Reducing Falls in the In-patient Setting

Transcription

1 Reducing Falls in the In-patient Setting Mary Catherine Rawls MS, RN-BC, CNL, FGNLA Clinical Specialist for Medical Specialties Objectives Define the magnitude of the problem of patient falls. Identify measurements used in process improvement initiatives. Describe an in-patient Falls Reduction Program: = Established, part of culture = In progress = Gap, may need to be done 1

2 Falls: An Adverse Event An unplanned descent to the floor with or without injury to the patient. Leading cause of fatal and non-fatal injuries for elders Leading cause of hospital admissions > 800,000 admissions/year > 27,000 deaths ¼ of Americans aged 65+ fall each year ED treatment: every 11 seconds Death: every 19 minutes 2013 total cost of fall injuries: $34 billion Possibly $67 billion by 2020 (2017, National Council on Aging) Quality of Life Issues Fear of falling increases Activities and social engagement limited Further physical decline Depression Social isolation Feelings of helplessness 2

3 Hospital Issues: A HAC 3%-20% of patients fall at least once in acute care and rehab facilities 30-50% result in some injury 6-44% of those injuries may lead to death Most from standing position (vertical deceleration injury) Falls associated with: Increased LOS 6.3 additional days (average stay is 4.8 days) Increased utilization of health care resources Poorer health outcomes Increased costs Fall w/o injury- $3500 > 2 falls- $16,500 Fall w/injury- $27,000 Hospital Improvement Innovation Network (HIIN) Center for Medicare and Medicaid Services (CMS) Partnership for Patients (PfP) The Health Research and Educational Trust (HRET) An affiliate of the American Hospital Association (AHA) Strategies Change concepts Actionable items HIIN Network change package Themes from successful practices across country Clinical practice sharing Organization site visits Subject matter expert contributions 3

4 AHA/HRET HEN Reduction Progress Reduced falls w/wo injury by 27% 1331 harms prevented, $882,453 saved Reduced falls w/injury by 3% 1409 harms prevented $18,265,000 saved By September 27, 2018: Goal: Reduce the incidence of harm due to falls by 20% Best Practices I. Interdisciplinary, house-wide approach II. Learning loop III. Identify high-risk, vulnerable populations IV. Assess and implement multifactorial plan V. Prevent delirium and functional decline VI. Provide optimum post-fall care VII. Provide appropriate level of surveillance/observation VIII. Engage patients and families 4

5 I. An Interdisciplinary Team Oversees the Strategic Plan for the Fall Prevention Program Organizational Support Across all disciplines and departments Standard interventions implemented Foster culture to: Promote accountability Safety awareness Teamwork Transparency of falls rates Change Ideas Assess effectiveness of current team, change leadership for fresh ideas Reinvent the team- from Falls Reduction to Safe Mobility Utilize Unit-Based Geriatric Safety Champions Steering Committee Membership: Executive Sponsor Patient/Family Representative Clinical Nurses Pharmacy OT Nursing Leaders Dietary Discharge Planner Falls Coordinator Provider PT 5

6 Safety Champions: Geriatric Measurement: Number of positions on interdisciplinary team filled 6

7 Leadership Ensures a Safe Environment Engage all levels of staff and disciplines in monitoring slipping and tripping hazards Get support of management Change Ideas Share Falls event consequences in daily house-wide safety huddles Develop an environmental safety checklist Designate a time of day for routine rounds Interdisciplinary Develop a visual cue for low-bed positions Create a mechanism for regular monitoring of bed position Identify responsibility and frequency Arrange patient s room for safety Clear pathways, no cords Conduct clutter rounds Lock all portable furniture for patients 7

8 Bed In High Position Indicator 8

9 Measurement: Percent of environmental rounds completed Number of hazards discovered Number of environmental hazards corrected Use a Patient-Centered Approach Interdisciplinary collaboration re: falls prevention from admission between clinicians Incorporate team-based success factors: Interdisciplinary discussion during rounds Medication review for all at risk during rounds Nurse rounds for education Hospital role Family s role at home Interdisciplinary post-fall huddle to discuss action plan 9

10 Change Ideas Educate providers Meds that can cause falls Patient self-assessment questionnaires Engage PT and pharmacy in care coordination Institute a NO-Pass culture Leadership, pharmacy and rehab participates in post fall huddles CMO or CNO rounds on patients and staff post fall Weekly systems fall reviews Incorporate TeamSTEPPS concepts of mutual support, shared mental model, other communication techniques Care Plan 10

11 Measurement: Percent of patients with a documented interdisciplinary Plan of Care II. Create Structure for Hospital-Wide Learning Loops Use Big Data Get support for systems that promote learning, ongoing evaluation and falls program improvements Analyze: Falls Injury rates Effectiveness of interventions 11

