Presentation Transcript

1. VISN 8 Patient Safety Center of Inquiry: Journey for Change:Innovations to Reducing Fall Incidence and InjurySession 6: “Intervention s to Reduce Falls and Falls Harm, Part 2 Thursday, Jan 17, 2013
2. Program Goal To provide VHA healthcare and quality teams with tools and strategies to reduce preventable falls incidence, injury from falls and outline key components of sustaining and spreading successfully.
3. Objectives Inventory tests of change in fall and injury prevention interventions Differentiate types of falls as a basis for analysis of program effectiveness Integrate injury prevention into existing fall prevention programs Summarize successes ready for adoption and spread
4. Looking Ahead Eight Sessions of Learning and Sharing Oct 25th: State of Science of Falls and Injury Prevention Nov 8th: Integrating Falls and Injury Assessment Nov 29th: Interventions to Reduce Falls and Harm, Part 1 (Equipment and Technology) Dec 20th: Injury Risk Assessment and Communication of Risk Jan 3rd: Sustain and Spread Improvements in Reducing Falls and Injury from Falls Jan 17th: Interventions to Reduce Falls and Harm, Part 2 (Intentional Rounding, Pre-shift Huddle, Post Fall Huddles) Jan 31st: Use of VANOD, NDNQI and SPOT Databases for Fall Program Evaluation Feb 7th: Summary of Your Accomplishments
5. For Today! Intentional/Purposeful Rounding – Annette Galinski, RN, NM, Palo Alto; Pat Quigley Pre-shift Huddles – Pat Quigley Post Fall Huddles-Levanne R. Hendrix, GNP, MSN, PhD, Nursing Quality Management, Extended Care, and Karen Boatright,RN, ACNS-BC, Extended Care Service Post Fall Huddles –Charlene David, RN, ACNS, BC, Pittsburg VAMC

6. Intentional Rounding

   Dr. Pat Quigley, ACNSR Annette Galinski, RN 11
7. Intentional Rounding Clinical Rounds with specific intention: Strategy to improve communication between the nurse and patient Strategy to improve patient satisfaction with care Innovation in patient safety Increase patient participation as active partner is care
8. Beginnings Developed by the Studer Group, another way to organize existing work Purpose: To anticipate and meet patient needs routinely and ensure patient safety (Shaner & McRae, 2007) Allow information to be gathered in a structured way, addressing problems as they occur (StuderGroup, 2005) Addresses patient needs proactively
9. Performing Intentional Rounding Specific scripts for consistency and reliability of the content Defined methods to hardwire implementation During Hand-off, explain to the patient who would be checking on them hourly (or frequency) to enhance their safety and address personal needs Schedule tasks during the rounds Before leaving the room, address the 4 “P’s”
10. The 4 “P’s” Pain Personal Needs (toileting) Positioning Placement Immediately before leaving the room, ask the patient if anything else was needed, emphasizing the nurse has the time to address any needs Lastly, inform the patient when the nurse would return
11. Study Designs: Melnyk: Meade, et al, (2006): quasi-experimental study: hourly rounding, bi-hourly rounding, and control, no regular rounding. 46 units in 22 hospitals: hourly rounding more effective than every 2 hour rounding and the control; 2 hour rounding more effective than control (no randomization) Halm Article Review: 11 reports
12. Results Reduction in call light use Decrease in falls Decrease in pressure ulcers Improved patient satisfaction and likelihood of recommending the hospital Improved nursing satisfaction: care is more efficient and less stressful Positive results exceed expectations
13. Evidence Reviews Evidence-based Practice Center: Madison Wisc VA: Dr. Beverly Preifer Since the publication of the Meade article, there have been other studies examining hourly rounding and fall prevention.  Additional Researchers found no difference in fall rates after one year of hourly rounding.  decrease in call light use but no difference in falls after implementing hourly rounding. Hourly rounding presents no harm to patients, Nurses / Teams need to clearly understand why they are implementing hourly rounding: what are the expected outcomes, and decide on your have the capacity for implementation.
14. Additional Actions Toilet before giving pain medication Test patient knowledge (and skill) about fall and injury prevention If prescribed hip protectors and /or helmet, inspect to ensure they are on If floor mats required and patient in bed, observe for floor mat Observe height of the bed (relevant to patient activity: if patient resting, is it in low position; if patient out of bed, is the bed raised-up)
15. Answers Accidental Falls Anticipated physiological Falls Unanticipated physiological Falls Intentional Falls
16. Is your approach likely to be successful?

17. WE’VE GOT THE SPIRITAT CLC2 IN LIVERMORE

    ANNETTE GALINSKI, NURSE MGR.
