Acute Care Nursing Assessment Self-Directed Teaching Package

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Acute CareNursing AssessmentSelf-Directed
Teaching Package

• The Flo Collaborative
• 2008

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What Is Flo?
The Flo analogy was developed to represent a real
patient experiencing an acute event who requires
care in an alternate setting following a hospital
stay. Flo is an 85-year old woman admitted to
hospital from her home with multiple
co-morbidities. Her frailty and declining
cognitive status necessitate transfer to a
nursing home. Flo continues to need quality care
in the right setting and the system needs to
support her and her family in getting her
there. The Flo Collaborative is intended to help
Ontarios health care system continue to provide
the care that Flo, and thousands of other people
like her require. The aim is to accomplish this
by making transitions from acute hospitals to
other settings faster, with fewer hassles,
bottlenecks and irritations to everyone including
Flo, her family and the staff who care for her.
Participating organizations will work together on
improving the effectiveness and timeliness of
patient transitions across care settings.
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Background

• The Flo Collaborative brings together hospitals,
  CCAC, LHINS and other sectors to participate in a
  quality improvement collaborative supported by
  the Ontario Health Performance Initiative (OHPI).
  There are a total of 29 teams from partnered
  organizations will work together for 18 months
  under the guidance of Improvement experts.
• The team at STEGH will be working on a number of
  different improvement projects. The aim of the
  first project is for 100 of patients on 5MU to
  be screened within 24 hours of admission for
  factors that may delay transition to subsequent
  care destinations. Those patients with
  identified risks will also have a documented plan
  in place to be followed to manage risk.

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History of Flo at STEGH

• To achieve this aim, the Flo Team has redesigned
  the Patient History/Nursing Assessment form to
  incorporate screening tools to be used on
  admission as well as adding triggers to ensure
  referrals are completed in a timely manner. This
  tool was trialed on 5MU and feedback from these
  Nurses was incorporated into revisions to the
  current Nursing Assessment tool.
• Early testing showed that there was virtually no
  delay in initiating referrals to needed services
  compared with about 22 hours using the old method.

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Benefit to the Patient

• Ensures a thorough timely assessment at the
  start of their journey through the medical system
• Identifies modifiable risk factors for the
  patient early so that they can be addressed
• Promotes the early involvement of other
  disciplines
• Facilitates the collection of information that is
  valuable to the plan of treatment

Currently up to 72 hr lag in referral orders
being written.
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Benefit to Nursing

• Empowers nurses to initiate referral process
• Reduces duplication of work
• Better way to manage use tools that are
  currently in place
• Ensures that a comprehensive assessment has been
  completed documented

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Documentation

• Documentation is an integral part of safe
  effective nursing care. Documenting nursing
  practice illustrates nursings unique
  contribution to health care. No matter what kind
  of documentation is used the same purposes
  expectations apply.
• The most important purpose of documentation is
  communication. All health care providers need
  access to client information on an on-going basis
  to provide appropriate care treatment.
  Documentation reminds nurses others of the care
  they have given assessments that they have made
  in order to make future care decisions.
• The health record enables nursing staff other
  health care providers to use current consistent
  data, problem statements, diagnoses, goals and
  strategies to facilitate continuity of care.

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Documentation

• The health record demonstrates nurses
  accountability and gives credit to nurses for the
  care they give. The health record is used to
  determine responsibility for the care and to
  answer questions or concerns. The nurses
  documentation is usually admissible evidence in
  legal proceedings such as lawsuits, coroners
  inquests and discipline hearings at CNO.
• Accepted standards of practice require nurses to
  document their assessments and the care that they
  give. Nursing care is not considered to be
  complete unless it is documented.
• Quality practice settings provide structures
  that help the nurse to document. The method of
  documentation needs to allow for a logical
  organization of information so that a clear
  picture develops about the needs of the client
  the actions of the nurse.

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Documentation

• Documentation needs to provide a clear picture of
  the needs or goals of the client, the actions of
  the nurse and the outcomes. CNO
• Accordingly, the nurse will
• Document an assessment of the clients health
  status and situation/circumstance.
• Document a plan of care that reflects the
  clients preferences.
• Document the implementation of the plan or
  action(s) taken.
• Document an evaluation or nursing strategies and
  client outcomes.
• Document both interdependent independent roles.
• Document information reported to other health
  care providers the health care providers
  response.
• Use forms provided.
• Advocate for policies procedures to provide
  structure consistency in documentation.

