Nurse reviews checklist
Registered Nurse Jill Peterson and patient Bill Lainsbury review a checklist of must-have items that Bill will need for an outing. (Photo: UHN)

What started as a small project in response to a patient safety incident has grown into a standardized tool that is spreading across Toronto Rehab's Lyndhurst Centre.

When an abrupt stop caused an inpatient with high-level quadriplegia to hit his head against the front seat of an accessible taxi during an appointment outing, the patient wasn't hurt, but he was definitely shaken.

It turns out that the driver hadn't properly secured the patient's chest strap.

"We realized we could do more to prepare patients for when they're out in the community," says Charlene Alton, a recreation therapist in the Brain and Spinal Cord Rehab Program.

Together with occupational therapist Colleen Anderson, the two led a committee in the development of an appointment outing checklist and directory label​ for patients on unit 1B, that standardizes preparations, educates patients and decreases the number of safety incidences related to outside appointments.

"It's not just about a seatbelt. It's about making the entire process of the appointment go as seamless as possible for our patients," says Charlene.

Promoting safety and self-management

While it's essential for patients to feel safe in the care of UHN, it's also important for them to see themselves as active participants.

"We performed a gap analysis with patients, and what they told us was, 'I trust you're making all the arrangements,' which is how they should feel," says Charlene.

"But they also need to advocate for themselves, take responsibility for their well-being, and really understand what's happening when they're out in the community."

The stress of leaving for an appointment can be challenging for patients, says Stephanie Teffer, a social worker who, along with Nicole Leong, a recreation therapist, adapted the checklist for unit 1A.

"That can play into memory, concentration, and the ability to focus. These tools simplify one portion of the process, promote appointment success, and provide order to what feels like a chaotic change in routine," she explains.

Just ask patient Bill Lainsbury, 57, who has been applying these tools with his healthcare team since he arrived at Lyndhurst in February.

"It makes me feel at ease, knowing that everything is being thought of," Bill says. "As with anything in life, using a checklist is helpful in making you think of things beforehand, as opposed to forgetting something that you'll need."

Checking off the list

It starts a week in advance of the appointment, when the program assistant adds the event to relevant calendars and charts, books transportation, and starts preparing a consultation package for the patient to take with them.

One day prior to the appointment, the occupational or physiotherapist will educate the patient on proper wheelchair safety during transportation, and a nurse ensures appropriate toileting education, self-care equipment and dietary needs have been reviewed.

On the day of the appointment, the nurse and patient pack supplies and review problem-solving strategies, such as what to do if they're dropped at the wrong location.

While the checklist is a useful tool for enhancing role clarity, it's the accompanying directory label that patients really appreciate.

Printed right onto the consultation envelope that patients take with them, it lists relevant phone numbers, such as the taxi company, appointment address and details and a short checklist of must-haves, such as medications, cell phone and snacks.

"The impact is huge. This is what promotes patient safety and self-management," says Charlene.

"Now, if someone is dropped at a different location, they can speak up and say, 'You're taking me to the wrong place – this is where I need to go.'"

Preparing patients for when they go home

At Toronto Rehab, where optimizing patients' safe integration back into their communities is a strategic goal, these tools give patients practice opportunities for when they go home.

"Strategies around advocacy, preparedness, learning, and navigating are not just important for appointments," Stephanie says. "They're the same strategies they'll use when going out for a meal, or even shopping.

"These tools provide a great framework that can be adapted for any area of life – that's why they're so valuable."

Bill says he'll definitely create his own checklist, once he returns home.

"There are things I'll always need, and I find this handy," he says. "Before I go, I can just comb through the list to make sure everything is packed."

Utilizing teach-back, saving money

The team relies on Caring Safely's teach-back tool to ensure patients can relay, in their own words, what is expected of them.

"If I just explained the label, I would ask, 'what would you do if you knew your appointment was running late?' and the patient would say, 'I'd call the taxi company and ask them to come later,'" says Charlene.

It may sound small, but this simple step is saving the unit, on average, $55 per trip.

"Taxis used to come to the pick-up spot, and then leave if the patient wasn't ready," Charlene says. "They'd drive back again later, but we'd be charged twice."

Since implementation, staff members have been quick to buy into the process.

In fact, a recent survey revealed that the majority of staff strongly agree that the process enhances their practice, promotes teach-back and self-management, and would recommend it to other staff.

"Our next steps will be developing a more condensed version," says Charlene.

"We're also hoping that it'll spread and be adapted to a variety of different patient populations and units." ​

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