1. Putting the Tools to Work in
Everyday Practice
Joseph Ouslander, MD Florida Atlantic University
Gerri Lamb, PhD, RN, FAAN Arizona State University
Laurie Herndon, GNP Mass Senior Care
Ruth Tappen, EdD, RN, FAAN Florida Atlantic University
Jo Taylor, RN, MPH The Carolinas Center for
Medical Excellence

2. Putting the Tools to Work in
Everyday Practice
Objectives
Describe the purpose and use of:
Stop and Watch
SBAR Communication Form and Progress Note
Decision Support Tools
Change in Condition File Cards
Care Paths 2

3. Putting the Tools to Work in Everyday Practice
Do any of you use the Stop and Watch Tool? What is your experience?

4. Purpose of “Stop and Watch”
Putting the Tools to Work in
Everyday Practice
Purpose of “Stop and Watch”
To guide frontline staff through a brief review of early changes in the resident’s condition
To improve communication between frontline staff and the nurse in charge 4

5. Putting the Tools to Work in
Everyday Practice
Video Clip
Examples of poor communication between CNA and licensed nurse, and improved communication using the Stop and Watch Tool 5

6. Putting the Tools to Work in
Everyday Practice
Stop and Watch helps frontline staff identify important changes in the resident’s condition
Who is frontline staff?
CNA’s and other nursing staff, rehab therapists, dietary staff, housekeeping staff, activities staff and any staff member with direct resident contact
Family members may also contribute valuable observations 6

7. What early changes in condition should be reported?
Putting the Tools to Work in
Everyday Practice
What early changes in condition should be reported?
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 7

8. Putting the Tools to Work in
Everyday Practice
Stop and Watch is the primary method for
CNAs to alert the LPN/RNs of changes in
the resident’s condition
and for the nurse to hear what the CNAs have to say.

9. Recognizing Changes in Condition
Putting the Tools to Work in
Everyday Practice
Recognizing Changes in Condition
Important changes to report are:
Actions or behaviors that are not part of the resident’s normal routine
A change from the resident’s usual condition 9

10. Putting the Tools to Work in
Everyday Practice
Your Eyes Are the Best
Frontline staff:
Know the resident best
See changes in condition first
Should identify important changes in the resident’s condition during their normal care routine
Must be empowered to communicate what they know and see 10

11. “Stop and Watch” is a great way to communicate changes
Putting the Tools to Work in
Everyday Practice
“Stop and Watch” is a great way to communicate changes
It helps …
The staff know what kinds of changes to report
The nurse understand what you have to say is important and when to take action 11

12. Putting the Tools to Work in
Everyday Practice
Unit nurses are busy
giving medications
and taking physician
orders
CNA’s are busy giving
direct care
“Stop and Watch”
reporting can help
close the gap! 12

13. Instructions for “Stop and Watch”
Putting the Tools to Work in
Everyday Practice
Instructions for “Stop and Watch”
If you have identified an important change while caring for a resident today, please circle the change and discuss it with the charge nurse before the end of your shift.
More than one change may be marked on the same form 13

14. Putting the Tools to Work in
Everyday Practice
S eems different than usual
Not their usual self? Change in personality or behavior?
T alks or communicates less than usual
Quieter? Drowsier? Confused? Altered speech?
O verall needs more help than usual
Needs more assistance? Changes in gait, transfer or balance?
P articipated in activities less than usual
Withdrawn? Decline in ADL’s? Change in normal routine? 14

15. Putting the Tools to Work in
Everyday Practice
Ate less than usual
(Not because of dislike of food) N
Drank less than usual 15

16. Putting the Tools to Work in
Everyday Practice
W eight change
A gitated or nervous more than usual
T ired, weak, confused or drowsy
C hange in skin color or condition
H elp with walking, transferring, toileting more than usual 16

17. Instructions: “Stop and Watch”
Putting the Tools to Work in
Everyday Practice
Instructions: “Stop and Watch”
Staff ____________________________
Reported to ______________________
Date __/__/__ Time ____________ 17

18. Putting the Tools to Work in
Everyday Practice
The SBAR is a tool for LPNs and RNs to evaluate changes in the resident’s condition and communicate them to the MD/NP/PA and document them