12 Change Ideas Use trended data to determine: Who is falling, When falls occur, Why falls occur Share data with leadership, staff, patients and visitors Identify fall characteristics: Time Location Day of week Age Race/ethnicity Sex Medical condition Functional abilities Unwitnessed falls are a system failure Adult Inpatient Falls High Level Data Specific Event Type 147 Safety Reports 33 From Bed 14 From Chair/ Wheelchair 14 From Commode/Toilet 1 From Stretcher 4 While Transferring 61 Ambulating/ Standing 4 with PT/OT 12

13 Measurement: Percent of nursing units with current falls data displayed Percent of leadership meetings in which falls data is shared 13

14 Conduct Immediate Post-Falls Huddles at the Bedside Facilitate critical thinking about the event Immediate review w/patient: Root Cause Analysis or Apparent Cause Analysis Measures to prevent a future fall Data emerges to identify trends Change Ideas Use a falls resource team/administrator on call to respond to falls for post-huddle Conduct the huddle immediately, involve patient Use rapid response system for unwitnessed falls Track circumstances of falls to identify opportunities for improvement Conduct weekly systems falls reviews Involve rehab services and pharmacy 14

15 Measurement: Percentage of falls that had a post-fall huddle completed with the patient within one hour of the fall 15

16 III. Identify High Risk, Vulnerable Patients and Populations Individualize patient assessment and treatment plans Clinicians use clinical judgement re; factors that put patients at risk Identify Patients with Fall/History of Falls: Apply Special Interventions Fall within past 12 months Highest predictor for recurrent fall 50% do not tell provider Need a multifactorial assessment by PT: Gait Mobility Balance Home Safety assessment Referral for strength and balance training (Tai Chi) 16

17 Change Ideas Interview family to obtain fall history Record Known Faller on EMR banner Order a PT evaluation for patients admitted with a fall Designate specific staff to screen patients for high risk/ vulnerable status Provide a home environmental safety assessment Strength and balance community classes: CDC s STEADI Patient Referral Resources Conduct multifactorial assessment, address risk factors EMR Notification 17

18 Measurements: Percent of patients admitted for a fall or with a fall within the past 6 months that received the organization's special interventions Provide Multifactorial Assessments for High Risk/Vulnerable Populations See AGS guidelines 18

19 American Geriatric Society Clinical Practice Guideline: Prevention of Falls in Older Persons (AGS Guidelines, 2010): Screening: Gait, balance and mobility assessment Medication review Cognitive assessment Heart rate and rhythm Postural hypotension Feet and footwear Home environmental hazards /0701/p81.html# Intervention: Medication Modification Exercise Vision Impairment Management of Postural Hypotension Cardiovascular Factors Vitamin D Supplementation Management of Foot and Footwear Problems Home Modification Education Change Ideas Evaluate current effectiveness of fall risk assessment tool and work process to create impetus for change Develop an assessment tool with linked interventions Define how initial screening is done Define who is responsible Define who is responsible for the initiation of the care plan to mitigate risk for each patient Define how the interdisciplinary collaboration will occur 19

20 EMR Flowsheet Extract: Screen for Risk for Injury Using the ABCS Criteria Age, Bones, Coagulation, Surgery 85 yo or greater, frail History of orthopaedic conditions On anticoagulation therapy Have a bleeding disorder or are post-op 20

21 Change Ideas Review high risk patients during shift huddles Use ABCS to identify those patients at highest risk to fall Assess for and treat osteoporosis and vitamin D deficiency Flag the EMR of patients on anti-thrombotics to increase awareness of risk Handoff Huddle 21

22 Measurements: Percent of patients with a risk for injury assessment completed within 24 hours of admission Percentage of patients on antithrombotics that are flagged as defined by policy Communicate Risk Across the Care Team and Across Disciplines Lack of communication a common failure Clinical and non-clinical team members who share information with face-to-face handoffs and huddles share a mental model Handoffs between departments Communicate risk factors related to meds that increase fall risk: Sedatives Hypnotics Pain meds 22

23 Change Ideas Use standardized visual cues for communication Red or yellow non-skid socks Colored wrist bands, lap blankets Signage inside and outside the patient room Standardize handoff communications Use Ticket to Ride handoff tool Communicate fall risk-increasing meds in handoff communications Incorporate alerts into the medical record Use in-room whiteboards for staff and family Ticket To Ride 23

24 Measurements: Percent of patients that are identified as having a fall risk that have appropriate visual cues in place per hospital policy. Percent of handoffs that include a discussion about patient fall risk as observed or documented. IV. Implement Multifactorial Interventions to Reduce Risk of Falling or Injury Implement Universal Falls Precautions for all patients Maintain a safe environment, free of tripping/slipping hazards Orient patient to surroundings and furniture w/wheels Keep bed in lowest position when patient in bed Raise bed for transfers and care Keep top 2 siderails up for mobility and support Place call light and frequently needed items within easy reach Teach family and patient fall safety precautions using teachback Ensure adequate lighting Provide proper-fitting, non-skid footwear (not slipper socks) Address any equipment that tethers the patient 24

