Preventing Falls by Providing a Good Night s Sleep. Sue Ann Guildermann RN, BA, MA Director of Education, Empira

Transcription

1 Preventing Falls by Providing a Good Night s Sleep Sue Ann Guildermann RN, BA, MA Director of Education, Empira sguilder@empira.org

2 How d we get here? We completed a three year PIPP Fall Prevention program in 2011 to investigate and identify the root causes of resident falls in 16 skilled nursing facilities From the Fall Prevention Program, we identified that sleep fragmentation at night and the lack of activity during the day were significant conditions that contributed to residents falling We spring boarded off of our previous PIPP Fall Prevention Program into Restorative Sleep We needed to become knowledgeable in the etiology of sleep and wake

3 Using root cause analysis to determine reasons for residents falls: RCA is a process to find out what happened, why it happened, and to determine what can be done to prevent it from happening again.

4 Tools to determine RCA RCA: Check, Call, Care 10 RCA Questions Post Fall Huddle Staff Interviews Fall Scene Investigation (FSI) Report FSI Report Rounding Needs for 4Ps MDS, QM/QI Report IDT Falls Committee Meeting

5 When you (all staff) see a resident who has fallen, do the following: 1. Immediately go to the resident, stay with the resident 2. If you are not a nurse, call for a nurse 3. Encourage the resident not to move 4. Ask them, What were you doing just before you fell? or What were you trying to do just before you fell? 5. Begin getting answers to the 10 Questions 6. Stay for the fall huddle, assist in getting a fall huddle started

6 10 Questions at the time a resident falls. Stay with resident, call nurse. 1. Ask resident: Are you ok? 2. Ask resident: What were you trying to do? 3. Ask resident or determine: What was different this time? 4. Position of Resident? a. Did they fall near a bed, toilet or chair? How far away? b. On their back, front, L side, or R side? c. Position of their arms & legs? 5. What was the surrounding area like? a. Noisy? Busy? Cluttered? b. If in bathroom, contents of toilet? c. Poor lighting visibility? d. Position of furniture & equipment? Bed height correct? 6. What was the floor like? a. Wet floor? Urine on floor? Uneven floor? Shiny floor? b. Carpet or tile? 7. What was the resident s apparel? a. Shoes, socks (non-skid?) slippers, bare feet? b. Poorly fitting clothes? 8. Was the resident using an assistive device? a. Walker, cane, wheelchair, merry walker, other 9. Did the resident have glasses and/or hearing aides on? 10. Who was in the area when the resident fell?

7 Fall Huddle (ground zero) Performed immediately after resident is stabilized Charge nurse has all staff, working in the area of the fall, meet together to determine RCA Review 10 Questions with staff Also ask staff: Who has seen or has had contact with this resident within the last few hours? What was the resident doing? How did they appear? How did they behave?

8 Fall Scene Investigation (FSI) Report Post fall investigation form Data collection tool used to assess clues and evidence to determine RCA Completed soon after the fall occurs and/or during the fall huddle Completed by nurse in charge on duty at time of the fall Sent electronically to Empira where the software program collates, aggregates and determines trends and patterns

9 Assessing for the Needs of 4 Ps Position: Does the resident look comfortable? Does the resident look bored, restless and/or agitated? Ask the resident, Would you like to move or be repositioned? Ask the resident, Are you where you want to be? Report to the nurse. Personal (Potty) Needs: Ask the resident, Do you need to use the bathroom? Ask if they d like help to the toilet or commode. Report to the nurse. Pain: Does the resident appear in to be uncomfortable or in pain? Ask the resident, Are you uncomfortable, ache or are in pain? Ask them what you can do to make them comfortable. Report to the nurse. Placement: Is the phone, call light, remote control, tissues, walker, trash can, water, urinal, all near the resident? Can they easily see them? Place them all within easy reach. Are they in contrast to background? Is the bed at the correct height?

10 External causes: Noise, busy activity, lack of environment contrasts, placement of furniture, equipment & personal items, floor surfaces Internal causes: Poor balance, sleep deprivation/ sleep fragmentation, need for the 4Ps, medications (type & amt), orthostatic B/P, lack of endurance Systemic causes: Time of day, shift change/times, break times, day of week, location of fall, type of fall, routine staff assignments, staffing levels

11 External lesson learned: if we can stop the noise, then we can reduce the falls.

12 Noise Where is it? What s causing it? Who s causing it?

13 Internal lesson learned: if we can stop disturbing sleep then we can reduce the falls.

14 RSVP: Sleep and Wake Challenges & Interventions CMS and LTC providers have never considered sleep as an integral part of the plan of care and services provided for the resident. MDS 3.0: Over the last 2 weeks, did the resident have any of the following problems: trouble falling or staying asleep, or sleeping too much? and How important is to you to go to bed when you want?

