if documentation is a reflection of our care, does it show that nurses make a difference ?

If documentation is a reflection of our care, does it show that nurses make a difference?

Changing focus from repetitive screening for Falls Risk to a model

that supports Falls Prevention Historically for each new issue addressed, we’ve added a new

section or Tab to HED – not sustainable and adds complexity to

documentation

As we work toward a Culture of Safety, we need a framework that

allows us to identify and address all safety risks efficiently and

document all education in a compliant, simpler fashion

Falls/Safety Documentation Changes – Why change?

Verbalize understanding of the changes in documentation and workflow associated with new Falls/Safety HED build

For your area, identify common Falls/Safety scenarios and how to address them

OBJECTIVES….

Use a practice scenario to document Safety Assessment and Plan including:

Determine the Morse Falls Risk Score Identify safety risk factors and safety problems; Start Safety Priority Problem, if

warranted Document Care Interventions, Patient/Family Teaching, and any Notifications &

Care Coordination actions Document response to safety interventions & shift goals/outcomes for Safety

Priority Problems (if there is a Safety Priority Problem)

We are starting training for Leaders who will implement this change during the week of the pilot in order to provide as much time as possible to train staff prior to rollout dates. Minor tweaks to what we see today are possible. We will update materials and share any modifications that we do make with you.

We will be adding training scenarios and other resources customized for the Psychiatric and Children’s Hospitals and these should be available by early next week. Today, we will use Adult scenarios.

Disclaimer

Pilot focuses on: ◦ Falls Risk portion of new Safety Build

Other New features that will be addressed:

◦ Role/Communication documentation

◦ Changes in documentation of Patient/Family education &

engagement

◦ Changes in Restraint, CIWA, and some other safety-related

documentation

Pilot: 9N September 18th

Safety Documentation, including assessment, interventions, teaching, and notification, will result in a safer environment for our patients and will prevent or minimize injury.

This will improve patient care and clearly define nursing’s contributions to patient care and the team.

Vision Statement

Safety/Falls Section: What’s Changing? Safety assessment on every patient, every shift. Also:o Adults: Morse Falls screen o Peds: Humpty Dumpty Falls

o on admission & with change in status/condition (e.g. Transfer to different level of care, change in mental status, etc.) . No longer required every shift.

o Streamlined documentation of Restraint Safety Care

Safety Problems (Injury Risk, Violence Risk, Substance Abuse, and others) will be identified. o If a safety problem will be a key driver of nursing care for that patient, also initiate as a

Priority Problemo CIWA documentation will be available in HED for units that implement CIWA protocol

Safety Interventions will be documented – things you: o Assess/Monitor/Evaluate/Observeo Care/Perform/Provide/Assisto Teach/Educate/Instruct/Supervise o Manage/Refer/Contact/Notify

Caregivers’ contact information (“Care Contacts”) – will be

documented in new Role/Communication section

Patient/Family Education & Engagement will be documented

in a way that captures required elements more efficiently

Education Tab: What’s Changing?

Plan of Care documentation

Priority Problems – continue to create and evaluate goals

Pathway, Nursing Summary, and Plan Priorities documentation in HED

Continue to assign e-docs pathway

Admission History

Continue to complete all sections (Contact Information will likely be

removed in future)

What’s Not Changing

Admission

• Falls Risk screen • Safety assessment as part of head-to-toe assessment; Identify problems

& Plan Interventions; Start Priority Problem if warranted

Beginning of Shift

• Safety assessment; Identify problems & Plan Interventions

• Document expected Short Term Goals for Safety Priority Problems

End of Shift

• Start/End Safety Priority Problems if warranted • Document Short Term Goal Status or outcome for Priority Problems • Document Response to all Safety Interventions

Condition/ Status

Change

• Falls Risk screen• Repeat Safety Assessment & Revise Planned Interventions as appropriate

What to Do & When

PRACTICE SCENARIO – Admission John Doe is an 85 year old male admitted for planned TURP for BPH.

Medical Conditions: COPD, Heart Disease, Hypertension, and migraine headaches.

Past Surgical Procedures: CABG (1987) Bilateral Knee Replacements (1997) shoulder surgeries (2002 & 2005). He has a history of falls with injury, resulting in rotator cuff tears and multiple rib fractures.

Medication History: 15 medications, some are anticonvulsants, Lortab for poorly controlled headaches, 2 antihypertensive, and Lasix.

Family/Support: His wife, the primary caregiver, shares that a lot of medications make him “dizzy” or “crazy”. She reports that he has stopped taking many medications because the side effects contributed to falls.

On admission: Mr. Doe has no IV, is alert and oriented x3 , and verbalizes awareness that he is very unsteady on his feet. He has Activity orders is to be OOB w/Assist and agrees to use the call light any time he needs to get out of bed. His wife is concerned that he may try to go to the bathroom without assistance because of urinary urgency and frequency associated with his prostate issues. His daughter will be secondary caretaker and will come on the weekends to relieve the wife.