25 Change Ideas Engage Falls Team, front-line staff and a patient/family advisor in designing optimal universal falls precautions Integrate precautions into charting, care plans and whiteboards Develop patient teaching materials or orientation checklist to precautions Whiteboard: Assist Levels 25

26 Measurements: Percent of patients observed to have bedside table, call bell, light switch and personal items within reach during leadership rounds Implement Multifactorial Interventions to Reduce Fall or Risk Injury From AGS: Medication Modification Individually Tailored Exercise Program Treat Vision Impairment (including cataracts) Manage Postural Hypotension Manage Heart Rate and Rhythm Problems Supplement Vitamin D Manage Foot and Footwear Problems Modify the Home Environment Provide Education and Information 26

27 Change Ideas Determine criteria and process for comprehensive multifactorial assessment Use Fall Resource Team or RN Champion Integrate assessment and care planning into admission documentation process Develop processes for interdisciplinary collaboration for care planning for high risk/vulnerable patients Clearly define which discipline completes each dimension Develop a multifactorial fall risk assessment and care planning documentation tool to guide clinicians in decisionmaking and documentation Review National Institute for Health and Care Excellence (NICE) assessment and management tool Change Ideas Engage physicians to collect data to determine risk factors that can be minimized. Collaborate w/primary care providers to address fall risks prior to hospitalization using STEADI resources. Provider Fall Risk checklist Preventing Falls in Older Patients: Provider Pocket guide Integrating Fall Prevention into practice Provide early activation of interventions for discharge planning purposes Home environmental safety assessment Exercise ambulation plan to prevent further functional decline Referral for community strength and balance training 27

28 From National Council on Aging 28

29 Measurements: Outpatient focus: Percent of patients 65 years and older with walking or balance problems with a fall in the past 12 months who report discussing falls or problems with balance or walking with the practitioner AND report a fall reduction intervention was received V. Prevent Delirium and Functional Decline in Vulnerable Populations Deconditioning occurs by day 2 in elderly Leading to increased risk for falls and immobility: Orthostatic hypotension, decreased muscle strength, increased bone loss, decreased bone density Mobility Interventions: Wear shoes/non-skid footwear PT and OT consults for evaluation/rx Instruct pt. to rise slowly Early and regular assisted ambulation of pts Repeated education of safety measures Assist with transfers Use pt. s assistive device, gait belts Regular assistance w/toileting Provide supportive chairs w/armrests Daytime/nighttime lighting Elevated toilet seats 29

30 Change Ideas Incorporate assessment of gait, balance, lower extremity muscle strength and functional abilities into initial assessments Use automatic triggers in the EMR to notify rehab services of the need for a PT/OT evaluation PT/OT staff attend daily rounds with charge nurses to discuss patients that need evaluation and intervention Review mobility on interdisciplinary rounds with PT/OT PT/OT recommend mobility schedule. Write on board Make gait belts available Provide appropriate footwear 30

31 Measurements: Percent of patients ambulating as prescribed. Percent of patients with mobility program defined on whiteboard. Avoid Meds that Affect the Central Nervous System: Follow Beers Criteria Changes in metabolism, slowed metabolism, decreased renal clearance, hepatic impairment Drug interactions,: additive/synergistic 4 or more meds increase fall risk Avoid the following: Anti-epileptics Anticholinergics Tricyclic antidepressants Antipsychotics Benzodiazepines Opioid receptor agonist analgesics Z hypnotics Avoid drug-drug interactions of 3+ CNS impacting hypnotics 31

32 Change Ideas Include a review of pt. medications in the fall and injury risk assessment Flag vulnerable patients for a review of their meds by a pharmacist Use the Beers criteria to determine inappropriate meds Ask pharmacy to recommend alternatives to meds that increase falls risk Place an alert in the system for care providers Review standing order sets for inclusion of high-risk meds such as Ambien- remove from order sets Educate nurses and patients about med side effects Create alerts in the MAR when a fall-risk increasing drug is given Published 9/19/ viewarticle/885881? src=wnl_infoc_170928_ MSCPEDIT_TEMP2&uac =221425FX&impID= &faf=1 32

33 Measurements: Percent of vulnerable patients receiving medication review by a pharmacist Percent of falls with medications attributed to the cause of the fall. VI. Provide Optimal Post-Fall Care to Minimize Injury Assess for injury prior to mobilizing the patient after an unwitnessed fall Evaluate for head injury, fracture and spinal injury before moving Staff may want to minimize patient embarrassment and get patient up immediately 33

