Aspects of Bowel and Bladder Care Using a Spinal Cord Injury Activity of Daily Living Nursing Note

Transcription

1 Aspects of Bowel and Bladder Care Using a Spinal Cord Injury Activity of Daily Living Nursing Note Ron Spencer, MS, RN, CRRN Staff Development Coordinator Richmond VAMC

2 Disclosure Ronald Spencer, RN has no interest to disclose PEGS and PVA staff have no interest to disclose. This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with PVA. PEGS, PVA and all accrediting organizations do not support or endorse any product or service mentioned in this activity.

3 Aim Optimize CPRS documentation and improve communication within the IDT of bowel and bladder care using standardized language

4 Objectives 1. Explain process involved in a Performance Improvement Project, (PI). 2. Recognize the importance of developing an easy-to-use 3. survey tool to keep staff engaged during a change in practice 2. Plan for and expect barriers when implementing changes in documentation practices 3. Compare current Nursing ADL note to the SCI Specific ADL note for potential integration into various facilities charting requirements

5 How it all Started Quality on Parade PI Summary Registration Form Poster (11/14) measured) Description of Measure, (brief explanation) Justification of Measure, (why it is being Contact info and poster authors Weekly IDT Conferences Nurses were inconsistently using FIM, the universal language used in rehab settings, to communicate patient s changes among group members. The current ADL note Failed at capturing usable, detailed information to be shared among members.

6 Formal PI Project Service Supervisor PI Project Title Mandate or Directive (if applicable) Start Date Deadlin e Status

7 Richmond PI Model Measure Documentation of care delivered was not reflected in ADL Note Change - Develop a pilot note with input from the entire team capture specific information regarding bowel and bladder aspects of care, likened to the ratings scored in FIM. Implement the new and revised SCI Specific ADL note into CPRS. Measure assess satisfaction with revised note and determine the consistent use of standard rehab language when discussing patient concerns in IDT Meetings.

8 Current ADL Note Nutrition Elimination (Bowel / Bladder) Hygiene (Bed Bath vs Shower) Mobility Sleep Safety GU

9 MEASURE Charge Nurses were given a printed copy of the CPRS note and asked to work with key staff, on designated shifts, to determine what changes they would like to see with the bowel / bladder aspects of the ADL Note. Numerous edits were recommended to the note to improve all 7 aspects of care: NPO, Aspiration Precautions, Adaptive Equipment, Sitting Protocol, Enteric Precautions, etc., etc., It s important to note is that staff performing the care recognized the need to improve documentation

10 Functional Independence Measures, FIM Measures patients functional abilities Statement Care will be delivered by engaged, collaborative teams in an integrated environment that supports learning, discovery and continuous improvement.

11 Functional Independence Measures FIM It is the most widely used disability measure in rehabilitation medicine. (SCI Clinical Practice Guideline: Outcome) 100% of the following staff are FIM Certified for 2016: MDs, RNs, Therapists, Psychologists and SW s CARF Certification 9/15 9/18

12 Functional Independence Measures, FIM Measures patients functional abilities Statement: Care will be delivered by engaged, collaborative teams in an integrated environment that supports learning, discovery and continuous improvement.

13 Bowel Care

14 BOWEL CARE RESULTS on Current Note Various Descriptions Scheduled vs Unscheduled Bowel Movements It was unscheduled, but it was not an accident Orders were sometimes absent No mention of use of assisted aids with bowel program Text boxes in Template dependent on training and skill of staff What is large to you might be small to me. What is a rectal tube anyway? 16 different descriptions for appearance of stool

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16 Bristol Stool Scale Explained An ideal poo is likely to be type 3 or 4, easy to pass without being too watery. A person with type 1 or 2 probably has constipation. Types 5-7 usually indicate a tendency towards diarrhea. If you are concerned about how your poo looks, seek medical advice. It may help to refer to the number on the Bristol Stool Scale.

17 Urinary Management

18 Non-Standard Terms 16 Characteristics of Urine Vagaries, - kick-off, triggered Failed to consistently and accurately capture patients current management protocol Redundant

19 Strategy and Micro Actions Alerted all staff that changes were being considered to improve the ADL Note in CPRS and evaluations of the changes could be anticipated Submitted request for New / Revised Template, (MCM 136, Attachment B) Informal networking among stakeholders to advance requested changes

20 CHANGE With constructed agendas, 3 specific meetings were held with key team members to outline specific changes need to make the note more meaningful for dedicated SCI patients. Non-agenda items were not discussed during these meetings.

