Margaret Knight PhD, PMHCNS-BC Catherine Coakley MS, RN-BC

Transcription

1 Margaret Knight PhD, PMHCNS-BC Catherine Coakley MS, RN-BC

2 By 2020, the cost of falls is estimated to be 30 billion per year. Fall Prevention: National Patient Safety Goal Focus on falls: older adults, frail individuals, neurological deficits and multiple medications.

3 Educate care providers Recognize common risk factors Older adult, frail Use of assistive devices Mental Status changes Multiple medications Identify hazards Environmental Strength & balance deficits Footwear Complex medication regiments

4 Many available for acute & LTC areas (Morse, STRATIFY, Conley Scale) Rapid assessment History of falls, Use of ambulatory aids or devices Medication Strength and balance Focus on the number of risk factors Disagreement regarding effectiveness (Morse et al. 1989; Oliver et al. 1997; Conley, Shultz, Selvin, 1997)

5 Fall prevention program instituted across several institutions in the Boston area. McLean Hospital was the only psychiatric hospital. Fall Rate on one adult unit was 4.83 (per 1000 patient days). Patients were young and middle-aged adults. Fall risk assessment was not sensitive to population. Primary diagnosis: Bipolar disorder, schizoaffective disorder or schizophrenia, psychosis NOS.

6 Patients were acutely ill, On multiple medications, Some were medication naïve, Frequent medication adjustments, Possible inadequate food and fluid, and Many had sleep disturbances

7 Design Sample Data Collection

8 Study period 3 months Received IRB approval Evaluated each fall incident as it occurred Review of the record

9 12 women and 2 men experienced a fall. Mean age 42 (range 21-64). Axis I Diagnosis Bipolar, Manic (5) Bipolar, Mixed (1) Bipolar, Depressed (1) Schizoaffective Disorder (4) Schizophreniform Disorder (1) Psychosis NOS (2)

10 Axis 2 Diagnosis (2) Axis 3 Diagnosis (6) Asthma Hypertension Diabetes Back Pain All individuals were physiologically and medically stable. All were on psychotropic medication. All had multiple medication changes during their hospitalization.

11 Analysis of incident: Where (bathroom, nurses station, room, etc.)? When (shift and time)? Involved in an activity? Environmental hazard (lights, wet floor, etc.)? Were other patients involved? Staff assessment/hunches?

12 Admission Last Recorded Data Data Date Date of Fall BP (sitting) (standing) BP (sitting) (standing) Alert Yes No Unit Pulse Pulse Oriented Time Yes No MR# Respirations Respirations Oriented Place Yes No Age Temperature Temperature Oriented Person Yes No Gender Height ECT Yes Confused No Yes No History of Falls: Weight Date of last Confusion Mild Yes No treatment Mod Severe

13 Functional Health Vision: Hearing: Aided? Glasses/lenses? Weakness: None Mild Mod Severe Gait: Steady Slight Mod Severe Impair Impair Impair Ambulation: Unassisted Partial Full Assist Assist Toileting: Unassisted Partial Full Assist Assist Showering: Unassisted Partial Full Assist Assist Rising Unassisted Partial Full Bed/chair: Assist Dressing: Unassisted Partial Full Assist Assist Current Medication (include PRN s) 24 hour dosage 48 hour dose 72 hour dose

14 Individual Case Analysis Cross Case Analysis

15 Age/G Axis 3 Antipsy 72 hrs 49/F Low back Pain Titration or added 3 Clozaril incr 25/day X 3 days Sleep med Traz 50 Med totals ( ) Ativan Clozaril VS P>100 w/i 24 hr Abilify Trilafon Complained of dizziness one time without symptoms

16 Age/G Axis 3 Antipsy 72 hrs Titration or added Sleep med Med totals ( ) VS 26/M none 2 On haldol 7.5 bid, risperdol being tapered down from 5 bid to 1 bid, Dep 1500 & Inderol 10 added 5 days prior at current doses. Traz 200 Risper Haldol Depakote Inderol P>100 w/i 24 hr Extreme agitation Multiple daily medication changes over 10 day period

17 Age, Medical issues, Number of antipsychotic medications, Number of psychotropic drugs, Medication changes, Loading doses of mood stabilizer, Postural VS over 72 hour period Patient or staff complaints/concerns

18

19 Fall Rate 6.0 for the 3 month period Only 1 patient had a slight impairment in gait (shuffling). Thirteen were steady and unassisted in ambulation & ADL s. Most patients were on complex drug regiments (3 or more psychotropic drugs) (N=12). Many had experienced titrations upward over a short period of time (9), All were on drug combinations which can increase negative side effects (sedation, dizziness and light headedness).

