Using the INTERACT Early Warning Tool: Session 3 Using 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 Project champion DON RNs LPNs Rehabilitation Therapists Welcome to the third module on the INTERACT program. This module is designed to provide a complete review of the INTERACT Early Warning Tool called Stop and Watch. The audience for this session includes all staff with direct resident contact who would be the first to see a change in the resident’s condition as well as the nurses who supervise and work directly with them. Examples of direct care workers include certified nursing assistants (CNAs) and all non-nursing staff with regular direct resident contact such as rehabilitation therapists, and those working in activities, dietary, and environmental services departments. Nurses who should attend this session include the project champion, key RNs and LPNs who supervise direct care workers, and the director of nursing. We want to acknowledge that the development and evaluation of the INTERACT quality improvement program have been supported by grants from The Commonwealth Fund and the Retirement Research Foundation. The development and evaluation of the INTERACT quality improvement program have been supported by grants from The Commonwealth Fund and the Retirement Research Foundation.

Using the INTERACT Early Warning Tool: Stop and Watch The INTERACT Interdisciplinary Team Joseph Ouslander, MD Florida Atlantic University Ruth Tappen, EdD, RN, FAAN Florida Atlantic University Jill Shutes, GNP Florida Atlantic University Nancy Henry, PhD, GNP Florida Atlantic University Maria Rojido, MD Florida Atlantic University Sanya Diaz, MD Florida Atlantic University Laurie Herndon, MSN, GNP-BC Mass Senior Care Foundation Jo Taylor, RN, MPH The Carolinas Center for Medical Excellence Gerri Lamb, PhD, RN, FAAN Arizona State University Annie Rahman, PhD, MSW USC Davis School of Gerontology Dan Osterweil, MD California Association of Long Term Care Medicine Mary Perloe, GNP Georgia Medical Care Foundation John Schnelle, PhD Vanderbilt University Sandra Simmons, PhD Vanderbilt University Alice Bonner, PhD, GNP Center for Medicare and Medicaid Services The care of older adults requires an interdisciplinary team approach. Caring for older adults is a team sport! Like those teams at your facility, members of the INTERACT team are from a variety of health professions including nursing, medicine, social work, and psychology. The INTERACT team has worked together on many projects related to INTERACT and other topics in long-term care over the past several years. The INTERACT team that has developed and evaluated the INTERACT program is listed on this slide. Your facility is one of several from many different states that is using the INTERACT program modules. Our team thanks you for joining us in this project and appreciates all of the feedback we get on how to continue to improve the program and resources we provide. In collaboration with participating nursing homes

What This Session Will Cover 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 [Build each bullet separately.] In this session we will describe the purpose of the INTERACT Early Warning Tool called Stop and Watch as well as the staff who should use the tool during their daily routine. We will review the primary changes in the resident’s condition which the tool helps identify, and that should be reported to a licensed nurse. We will discuss common barriers that prevent successful communication of resident changes in condition and provide suggestions on how to implement the STOP and WATCH in your facility. 3

[Video of expert talking] [Introduction of expert.] [Expert talking – can use additional animations as well with bullets of key points appearing] [Stop and Watch Tool should be shown as well] The key to reducing unnecessary hospitalizations is the early identification of a resident’s acute change in condition. The INTERACT program provides an early warning tool called STOP and WATCH and a process which makes successful communication about early resident changes more likely. Identifying and reporting early changes is the critical first step in the INTERACT process to prevent unnecessary hospital transfer. However, the early identification of changes can only be done by staff like you who have daily, direct contact with the resident. With INTERACT, as in many other programs to improve the quality of resident care, direct caregivers are the most important link for success. Frontline staff know the resident best. Direct care workers need the skills to observe and correctly identify early changes in the resident’s condition and be empowered to communicate these changes to the nurse in charge. Many of you already report changes in resident condition to your supervisor. However, this communication may not be consistent each day or always be successful. There are many reasons for this breakdown in communication between staff. As a result, staff may not identify, assess, and manage the resident’s change early enough to make a difference. Identification of early resident changes is the key to managing many conditions in the nursing home so that the older adult is not exposed to the dangers associated with hospitalization such as fall injury, pressure ulcers, catheter use, and infections. Early identification of resident changes using the STOP and WATCH will also help staff get timely acute care for those residents who do need to be transferred to the hospital. Not all hospital transfers are avoidable. In both cases, whether the resident is managed in the nursing home or is transferred to the hospital, INTERACT helps staff to improve their quality of care through the early warning tool called, STOP and WATCH. Many nursing homes find it extremely helpful to use the Stop and Watch tool and see an immediate improvement in the communication of early resident changes. During this presentation think about how you communicate changes in residents now and how INTERACT can help you to improve this process. Early, reliable communication about acute changes in your residents means that the right steps can be taken to treat new conditions early and perhaps prevent hospital transfer later. ]

