WRISTBAND STANDARDIZATION Presentation to NHONL – Rachel Rowe, Associate Executive Director November 6, 2007

Rationale for Standardization in AZ… A survey conducted in March 2006 showed that 8 different colors/methods were being used to convey DNR 60% - No Band 2% - White 13% - Blue 2% - Yellow 13% - Orange 2% - Green 6% - Purple 2% - Red

Rationale for Standardization in PA… In 2005, clinicians failed to rescue a patient who had a cardiopulmonary arrest because the patient had been incorrectly designated as “DNR”. Source of confusion was a nurse that had incorrectly placed a yellow wristband on the patient (which meant DNR at that hospital) In a nearby hospital where she also works, yellow meant “restricted extremity” which was her intent as an alert

Arizona Process… Wristband Standardization Workgroup: Address DNR, Allergy, Fall Risk Workgroup included nurses, pharmacists, patient safety officers, physicians, QI staff, and educators Deliverables: Standardize color-coded wristbands Reach consensus on color definitions Develop a workplan and Implementation Tool Kit for hospitals to use to adopt the standardization of color-coded wristbands

It was made clear that… The safety of our patients across the state and success in this effort depends on the participation and adoption of each and every hospital in the state. This will require a willingness to change for the greater good.

DO NOT RESUSCITATE Rationale for banding for DNR: Increasing number of healthcare providers are not hospital based, current processes need to take this into account. Travelers or non-clinical staff may be unaware of where to look in the medical record if they are new to your hospital When seconds count, having an alert wristband will serve as ready communication in a crisis situation, evacuation situation, or with patients in transit Serves as a means to communicate to the family that you are clear about their end of life wishes

Rationale for purple: Blue? Most hospitals announce a code using “Code Blue” – too much potential for confusion Orange? Many hospitals use this color to indicate the presence of an Advanced Directive Green? Due to color blindness, avoid it

ALLERGY Why red? 75% of hospitals in AZ already use red Red is used in other industries to imply “extreme concern” The American National Standards Institute uses red to communicate “Stop!” or “Danger!” When a caregiver sees a red band, they are prompted to “Stop!” and double check the medication, food, or treatment they are about to receive.

Allergies written on wristband? NO! Legibility may hinder the correct interpretation One may assume the list is comprehensive and not check the medical record During the hospitalization, allergies may be discovered and added to the medical record and not always a wristband

FALL RISK Why Yellow? Other industries use yellow to imply “caution” ANSI uses yellow to communicate “Tripping or Falling hazards” Caregivers need to use caution with a person with a history of previous falls, dizziness or balance problems, or confusion

Why band for Falls? More than a third of adults over 65 fall each year Older adults are hospitalized for fall- related injuries 5 times more often than they are for injuries from other causes Of those who fall, 20%-30% suffer moderate to severe injuries Total projected cost of all fall injuries by 2020, is $43.8 billion

Risk Reduction Strategies 1. Use wristbands with the alert message pre-printed (such as DNR) 2. Remove any “social causes” wristband (such as Live Strong) 3. Remove wristbands that have been applied by another facility 4. Initiate banding upon admission, changes in condition, or when information is received during the hospital stay

Risk Reduction Strategies… 5. Educate patients and family members regarding purpose and meaning of wristband 6. Coordinate medical record/white board/care plan/door signage/stickers with the same color coding 7. Verify patient color-coded ‘alert’ wristbands upon assessment, hand-off of care and facility transfer communication

Other States…

Proposed Plan for NH… Establish small working group of nurse leaders, pharmacist, QI professionals, and physicians to review the Arizona model and toolkit Reach consensus on the “interest and readiness” to propose a statewide initiative Recommend adoption of an existing model with NH specific Toolkit Develop a work plan and timetable for implementation