15 Empira s RSVP: Restorative Sleep Vitality Program This program is a combination of nationally recognized evidence-based, sleep hygiene research studies and the application of cutting edge practices to enhance residents sleep & wake Empira is challenging some of the standards of practice and operational procedures for providing cares and services in skilled nursing facilities Empira staff and corporate representatives attend national & international sleep conferences and conventions to learn and educate membership

16 Background & Process Empira awarded 3-year MN DHS PIPP grant, began 10/1/11 ~ A project implementing best practices from evidence based studies ~ Reduction Goal: Undisturbed sleep at night, w/o any negative effects Fully awake & engaged during the day, w/o negative effects ~ Goal: Reduce baseline average for 5 CMS QI/QMs and Vital Research Questions, Can you get up in the morning when you want?, Can you go to bed when you want?, Are you bothered by noise when you are in your room?, Are there things to do here that you enjoy? 23 SNFs, 4 companies participate in PIPP, RSVP project RSVP Leader in each SNF reports to administrator who oversees the program it s not a nursing program! Project completion date: 10/1/14

17 Restorative Sleep Vitality Program: Goal: Undisturbed sleep at night without experiencing any negative effects

18 Restorative Sleep Vitality Program: Goal: Fully awake & engaged during the day without experiencing any negative effects

19 The Etiology of Sleep and Wake: How Do We Sleep? How Do We Wake?

20 Human Circadian Clock: Ideal 24 Hours (3:30 PM) Serotonin secretion starts (6:00 PM) 20:00 Serotonin secretion stops (8:00PM) Lowest blood pressure Greatest healing and growth occurs

21 Sleep: Cycles & Stages In humans, an average 7 8 hour night s sleep should contain 4 5 sleep cycles. Each cycle should last 90 to 120 minutes. Each cycle has 3 Non REM stages and 1 REM stage of sleep. Each stage provides distinct physiological and emotional benefits for the body.

22 One night of 7 8 hours of sleep 1 stage R E M stage 1 R E M stage 2 2 stage 3 3 stage Cycle Cycle

23 Tests for Sleep Sleep, its stages and characteristics, assessed by tests in sleep labs. Tests that identify the sleep and wake cycles include, polysomnography: Electroincephlogram (EEG) measuring the electrical activity of the brain, or brain waves Electrooculography (EOG) measuring eye movements, Electromyography (EMG) measuring the skeletal and muscle activity/tonicity, Actigraphy

24 Actigraphy: Measures Rest and Sleep Measures Activity and Tonicity Measures Light Source and Quantity of Light source Over a 24 Hour Period Worn continuously for multiple days Worn on the wrist Cost effective

25 Minor rest Sleep Cycle Major sleep Minor rest Onset latency Snooze

26 The human body has evolved to function optimally in the upright position for about 16 hours a day. Average adult sleeps 7-8 hours a day, in a supine position. Consistently sleeping for more than 9 hours or fewer than 8 hours a day has a negative impact on physiological, psychological and cognitive functions. (Van Dongen et al, 2003) dehydration, progressive cardiac de-conditioning, postural hypotension reduced lung function, increased susceptibility to respiratory infection increased anxiety, confusion and depression, impaired memory function progressive slowing down of metabolic rate, reduction in insulin sensitivity gastric reflux and constipation urinary retention, increased risk of urinary tract infections venous stasis and blood vessel damage loss of muscle strength and endurance altered skin integrity osteoporosis

27 Implementing the Restorative Sleep Vitality Program What disturbs sleep? Identify environmental factors. Identify clinical factors. Identify operational factors. What keeps people awake? Identify environmental factors. Identify clinical factors. Identify operational factors.

28 Top Disturbances to Sleep 1. Noise 2. Light 3. Sleeping Environment: surface/mattress, temp, bedding 4. Napping 5. Medications 6. Continence Needs 7. Pain 8. Positioning 9. Inactivity/activity 10. Diet Harvard Sleep Study, 2011

29 Root Cause Analysis: Disturbances to Sleep What are the causes for the disturbances to sleep? Eliminate the disturbances to sleep Prioritize grab the low hanging fruit first do the easier, quicker successes first then take on the greater challenges

30 Greatest Challenge to Undisturbed Sleep at Night: Skin Conditions & Repositioning Nancy Bergstrom, PhD., U of Texas at Houston, Turning for Ulcer ReductionN, Journal of the American Geriatrics Society, Vol. 61, Issue 10, Pages , October /pdf Jeri Lundgren, RN, BSN, CWS. Wound Care Advisor, Turning Programs Hinder a Good Nights Sleep. March/April 2014, Vol. 3 No. 2.

31 Greatest Challenge to Undisturbed Sleep at Night: Incontinence Increase fluid intake in the morning hours Taper fluid intake as day progresses Reduce fluid intake after the evening meal No bedside water pitcher after the evening meal, unless requested by the resident or indicated by medical condition Use correct overnight incontinent product

32 Did the Restorative Sleep Vitality Program help to reduce falls even more?

33 IMPLEMENTING SLEEP STRATEGIES RESULTS: NO FALLS AT NIGHT AND REDUCED FALLS DURING DAY bed SNF December falls December falls SE Falls Tracker

34 IMPLEMENTING SLEEP STRATEGIES RESULTS: NO FALLS AT NIGHT AND REDUCED FALLS DURING DAY bed SNF 3 2 Oct Falls Oct Falls 1 0 M Falls Tracker

35 Comparison Report: Awake in Room: 9-11p.m. 23% 25% 13% 11-1:00a.m. 14% 7% 8% 1-4:00a.m. 13% 2% 1% 4-6:00a.m. 8% 2% 1% Personal Alarms Sounded: 9-11p.m. 9% 0% 0% 11-1:00a.m. 9% 0% 0% 1-4:00a.m. 9% 0% 0% 4-6:00a.m. 3.5% 0% 0% Passing Water/Stocking Incontinent Products in Rooms: 9-11p.m. 100% 0% 0% 11-1:00a.m. 0% 0% 0% 1-4:00a.m. 0% 0% 0% 4-6:00a.m. 0% 0% 0% Percentage of Residents who have 2 hour Checks and/or Change: 99% 58% 7%