Using the INTERACT Early Warning Tool: Stop and Watch o “Stop and Watch” 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 The purpose of Stop and Watch is to guide direct care staff through a list of those early changes in the resident’s condition which should be reported to the nurse. In addition, this tool will help to improve communication between frontline staff and the nurse in charge. 5

Using the INTERACT Early Warning Tool: Stop and Watch” Purpose To improve the quality of care for residents To prevent unnecessary transfers to hospital The final positive outcome of using the Stop and Watch tool is to improve the quality of care for your residents while preventing unnecessary transfers to the hospital. When frontline staff identify and communicate early changes in a resident’s condition and the proper steps are taken to treat the resident in the nursing home, visits to the Emergency Department and hospital admissions can sometimes be prevented. This means the resident doesn’t experience the trauma of leaving the facility and being exposed to all of the risks associated with a hospitalization. Most staff know what it is like to get a resident back from the hospital who has experienced a fall injury, or side effects from medications, or pressure ulcer, or catheter use, or hospital acquired infection. Often, it takes many weeks for the older adult to regain the function and mobility that was lost during a hospital admission as a result of treatment and bed rest. 6

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 [Build each bullet separately.] [Show picture of a resident and perhaps one on the stretcher] When your facility uses INTERACT to prevent unnecessary hospital transfers there are benefits for the resident and family, the staff, and the facility. Residents who are managed in the nursing home without a hospital transfer benefit from: Continuity of care where staff who know them well are able to respond to their individual preferences and needs. A familiar environment where they can maintain their normal routines. When managed at the nursing home, residents avoid long uncomfortable trips and wait times in the emergency room. Finally, residents are not exposed to the complications associated with the hospitalization of older adults.

Benefits of INTERACT Participation 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 [Build each bullet separately.] [Show staff interacting with residents] Staff who learn to manage acute changes in their residents develop and benefit from the: Knowledge to identify and manage residents in the facility when it is safe and practical to do so. Knowledge to identify residents who require acute care transfers to the hospital more rapidly. Ability to maintain a connection and provide support to the resident and family which would be lost if the resident were transferred to the hospital. Ability to practice at a level for which they are trained and licensed using the educational and clinical practice resources available in the INTERACT program.

Benefits of INTERACT Participation For facility: Better resident outcomes Improved resident and family satisfaction Reduced time associated with transfers Preparation for payment reform Improved communication and documentation [Build each bullet separately.] [Show picture of a resident with family or staff] When acute changes in resident conditions are managed effectively by staff in a timely manner, the facility experiences: Better resident outcomes which will result in more referrals from hospitals Improved resident and family satisfaction Reduced time associated with transfers, hospitalizations, and readmissions. Preparedness for payment reform and partnering with hospitals in Accountable Care Organizations, bundled payments, and other similar initiatives. Improved communication and documentation using expert-recommended protocols which will help with regulatory surveys and protect from legal liability.

Stop and Watch is the way for CNAs to alert the LPN/RN of changes in resident condition AND for the nurse to hear what the CNA has to say. [note that this figure will change] This is the INTERACT Flow Chart that was introduced in the first session. It shows how the INTERACT tools can work together to prevent unnecessary hospital transfers. Remember, that not all hospital transfers are avoidable. Some residents do need to be hospitalized for the treatment of serious medical conditions. Using the INTERACT program will help you identify these residents quicker and promote better treatment for them as well. All of the INTERACT tools are in blue boxes on the left and right sides of this slide. Those on the left are decision support tools to be used by staff when making decisions about care. [Highlight all blue boxes on the left side of the slide.] Those tools on the right are for staff to use during communication and problem solving. [Highlight all blue boxes on right side of slide.] The first tool shown in the chart is the Stop and Watch. [Highlight Stop and Watch Tool.] You can see that this tool comes first. Without this early communication between the CNA or other direct care staff and the nurse, nothing else can happen. Without you, no one else may notice the change in condition. As a result, the change may worsen and the chance for early intervention is missed. Using the Stop and Watch tool is the first, critical step to improve the quality of resident care and to prevent unnecessary hospitalizations.