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Next Steps

• All nursing staff are required to complete this
  learning package
• Super Users have been trained to act as support
  for staff to coordinate further feedback
• Super Users on AMU
• .

• Lori Deline
• Gemma Nott
• Ann Marie Harrison
• Susan Folley
• Silvia Correia
• Sandra Lannin

• Pat Sullivan
• Mary Lou Smart
• Theresa Dunphy
• Nancy Berman
• Sandra McDonald
• Lisa Taylor
• Lynn Peterson

Who is a Super User? A resource person to
support other staff through their learning of the
revised assessment
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Next Steps

• Draft Nursing Assessment will be used on all
  patients on AMU 5
• All Nurses are expected to begin using the new
  tool as soon as they have completed the self
  learning package
• Ongoing weekly auditing for completion of Nursing
  Assessments on admission
• Ongoing data collection to assess the
  effectiveness of the new tool.
• Formal review with Super Users to ensure that all
  staff feedback has been considered
• Final revisions incorporating all staff feedback

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Key Principles

• Comprehensive patient assessment is a Nursing
  responsibility
• Discharge planning starts on admission
• Nurses need to be involved in all aspects of the
  care planning process

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How Are These Principles Supported by the New
Process?

• Triggers have been added to alert nurse of
  actions to take based on information that has
  been gathered.
• Nursing has the ability to refer to allied health
  for assessment without physician order.
• The new form organizes information in a logical
  manner.
• A clear picture of the needs of the client is
  easily seen.
• Every effort should be made to complete the
  assessment on admission.
• Incomplete assessments need to be verbalized to
  the next shift to ensure completion.

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Review of Nursing Assessment Tool
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Admission Tool Kit

• Has been created to facilitate the admission
  process by ensuring that you have the right tools
  at the right time in the right place.
• Located At the Nursing Station
• Contents
• Nursing Assessment forms
• Other forms that are triggered through the
  assessment
• Stethoscope
• Calculator
• Fall Precaution Bracelets
• Scissors

Please let Gemma know if there are other items
that you would like to see added to the tool kit.
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Page 1 - Draft Form
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Page 2 - Draft Form
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Page 3 - Draft Form
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Page 4 - Draft Form
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Page 5 - Draft Form
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Smooth Sailing

• Several sections work together to facilitate the
  patients journey through the system promote
  appropriate LOS
• Decision makers
• Cognitive screen
• DNR
• Chief Complaint
• Culture

The thorough completion of these sections will
identify issues early in the patient stay
allowing them to be addressed in a timely manner.
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• Decision Makers
• A quick screen to assess if the patient is
  capable of making their own decisions.
• If the patient has identified POA, we need to
  have copies for the chart.
• If there are concerns about the patients
  capacity or other areas around decision maker,
  consult Social Work
• DNR
• Follow current practice for resuscitation
  discussions using STEGHs DNR Discussion policy.
• The DNRC form does not replace the DNR Decision
  Record, this still must be completed.
• If the patient has a completed DNRC form to be
  used when a patient requires transportation
• place a copy of the form on the chart
• Record the serial on the admission form
• Return original to the family

This will stop delays that may happen later in
the patient stay if there are on going issues
around decision making or consent.
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• Chief Complaint
• Should be documented in patients own words.
• Culture
• If a language barrier is identified, document the
  name contact information for a family member
  who can act as a reliable translator
• Follow STEGH policy if the patient is unable to
  provide this information

Provides insight into how much teaching may be
required to prepare the patient for discharge
potential barriers to effective learning.
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Patient Safety

• The following sections are included in the
  Nursing Assessment tool and address patient
  safety quality care
• Falls Prevention
• Unit Information
• Morse Fall Scale
• ADLs
• Allergies
• Skin Integrity
• Infection Control

Many adverse events that occur during
hospitalizations may be prevented or the severity
decreased by the identification, documentation
and implementation of interventions to address
modifiable risk factors.
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• Falls Prevention
• Morse Scale
• Identifies Falls Risk Level interventions
• ADLs
• ID discrepancies between usual level of
  functioning current level which may increase
  risk of falls
• Please complete both sections so we will be able
  to better determine the goals for the pt.
• Record any equipment that comes with the patient
• Unit Information
• Ensure that patients are orientated to the Unit
  understand how to use the Call Bell system

Falls their sequelae are a major contributor to
increased LOS.
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Cognitive Deficits
Whether pre-existing or hospital acquired, are a
major cause of increased LOS, inappropriate LTC
placement and adverse events (including death).

