Stepping up to the challenge of falls at Basildon Hospital

Transcription

1 WELCOME TO THIS SIGN UP TO SAFETY WEBINAR Stepping up to the challenge of falls at Basildon Hospital All participants lines are muted to reduce background noise

2 Stepping Up to the challenge of falls Anne Hendry Lead Nurse Osteoporosis & Falls

3 Falling is a symptom Functional decline Medical decline Social factors Environment System failure

4 What does the data mean? Falls per 1,000 bed days 5.6 falls/1,000 bed days NPSA standard 2010 BTUH evidence 2010/ / / / /15 Falls Falls per 1,000 bed days (source Quality Report) The figure above is for all patient falls, there is no test for avoidability

5 Seasonal variation NB Nov to Feb = Black / Red alert 5 injurious falls 4 severe harm FallSafe started FallSafe education cancelled = Black Alert 4 injurious falls severe harm 3 injurious falls moderate harm

6 Falls & injury Severe Harm fracture spine, hip, pelvis, humerus intra-cranial bleed Moderate Harm other long bone fractures lacerations that need suturing

7 Extent of Harm Calculate the percentage of injury against the total number of falls per month

8 Royal College of Physicians National Falls Audit Their challenges are ours! Delirium Lying & Standing BP Medication Review

9 FallSafe An RCP QI initiative evidence-based falls prevention assessment and intervention multidisciplinary approach reduce falls & injury improve knowledge & quality care delivery. Year 2 results 25% reduction in falls small not significant decrease in injurious falls

10 Our road to FallSafe? Challenges of injurious falls Incomplete falls assessments & plans of care Poor post falls protocol adherence Inadequate multi-disciplinary engagement Compromised patient experience

11 Out of the 1,143 falls in Oct 2012 Sept harmful events 2 deaths from subdural haematoma 12 hip fractures 3 wrist fractures 2 shoulder fracture 1 tibia fracture 1 ankle fracture

12 The power of patient stories 86-year-old male admitted to AMU Chest infection Fast atrial fibrillation Abbreviated mental test score: 10/10 No falls assessment or plan completed 20 hours post transfer Became unwell with fast atrial fibrillation Administered beta blockers 24 hours post transfer Unwitnessed fall - suspected fractured neck of femur Fracture excluded but monitor neurologically No post falls protocol completed 4 hours post fall Became unconscious, unresponsive 45 minutes later: cardiac arrest

13 Every hospital has a patient story Mrs Andrews experience demonstrates a failed care pathway

14 How we started Rise to the pressure Turn challenges into opportunities Recruit your supporter Broaden your horizons

15 Next steps need investment Agreed a 4 day Foundation programme and monthly study days Champion recruitment - sell it as a development role too! Identify colleagues to help Develop relationship with comms Invent a branding Don t compromise on quality This will take time set realistic timescales

16 Raising the profile

17 Champions Foundation Programme QI v Audit ward reports how to gather data how to use results

18 FallSafe Champions Contract 2014 Raise awareness of the FallSafe Care Bundles Educate and empower our colleagues, patients and carers Improve falls related incident reporting Facilitate a multi-disciplinary approach to Falls Risk Management Ensure the continuation and development of FallSafe We will utilise the experience of the last 4 days, to work with our colleagues and clinical teams to create a domino effect of Knowledge Support and Practice Improvement

19 FallSafe Quality Improvement Sessions AM Reflection on the month Analysis of the figures Knowledge session Projects PM Ward QI metric assessment Ward based teaching

20 Engagement be inventive! Acronym 2014 FallSafe Friday

21 Monthly QI Falls Assessment

22 Commitment yields improvement

23 Championing QI Lying & Standing BP / manual pulse Local data analysis Ward falls communication standard Falls on top agenda Flash Huddles Message of the week FallSafe folders Falls as one bundle Acronym & film Champion team reflection Alert to falls injurious risk slippers and magnets

24 Knowledge & Engagement

25 Challenges Time Activity Staff turnover Engagement Facilitating the team approach Sustainability

26 Where next? Charter Leading the way in falls improvement As a team the FallSafe aspirations for this year are to:- Demonstrate falls leadership trust wide and strengthen the visibility of FallSafe Champions. Promote the early identification, assessment and management of falls risk. Reduce harm experienced from falls. Improve the communication of patients falls risk and care planned to reduce risk. Develop strategies to improve multi-disciplinary involvement in falls. Embrace Quality Improvement methodology and identify areas for improvement and implement tests of change.

27 Sign up to Falls Put safety first By December 2017 to reduce severe harm from falls, by 50%. 25% reduction in year 1 40% from baseline in year 2 50% by year 3 Continually learn Honesty Collaborate Support Contribute to the organization s risk reduction strategy by Evaluating outcomes - activity, care delivery and incidents Implement a falls based competency & education strategy Novel approach s to falls alert technology Partnership working Ensure the patients/carers are fully informed by Involving the patient/carers in risk assessing and planning care for falls When an incident/injury occurs communicate findings Ensure a successful multi-disciplinary approach to falls FallSafe multi-disciplinary Care Bundle Falls Safety Huddles/ Board Rounds Implement strategies to communicate falls risk Utilize data to influence corporate and divisional falls improvement plans Establish patient alert strategies for those at highest risk support clinical care delivery, ensure success is celebrated and when things go wrong we improve Demonstrate falls clinical leadership Ward based leadership and succession planning FallSaf e Champions & FallSafe Buddy team Implement robust peer review strategies Deliver falls education in the clinical environment. Develop an electronic resource to support clinical care Monthly communiques

28 In their words