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Clinical Academic Project Presentation
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Clinical Academic Project Presentation

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    2. Introduction Problem Increasing fall or injury rate on a medical telemetry patient care unit with high fall risk patients (elderly patients). Falls create high medical expense. Target population All patients admitted to 9T

    3. SLEH Monthly Unit Fall & Injury Trend Report

    4. SLEH Monthly Unit Fall & Injury Trend Report

    5. SLEH Monthly Unit Fall & Injury Trend Report

    6. Introduction Purpose of proposed CAP Creates high patient satisfaction Decrease in medical expense Improve quality of care Improve quality of life

    7. Needs Assessment Medical telemetry 34 bed (adult) Fall tracking awareness Sharing information with staff Resources- staffing matrix according to patient acuity

    8. Needs Assessment Individuals involved Nurse Manager/Asst. NM MS Education Specialist Staff nurses Patient care assistants Unit secretary Patients family and significant other

    9. Review of Literature Patient falls were significantly reduced only during the one-hour experimental rounding (Meade, Bursell, & Ketelsen, 2006). Early identification and full assessment of individuals at particular risk (Campbell, 2006).

    10. Project Model Purpose and Goals To reduce fall and injury rates (per 1000 patient days) < 2 over a period of four months Methodology PDSA tool

    11. PDSA Tool Plan Institute hourly rounds protocol on 9T Communicate protocol to staff, patients, and families/significant other Track number of patient falls

    12. PDSA Tool DO Develop hourly rounding protocol Even hours- RNs Odd hours- PCAs Develop communication mechanism Provide training to nursing staff Plan kick-off date Conduct 120 day pilot data review

    13. PDSA Tool STUDY Evaluate monthly fall and injury rate. Analyze and compare to previous results Call light numbers Patient and family satisfaction Staff satisfaction

    14. PDSA Tool ACT ASSESSMENT ASSESSMENT ASSESSMENT Review of HENDRICHs fall risk assessment Institute HUDDLE per SLEH protocol

    15. Projected Cost Analysis FTE 8 hour project preparation Ongoing analysis- 4 hr monthly

    16. Evaluation Evaluate fall and injury rates after 120 days pilot by comparing results prior to pilot. Significant improvement- implement to 15T and 24T If not- start over for another 120 days.

    17. Evaluation Effectiveness Staff commitment Management support SLEH commitment Adequate staffing- staffing matrix

    18. Conclusion PDSA HENDRICHs fall risk assessment tool HUDDLE at shift change

    19. Conclusion Strengths Staff commitment Management commitment Weaknesses Staffing issues Time management

    20. References Campbell, J. (2006) How do we apply the results of falls prevention trials in the real world? Internal Medicine Journal, 36 (Suppl. 5) A163-A188 Meade, C., Bursell, A.L., & Ketelsen, M. (2006) Effects of nursing rounds: On patients call light use, satisfaction, and safety. American Journal of Nursing, Vol. 106 (9), p. 58-70