Appendix 1-A. Suggested Slides for Module 1

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.

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Improving Patient Safety in Long-Term Care Facilities