21 Anticipated Barriers and Considerations Lukewarm participation support and ownership by leaders Varying expectations from stakeholders Something new for staff to do Opposition from labor partners

22 Let the Games Begin Barriers Physician Desires - Competing agendas Therapist Desires - Is patient meeting goals? Nursing Desires competes with duties, unpleasant, Nursing Administration Forms and follow-thru IT Desires: Skills and Personalities Imagine yourself as a fulcrum working to improve patient care

23 Pilot Template Developed Pilot template from key staff as previously mentioned

24 Pilot Template LOCAL TITLE: NURSING ADL NOTE (S) STANDARD TITLE: NURSING INPATIENT NOTE DATE OF NOTE: MAY 15, ENTRY DATE: MAY 15, AUTHOR: BURNS,RACHEL L EXP COSIGNER: URGENCY: STATUS: COMPLETED NUTRITION: Meal: dinner (%) 100 Functional Status: needs maximum assist ELIMINATION: Bowel Management Techniques: Date of last BM: May

25 Methodology: Descriptive Quantitative and Qualitative Study Steps Developed a Pilot Progress Note IDT Direct Involvement Identified an IT Specialist for inclusion to make modifications into existing template Developed survey tool with narrative questions to retrieve information on the level of satisfaction with pilot note Developed a spreadsheet to collate responses Sample Size: 140 folk asked to complete survey. Meetings conducted to educate staff and keep them engaged with potential improvements forthcoming

26 1. Importance of using standard rehabilitation language to document elimination concerns for SCI patients. Survey Tool 2. Education regarding anticipated revisions of the note prior to implementation 3. The availability of assistance to complete the notes when uncertainty with documentation was an issue 4. Opportunities to evaluate and offer suggestions for improvements in the revised note during the 30 day pilot period. 5. Various bowel management techniques are now included in the note 6. The Bristol Stool Scale provides adequate description of bowel movements. 7. Management of various urinary devices can be documented consistently with outputs noted in the chart 8. The SCI specific note captures detailed information about the patients functional capabilities with bowel and bladder aspects of care 9. As a result of the revised note, I am now able to provide comprehensive reports of patients elimination concerns during Interdisciplinary Team, (IDT), meetings 10. Patient goals can be captured and measured allowing the team to be more focused and collaborative in targeted care delivered

27 Satisfaction Survey Limitations Likert Scale, focused on level of interest in capturing and measuring current delivery of care; while focusing on improving the level of care. Comments Section allowed for expression of unmeasured items and suggestions / concerns not mentioned in the tool Statistical models; validity, reliability and standard deviation were minimal considerations in this study

28 Survey Results Participants: 24 /140 Response Rate: 17%+ Many members collaborated in the comments section of the survey to reflect satisfaction or desires with the note making the response rate as undetermined. Dominant responses were excellent / good in all areas being measured

29 Evaluation Survey Results Excellent Good Fair Poor Not Applicable Standard language Education Assistance Offer Suggestions Bowel Techniques Bristol Stool Scale Urinary Devices Detailed Information IDT Meetings Patient Goals

30 Optics Excellent Good Fair Poor Not Applicable 0

31 Comments Section

32 Dislikes: Delete Redundancy Results are subjective Unable to quickly determine if patient had BM on shift Variety of language to mean same thing: spontaneous, unscheduled, accident Bristol Stool Scale - No Credit to developer Takes too much time to check all boxes in the note Requested Changes If independent with bowel care remained of note should be unnecessary If no BM this shift, then remainder of note should be unnecessary Decrease number of mandatory fields Add Color to stools; i.e., tan, black tarry, yellow, blood tinged, mucous Add box for Excess Flatus Add and reposition the following two (2) Boxes: Independent with Bowel Care Independent with Ostomy Il t

33 Execution Plan Work closely with IT staff during each phase of the development and trial the note before implementation Develop a schedule to train staff on using the revised note Final Meeting with key stakeholders seeking input and informing them of changes to the pilot note Recommendations to IDT for permanent changes to note Alert staff of target implementation date

34 Training Schedule 5/11 7:30A 1U Conference Rm. 8:00a 1W Conference Rm 5/11 3:30p 1U Conference Rm. 5/11 4:00p 1W Conference Rm. 5/12 6a 1U Conference Rm. 6:30a 1W Conference Rm. 7:30a 1U Conference Rm. 8:00a 1WConference Rm. 3:30p 1U Conference Rm. 4:00p 1W Conference Rm. 7:00p 1U Conference Rm. 8:00p 1W Conference Rm. 5/13 6a 1U Conference Rm. 7:30a 1W Conference Rm. 8:00a 1U Conference Rm. 3:30p 1W Conference Rm. 4:00p 1U Conference Rm. 7:00p 1W Conference Rm. 8:00p 1W Conference Rm.

