Successful Falls Prevention in Aged Persons Mental Health. Reducing the risk and decreasing severity of outcome

Transcription

1 Successful Falls Prevention in Aged Persons Mental Health Reducing the risk and decreasing severity of outcome Vahitha Koshy Seema Dua Elda Kimberlee

2 Introduction Unit 3- Acute Aged Mental Health inpatient unit Concerns- High Incidence Severity Rating (ISR) 2-3 Aim- reduce harm from falls in Aged Persons Mental Health Acute Quality improvement project implemented

3 Mapping Quality Project Mapping started at Unit 3 (Acute inpatient service for Aged Persons Mental Health) Project started 2017 Jan-Dec and continues at present in 2018 Mapping of all falls- date, time and location Information was transparent to all staff, family and visitors

4 2017 Mapping Unit 3

5 2017 Mapping

6 2017 and 2018 Data Falls Mapping data Unit JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC ISR ISR ISR

7 2018 Mapping Unit 3

8 2018 Mapping

9 Our hypothesis?? What we thought. Falls happen in patients bedrooms Falls occurred in bathroom area Falls happen at night ISR 2 falls are not preventable Agitated patients always fall Aged patients always fall

10 What data told us?? What we found Most falls happen in the lounge area More falls happen in the afternoon shift (sun downing) ISR 2 falls are preventable Higher observation in the lounge decreased falls Individual care makes a difference Identified strategies makes a difference Patient engagement makes a difference

11 What we did? Full investigation of ISR and post falls procedure Audit current Falls tool (FRAT) Audit care plans with specific falls interventions Audit medical documentation Implemented a medical guide for falls prevention Implemented a new Trial of Falls tool Implemented falls prevention strategies Changed practice Implemented falls tagging system

12 Interventions implemented Patients in high profiles areas Higher staff profile Spending more time with patients Engaging patient in their care Families can be engaged in falls prevention Mapping and tracking awareness

13 Outcomes Enablers Communication in staff meetings Staff already engaged in Falls Prevention strategies Staff positive about a Psychiatric Specific falls tool Feedback from Accreditation re: Mapping Engagement with education team Taking staff on the journey was important Leadership is the key High profile of falls on the ward

14 Outcomes Challengers More change and burnout Extra work with new tools 24 hour shifts New Forms from Mental Health due to EMR Time line Copyright and legal teams

15 What did we learn? Falls can occur at all ages Frequency and severity of falls, and subsequent harm, increases significantly at 65 years and older Considering all the unique factors Patient and carer are aware of falls risks Developing care plans in partnership with patients and carers Assessment outcomes are routinely recorded in the medical record and form the basis for a care plan which is acted upon Targeting individual falls risk factors REDUCES the rate of falls and the harm experienced from them

16 Where to from here? Recommendations from accreditation team Recommendation of tool specific to Mental Health Continue to trial new falls tool Continue to complete 2018 mapping Auditing to continue till end of August Plan-To apply for copyright and use Falls tool without it being a trial

17 References Edmonson, D., Robinson S.,& Hughes, L. (2011). Development of the Edmonson Psychiatric fall Risk Assessment Tool. Journal of Psychosocial Nursing and Mental Health Services, 49(2), Department of Health and Ageing (DoHA) (2003).Projected Costs of Fall Related Injury to Older Persons Due to Demographic Change in Australia, Department of Health and Ageing, Australian Government, Canberra. Howard, L., Kirkwood, G., & Leese, M. (2007).Risk of hip fracture in patients with a history of schizophrenia. British Journal of Psychiatry,190,

18 Any Questions?