20 Yes No Postural BP 2 (minor, < 10mmhg) Postural Pulse (incr. 5-9) Postural Pulse (incr. >10 ) 3 11 Pulse >100 Preceding 24 hrs 9 5

21 Number Antipsychotic Drugs Number Patients Number Psychotropic Drugs Number Patients

22

23 Discussed findings: Program Director, Psychiatrists, and Nurses. Developed and implemented interdisciplinary Quality Improvement Plan. Evaluated 3 month fall rate.

24 Heart rate > 100. Greater than 2 antipsychotic drugs. Greater than 10 medications overall. Greater than 2 Mood Stabilizers. Loading dose Mood Stabilizer. New Admit; prior compliance problem. Variations require Program Director consultation.

25 Night RN s review record and complete data tracking form daily. Form is easy to complete, it is included in shift report. Content is discussed in interdisciplinary rounds daily. Program Director alerted to variations in practice for consultation.

26 Fall Risk Assessment Patient Age DATE (Check for MD assessment) Vital Signs Postural BP > 20 mmhg Pulse >100 in past 24h Observations or Complaints Confused Sleepy Tired Sedated Dizzy Medication Number meds > 10 Antipsychotic > 2 Mood Stabilizer >2 Beta Blocker New Admit; prior compliance problem Acute Loading: Mood Stabilizer

27 Fall Rate Reduced to 0.46 in subsequent 3 month period. Cumulative Fall Rates have remained at or below 1.3 per 1000 hospital days

28

29 Healthy, non-elderly individuals with acute psychiatric problems are at risk for falls. Typical risk factors are not present. Complex medication regimens may play a role.

30 Tachycardia was present in 64% of individuals who experienced a fall. Only Clozaril has been linked to tachycardia. Elevated heart rate may increase risk for arrhythmia s.

31 Mandate rapid management of symptoms. Often call for rapid titration or change in medication for acutely ill patients. Sedation, dizziness and light-headedness can manifest suddenly. Individuals who have been non-compliant or who are drug naïve may be at greater risk.

32 What role if any does acuity play? Is tachycardia one indicator of physiological instability? Is tachycardia an ongoing health concern for individuals who take psychotropic medication long term to manage symptoms? Is an one medication implicated?

33 Conley D, Schultz AA, Selvin R. (1999). The challenge of predicting patients at risk for falling: development of the Conley Scale. MEDSURG Nursing, 8(6), Knight M, Coakley C. (2010). Fall risk in patients with acute psychosis. Journal of Nursing Care Quality, 25(3), Morse JM, Black C, Oberie K, Donahue P. (1989). A prospective study to identify the fall prone patient. Social Science Medicine, 28(1), Oliver D, Britton M, Seed P, et al. (1997). Development and evaluation of an evidence based risk assessment tool (STRATIFY) to predict which elderly inpatients will fall: Case controlled and cohort studies. British Medical Journal,315,

34 Margaret Knight PhD, PMHCNS-BC Catherine Coakley MS, RN-BC

35 By 2020, the cost of falls is estimated to be 30 billion per year. Fall Prevention: National Patient Safety Goal Focus on falls: older adults, frail individuals, neurological deficits and multiple medications.

36 Educate care providers Recognize common risk factors Older adult, frail Use of assistive devices Mental Status changes Multiple medications Identify hazards Environmental Strength & balance deficits Footwear Complex medication regiments

37 Many available for acute & LTC areas (Morse, STRATIFY, Conley Scale) Rapid assessment History of falls, Use of ambulatory aids or devices Medication Strength and balance Focus on the number of risk factors Disagreement regarding effectiveness (Morse et al. 1989; Oliver et al. 1997; Conley, Shultz, Selvin, 1997)

38 Fall prevention program instituted across several institutions in the Boston area. McLean Hospital was the only psychiatric hospital. Fall Rate on one adult unit was 4.83 (per 1000 patient days). Patients were young and middle-aged adults. Fall risk assessment was not sensitive to population. Primary diagnosis: Bipolar disorder, schizoaffective disorder or schizophrenia, psychosis NOS.