18. IMPLEMENTATION STRATEGIES OUR CURRENT ACRONYM FOR OUR FALL PREVENTION PROGRAM IS S-P-I-R-I-T -- WE’VE GOT THE SPIRIT TO MAKE FALL REDUCTION A PRIORITY, ESPECIALLY AFTER WE HAD ONE MONTH OF 11 FALLS IN OCTOBER. WE NEEDED SOMETHING FRESH AND NEW TO GET STAFF INTERESTED AGAIN. WE ROUND HOURLY ON THE RESIDENTS WHO ARE THE HIGHEST FALL RISK, UTILIZING THE S-P-I-R-I-T GUIDELINES.
19. REASONS BEHIND SPIRIT AND WHAT IT STANDS FOR: SAFETY: SAFETY OF THE ENVIRONMENT IS KEY. PAIN: ESPECIALLY IN OUR HOSPICE RESIDENTS, PAIN CAN LEAD TO FALLS INGESTION: OFFERING FOOD AND FLUIDS OFTEN WORKS TO PASSIFY RESIDENTS WHO ARE FIDGETING IN THEIR CHAIRS RESTLESSNESS: TERMINAL RESTLESSNESS IS SEEN IN HOSPICE RESIDENTS AS WELL. STAFF NEED TO OBSERVE TO ASCERTAIN THE CAUSE INVOLVEMENT: RESIDENTS NEED TO BE INVOLVED IN ACTIVITIES TOILETING: MANY FALLS SURROUND TOILETING ISSUES. STAFF NEED TO BECOME AWARE OF HABITS OF THEIR RESIDENTS.
20. CHANGES WE HAVE MADE SOME DAY SHIFT STAFF AGREED TO ROTATE INTO A SPLIT SHIFT TOUR SO THAT THERE WOULD BE MORE STAFF SUPPORT ON EVENINGS THROUGH THE DINNER HOUR AND THE EXPECTED TOILETING RITUAL SOON AFTERWARD. “STOP” SIGNS HAVE BEEN POSTED ON BATHROOM DOORS. WE ARE AGGRESSIVELY ENCOURAGING RESIDENTS TO USE HIP PADS. WE HAVE OBTAINED A LARGE BULLETIN BOARD FOR QM MONITORS AND HAVE A VERY VISIBLE MONTHLY CALENDAR IN WHICH WE POST EACH FALL A ND WHAT TOUR IT OCCURRED ON. THIS IS A GREAT PEER PRESSURE TOOL.
21. CHANGES WE HAVE MADE WE STARTED A NEW PRACTICE IN PEER TO PEER HAND OFFS AT CHANGE OF SHIFT. HANDOFF WILL INCLUDE WHAT HAS BEEN GOING ON WITH THE RESIDENTS, WHAT WORKED AND WHAT FALL MEASURES DID NOT WORK. PM SHIFT STAFF MAKE SURE THAT WHEN THEY ASSIST A RESIDENT TO BED THAT THEY AUTOMATICALLY PUT ON NON-SKID SOCKS. FOR RESIDENTS WITH A CHANGE IN CONDITION, THE EXPECTATION IS TO HAVE STAFF TAKE TURNS IN CLOSE MONITORING. DAY STAFF TAKES OWNERSHIP IN MAKING SURE FALL PREVENTION SUPPLIES ARE READILY AVAILABLE. UNIT BASED COUNCIL HAS TAKEN ON FALLS AS ONE AREA OF CHANGE AND MEMBERS ARE BRAINSTORMING NEW IDEAS FOR FALL PREVENTION. CC
22. CHANGES WE HAVE MADE WE ARE ENCOURAGING STAFF ON ALL SHIFTS TO TAKE OWNERSHIP OF OUR PROGRAM. WHEN THERE IS A FALL, THE GROUP OF STAFF ON THAT SHIFT DISCUSSES IT AND NOT ONLY GOES OVER THE FALL DURING THE POST FALL HUDDLE, BUT TRY TO COME UP WITH NEW IDEAS OR RESOLUTIONS TO HELP PREVENT A SIMILAR EVENT FROM HAPPENING. THIS INFORMATION CAN GO INTO THE POST FALL HUDDLE NOTE. WE HAVE ALSO DIVIDED BREAK TIMES INTO 3 DIFFERENT TIMES ON DAY SHIFT TO MAKE MORE STAFF AVAILABLE ON THE FLOOR DURING LUNCH. WE ARE ENCOURAGING THE EVENING STAFF TO DO THE SAME.
