNP Florida Atlantic UniversityNancy Henry, PhD, GNP Florida Atlantic UniversityMaria Rojido, MD Florida Atlantic UniversitySanya Diaz, MD Florida Atlantic UniversityLaurie Herndon, MSN, GNP-BC Mass Senior Care FoundationJo Taylor, RN, MPH The Carolinas Center for Medical ExcellenceGerri Lamb, PhD, RN, FAAN Arizona State UniversityAnnie Rahman, PhD, MSW USC Davis School of GerontologyDan Osterweil, MD California Association of Long Term Care MedicineMary Perloe, GNP Georgia Medical Care FoundationJohn Schnelle, PhD Vanderbilt UniversitySandra Simmons, PhD Vanderbilt UniversityAlice Bonner, PhD, GNP Center for Medicare and Medicaid Services

In collaboration with participating nursing homes

Using the INTERACT Early Warning Tool: Stop and Watch

What This Session Will Cover

• Purpose of Stop and Watch• Staff who should use Stop and Watch• Changes in resident condition to identify

and report • Common barriers to communicating early

changes• How to implement Stop and Watch in

your facility


[Video of expert talking]

Purpose

To guide direct care staff through a brief review of early changes in the resident’s condition

To improve communication between frontline staff and the nurse in charge

Using the INTERACT Early Warning Tool: Stop and Watcho “Stop and Watch”

To improve the quality of care for residents

To prevent unnecessary transfers to hospital

Purpose

Using the INTERACT Early Warning Tool: Stop and Watch”

Benefits of INTERACT Participation

For Your Residents:• Continuity of care• Familiar environment• Avoid discomfort and long waits in emergency

room• Eliminate risk of complications from hospital


For staff:• Knowledge to identify and manage acute

changes in the facility when safe and practical• Knowledge to identify residents who require

acute care transfers more rapidly• Maintain connection and provide support to

resident and family• Ability to improve care using clinical practice

tools


For facility:• Better resident outcomes • Improved resident and family satisfaction• Reduced time associated with transfers• Preparation for payment reform• Improved communication and documentation

Stop and Watch is the way for

CNAs to alert the LPN/RN of changes in

resident conditionAND

for the nurse to hear what the CNA has

to say.


Those who should use Stop and Watch

Direct care CNA’s and other nursing staff, rehabilitation and

activities therapists, dietary and housekeeping staff, and any staff member with direct resident contact

Others Family and close friends with regular direct contact


Examples of Using Stop and Watch

• CNA notices an early change in mental status during AM care and lets her charge nurse know that the resident is more confused than normal• CNA reports to the charge nurse that her resident was up three 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 who reports to the nurse supervisor that the resident’s strength and coordination was much less on Friday than it was on Wednesday• The daughter who 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

Early changes in resident condition toidentify and report

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


In Summary

Important changes to report are:

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 Tool: “Stop

Unit nurses are busy giving medications,

taking physician orders, and admitting

new residents

CNA’s are very busy giving direct care

Stop and Watchcan help

close the gap!

Common barriers to communicating early changes in residents

When to Report Changes Using Stop and Watch

During your shift

Make it a part of your normal routine

Waiting to report a change in your resident’s condition may have serious results!


Video Clip

A CNA notices one of her residents becoming more confused throughout the

day. She knows this is not a normal behavior pattern for this resident.

Early Warning Tool: “Stop and Watch”

Instructions for Stop and Watch

If you noticed a change in a resident today, please circle the change. Report it to the charge nurse today.

More than one change may be marked on the same form.

Name of Resident ____________________


STOPSeems different

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?

Participated in activities less Withdrawn? Decline in ADL’s? Change in normal routine?

Pain level increased

AND

Ate less than usual

(Not because of dislike of food)

No bowel movement in 3 days or diarrhea

Drank less than usual

WATCH

Weight gain or loss

Agitated or nervous

Tired, weak, confused, or drowsy

Change in skin color or condition

Help with walking, transferring, or toileting more than usual

Instructions: Stop and WatchYour name: ____________________________

Reported to: ____________________________

Date: __/__/__ Time: ____________

Nurse response:

______________________________

Date: _ /____/___ Time: _____________

Nurse’s name: _______________________


How to Implement Stop and Watch in Your Nursing Home

Keep the pocket card with you at all times.

Complete the Stop and Watch form during your shift before you leave.