39 Patients were acutely ill, On multiple medications, Some were medication naïve, Frequent medication adjustments, Possible inadequate food and fluid, and Many had sleep disturbances

40 Design Sample Data Collection

41 Study period 3 months Received IRB approval Evaluated each fall incident as it occurred Review of the record

42 12 women and 2 men experienced a fall. Mean age 42 (range 21-64). Axis I Diagnosis Bipolar, Manic (5) Bipolar, Mixed (1) Bipolar, Depressed (1) Schizoaffective Disorder (4) Schizophreniform Disorder (1) Psychosis NOS (2)

43 Axis 2 Diagnosis (2) Axis 3 Diagnosis (6) Asthma Hypertension Diabetes Back Pain All individuals were physiologically and medically stable. All were on psychotropic medication. All had multiple medication changes during their hospitalization.

44 Analysis of incident: Where (bathroom, nurses station, room, etc.)? When (shift and time)? Involved in an activity? Environmental hazard (lights, wet floor, etc.)? Were other patients involved? Staff assessment/hunches?

45 Admission Last Recorded Data Data Date Date of Fall BP (sitting) (standing) BP (sitting) (standing) Alert Yes No Unit Pulse Pulse Oriented Time Yes No MR# Respirations Respirations Oriented Place Yes No Age Temperature Temperature Oriented Person Yes No Gender Height ECT Yes Confused No Yes No History of Falls: Weight Date of last Confusion Mild Yes No treatment Mod Severe

46 Functional Health Vision: Hearing: Aided? Glasses/lenses? Weakness: None Mild Mod Severe Gait: Steady Slight Mod Severe Impair Impair Impair Ambulation: Unassisted Partial Full Assist Assist Toileting: Unassisted Partial Full Assist Assist Showering: Unassisted Partial Full Assist Assist Rising: Unassisted Partial Full Bed/chair: Assist Dressing: Unassisted Partial Full Assist Assist Current Medication (include PRN s) 24 hour dosage 48 hour dose 72 hour dose

47 Individual Case Analysis Cross Case Analysis

48 Age & Gender Axis 3 Diagnosis Number of Antipsychotics Titrations/Additions Sleep Medication Vital Signs 49 F Low Back Pain 3 (Clozaril, Abilify, Trilafon) Clozaril, increase 25 mg/day X s 3 days Trazadone 50 mg qhs Pulse rate > 100 within 24 Hours Total past 24 Total past 48 Total past 72 Ativan Clozaril Abilify Trifafon 0 0 4

49 Age & Gender Axis 3 Diagnosis Number of Antipsychotics Titrations/Additions Sleep Medication Vital Signs 26 M None 2 (Risperidone & Haldol) On haldol 7.5 mg bid, Risperidone being tapered down from 5mg bid to 1 mg bid, Depakote 1500 mg & Inderol 10 mg added 5 days prior at current dose.** Trazadone 200 mg qhs Pulse rate > 100 within 24 Hours Total dose 24 hrs Total dose 48 hrs Total dose 72 hrs Haldol Risperidone Depakote Inderol

50 Age, Medical issues, Number of antipsychotic medications, Number of psychotropic drugs, Medication changes, Loading doses of mood stabilizer, Postural VS over 72 hour period Patient or staff complaints/concerns

51

52 Fall Rate 6.0 for the 3 month period Only 1 patient had a slight impairment in gait (shuffling). Thirteen were steady and unassisted in ambulation & ADL s. Most patients were on complex drug regiments (3 or more psychotropic drugs) (N=12). Many had experienced titrations upward over a short period of time (9), All were on drug combinations which can increase negative side effects (sedation, dizziness and light headedness).

53 Yes Postural BP 2 (minor, < 10mmhg) Postural Pulse (incr. 5-9) 3 No 12 8 Postural Pulse (incr. >10 ) Pulse >100 Preceding 24 hrs 3 9 5

54 Number Antipsychotic Drugs Number Patients

55 Number Psychotropic Drugs Number Patients

56

57 Discussed findings: Program Director, Psychiatrists, and Nurses. Developed and implemented interdisciplinary Quality Improvement Plan. Evaluated 3 month fall rate.