Using the INTERACT Early Warning Tool: Stop and Watch 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 [Stop and Watch Tool should appear] The Stop and Watch tool is designed for daily use during routine care. While most of the time it will be used by certified nursing assistants, there are many other staff who need to know how to use this tool effectively because of their direct contact with residents. Examples of other employees include rehabilitation and activities therapists, and dietary and housekeeping staff. Some facilities have found it helpful to teach family members how to use the Stop and Watch tool. Close friends and family members who notice changes in the resident can alert staff as well. [The part below should be animated – maybe on a separate slide] Examples of how the Stop and Watch tool may be used by different staff include the following: the CNA who notices an early change in mental status during AM care and lets her charge nurse know that the resident is more confused than normal the CNA who reports to the charge nurse that her resident was up three times during the night shift because of increased agitation and anxiety the housekeeper who notices and reports that a resident slept most of the morning and did not respond when she said hello and asked the resident how she was doing 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 11

Using the INTERACT Early Warning Tool: Stop and Watch 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 [The part below should be animated – with appropriate pictures appearing] Examples of how the Stop and Watch tool may be used by different staff include the following: the CNA who notices an early change in mental status during AM care and lets her charge nurse know that the resident is more confused than normal the CNA who reports to the charge nurse that her resident was up three times during the night shift because of increased agitation and anxiety the housekeeper who notices and reports that a resident slept most of the morning and did not respond when she said hello and asked the resident how she was doing 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 12

Early changes in resident condition to identify and report Using the INTERACT Early Warning Tool: Stop and Watch Early changes in resident condition to identify 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 [Bullet points should build in] STOP and Watch was designed by nurses and physicians to help staff know what and when to report. These changes in the resident’s condition include: Changes in mental status, for example increased sleepiness, confusion, agitation, or anxiety. Remember that increasing confusion can be a sign of a new acute condition such as infection or worsening of a chronic condition such as heart failure or diabetes. Changes in physical status such as problems with walking or transferring Changes in function which include any new or different problems with the resident’s activities of daily living such as their ability to participate in AM or PM care as well as their participation at mealtime Changes in behavior such as new or different patterns of wandering, combativeness, yelling, and verbal or physical aggression Changes in pain level such as new pain or an increase in pain level 13

Using the INTERACT Early Warning Tool: Stop and Watch Tool: “Stop 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 [Pictures of CNA with a resident and/or a nurse] To summarize, the CNA and other direct care staff should report actions or behaviors that are not part of the resident’s normal routine and are a shift away from the resident’s baseline behavior. Of course there is a balance. Staff do not want to report every little thing, but on the other hand staff don’t want to miss important changes. It takes practice to know what to report. Generally speaking, it is better to report a change even if you have doubts about how important a change it may be for the resident. Many facilities use the saying, “When in doubt, fill it out!” The most important part is knowing the resident’s baseline, their normal activity level and usual mental status. We must know the resident very well before we can tell what is an important change. Observe closely. If for some reason you do not know the resident, you may need to ask others who have more knowledge of the resident. Consistent assignment helps all staff to know the resident’s baseline which is another reason why assigning staff to the same residents each day is an important strategy to improve the quality of resident care. Of course, if the change is an improvement for the better such as decreased pain, we would report these desirable changes to the nurse but not use the Stop and Watch tool. Stop and Watch is designed to alert staff to those changes which signal a new condition or worsening of an existing one. 14

Common barriers to communicating early changes in residents Unit nurses are busy giving medications, taking physician orders, and admitting new residents CNA’s are very busy giving direct care Stop and Watch can help close the gap! [Colors can be changed. Aspects of the figures should be highlighted as appropriate during the narrative] We know that licensed nurses are often very busy passing medications several times a shift, admitting new residents, taking physician orders, and giving treatments. It is also true that CNAs and other staff who care for large numbers of residents are very busy with direct care. Sometimes those closest to the resident do not take the time out of their busy schedule to report changes and provide follow-up. A break in the chain of communication may come when the CAN or other staff member has something to report but no one to listen to them. Depending upon the culture of your nursing home, communication can be tough not only between staff on the same shift but between different shifts as well. There are many reasons why the chain of communication breaks in the nursing home. Staffing issues, lack of teamwork, poor time management, and a culture where staff do not interact with each other in a positive way are a few examples. The Stop and Watch tool is a way to fix that broken pattern of communication. It helps CNAs report what should be reported and it helps nurses know how and when to listen. The Stop and Watch tool is a written document. This means that a written record of your observations was made and the nurse in charge must respond to you. Frontline staff need to have the skills to observe and correctly identify early changes in the resident’s condition and be empowered to communicate these changes to the nurse. The Stop and Watch tool helps you to do both. 15

When to Report Changes Using Stop and Watch Using the INTERACT Early Warning Tool: Stop and Watch 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! [Have tool appear] Use the Stop and Watch tool as part of your normal routine when you notice changes during AM or PM care, ambulation and transfer, rounding, helping with meals, toileting, participating in activities, sleeping, and so forth. Complete it during your shift when you have changes to report. Don’t wait to report a change in your resident’s condition until the next day. It may be too late and the resident may have gotten much sicker as a result of your waiting. Remember, the Stop and Watch tool helps you to give better care. 16