35 Accessing the Revised 1. Note Go to ADL Template 2. All 7 domains of ADL are still assessed 3. The change occurs when you click on ELIMINATION 4. Question: Is this a Spinal Cord Injury patient? 5. Two Options: No Yes 6. When YES is clicked, Radio Buttons and Text Boxes become active. 7. Remainder of ADL note remains unchanged

36 Actual Note #1 ELIMINATION: Bowel Management Techniques: Date of last BM: Jul 13,2016 Patient had 0 scheduled and 0 unscheduled bowel movement(s) on this shift. Bristol Stool Scale: No BM this shift Color of stool: Bladder Management: Patient:

37 Actual Note #2 ELIMINATION: Bowel Management Techniques: Date of last BM: Jul 27,2016 Patient wears incontinence briefs? No Patient has a colostomy? No Patient Refused Bowel Care? No Reason refused: Bowel care ordered? Yes Patient had 0 scheduled and 1 unscheduled bowel movement(s) on this shift. Patient had bowel movement this shift with medium results. stool Bristol Stool Scale: Type 6-Fluffy pieces with ragged edges, a mushy Color of stool:

38 Actual Note #3 ELIMINATION: Bowel Management Techniques: Date of last BM: Jul 25,2016 Patient wears incontinence briefs? No Patient has a colostomy? No Bowel care ordered? Yes Patient had * scheduled and * unscheduled bowel movement(s) on this shift. Patient had bowel movement this shift with medium results. Level of assistance: Total assistance Bowel Care performed during this shift with good results. Performed by nursing staff Bristol Stool Scale: Type 6-Fluffy pieces with ragged edges, a mushy stool

39 ELIMINATION: Bowel Management Techniques: Date of last BM: Jul 24,2016 Patient wears incontinence briefs? Yes Patient has a colostomy? No Patient Refused Bowel Care? No Reason refused: Bowel care ordered? Yes Patient had 1 scheduled and 0 unscheduled bowel movement(s) on this shift. Patient had bowel movement this shift with X-large results. Level of assistance: Total assistance Bowel Care performed during this shift with good results.

40 ELIMINATION: Bowel Management Techniques: Patient wears incontinence briefs? Yes Bristol Stool Scale: No BM this shift Color of stool: Bladder Management: Patient: Has a condom catheter - 50 ml. External came off? No Suprapubic tube: 250 ml. Urine appears: Hazy, Yellow

41 Measure Informal, 3 WEEKS AFTER IMPLEMENTATION Some remaining jokes about the Bristol Stool Scale Some staff continued to use the former ADL Note without SCI revisions Most folk expressed satisfaction with the new note

42 Staff Expressions LIKES: Helps me understand my patient s better. Pulled staff I wish we had a note like this in our area. I can now give accurate reports to the team about specific patients. DISLIKES: It takes longer to complete the note, its now more about the care that I have to consider. That new description of stool is disgusting. FENCE-SITTERS: Now if we can just get staff to complete the note Can we go back to the was it was before?

43 LESSONS LEARNED When birthing a new idea / practice realize that you may be alone, initially Don t hesitate to involve new staff into PI projects Measure buy-in from others and negotiate pathways to success, (leaders, peers and labor partners) Avoid temptation to make major system changes or deviate from stated goals Momentum - Follow-up Maintenance, (behavioral / educational / resistance concerns) Other Services, i.e., CLC, may request assistance in improving documentation in their areas

44 Desired Outcomes and Benefits Consistency with documentation of elimination concerns Decreased LOS Easy to use Standardized language Team Building with a shared sense of accomplishment Provide information about the injury, treatment needs, possible and preventable complications Agreement with Clinical Practice Guidelines

45 TimeLine 11/14 Quality on Parade 5/18/15 Note was created and inserted into existing template 5/18/15 5/31/15 Pilot period 6/1/15 6/4/15 Survey for evaluation of changes and satisfaction with note 6/5/16 6/9/15 Requested changes made to note 6/18/15 Permanent SCI ADL note incorporated into CPRS

46 Looking head opportunities for the future improvements Documentation of I&O s in SCI specific ADL Note Level of Injury; UMN / LMN Clinical Warnings Calorie Counts added, etc.,

47 Review of Objectives 1. Explain process involved in a Performance Improvement Project, (PI). 2. Recognize the importance of developing an easy-to-use survey tool to keep staff engaged during a change in practice 2. Plan for and expect barriers when implementing changes in documentation or any other clinical practice issue 3. Compare current Nursing ADL note to the SCI Specific ADL note for potential integration into various facilities charting requirements

48 Sources and References Bhimani, Rozina, DNP, PhD, CNP, CNE, Understanding work related musculoskeletal injuries in rehabilitation from a nursing perspective. Rehabilitation Nursing. March / April, 2016, p , Chumney, Douglas, et., al. Ability of Functional Independence Measures to accurately predict functional outcome of stroke dependent population: Systemic Review. The Journal of Rehabilitation Research and Development. 47 (1), Consortium for Spinal Cord Medicine. Clinical Practice Guideline: Outcomes Following Traumatic Spinal Cord Injury: Clinical Practice Guidelines for Health-Care Professionals Joint Commission of Accreditation of Healthcare Organizations. Oakbrook Ter., Illinois. October Lewis, Stephen, MD, and Ken Heaton, MD; The Bristol Stool Scale. Scandinavian Journal of Gastroenterology, Rating the FIM Instrument for the FIM System. Uniform Data Systems for Medical Rehabilitation. A division of UB Foundation Activities, Inc. (UBFA). 5.2, 2009 VAMC Policy, MCM 136, Attachment B Request for new /revised template, 2014.

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