CHANGE OF CONDITION SBAR AHIS, Inc. CHANGE OF CONDITION SBAR Welcome to the Change of Condition Workshop and what we are also going to refer to as Clinical Care Paths. We will also talk about the Change of Condition documentation as you know it now and some of the focus of the Situation (Presenting Problem) Background or the findings and the Assessment (your findings on examination/observation) and Recommendations/discussion of treatment with the physician, also known as (SBAR). We will discuss a modification of the SBAR that meets our needs in the skilled nursing facility with both RNs and LVNs who conduct resident evaluations and observations. SBAR is the change of condition resident evaluation/observations. We will focus not on the actual resident intervention but on the supporting documentation and the notification to the physician; having all the key information for the physician to make a decision about the best course of action for the resident. We will also focus along with the staff who provide the services that makes quality happen in a facility. Another focus will be the activities carried out by the Health Information Management/Record Designees review of the records for standup and to bring that key information to the meeting. We cannot forget the standup reviews or however you handle that review. It is at this meeting the Adm., DNS and others can assign and/or take responsibility for follow up to assure that quality services that we are proud to say we provide. The Focus to Resident Care, Documentation & Audits COC SBAR Presentation rev. 07/11/13 1

Regulatory Requirements AHIS, 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 – Clinical Care Paths and the SBAR system Anytime there is a change in condition, the urgency will dictate how quick Federal regulations indicate the resident has the right to care and treatment at a level that supports the $$ received. This is what it is all about, services provided with quality. The regulations indicate that the physician shall be notified of changes in condition, so shall the resident/representatives be notified of the changes in condition, including when there are changes in medications. The state regulations also require that you notify the physician when there are changes in condition/medication, etc., that the CP be updated and services modified to meet the needs of the resident. With that said; there is a need to focus on the quality of the observation and examination of the resident prior to the notification to the physician. We will refer to that as SBAR- Situation, Background, Assessment (evaluation/observation by the licensed nursing staff) and Recommendations; discussion with the physician re: options and the physicians directions for care and treatment, ordering of tests, treatment in the facility or transfer to the acute. We do not forget the notifications to the family and the resident re: the condition of the resident based on the requests and agreement of the resident. COC SBAR Presentation rev. 07/11/13 2

Change of Condition Title XXII 72311(a)(2) AHIS, Inc. Change of Condition 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* *Unless something different is stipulated by the physician, weight trends identified must also be reported. Weight change documented (unplanned gain/loss of 5 lbs, 5%-30 days, 7.5%- 90 days, 10%-180 days). COC SBAR Presentation rev. 07/11/13 3

Change of Condition -2 Title XXII 72311(a)(2) AHIS, Inc. Change of Condition -2 Title XXII 72311(a)(2) (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 COC SBAR Presentation rev. 07/11/13

SBAR When to call the MD Vital signs Lab reports Change in Condition

What Is SBAR About? Representative the resident and the facility in a highly clinical fashion This is the reference to the evaluation/observation if the resident and the findings on that review. Knowing the code status and presenting that to the physician as applicable Providing the background status re: the resident

What Is SBAR About? -2 Gives the physician an immediate past Hx, admission diagnosis Describes recent lab work any key medications – focus on medications that are related to the condition or may impact

AHIS, Inc. Change of Condition -3 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… The Federal regulations are more generic in the comments re: change of condition than in the Title 22 Notify 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. The notifications to the resident of change and to the famiy legal representative., Also, the key is to consult with the physician re: the condition; be prepared to provide the physician with key Information. COC SBAR Presentation rev. 07/11/13 8

Change of Condition -4 Notify 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

Change of Condition -5 The SBAR – Change of Condition process will be used for all C of C Change of Condition form to be used (H.O. #2.2) If the form does not accommodate the change of condition, document in the Nurse Progress Notes and use the same process to describe the condition change, i.e., Situation/Presenting Problem, Vital Signs

Change of Condition -6 Evaluate/observe the condition and document the findings applicable to the condition, i.e., Resp., UTI, falls, etc. and follow up with the physician; also provide all the required clinical observations and vital signs Use SBAR Process We will review the form/format a little later

Change of Condition Monitor AHIS, Inc. Change of Condition Monitor An integral part of Daily Stand up will review residents w/ C of C via the C of C Monitor 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 Not all complaints or concerns indicate a change of condition but some can be the precursor to the onset of an actual change of condition. We’ll talk more about monitoring systems for resident and family concerns later in the program. COC SBAR Presentation rev. 07/11/13 12

SBAR This is the reference to the evaluation/observation if the resident and the findings on that review What is the Situation or Presenting Problem What are the Vital Signs and are these within normal limits? Be prepared to discuss these with the physician in ALL CASES when the physician is called

What Is SBAR About For Asm’t? What the observations point to on examining the resident? Provide key information from the areas observed/examined Some body systems may have no abnormal signals/symptoms Determine the area that is presenting the primary problem for the resident; do not dismiss other body systems

SBAR -2 Observation/evaluate and identify those areas that need assessment for the presenting problem, i.e., Mental Status – this area may be relevant to any number of conditions i.e., UTI, Falls, etc.