Early Warning Tool: “Stop and Watch” 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. [I think we should use the existing clip for this] [Either use the current INTERACT video or create a new one with the scenario below. Scenario for the video 1. Not using the “Stop and Watch Tool” A CNA notices one of her residents becoming more confused throughout the day. She knows this is not a normal pattern for this resident. She reports this to the LPN during a busy med pass. The nurse says she doesn’t have time and to just keep watching the resident. She has a “don’t bother me” attitude. She says that she will get to it when she can. She forgets because there is a new admission and the CNA does not follow up and leaves for the day without reporting it again. The next morning at report the CNA hears from another that the resident was taken to the Emergency Department of the local hospital because of worsening confusion related to delirium secondary to a urinary tract infection. The CNA is heard saying to the family, “I told the nurse your mother needed a doctor! If they would have listened to me, she would have been alright.” Using the “Stop and Watch” Tool The CNA notices her resident becoming more confused throughout the day which is not a normal pattern for this resident. She completes the “Stop and Watch” Tool circling the following two symptoms: Seems different than usual Tired, weak, confused or drowsy The CNA hands the completed form to the nurse after her mid-day med pass. The LPN looks at it, says thank you, reassures the CNA that she will follow-up, and then gives it to the RN supervisor when she goes into the station to do her charting and complete the paperwork for the new admission. The RN supervisor checks the resident’s chart and MAR and then goes in to see the resident to complete an assessment and determine the proper course of action. 17

Instructions for Stop and Watch 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 ____________________ [Tool should be shown] Let’s review the actual tool itself. If you noticed a change in a resident today, please circle the change and report it to the charge nurse today. More than one change may be marked on the same form. Remember, you do not need more than one form per resident per day. Just mark more than one change on the same form. First write, Name of Resident ____________________ 18

STOP Seems different Talks or communicates less 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 [Each section should build in –real tool should shown as well] These are the changes you might circle for a resident. Each one begins with a different letter in the word, STOP. Seems different Not their usual self? Do you see a change in personality or behavior? Talks or communicates less Quieter? Drowsier? Confused? Have you noticed a change in speech? Overall needs more help Needs more help? Do you see any changes in gait, transfer, or balance? Participated in activities less Withdrawn? Decline in ADL’s? Is there a change in their normal routine? Pain level increased Does the resident complain of new pain or more pain than is usual for them? Remember to rely upon the resident’s verbal complaints as well as changes in behaviors for those residents who cannot tell you about pain. Grimaces, clenched teeth, and other facial expressions; pulling away; rubbing body parts; moaning; crying; and withdrawal are all examples which may indicate pain. 19

AND Ate less than usual No bowel movement in 3 days or diarrhea (Not because of dislike of food) No bowel movement in 3 days or diarrhea Drank less than usual [Each section should build in –real tool should shown as well] The next word AND stands for the following resident changes: Ate less than usual (Not because of dislike of food) No bowel movement in 3 days or diarrhea Drank less than usual 20

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 The third word, WATCH, includes letters which stand for the following resident changes: 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 21

Instructions: Stop and Watch Early Warning Tool: “Stop and Watch” Instructions: Stop and Watch Your name: ____________________________ Reported to: ____________________________ Date: __/__/__ Time: ____________ Nurse response: ______________________________ Date: _ /____/___ Time: _____________ Nurse’s name: _______________________ After circling the change or changes which you have seen in the resident, write your name, the nurse’s name you plan to report this to, the date, and time. The nurse is then asked to record their response as well as the date and time of the response. 22

How to Implement Stop and Watch in Your Nursing Home Using the INTERACT Early Warning Tool: Stop and Watch 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 [Build each bullet separately.] There are three basic rules to remember when using the Stop and Watch tool. First, keep the pocket card with you at all times. Your facility may make the Stop and Watch tool into a pocket card which you can keep with you. The idea is that you should have at least one copy with you in a pocket for easy reference. Other blank copies of the Stop and Watch tool can be kept at the station or any place where they are easy to find and complete. Second, complete the form at the time you notice a change in the resident’s condition, that is, during your shift. Remember, do not wait. Third, give the form to the nurse taking care of the resident. Through daily use of the STOP and WATCH tool, direct care staff will begin the important process of early identification and management of acute resident conditions to prevent unnecessary hospital transfers. 23

Using the INTERACT Early Warning Tool: Stop and Watch 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 Please complete the Quiz and Evaluation before logging off. If you do not complete them you will not receive continuing education credit, and if your facility is tracking who completes specific modules, you will not be counted. Thank you very much for your participation.