Improving Patient Safety in Long-Term Care Facilities

Slide 1

Knowledge objectives

Participants will be able to understand:

• Why detecting change is important.
• How to know a resident's normal (baseline) condition.
• How to watch for change.
• How the Early Warning tool and SBAR tool work.
• How to communicate about change.

Slide 2

Performance objectives

Participants will be able to:

• Summarize a resident's normal (baseline) condition for other team members.
• Identify whether changes in a resident's condition are important or not important.
• Promote behaviors that improve change detection.

Slide 3

Performance objectives (continued)

Participants will be able to:

• Use the Early Warning tool and SBAR tool.
• Decide when to report or when to ask for help when observing changes in a resident's condition.

Slide 4

Case Study: Ms. A

• 79-year-old frail woman.
• Admitted after hip fracture, followed by hospital and rehabilitation stays.
• Walks with a walker.
• Daughters visit on weekends.
• Liquid diarrhea.
• Falling blood pressure, rising heart rate.
• Fever of 102^o F.
• Transferred to the hospital intensive care unit.

Slide 5

Case Study: Ms. A

• How did Ms. A get so sick with only diarrhea?
• When might you have decided to report it?
• What would you have reported and to whom?

Slide 6

Key Lessons

• Learn to notice a change early.
• Not reporting a change can lead to other things going wrong.
• The sooner something is done, the better.

Slide 7

Role of Nursing Assistants and Licensed Nurses

• Your role in a long-term nursing center is important.
• Nursing assistants see the residents most often.
• Residents in long-term care depend on nursing assistants to notice changes.
• Nursing assistants are the eyes, ears, and hands of the care team.

Slide 8

Detecting Change

• Know the resident's normal (baseline) condition.
• Note the resident's ability to move around.
• Know how the resident does with activities of daily living.
• Know the resident's preferences for activities, eating, and dressing.

Changes from the resident's normal condition can signal a medical change.

Slide 9

Recognizing Changes

• Do a shift-to-shift comparison.
• Make sure the needed equipment is available.
• See if a change occurred in any of the resident's other vital signs.
• Check the resident's records of urination and bowel movements.

Slide 10

Registered Nurse's Assessment

• Ask the resident how he or she feels, even if the resident is confused or seems to be "out of it."
• Ask the resident how and when the symptoms began.
• Take the resident's vital signs again.
• Perform a general exam; assess level of consciousness and cognitive and physical function.
• After the assessment, organize the information and report it to the resident's nurse practitioner or doctor, if warranted.
• Several tools to help with evaluating mental status can be found in the MDS.

Slide 11

Top 12 Changes in Residents

Physical Changes:

• Walking.
• Urination and bowel patterns.
• Skin.
• Level of weakness.
• Falls.
• Vital sign.

Non-Physical Changes:

• Demeanor.
• Appetite.
• Sleeping.
• Speech.
• Confusion or agitation.
• Resident complaints of pain.

Slide 12

Watch for Physical Changes

• Walking—e.g., how much assistance the resident needs with walking.
• Urination and bowel patterns—e.g., the resident is urinating less frequently.
• Skin—e.g., the resident's skin is puffy.
• Level of weakness—e.g., the resident is having difficulty lifting his or her arm.
• Falls—e.g., the resident reaches for objects when in a wheelchair.
• Vital signs—e.g., the resident is breathing faster than normal.

Slide 13

Watch for Non-physical Changes

• Demeanor—e.g., the resident is socializing less than normal.
• Appetite—e.g., the resident is not interested in his or her food.
• Sleeping—e.g., the resident falls asleep in unusual places.
• Speech—e.g., the resident's speech is slurred.
• Confusion or agitation—e.g., the resident is talking a lot more than usual.
• Resident complaints of pain—e.g., the resident grimaces or winces when moving.

Slide 14

Watching for Change

• The key is to always be watching.
• Residents should be watched wherever they are, all the time.
• Check in with residents often.
• Talk with others who provide care for your residents.

Slide 15

All Members of the Interdisciplinary Team Must Watch for Changes

Physical Changes:

• Walking.
• Urination and bowel patterns.
• Skin.
• Level of weakness.
• Falls.
• Vital sign.

Non-Physical Changes:

• Demeanor.
• Appetite.
• Sleeping.
• Speech.
• Confusion or agitation.
• Resident complaints of pain.

Slide 16

What is important enough to report?

• For about every three to five reports, one full assessment is done.
• It is more important to report anything that might matter than to get the amount of reported information perfect.

Slide 17

How to Follow Up on the First Sign of Changes

• Shift-to-shift comparisons.
• Are there any changes that should be watched for or reported?
• Early Warning tool:
  • Form that nursing assistants can use to write down what they have noticed about a resident's condition.
  • Use the tool anytime a resident has had a change.
• SBAR tool:
  • An abbreviation that helps you to remember how to communicate change.
  • SBAR stands for Situation, Background, Assessment, Recommendation.

Slide 18

Observing and Reporting

• Who is responsible?
• Front-line providers are the eyes and ears of the team.
• Part of helping the team perform best is sharing information.
• Receptionists, occupational therapists, chaplains, volunteers, housekeeping staff, other staff members, and visitors are important observers.

Slide 19

A Safe Environment

• Reporting changes helps keep residents as safe as possible.
• Learning and experience help providers to keep residents safe.
• Open communication among team members helps to keep residents safe.
• Team members must move beyond blaming someone.
• Those who care will speak up.

Slide 20

Summing Up:

• Detecting changes can prevent illness from getting worse.
• Nursing staff know the resident best.
• Nursing staff must be alert to watching for changes.
• The need to share observations and respond to changes is very important.
• Staff must know what's normal for the resident so it can used for comparison when there is a change.
• Staff must know the different changes they need to watch for.

Slide 21

Pearls

• The best way to detect a change in a nursing center resident is to get to know what is normal for that resident.
• You can learn to be observant and to make a habit of being "tuned in" to residents.
• Older people tend to respond less to change and may exhibit symptoms of illness that are different from those seen in younger people.
• A safe environment supports open reporting of resident changes and does not find fault with reporters.
• When in doubt, report a change.

Slide 22

Pitfalls

• Feeling that it is hard to report a change due to fear of blame is a barrier to safe care.
• Forgetting to use reporting tools makes it harder to alert the care team to changes in a resident's condition.
• Expecting someone else to take action when change is detected does not help residents stay safe.
• Assuming someone else knows the resident better or knows more than you can get in the way of your desire to report what you think might be a change.