SBAR -3 Consider if the condition is a: Cardiovascular issue Respiratory Gastrointestinal Genitourinary Possible Infection-Generalized Skin Condition Fall Unplanned weight change….etc.

SBAR -4 While there may be other conditions not on C of C form, then use the Nurse Notes and not the Change of Condition Form If resident is placed on Oral Antibiotics, also use SNF form, Physician Oral Antibiotic Orders, in addition to the Change of Condition format as you are doing now – aside from your Nurses Notes

SBAR Change of Condition – Fitting into the Big Picture Quality Care & Review System

Acute Mental Status Care Path When making an assessment of the Mental Status of the resident, consider that may affect many of the changes of conditions also for other areas besides Mental Status Refer to the Book – Guide to Nurses

Acute Mental Status Let’s review the Care Path (H.O. #2.3) 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

Congestive Heart Failure Let’s review the Care Path (H.O. #2.3) for symptoms and the clinical decisions that are important for evaluation/observation and notification of the physician.

Change of Condition Form Let’s review the form (H.O. #2.2) you will complete – Check out the Cardiovascular and the Respiratory and the condition you are observing/evaluating

Dehydration Let’s review the Care Path (H.O. #2.4) for symptoms and the clinical decisions that are important for evaluation/observation and notification to the physician. Note this gives you a clue of other areas you should evaluate/observe- i.e. Mental Status, Functional Status, Respiratory, GI and Skin

Change Of Condition Form Let’s review the form (H.O. #2.2) you will complete. Check out the Dehydration, mental status, respiratory, gastrointestinal and skin. What are your findings on observation/examination? Document those findings before calling the physician.

Fever Review of the Care Path (H.O. #2.4) for 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

Change Of Condition Form Let’s review the form (H.O. #2.2); note there is the place to document Fever and determine if it is above the normal. Dr. notification of the fever alone is not enough. Evaluate the other systems to determine if there are symptoms for any of these areas. Also, make added notes in the nurses notes if there is not enough space here or you have added information

Respiratory Infection Review of the Care Path (H.O. #2.5) 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

Urinary Tract Infection AHIS, Inc. Urinary Tract Infection Review the Care Path (H.O. #2.5) Consider the Vital Signs; > temp. Glucose Lab Testing and any urinalysis maybe already completed and the findings, Look at recent blood counts, persistent nausea and vomiting, unstable VS Dysuria, alone, Fever, frequency, urgency

SBAR C of C Form Review Change of Condition Form (H.O. #2.2) Consider the Vital Signs and abnormal results Mental Status GI/Hydration GU Skin Falls, if there was also a fall.

SBAR C of C Form -2 Review Change of Condition Form AHIS, Inc. SBAR C of C Form -2 Review Change of Condition Form General Instructions On change in Resident’s condition, the licensed nurse evaluates the situation, identifies presenting problems, gathers information on all applicable systems and reports key observational findings to physician. The change of condition form is a brief description of the findings on identification of change in condition. The licensed nurse evaluates the situation/presenting problem, gathers the information on all applicable systems and reports key observational findings to the physician. It is important that the key clinical information is available and ready to be provided to the physician when they are contacted. All changes in condition are to be reported promptly to the physician. You will complete each section following evaluation of the resident, i.e. if there is a System that on evaluation is normal and there are no abnormal signs or symptoms then you will check ( ) No Abnormal signs or symptoms. COC SBAR Presentation rev. 07/11/13 30

SBAR C of C Form -3 Mental Status Possible Infection, general Cardiovascular Skin Respiratory Falls Gland Unplanned Weight Change Gastrointestinal/ Hydration Genitourinary

SBAR C of C Form –4 BACKGROUND AND REVIEW OF VITAL SIGNS AND FINDINGS Document Review of Recent labs – consider the SBAR for the various conditions and the abnormal findings Identify any new medications recently ordered and has the change occurred since then???

SBAR C of C Form -5 List any allergies as those need to be known to tell the Physician in case there are med. Orders Identify the system review. Physician’s Notification and response Resident and Family, Resp. Rep. notified Add additional comments, date and sign

SBAR C of C Form -6 If need additional space use the Nurses Notes, Enter, Date, Time At any time if a nurses note is not complete before you start the C of C form, draw a diagonal line through the page. Write See C of C.

Question… Initiate SBAR Form Document on SBAR If a page on Nursing Notes was partially filled then draw a diagonal line, date and sign

It’s up to you! Make It Happen! AHIS, Inc. AHIS, Inc. office@ahis.net 36