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

1. 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 The development and evaluation of the INTERACT quality improvement program have been supported by grants from The Commonwealth Fund and the Retirement Research Foundation.

2. 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 In collaboration with participating nursing homes

3. 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 Using the INTERACT Early Warning Tool: Stop and Watch

4. [Video of expert talking]

5. 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 Watch o “Stop and Watch”

6. To improve the quality of care for residents To prevent unnecessary transfers to hospital Using the INTERACT Early Warning Tool: Stop and Watch” Purpose

7. 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

8. 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

9. 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

10. 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.

11. 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 directresident contact • Others • Family and close friends with regular direct contact

12. 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

13. Using the INTERACT Early Warning Tool: Stop and Watch 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

14. Using the INTERACT Early Warning Tool: Stop and WatchTool: “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

15. Common barriers to communicating early changes in residents CNA’s are very busy giving direct care Unit nurses are busy giving medications, taking physician orders, and admitting new residents Stop and Watch can help close the gap!

16. 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! Using the INTERACT Early Warning Tool: Stop and Watch

17. 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.

18. 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 ____________________ Early Warning Tool: “Stop and Watch”

19. STOP Seems 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

20. AND Ateless than usual (Not because of dislike of food) Nobowel movement in 3 days or diarrhea Drankless than usual

21. 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

22. Instructions: Stop and Watch Your name: ____________________________ Reported to: ____________________________ Date: __/__/__ Time: ____________ Nurse response: ______________________________ Date: _ /____/___ Time: _____________ Nurse’s name: _______________________ Early Warning Tool: “Stop and Watch”

23. How to ImplementStop and Watchin 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 Using the INTERACT Early Warning Tool: Stop and Watch

24. How to ImplementStop and Watchin Your Nursing Home Using the INTERACT Early Warning Tool: Stop and Watch • How will the tool be used to report resident changes? • Which nurse will the direct care staff give the Stop and Watch tool to? • How will the nurse receiving the tool respond back to the person giving it? • How will the nurse document resident follow-up and actions taken?

25. How to ImplementStop and Watchin Your Nursing Home Using the INTERACT Early Warning Tool: Stop and Watch • 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

26. 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.) Using the INTERACT Early Warning Tool: Stop and Watch

27. [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.]

28. 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

29. Using the INTERACT Early Warning Tool: Stop and Watch Let’s Try It Mr. 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.]

30. [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.]

31. 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

32. Using the INTERACT Early Warning Tool: Stop and Watch Let’s Try It When 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.]

33. [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.]

34. 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

35. 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

36. 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: Select one unit to start The project champion or co-champion should train all staff on that unit in use of the Stop and Watch tool Make enough copies of Stop and Watch for use by each CNA on each shift for one week Try using the Stop and Watch for a week Ways To Get Started

37. 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 When procedures are smooth, distribute Stop and Watch to other staff and train them in its use Consider training families in its use also Ways To Get Started (cont.)

38. 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