INTERACT: A Nurse’s Perspective

      Jill M. Shutes, MSN, GNP-BC, sees nursing home care and decision-making from both sides of the fence. Having worked both as a geriatric nurse practitioner and a clinical services manager for Evercare, she knows how challenging it can be, as a clinician, to receive information about a resident that is more “big picture” than concise. And she knows how frustrating it can be, as a nurse, to lack confidence in communicating with a clinician about a resident’s status and to receive orders that are sometimes unclear and even indefinite in nature.
      This is why the INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program care paths and their compatible order sets are so important for nursing homes, Ms. Shutes said at the AMDA — the Society for Post-Acute and Long-Term Care Medicine Annual Conference in Orlando, FL.

      Ten Care Paths

      INTERACT enables the early identification and management of 10 common symptoms and conditions that have been shown to be responsible for the majority of potentially avoidable hospitalizations.
      The program is in essence a set of tools and strategies for communication and documentation. Its 10 care paths, which cover areas such as acute mental status changes and symptoms of lower respiratory illness, are one of INTERACT’s main tools for nurses in their decision making about when and how to evaluate changes in a resident’s condition, and when to communicate with primary care clinicians. The care paths also provide some guidance on management.
      The INTERACT-compatible patient order sets were developed more recently to give physicians and nurses more specific and practical assistance in managing a patient’s individualized nursing, diagnostic, and treatment orders. Each of the 10 evidence-informed order sets is compatible with a care path; the acquired pneumonia patient order set, for instance, is an extension of the INTERACT care path for symptoms of lower respiratory illness.
      Ms. Shutes, a research associate at Florida Atlantic University and an assistant professor at Palm Beach Atlantic University, has a vested interest in the program. She served on the expert advisory panel that collaborated with the Think Research Corporation on developing the order sets, and she continues to serve as a consultant for the company. The advisory panel was led by FAU’s Joseph Ouslander, MD.
      Her conviction in INTERACT’s value is deeply rooted. The care paths and order sets “have validated everything I’ve been doing on a regular basis as a geriatric nurse practitioner,” Ms. Shutes said. “There are a lot of nurse practitioners in nursing homes who aren’t geriatric trained, who need that extra layer of geriatric guidance, and there are nurses who need that extra support.”

      Solid Knowledge

      Nurses’ knowledge is solid, she said. When she trains nurses on how to use the care path for symptoms of congestive heart failure, for instance, she first “turns it upside down” and asks them to name symptoms of CHF, to describe an evaluation, and to name the criteria and vital sign measures that should prompt notification of the clinician. “They miss very little,” Ms. Shutes said. “They just sometimes need a little guidance and support to be able to get through the process and to [effectively] communicate the information to the physician.”
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      The Interact patient order sets are particularly helpful to nursing staff when they receive clinician orders that are unclear or undefinitive.
      From Think Research Corporation, Toronto, Ontario, Canada.
      Once contact with the physician is made, the practitioner completes the order set, marking orders for laboratory studies, for instance, and indicating steps to be taken for managing the condition in the nursing home. He or she then sends it back to the charge nurse.
      Order sets have a standardized format, with menus of evidence-based and expert-recommended orders as well as optional and default orders, and visual alerts and reminders. But like the care paths, order sets can be customized for individual facilities and groups of providers.
      Each order set incorporates evaluative results obtained with the associated care path, and it may, in turn, refer back to the care path for parameters or other guidance relating to continued management. The order sets can be used as part of a paper record process or integrated into an electronic record system.
      Most importantly, Ms. Shutes said, order sets enable “physicians and nurses [to] communicate on the same level … to speak the same language,” which is increasingly important as the Centers for Medicare & Medicaid Services, the Society, and others work to reduce hospitalizations among patients in skilled nursing facilities.
      Care paths are available on the INTERACT website (, and the order sets are available through Think Research (
      An overview of the program, including a description of the care paths and findings on the program’s effectiveness, was published two years ago (J Am Med Dir Assoc 2014;15:162–70), and a description of the order sets ran last year (J Am Med Dir Assoc 2015;16:524–26).
      Christine Kilgore is a freelance writer based in Falls Church, VA.

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