nurses reviewing other nurses documentation during the handover process find it hard to identify...

Nurses reviewing other nurse’s documentation during the handover process find it hard to identify care priorities to focus on

Managers & Regulators reviewing nursing documentation find it difficult to determine the most important patient problems – Recent JCAHO survey prompted us to try changes

Paper Pathways are not easy to find in the pt’s chart, not part of the electronic record & nurses feel that printing is just busy work

8 VCH & 8S VUH piloted a new way to document in HED…. “Priority Problems”

Nurses like it because it’s easier to plan & manage patient care. Terminology is standardized and simplified using CCC Saba model.

Nurses find that documenting “Priority Problems” is a PRACTICE change with no new computer skills to learn

Verbalize understanding of the vision for Priority Problems and Clinical Care Classification* (CCC) Nursing terminology.

For your area, initiate list of top 10 pathways and 5 problems for each. Define for common problems the problem category, problem, related to…., expected outcomes and short term goals

Use CCC Nursing terminology to document planning and managing care for a practice scenario. Including

• Assign & save a pathway to a patient’s medical record in StarPanel• Initiating 2-3 top priority problems and their expected and actual

outcomes• Documenting shift expected/actual goals, Nursing Summary and

Plans

Priority problems will simplify and standardize how nurses:

document and communicate the patient’s top priority

problems

identify plans and goals

assess actual outcomes

This will improve patient care and clearly define nursing’s contributions to patient care and the team.

Save Electronic copy of Pathway in StarPanel

Identify 2-3 priority patient problems and outcomes and short term expected/actual goals using CCC model WHY? Nurses, and all team members, need to focus on

the most urgent needs & identifying the interventions to help patients achieve their goals.

Not Changing: Document the pathway name, phase, nursing summary & plan priority in HED

We all have different ways of describing or talking about problems. You call it pain, I call it alteration in comfort

The decision was made to standardize how we talk about nursing care. The Clinical Care Classification* (CCC) Saba Model was selected.

*Developed by Virginia K. Saba, RN , PhD

Over 40,000 charts were reviewed to derive the 182 Clinical Care Classification problems.

The Clinical Care Classification (CCC) System* is a standardized, coded nursing terminology that identifies the specific elements of nursing practice.

CCC provides a unique framework and coding structure for capturing the essence of patient care in all health care settings

You can learn more on the Sabacare.com website about the CCC.

21 Categories w/82 Problems

3 Expected Outcomes ◦ Improve

◦ Stabilize

◦ Support decline 3 Actual Outcomes

◦ Improved◦ Stabilized◦ Decline supported

Physiological◦ Cardiac◦ Bowel/Gastric◦ Life cycle (pregnancy)◦ Metabolic (glucose)◦ Physical Regulation

(infection)◦ Respiratory◦ Skin Integrity◦ Tissue Perfusion◦ Urinary

Medication

Psych/Behavioral◦ Cognitive◦ Coping◦ Health Behavior◦ Role Relationship◦ Self Care◦ Self Concept

Functional◦ Activity◦ Fluid Volume◦ Nutrition◦ Safety◦ Sensory/Pain

1. Improve/ImprovedCondition will change and/or recover (fracture,

pneumonia)

2. Stabilize/Stabilized Underlying chronic condition will not change but requires

no further nursing care to maintain (asthma, heart failure)

3. Support Decline/Decline SupportedCondition will change and worsen (cancer, ESRD).

Nursing action supports decline.

Build an Outcome Oriented Documentation Framework

Putting it all together to

Choose the pathway that most closely reflects the expectedpatient progression. Usually the reason for admission. EXAMPLES:

Medical Pathway – Heart FailureAdmission – Orders & interventions are aimed at achieving stabilization (improving pump action through diuresis, O2, hemodynamic stability, . . .)Stabilization - achieving controlled symptoms (fluid excess control, med mgmt)Discharge – Ready for self-care; or care by another caregiver.

Surgical Pathway - Knee ReplacementPre-opPost-op StabilizationDischarge

Admission

Select & Save Pathway (StarPanel ) Document Pathway Name & Phase (HED) Create 2-3 Priority Problems (HED)

Day of go-live

also

Specific pathways will have phases, goals and interventions that are a better fit.

The evidenced based pathways can better guide care.

Use generic pathways only as a last resort

1. Click Action

2. Click EDOCS Pathway

List of pathways display

Admission

Select & Save Pathway (StarBrowser/StarPanel ) Document Pathway Name & Phase (HED) Create 2-3 Priority Problems (HED)

3. Type the name of the pathway in search.

4. Click on Pathway to add to medical record

5. Click OK to add to Starpanel

Pathway Will Display in Assessment Section of the OPC with a Link for

Easy Access

Click to display pathway

You are working day shift and your 27 yo ,Mary Lou was admitted to the

Ortho unit around 5pm after an MRI revealed a cervical cord mass. She

is experiencing weakness, is ataxic and has neck and back pain. Her

pain score is a 5 with morphine on board. She is scheduled for a cervical

laminectomy tomorrow. She is a single mother and concerned about her

4 and 2 year old children and how she will care for them after surgery.

1. Assign best fit Pathway in StarPanel

2. Document Pathway and Phase in HED

3. Create 2-3 Priority Problems (HED)

Notice that the cervical surgery pathway does not have a preop phase so pick the best fit – Day of

Surgery since the pt is going for surgery tomorrow.