Give the Stop and Watch form to the nurse taking care of the resident.

If you have copies, keep a copy and follow up on what happened after you reported the change



1. How will the tool be used to report resident changes? 2. Which nurse will the direct care staff give the Stop

and Watch tool to? 3. How will the nurse receiving the tool respond back to

the person giving it? 4. How will the nurse document resident follow-up and

actions taken?



• Written documentation in addition to verbal communication is encouraged

• The Stop and Watch Tool serves as a nurse alert, and the nurse’s response should be documented


Let’s Try IT

Your resident, Mrs. Clarke is usually hungry in the morning and eats eggs and toast with coffee. This morning she only had two bites and wanted to go back to bed by 10 a.m. Usually she stays up until after lunch when she naps for 1 hour. She responds to you and is able to answer questions but is certainly not her normal self. She is drowsy, not hungry, and not interested in anything but getting back into the bed. It is now 11 a.m. Your charge nurse is Beth. [Picture of resident refusing to eat or wanting to return to bed.)


• [Picture of a Stop and Watch Tool that can be completed by a person using a keyboard to complete the information by typing in and circling the areas to report.]

How Did You Do?

Mrs. Clarke’s changes in condition could signal many things. Your reporting them early is the key to further assessment and timely management. Here are the changes to report:– Seems different than usual– Ate less than usual– Drank less than usual– Tired weak, confused, or drowsy


Let’s Try ItMr. Morgan hasn’t been himself all evening. He’s more

confused than usual. He even forgot it was Thursday night and that his favorite singers were coming to perform at the nursing home. He ate most of his dinner, but when you helped him transfer into the wheelchair, he could not bear any weight. Usually he helps during transfer and has the strength to bear partial weight. The same thing happened when you transferred him to bed. He also needed more help undressing. It is 9 p.m. The evening nurse supervisor is Sarah. [Picture of resident during a transfer who needs a lot of help.]

• [Picture of a Stop and Watch Tool that can be completed by a person using a keyboard to complete the information by typing in and circling the areas to report.]

How Did You Do?

Mr. Morgan’s changes in condition could mean many things. Your reporting them early is the key to further assessment and timely management. Here are the changes to report:– Seems different than usual– Overall needs more help– Tired weak, confused, or drowsy– Help with walking, transferring, or toileting more

than usual


Let’s Try ItWhen Mrs. Taylor woke up this morning she seemed to

have less energy than usual. She complained that she didn’t feel like herself today. During her AM care, you noticed that both legs were more swollen than usual. Putting her shoes on was difficult because her ankles and feet were puffy. After you helped her to dress, she complained of fullness around her stomach and that her pants were tight. It is 9:30 a.m. The charge nurse for Mrs. Taylor is Shawna. [Picture of a resident with leg edema.]

[Picture of a Stop and Watch Tool that can be completed by a person using a keyboard to complete the information by typing in and circling the areas to report.]

How Did You Do?

Mrs. Taylor’s change in condition could mean many things. Your reporting them early is the key to further assessment and timely management. Here are the changes to report:– Seems different than usual– Weight gain– Tired, weak

Suggested Ways to Monitor and Improve Use

• Clinical champion and/or DON• Monitor

– Who completes tool– Who the tool is reported to– Action taken by the nurse– Documentation– Final outcome

• Computerized summary or paper flow • Daily, weekly, monthly

Your facility’s project champion and co-champion are responsible for coordinating INTERACT implementation. She or he may ask you to complete specific activities.

Suggested activities include: 1.Select one unit to start2.The project champion or co-champion should train all staff

on that unit in use of the Stop and Watch tool 3.Make enough copies of Stop and Watch for use by each

CNA on each shift for one week 4.Try using the Stop and Watch for a week

Ways To Get Started

1. The champion should meet with staff to discuss how the tool was used, what barriers arose, and ways to improve. Try again for another week and monitor

2. When procedures are smooth, distribute Stop and Watch to other staff and train them in its use

3. Consider training families in its use also

Ways To Get Started (cont.)


Quiz and Evaluation

• Please complete the Post-Session Quiz and Evaluation• If you do not complete them:

– You will not receive continuing education credit– If your facility is tracking who completes specific modules, you

will not be counted

Session 3 Using the INTERACT Early Warning Tool: Stop and Watch This session is designed for:

Documents

Transcript of Session 3 Using the INTERACT Early Warning Tool: Stop and Watch This session is designed for: