Transcript The Nursing Problem List


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

Verbalize understanding of the changes in documentation and
workflow associated with new Falls/Safety HED build
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)
For your area, identify common Falls/Safety scenarios and how to
address them


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.

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
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.

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 Problem
o CIWA documentation will be available in HED for units that implement CIWA
protocol

Safety Interventions will be documented – things you:
o
o
o
o
Assess/Monitor/Evaluate/Observe
Care/Perform/Provide/Assist
Teach/Educate/Instruct/Supervise
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

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)
•
•
Admission
Falls Risk screen
Safety assessment as part of head-to-toe assessment; Identify problems
& Plan Interventions; Start Priority Problem if warranted
• Safety assessment; Identify problems & Plan Interventions
Beginning
of Shift
• Document expected Short Term Goals for Safety Priority Problems
• Start/End Safety Priority Problems if warranted
• Document Short Term Goal Status or outcome for Priority Problems
End of Shift • Document Response to all Safety Interventions
Condition/
Status
Change
• Falls Risk screen
• Repeat Safety Assessment & Revise Planned Interventions as appropriate
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
• Morse Falls Risk screen
• Safety assessment as part of head-to-toe assessment; Identify problems
& Plan Interventions; Start Priority Problem if warranted

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
• Safety assessment; Identify problems & Plan Interventions
Beginning of
Shift
• 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?
• Start/End Safety Priority Problems if warranted
• Document Short Term Goal Status or outcome for Priority Problems
End of Shift • 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.
Condition/
Status
Change
• Morse Falls Risk screen
• Repeat other Safety Assessment & Revise Planned Interventions as
appropriate

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
• Safety assessment; Identify problems & Plan Interventions
Beginning
of Shift
• Document expected Short Term Goals for Safety Priority Problems
• Start/End Safety Priority Problems if warranted
• Document Short Term Goal Status or outcome for Priority Problems
End of Shift • Document Response to all Safety Interventions
Condition/
Status
Change
• Falls Risk screen
• Repeat Safety Assessment & Revise Planned Interventions as appropriate




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?
Question
1. 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?
Answer
1. 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.

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)
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