23. RELIABILITY CHECKS FALLS CHAMPIONS AND CHARGE NURSES ARE MAKING SURE THAT ASSIGNMENTS ARE MADE EACH SHIFT AND THAT THE ROUNDING TOOL IS BEING FILLED OUT EACH HOUR. WHEN ROUNDING, STAFF ARE ASKING THE RESIDENTS IF THEY NEED ANYTHING WHILE THEY ARE IN THE ROOM. SOME RESIDENTS HAVE EXPRESSED SATISFACTION WITH HOURLY ROUNDING AND APPRECIATE THE EXTRA ATTENTION.
24. OUTCOMES SINCE WE HAVE JUST BEGUN THIS NEW “WE’VE GOT THE SPIRIT” PROGRAM, WE HAVE ONLY ONE QUARTER OF DATA. OCTOBER 11 FALLS, NOVEMBER 3 FALLS, DECEMBER 2 FALLS WE CAN SAY THAT WE HAD ONLY ONE FALL WITH INJURY OVER THE PAST YEAR. OUR FALL DATA FOR 2012 WAS 47 FALLS AS COMPARED TO 2011 IN WHICH WE HAD 59 FALLS SO OUR FALLS ARE DECREASING. WE ARE WORKING VERY HARD TO HAVE LESS FALLS IN 2013.
25. Challenges Use of formal scripting Hardwiring Sustainability Accepting rounds are value added
26. Other Outcomes What Type of Falls would be sensitive to intentional rounding? Your choices are: Accidental Falls Anticipated physiological Falls Unanticipated physiological Falls Intentional Falls
27. Pre-shift Huddles – Pat QuigleyStandardize Safety Communication High Fall Risk communication in hand-offs: Nurse-to-nurse hand-off (including unit-to-unit) Charge-nurse-to-charge-nurse hand-off Purple hand-off form (Ticket to Ride) for off-unit movement Best Practice: Safety Huddles (at shift change or on rounds) verbally tell the whole team who is vulnerable, at greater risk for falls and Injury and WHY 40
28. The Proactive Safety Huddle Goals: To make entire staff aware of which patients are at risk for fall and injury and WHY To create awareness of specific prevention measures in place for each patient To create team vigilance for all unit patients at risk To reduce anticipated physiologic falls 41
29. Method: Pilot Unit On 5 South: After nurse-to-nurse hand-off, the entire unit comes together for a brief (10-15 minute) shift huddle. Each patient who is at even greater risk for falls and injury is discussed: what is their fall risk level (score)? Reason for risk level (age, condition, meds, history of falls, mental status, etc). Also shared in the huddle is any other change or event that wasn’t already identified in the shift report (increased agitation, addition of diuretics, etc) 42
30. Items for Change of Shift Huddle(s)                  updated 10-6-2010 PATIENT ITEMS UPDATES ONLY –  around the room. Please, do not read your whole report. DNRs High acuity patients Patients at risk for FALLS – Patients at risk for HARM from falls (h/o Osteo, low platelets, h/o falls, on anticoagulants, fall scale score of 50 or greater, 85 or older). Check for bed alarm activation. Hip protectors, yellow arm bands are in supply room. HIP PROTECTORS ON PATIENTS WITH H/O HIP SURGERY, BONE DISEASE, ETC. Patients receiving chemotherapy Identify patients to be turned every 2 hours (even hour). Patients at risk for skin breakdown. Discharge appointments times PRN effectiveness list printed every 2 hours automatically. Please check list. Patients on tele STAFF ITEMS_________________________________________________________ 43
31. Method: Test Unit Two On 6 South: An hour into the tour, the charge nurse conducts a huddle of all the unit staff to discuss patients who are at higher risk for falls and injury and other safety issues (restraints, name-alerts). The charge nurse asks: “What makes this patient a high fall risk?” (previous fall, confusion, anemia, syncope, etc)? What is the plan to keep the patient safe? 44
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33. Benefits of Proactive Safety Huddle Better customization of care for vulnerable patients Enhanced staff learning about fall contributing and prevention factors Improving “systems thinking” among the staff Better sense of “community”; everyone is involved in keeping all the patients safe, not just “theirs” Building upon one another’s knowledge of the patients individual needs and issues Decrease in anticipated physiologic falls 46
34. Veterans Affairs Palo Alto Health Care System Nursing Quality & Safety Council Falls Prevention Team Levanne R. Hendrix, GNP, MSN, PhD Nursing Quality Management, Extended Care Karen Boatright,RN, ACNS-BC, Extended Care Service
35. VAPAHCS Fall Prevention Team About Us: VAPAHCS has 833 operating beds, 360 are CLC, 94 acute med-surg, 92 acute psychiatry, 43 spinal cord injury, 32 blind rehab, and 30 traumatic brain injury beds. We consist of 3 inpatient divisions at 3 sites, and 7 outpatient clinics (CBOC’s). We have over 3,660 full time employees.