Admission

Select & Save Pathway (StarPanel ) Document Pathway Name & Phase (HED) Create 2-3 Priority Problems (HED)

Before doing anything in HED, think about the 2 or 3 Priority Problems for Mary Lou. Review the CCC definitions as needed.

Place a check mark next to them on “Standard Nursing Problem List”

Admission

Select & Save Pathway (StarPanel ) Document Pathway Name & Phase (HED) Create 2-3 Priority Problems (HED)

Definitions located in “links” from HED

Document Priority Problems in Plan of Care Tab

Locate the 3 categories you identified for Mary Lou.

Note the 21 categories of

problems

1. Click Start Priority problem

2. Select problem

3. Denote “ may be related to…”

4. Select expected outcome

5. Type “T” for today's date and time or type in another date/ time

6. Save

Admission

Select & Save Pathway (StarPanel ) Document Pathway Name & Phase (HED) Create 2-3 Priority Problems (HED)

Hover over icon to see detail of problem.

Problem Screen works like IV Manage, Foley Catheter & Wounds.

Sample Nursing SummaryMother of 2 young children admitted w/ surgical mass scheduled for cervical laminectomy in am. Has weakness, ataxia and 5/10 pain.

Sample Plan PrioritiesControl pain, prep for surgery & explain post op course, assure no falls and provide emotional support

Beginning of Shift

Review Pathway & Phase - change prn (HED) Document expected Short Term Goals for your shift (HED)

Keep in Mind….

Day and Night shift goals may differ.

In HED, type the short term goal for the shift for each problem that will be addressed that shift.

Start/End Priority Problems - adjust Pathway & Phase prn (HED)

Document Short Term Goal Status or outcome (HED) Document Nursing Summary & Plan & Priorities for next shift (HED)

Ending problems works the same as ending a PIV or Foley. Select the magnifying glass, fill in appropriate fields.

End of Shift

End of Shift

Start/End Priority Problems - adjust Pathway & Phase prn (HED) Document Short Term Goal Status or outcome (HED) Document Nursing Summary & Plan & Priorities for next shift (HED)

Short Term Goal Status

1. Hover over icon to see detail of goal.

2. Document status (met, improving, unchanged, deteriorating, not met.

End of Shift

Start/End Priority Problems - adjust Pathway & Phase prn (HED)

Document Short Term Goal Status or outcome (HED) Document Nursing Summary & Plan & Priorities for next

shift (HED)

Rule of thumb between the hours of 3 -5 to allow for printing of

OPC for next shift

Transfer/

Discharge

Start/End Priority Problems. Change Pathway &/or Phase prn. Document Short Term Goal & status (HED) Document Nursing Summary & Plan & Priorities in HED Document D/C Plan in HED & denote Post Discharge Plans to

address unmet goals

Reports will be emailed to leadership every day to assist with monitoring progress of staff and patients.

Problems, expected outcomes and the short term goals and status.

Patients have many problems, what makes it a priority problem?

◦ When it is the patient’s priority (pain, SOB, anxiety)◦ Keeps the patient from moving to the next phase (fluid

volume excess)◦ High probability for harm (infection risk, falls) ◦ Delays discharge

Note that Day & Night shift may have different priorities (ambulation vs. sleep)

How do I choose the right problem descriptor?

Example : My pt has Heart Failure – which problem do I pick?

Match problem closely with the interventions

If you are focusing on fluid mgmt (IV diuretics, I&O, low Na diet, fluid restriction) pick Fluid Volume Excess

If you are focusing on breathing treatments, choose Respiratory Alteration

Neither are wrong – both may be selected

Keep Problem List Short & Useable

Do make Plan Priorities reflect priorities for the next 12 hr shift.

Use problems started on prior shift until significant progress is made or the problem has been resolved.

Make goals/ plans specific and realistic. Example monitor o2 sat w/ ambulation

Review pathway and document any changes to pathway or phase.

Do NOT Repeat all the problems from the pathway.

Do NOT replicate standards of care unless they are specific to a priority problem

Do NOT include “Continue to Monitor” unless there are details re: what to monitor.

Do NOT change problems for a slightly better descriptor.

Not all problems need be addressed every shift – day and night shift will have different priorities.

1. Print 1 high use pathway for your areas

2. Use the Priority Problem Assessment tool to identify 5 common problems for this pathway.

3. Complete the Sample plan of care exercise for these 5 problems.

4. Identify a plan to complete other 9 pathways sample plan of care or your area.

Live Date: Tues

Training Plan: 90% of Staff Trained by go live

Small groups will have opportunity to practice and ask questions

Everyone needs to practice before go live3-4 terminals will need to be identified to setup with priority problems in HED train… get those terminal IDs to your SSS person ASAP.

Add to the practice scenario, a scenario for your patient population.

Resources:◦Priority Problem Resource Manual

Top 10 pathways for unitExample of 5 common problems

◦Super Users/ EducatorNeed enough super users for each shift

Implementation SupportSuper User 9a-5p and 9p-5a Tue- FridaySSS 9a-5p and for 2 hours between 9p-5a Tue- Friday

Complete 10 Top use Pathway and 5 common problems exercise (suggested to involve super users)

Complete Sample Plan of Care exercises

Complete Training Plan ( including recruiting super users)

Identify 3-4 terminals to set up for practice and get terminal IDs to your SSS rep

ASK QUESTIONS