• Completion of the Confusion Assessment Method
  Instrument (CAM) will help to identify high risk
  patients.
• If a patient is unable to complete any part of
  the CAM screening tool, request an OT consult.
• You can come back to CAM at end of assessment if
  needed.
• Delirium is a medical emergency must be
  recognized

If you need an update on the 3 Ds (Delirium,
Dementia Depression), check out the Best
Practice Guidelines on the RNAO website
www.rnao.org. Easy to read full of practical
info!
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A new Medical Directive for Delirium can found in
the Admission Tool Kit
For use on admission with the new Nursing
Assessment Tool only!
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• Braden Scale
• Refer to the detailed score description in the
  Admission Tool kit.
• It is important to be especially careful to
  complete an accurate assessment of both coccyx
  and feet at time of admission
• Follow Braden Scale interventions as described on
  the form including referral to OT, PT
  Nutrition.

This is an initial screen that may identify that
there are concerns with skin integrity. It
starts the ongoing process of intervention and
monitoring through use of the Braden Scale
monitoring.

• New!
• Infection Screening Standards
• The following pts MUST BE SCREENED
• Pts who have been in ER for more than 12 hours
  but have not been admitted
• Pts receiving current CCAC service
• Timely screening is necessary to reduce
  transmission rates.

Note Nasal Swab MRSA only Rectal Swab MRSA
VRE
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Physical Assessment

• Incorporated throughout the tool organized by
  system
• Cardiovascular
• Respiratory
• Integumentary
• Musculoskeletal
• Endocrine
• Genitourinary
• Neurological
• Pain

If your physical assessment skills could use a
refresher, check out the Self-Directed Modules
available on STEGHnet May 1st. Facilitated
Learning Lab sessions are also available for all
Nurses through Professional Practice.
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Discharge Planning

• Several sections support the key principle that
  discharge planning begins on admission
• Blaylock
• Home Situation
• ADLs
• Discharge Planning

The thorough completion of these sections will
identify issues early in the patient stay
allowing them to be addressed in a timely manner.
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• Blaylock
• Identifies patients at risk for difficulties
  after discharge at time of admission so the
  barriers can be promptly addressed.
• Home Situation
• Will help to prevent discharge delays by being
  fully aware of supports
• ADLs
• Indicate current status what patient was like
  prior to admission
• Discharge Planning
• Important to get a sense of patients future plans
• Goal should be to return patient to their
• original location after their acute care stay

These areas support one of the key principles of
Flo - - Discharge planning starts on admission
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Signatures

• Nurse Initiating/Completing
• Every effort should be made for the admitting
  nurse to complete the nursing assessment at the
  time of admission
• If completion is not possible, hand-off should
  occur in report rationale sections completed at
  the bottom of the last page of the form
• All nurses completing any part of the form must
  sign
• Trigger Signatures
• Nurse completing the assessment is responsible to
  ensure that the appropriate referrals are
  initiated

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Feedback

• Feedback can be provided
• to Super Users
• to any member of the Flo Collaborative
• in writing on the Flo Communication Board

All suggestions are important as there will be
another round of revisions before the Nursing
Assessment Tool becomes fully implemented.
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Reminders

• Allied Health assessment in Power Chart should be
  entered as Assessment Only.
• Continuum needs to be completed at time of
  admission.

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Reminders
Professional documentation reflects professional
care. It allows and provides for communication,
quality assurance and research. Nurses are
accountable for safe, effective and ethical
nursing care. Quality documentation is an
integral part of providing such care.
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Flo Collaborative Team Members
STEGH is pleased to be working in partnership
with SW CCAC on this project.

• Lori Deline, Team Co-Leader
• Nancy Johnson, Team Co-Leader
• Gemma Nott, Manager AMU
• Sandra McDonald, Hospital Case Manager
• Carol Watson, Community Case Manager
• Nancy Berman RN, Unit Leader AMU
• Deb Barney RN, Unit Leader CCC
• Dr Martin Hug, Physician
• Jennifer Fazakerley, SW CCAC Improvement Advisor

Feedback can be provided to any Flo Collaborative
Team Member at any time.