36. VAPAHCS Falls Prevention TeamPOST FALL HUDDLE GUIDELINE BACKGROUND – (Refer to Guideline) FY 2011 – VAPAHCS had 850 inpatient falls 355 of the falls were repeat falls (3+) All except 7 of the repeat falls (3+) were in CLC’s There was only one serious injury of the repeat falls (3+) Acute care inpatient areas had veterans who fell only once or twice.
37. VAPAHCS Falls Prevention Program 5 Point Program for all Clinical Units: 1) Hip Protectors 2) Non-Skid Socks a. Yellow – All patients needing socks & high risk. b. Red – Highest risk for fall & injury. 3) Floor Mats 4) Bed & Chair Alarms 5) CALL DON’T FALL Stop signs – Patient Rooms & Bathrooms.
38. VAPAHCS Falls Prevention Program FALLS With SERIOUS INJURY: FY2011 - 23 Falls FY 2012 – 9 Falls Reduction of 61 % FALL PREVENTION Is Everyone’s Business!
39. VAPAHCS Falls Prevention TeamPOST FALL HUDDLE GUIDELINE IMPLEMENTATION Falls Team Goal for FY 2012 – Standardize the Post Fall Huddle Process Developed & refined by the Falls Prevention Team No duplicate documentation Focus Analysis on individual falls Stimulate Critical Thinking Collection of Data by types of Fall (Anticipated, Unanticipated, Accidental) Encourage integration of ABCS for risk of injury Guideline introduced by unit-based Falls Champions
40. VAPAHCS Falls Prevention TeamPOST FALL HUDDLE GUIDELINE SUSTAINABILITY Form is purposefully de-identified Used for individual analysis and aggregate review at unit level (new). Information is used for monthly reporting. Guideline forms and monthly reports used to perform a written quarterly analysis and report (new). Quarterly reports are shared with the interdisciplinary VAPAHCS Falls Prevention Team.
41. Post-Fall Huddle: Acute Care Side Great tool for the Manager , staff nurses, and Falls Champions to have open discussions for other preventive measures. Guides the Staff Nurse in interventions and critical thinking when a fall occurs. Feedback from staff: easy checklist Visually helpful: post-fall huddle paperwork compiled into a binder. Courtesy of Evamarie De Mayo, RN Staff Nurse
42. Roll out of the Post Fall Huddle Guideline in the CLCs Training & Buy-in Critical thinking Documentation Communication
43. Challenges: How Are We Doing Thus Far? Successes: Staff that fully utilized the Huddle Guideline revealed: more thorough documentation collaboration with team improved written and verbal communication awareness and follow-through for risk for injury interventions Staff that have not fully utilized the Huddle guideline revealed: incomplete documentation Key risks factors not addressed Opportunities for individualized interventions missed Did not incorporate critical thinking with ABCS and Morse results
44. Challenges for FY2013 Recent audits indicate that information (fall prevention interventions and injury prevention interventions) from the Post Fall Huddle Guideline is not being documented in CPRS notes and the care plan. There is inconsistent use across clinical units. Action: We will review the documentation process for usability & duplicate documentation.
45. What’s next? Continue audits of all Fall reports and huddles Education- 1:1 and as a group with in-services and through the monthly Falls Team meetings Advocate for a CPRS Post Fall Template

46. Safety Huddle/Fall Consult for Repeat Fallers

    Charlene M. David, RN, ACNS, BC VA Pittsburgh Healthcare System
47. What is it? In depth examination of veteran’s fall risk factors, risks of injury, history of falls, and environment. The huddle/consult ‘s sole purpose is to ensure Veteran’s risk factors are matched with interventions to reduce risk.
48. Who is involved? Varies depending on availability of caregivers & veteran’s needs: Care givers closest to the veteran i.e. RN’s, NA’s, NP, physician Veteran and significant other Specialty services if needed Unit administration Pharmacist Staff member dedicated to fall reduction i.e. CNS, fall coordinator, unit fall champion.