Admission

• Falls Risk screen • Safety assessment as part of head-to-toe assessment; Identify problems

& Plan Interventions; Start Priority Problem if warranted

Click on HED Train tab and select the Safety Falls/ Risk tab

Locate and complete the Morse Falls Risk Section

Admission

• Morse Falls Risk screen • Safety assessment as part of head-to-toe assessment; Identify problems

& Plan Interventions; Start Priority Problem if warranted

How would you assess the patient’s:◦ Ambulation aid◦ Gait

Admission

Document the Safety Assessment on admission and identify at least one safety problem and 2-3 interventions to address the problem.

Would “Falls Risk” likely be a Priority Problem for this patient?

Click on the Education tab and document contact information for primary and secondary caregiver

• Morse Falls Risk screen • Safety assessment as part of head-to-toe assessment; Identify problems

& Plan Interventions; Start Priority Problem if warranted

Beginning of Shift

• Safety assessment; Identify problems & Plan Interventions

• Document expected Short Term Goals for Safety Priority Problems

Would you need to document another Morse Falls Risk Screening at the beginning of every shift?

What safety interventions might you document for this patient?

End of Shift

• Start/End Safety Priority Problems if warranted • Document Short Term Goal Status or outcome for Priority Problems • Document Response to all Safety Interventions

What are some examples of patient responses to Safety Interventions you might document for this patient?

Mr. Doe returns from the OR on IV antibiotics receiving bladder

irrigation with a 3-way foley catheter in place for the next 48 hrs. He is

confused and keeps trying to pull out his foley despite numerous

interventions from family members and staff. Restraints are ordered

to protect him from injuring himself.

PRACTICE SCENARIO – Status Change

• Morse Falls Risk screen• Repeat other Safety Assessment & Revise Planned Interventions as

appropriateCondition/

Status Change

Now with this change in status, go back to the Safety/Falls tab.

Complete a Morse screening and new Safety Assessment

Condition/ Status

Change

• Morse Falls Risk screen• Repeat other Safety Assessment & Revise Planned Interventions as

appropriate

Mr. Doe’s IV, GU irrigant, and foley are discontinued. He experiences bladder spasms

and urinary urgency at intervals throughout the day. He is ambulating short distances

with 2 assisting using a walker. He is oriented to pre-surgery level. A pharmacy

consult was completed to discuss his medication side effects and they have

recommended some changes that have been ordered. Discharge teaching is done

with Mr. Doe & his primary and secondary caregivers. They request and are provided

with information on how to make his home environment safer and a Home Health PT

consult is ordered to do an environmental assessment and recommend improvements.

Fall Safety education is provided, including a video, printed materials, and verbal

instruction. Patient and both caregivers verbalize overall understanding but you notify

Home Health Agency to reinforce education post discharge.

Condition/ Status

Change

• Morse Falls Risk screen• Repeat other Safety Assessment & Revise Planned Interventions as

appropriate

• Where & how would you document the referrals to Pharmacy and Home Health PT?

• Where & how would you document the patient/caregiver education?

Admission

• Falls Risk screen • Safety assessment as part of head-to-toe assessment; Identify problems

& Plan Interventions; Start Priority Problem if warranted

Beginning of Shift

• Safety assessment; Identify problems & Plan Interventions

• Document expected Short Term Goals for Safety Priority Problems

End of Shift

• Start/End Safety Priority Problems if warranted • Document Short Term Goal Status or outcome for Priority Problems • Document Response to all Safety Interventions

Condition/ Status

Change

• Falls Risk screen• Repeat Safety Assessment & Revise Planned Interventions as appropriate

What to Do & When

When the patient’s condition deteriorates 2 hrs. after she arrives on your unit, does the Morse Falls Risk screen need to be repeated? Why?

Will she have a Safety Priority Problem started? Why?

How will the Care Contact information change from day of surgery to day of discharge?

What education and notifications will you document on day of discharge?

Second Scenario

Question1. Do I have to

document a Falls Screen every shift?

2. Do I still need to do Restraint documentation every 2 hrs. ?

3. Will safety issues still be Priority Problems?

Common Questions

Answer1. No, only with

changes in condition/status

2. Yes, but you now document a single checkbox instead of multiple checkboxes

3. Sometimes but not all Safety issues rise to that level.

GO LIVE DAY New Safety/Fall Risk section will replace the old Falls

Risk section in Assessment/Interventions tab

New content will appear in Education tab

Restraints tab will be removed

Past data will be viewable for the Restraints and Fall

Risk sections of Assessments/Intervention Tab but will

not contain charting boxes.

VUH – Oct. 16 VPH – Oct. 23 VCH – Oct. 30

Resources:◦Provided by SSS:

All resource materials will be accessible from Systems Support Services Web Site by Sept. 25 CAPS will partner with Unit-Based Resources to complete education & will provide support

◦Provided by Unit: Super-Users/ Educator

Need enough super-users for each shift Go Live week

Implementation Support Super-user: 9a-5p and 9pm to 5am SSS: 9a-5pm and 9pm to 5am (Night Shift will

support multiple units concurrently; rounding schedule to be posted)

Training and Implementation Plan

Unit Leader TO DO LIST Meet with CAPS person to formulate specific plan for

our unit Review the documents provided (posted on SSS

website) Complete Unit-Specific Implementation Plan

(including recruiting Super-users) and use that Plan and Implementation Checklist to track progress through implementation process

Identify Super-users and best way to do training for your unit

ASK QUESTIONS