19. Putting the Tools to Work in
Everyday Practice
Video Clip
Example of how good evaluation and communication using SBAR can prevent an acute care transfer and hospitalization

20. Purpose of the SBAR Communication Form and Progress Note
Putting the Tools to Work in
Everyday Practice
Purpose of the SBAR Communication Form and Progress Note
Improve communication
Standardized evaluation
Consistent language
Communication that is efficient and effective
Documentation that is thorough and focused

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Everyday Practice

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Everyday Practice

23. Getting a comprehensive history: Who to involve
Putting the Tools to Work in
Everyday Practice
Getting a comprehensive history: Who to involve
CNAs
Social Workers
Rehab, Activities, Dietary
Other staff
Family members

24. Putting the Tools to Work in
Everyday Practice

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Everyday Practice

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Everyday Practice

27. Putting the Tools to Work in
Everyday Practice
Progress Note

28. Making the Case for SBAR
Putting the Tools to Work in
Everyday Practice
Making the Case for SBAR
Assists nurses in organizing their evaluation
Improves communication with MDs/NPs/PAs
Improves shift to shift communication
Alerts all providers about a change in condition
Enhances documentation
Can be copied and sent to ER with resident

29. Putting the Tools to Work in Everyday Practice
Do any of you use the SBAR?
What is your experience?

30. Putting the Tools to Work in
Everyday Practice
INTERACT Decision Support Tools: Care Paths and Change in Condition File Cards

31. Putting the Tools to Work in
Everyday Practice
The INTERACT Care Paths and Change in Condition File Cards are decision support tools
Available for guidance when changes in status or specific symptoms and signs occur

32. Putting the Tools to Work in
Everyday Practice
The Change in Condition File Cards and Care Paths help guide decisions about:
Further evaluation of changes in condition
When to communicate with the MD/NP/PA
When to consider transfer to the hospital
How to manage some conditions in the NH

33. Who Uses the INTERACT Decision Support Tools?
Putting the Tools to Work in
Everyday Practice
Who Uses the INTERACT Decision Support Tools?
RN’s
LPN’s
Nurse supervisors
Nurse educators
MDs, NPs, PAs

34. Putting the Tools to Work in
Everyday Practice
The Care Paths and Change in Condition File Cards are meant to be used with other tools
The change in condition or new symptom or sign may have been noted using the Stop and Watch Tool
Nurses should consider completing an SBAR Form and Progress Note using guidance from these tools

35. Putting the Tools to Work in
Everyday Practice
The INTERACT decision support tools are based on established clinical guidelines published by several national professional organizations
Most are based on expert opinion because we lack definitive scientific clinical trials

36. Putting the Tools to Work in
Everyday Practice
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

37. Putting the Tools to Work in
Everyday Practice
The INTERACT Change in Condition File Cards include recommendations
Immediate vs. non-immediate notification for specific:
Vital signs
Lab results
Symptoms and signs

38. Putting the Tools to Work in
Everyday Practice
The INTERACT Change in Condition File Cards:
The case of Mrs. S: a classic case that illustrates their purpose

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Everyday Practice

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Everyday Practice

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Everyday Practice

42. Using the Change in Condition File Cards
Putting the Tools to Work in
Everyday Practice
Using the Change in Condition File Cards
Staff education to develop critical thinking skills
Nurse educators and managers use Change of Condition File Cards when teaching staff nurses who are assessing a resident’s change in condition
Strategies
5-minute huddle on the unit
Morning stand-up meeting
Report between shifts

43. Putting the Tools to Work in
Everyday Practice
The INTERACT Care Paths focus on 6 conditions that are:
Common reasons for hospital transfer
Often manageable in the nursing home
Frequent causes of potentially avoidable and preventable transfers or hospitalizations
The INTERACT Care Paths :
Acute mental status change
Fever
Dehydration
Symptoms of CHF
Symptoms of Lower Respiratory Illness
Symptoms of UTI

44. Putting the Tools to Work in
Everyday Practice
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

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Everyday Practice

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Everyday Practice

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Everyday Practice

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Everyday Practice

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Everyday Practice

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Everyday Practice

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Everyday Practice
Questions?
Comments?
Suggestions?