49. When is it completed? Soon as possible after 2nd fall May be delayed d/t: Admission to acute care Availability of essential staff
50. Where is it completed? In the Veteran’s environment
51. First Step: Come to Huddle/Consult Prepared by Listing Risk Factors In depth review of Veteran’s: Interventions currently in place and attempted to reduce risk PT, OT, Restorative, safe exiting side, hip pads, mats alarm, est. History of falls Actions, environment, time, participating factors, devices in use/or not, injuries with falls Physical ability SPH equipment needed, Rehabilitation Therapy opinion, ambulatory aids used, hx of ADL functionality Medical history Acute/chronic illness; Medication history including recent changes, sedatives, poly pharmacy, ; Cognition including safety awareness, anxiety issues, agitation, confusion; Sensory deficits. Determine risk of injury Bone disease Hx of fractures Advanced age Liver disease Cancer’s or cancer therapy that compromised bone marrow Anti-coagulant use
52. Second Step: Staff interview Ask specifically why they feel the Veteran is at risk and how they can help reduce his/her risk Interventions are often unique: Ensuring clock is in view to decrease anxiety regarding time of activities Using foam pool floaties to cover hard sink edges Ensuring room objects are always in same place to aid in decreased anxiety
53. Third Step: Conduct Huddle/Consult All available care givers should be involved in the assessment including the significant other and the Veteran What is done during evaluation: Evaluation of environment w/c, bed, pathways, lighting, est. Veteran/Significant other conversation Tell me what happened? Why? What can we do to keep you safe from falls? Provide education including plan to keep veteran safe from falls Veteran demonstration of skills Gait, transfer, stand, sit, est.
54. Step Four: Implement Plan based on Risk Examples of a few very generic risks and matched interventions: Mobility impairment Consult OT, PT, w/c consult, Restorative Care Safe exiting side of bed Ensure Veteran has proper ambulation device Sensory deficit Educate Veteran to look through bottom lenses while walking Consistent lighting High risk for hip fracture Hip pads, low bed while resting Anxiety Consult geriophyscology Decrease stimulation Alternatives i.e. music, lavender
55. Final Step: Documentation Should include: Caregivers present (include Veteran & significant other) Hx of Falls Risk Factors for falls and injury Unit staff input Veteran Input (if available) Veteran education given Evaluation and Recommendation (match risks)
56. Huddle/Consult Aids with… Veteran Education Staff Education Reducing Risk of falls/injury Liability
57. AAR Part 2: Types of Falls Select which type of fall occurred. Select only one of the first four types of falls. Part 1. Fall Type Accidental Fall: Fall due to extrinsic environmental risk factors: spill on the floor, clutter, tubing / cords on the floor, etc. Or Anticipated Physiological Fall: Factors associated with known fall risks as indicated on the Morse Fall Scale: loss of balance, impaired gait or mobility, impaired cognition/confusion, impaired vision. Falls that we anticipate will occur to the patients’ existing physiological status, history of falls, and decreased mobility upon assessment. Or Unanticipated Physiological Fall: Factors associated with unknown fall risks that were not predicted on a fall risk scale: unexpected orthostasis; extreme hypoglycemia; stroke; heart attack. Or Intentional Fall: Patient who voluntarily positions his/her body from a higher level to a lower level. Part 2. Additional Fall Information Select the following items if the fall was assisted by staff or a repeat fall for this patient: Assisted Fall: Patient was physically assisted to the floor by a staff member. Repeat Fall: A fall has already occurred for this patient Morse J. (1997). Preventing patient falls. CA: Sage. 38
58. Benefits of Post-Fall Huddle Identify root cause of fall Prevent recurrence Update the care plan Define type of fall that occurred Educate patient and family about causes of fall and prevention, protection strategies 39
59. Outcomes Intentional Rounds: Reduce accidental and anticipated physiological falls Pre-shift Huddles: Reduced anticipated physiological falls Post-fall Huddles: Eliminate repeat falls (same type and root causes), Changed Plan of Care, Reduce Accidental and Anticipated Physiological Falls
60. Assignments for Next Week Test intentional rounding on one or more of your patients at high risk for falls or injury Test the pre-shift huddle Test the post-fall huddle Examine strategies to hardwire these practices 60
61. Looking Ahead Next Session Jan 31st: Use of VANOD, NDNQI and SPOT Databases for Fall Program Evaluation Feb 7th: Summary of Your Accomplishments