34 Change Ideas Use a Rapid Response Team to respond to falls: Suspected head injury Unwitnessed falls a Fall where the patient is on anti-thrombotics Establish protocols for VS and neuro checks for patients on anti-thrombotics and with suspected head injury Communicate patient s injury risk factors to all team members: age, bones, recent surgery, anti-thrombotics Escalate unwitnessed falls to an administrator on call, supervisor or leadership point person to assure care and diagnostics are delivered Measurements: The percentage of patients who fell who had documented physical assessment prior to mobilization. 34

35 Provide Specialized Post-Fall Care for Patients on Anti-thrombotics Change Ideas: Establish protocols for post-fall VS and neuro checks for all patients on anti-thrombotics Communicate that the patient is on anti-thrombotics to the RRT and provider to determine treatment plan and/or diagnostics needed Measurements: The percentage falls with patients on anti-thrombotics who had their antithrombotic status included in the postfall care plan. 35

36 VII. Provide the Appropriate Level of Surveillance/Observation Implement Intentional Rounds on Patients Hourly rounding with toileting assistance More than 45% of falls are related to toileting Improves patient satisfaction and safety Hospital personnel experience less job fatigue and burnout Fewer call bells throughout the shift Change Ideas Engage front-line staff in designing rounding workflows Combine rounds with other patient tasks: Turning Pain Assessment VS Educate the patient about rounds- 5 Ps Pain, position, personal belongings, pathway and potty Involve all staff in patient s care in rounds expectations 36

37 Bathroom Signage Measurements: Percent of patient rooms with documented periodic rounds as per hospital policy Percent of patients who report that toileting is offered each time staff rounds on them. 37

38 Keep Vulnerable Patients at Arms Length When Toileting Change Ideas: Provide patient and family education using teach-back Listen to patient and staff concerns regarding privacy. Modify assignments as needed Male vs. Female care-givers Use signage, scripting and messaging to support safety on the toilet Safety Trumps Privacy Bathroom Signage 38

39 Measurements: Percentage of patients to be at arms-length observed to receive that level of supervision in toileting Increase Intensity and Frequency of Observation Sitters have little impact on falls rate Increased surveillance and supervision by nursing has more consistent positive effect on falls rates. 39

40 Change Ideas Encourage family members to stay with patients whenever possible Place high-risk patients in rooms closer to the nurse s station: More visible, direct line of sight Round more frequently than every 1-2 hours Escalate to every 15 minutes Identify patients needing more frequent monitoring in pre-shift huddles Develop an individualized toileting schedule Use video surveillance Utilize 1-to-1 companions or sitters for high risk times of day Measurements: Percentage of close-monitoring patients that have documented observations Percentage of nursing staff who report in leadership rounds they have the tools and resources to adequately monitor the safety of high-risk patients. 40

41 VIII. Engage Patients and Families in Design and Implementation of Fall Injury Prevention Activities Use Patient and Family Advisors for program design Change ideas: Invite 2-3 patient/family advisors to join the falls improvement team Ask a patient who experienced a fall to share their experience with staff as part of new hire orientation Ask advisors to preview educational materials or documents provided to patients as tools: readability, understanding, etc. Include patient/family advisors in environmental design for fall safety Involve in small tests of change, seek input 41

42 Measurements: Percentage of falls education materials or handouts that have been reviewed by a patient/family advisor. Engage Patient and Caregivers in Fall Safety at the Bedside Change Ideas: Determine who the learners are Get patient permission Address family members Provide structured fall safety education that includes: Info about fall risks: Meds Tripping hazards Orthostatic hypotension (esp. in AM) Footwear Rolling equipment, furniture IV and other tubing/catheter hazards Include the fall prevention program on the whiteboard 42

43 Change Ideas, cont d. Initiate a Patient Agreement/Contract for those reluctant to call- patient and staff responsibilities Provide Fall Safety Tips to each patient upon admission At handoff- Include fall prevention status with pt/family Use teach-back method Reason for patient risk Necessary precautions Methods to keep patient safe If no understanding, provide additional teaching and another teach-back request Falls Education Signage 43

44 Measurements: Percent of patient whiteboards with fall prevention program outlined as observed during leadership rounds Percent of bedside hand-offs that include the patient and family in fall prevention Annotated Bibliography Dupree, E., Fritz-Campiz, A. & Musbeno, D. (2014). A New Approach to Preventing Falls With Injuries. Journal of Nursing Care Quality 29(2), Results of 18-month projects with 7 hospitals and The Joint Commission Center for Transforming Healthcare piloting falls reduction strategies. Health Research & Educational Trust (2017, February). Falls with Injury Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at A change package summarizing themes from successful practices of high-performing health organizations across the country. National Council on Aging. (2016). Falls Prevention Fact Sheet. Accessed at Facts about fall challenges and the NCOA s role. 44

45 Questions? Thank You!