Maryann Coletti

Early illness recognition is central to managing resident condition change and reducing potentially avoidable hospitalizations. Every staff member, provider and family play a role in identifying when a resident has a condition change.

By using consistent processes for communication and reporting condition change, diagnosis and treatment can start early — decreasing the likelihood that a hospital transfer is required.

The Interventions to Reduce Acute Care Transfers, or INTERACT, program is a comprehensive quality improvement program designed to improve care processes related to resident condition change. Two INTERACT tools that can promote communication and accurate documentation regarding early illness recognition are the Stop & Watch (S&W) and Situation, Background, Appearance, Request (SBAR) tools.

Both S&W and SBAR were key elements of the eight-year Missouri Quality Improvement initiative, a federally funded study that focused on reducing avoidable hospitalizations from 16 nursing homes in Missouri.  Additionally, advanced practice registered nurses provided expert consultation to promote early illness recognition concepts.  

Certified nursing assistants, physical therapy personnel and certified medication technicians typically use the S&W form to report a condition change to the staff nurse. Relatives and visitors may also use the S&W to report a change or concern. 

In our study, a completed paper S&W was given to the nurse with a brief verbal report. The S&W is also available in some electronic medical record systems, where completion alerts a nurse. In either case, the nurse should investigate and assess the resident and determine if further action is necessary. The nurse uses the completed SBAR to guide the communication with the healthcare provider.  In many nursing homes, the completed SBAR is used to document management of a condition change.

Use of the S&W form improves communication among CNAs, med techs, ancillary staff and nurses. A thorough nursing assessment and the completed SBAR improves the quality of information communicated to the HCP, resulting in informed clinical decision-making.  Nurse managers can track SBAR completion and follow-through in the EMR to ensure appropriate documentation and management of condition change. 

The use of early illness recognition and management tools:

  • Improves communication and collaboration among staff,
  • Establishes a process for direct-care staff to report observations,
  • Promotes teamwork and collegiality among staff and providers, and
  • Improves the quality of information given to a provider. SBAR’s format helps tell the “resident’s story” effectively.

A broader benefit of these standardized processes is that they can serve as the basis for performance improvement projects involving a wide range of staff members. Involving direct care staff in PIPs can enhance their engagement in the shared mission of quality resident care. Thus, early illness recognition can be part of a mandated nursing home quality assurance program.

Sharon Kist

Implementation of S&W and SBAR requires commitment from nursing home leaders and enhanced education programs.  In addition, ongoing education is necessary due to staff turnover, even though new hires are often familiar with the now-commonINTERACT tools.

MOQI staff worked closely with nursing home leaders and employees to set expectations for use and reinforce education. Some nursing facility leaders established daily reminders regarding the use of S&W either during report huddles or as part of the EMR.

To implement and sustain early illness recognition:

  • Incorporate a wide range of strategies to promote early illness recognition based on characteristics and needs of an individual facility.   
  • Implement and reinforce a culture of trust and respect among all staff to report resident condition changes immediately.  
  • Ensure facility leaders and managers value the input of direct care staff, and tie these expectations to performance reviews. 
  • Use shift-change reports to give daily reminders about the importance of reporting and managing resident condition change. 
  • Place S&W forms in highly visible locations, and post reminders to complete them.  
  • Include reminders to use S&W as part of CNAs’ electronic daily assignments. 
  • Demonstrate S&W content and completion in facility-wide orientation to encourage use by all staff.  
  • During orientation, review the SBAR form and the importance of completing it to standardize documentation.
  • Use case studies to allow staff to practice processes for early illness management.
  • Have nursing leaders’ routinely review the SBAR form to encourage accurate documentation. 
  • Incentivize the completion of S&W and SBAR with praise and positive reinforcement, such as monthly prize drawings or nursing unit celebrations.

As with many process changes, sustaining use of S&W and SBAR requires ongoing leadership support and education. Following initial staff education, use increased considerably. But over the course of the study, usage waxed and waned. Additional staff education and daily reminders generally resulted in improved usage. 

Every employee has a role to play in providing quality resident care and in early illness recognition. The MOQI team found the use of S&W and SBAR to be an effective means of reporting and communicating about condition change.

Maryann R. Coletti, B.S., R.N. has served as INTERACT/QIPMO Coach with the Missouri Quality Improvement (MOQI) Initiative for the past eight years.  This CMS funded study focused on reducing avoidable hospitalizations in long-term care by promoting early illness recognition.

Shari Kist, Ph.D., R.N. has worked with MOQI for the past four years.