58 Heart rate > 100. Greater than 2 antipsychotic drugs. Greater than 10 medications overall. Greater than 2 Mood Stabilizers. Loading dose Mood Stabilizer. First psychiatric admission. Poor compliance. Variations require Program Director consultation.

59 Night RN s review record and complete data tracking form daily. Form is easy to complete, it is included in shift report. Content is discussed in interdisciplinary rounds daily. Program Director alerted to variations in practice for consultation.

60 Fall Risk Assessment Patient Age DATE (Check for MD assessment) Vital Signs Postural BP > 20 mmhg Pulse >100 in past 24h Observations or Complaints Confused Sleepy Tired Sedated Dizzy Medication Number meds > 10 Antipsychotic > 2 Mood Stabilizer >2 Beta Blocker New Admit; prior compliance problem Acute Loading: Mood Stabilizer

61 Fall Rate Reduced to 0.46 in subsequent 3 month period. Cumulative Fall Rates have remained at or below 1.3 per 1000 hospital days

62

63 Healthy, non-elderly individuals with acute psychiatric problems are at risk for falls. Typical risk factors are not present. Complex medication regimens may play a role.

64 Tachycardia was present in 64% of individuals who experienced a fall. Only Clozaril has been linked to tachycardia. Elevated heart rate may increase risk for arrhythmia s.

65 Mandate rapid management of symptoms. Often call for rapid titration or change in medication for acutely ill patients. Sedation, dizziness and light-headedness can manifest suddenly. Individuals who have been non-compliant or who are drug naïve may be at greater risk.

66 What role if any does acuity play? Is tachycardia one indicator of physiological instability? Is tachycardia an ongoing health concern for individuals who take psychotropic medication long term to manage symptoms? Is any one medication implicated?

67 Conley D, Schultz AA, Selvin R. (1999). The challenge of predicting patients at risk for falling: development of the Conley Scale. MEDSURG Nursing, 8(6), Knight M, Coakley C. (2010). Fall risk in patients with acute psychosis. Journal of Nursing Care Quality, 25(3), Morse JM, Black C, Oberie K, Donahue P. (1989). A prospective study to identify the fall prone patient. Social Science Medicine, 28(1), Oliver D, Britton M, Seed P, et al. (1997). Development and evaluation of an evidence based risk assessment tool (STRATIFY) to predict which elderly inpatients will fall: Case controlled and cohort studies. British Medical Journal,315,

68 Margaret Knight PhD, PMHCNS-BC Catherine Coakley MS, RN-BC

69 By 2020, the cost of falls is estimated to be 30 billion per year. Fall Prevention: National Patient Safety Goal Focus on falls: older adults, frail individuals, neurological deficits and multiple medications.

70 Educate care providers Recognize common risk factors Older adult, frail Use of assistive devices Mental Status changes Multiple medications Identify hazards Environmental Strength & balance deficits Footwear Complex medication regiments

71 Many available for acute & LTC areas (Morse, STRATIFY, Conley Scale) Rapid assessment History of falls, Use of ambulatory aids or devices Medication Strength and balance Focus on the number of risk factors Disagreement regarding effectiveness (Morse et al. 1989; Oliver et al. 1997; Conley, Shultz, Selvin, 1997)

72 Fall prevention program instituted across several institutions in the Boston area. McLean Hospital was the only psychiatric hospital. Fall Rate on one adult unit was 4.83 (per 1000 patient days). Patients were young and middle-aged adults. Fall risk assessment was not sensitive to population. Primary diagnosis: Bipolar disorder, schizoaffective disorder or schizophrenia, psychosis NOS.

73 Patients were acutely ill, On multiple medications, Some were medication naïve, Frequent medication adjustments, Possible inadequate food and fluid, and Many had sleep disturbances

74 Design Sample Data Collection

75 Study period 3 months Received IRB approval Evaluated each fall incident as it occurred Review of the record

76 12 women and 2 men experienced a fall. Mean age 42 (range 21-64). Axis I Diagnosis Bipolar, Manic (5) Bipolar, Mixed (1) Bipolar, Depressed (1) Schizoaffective Disorder (4) Schizophreniform Disorder (1) Psychosis NOS (2)

77 Axis 2 Diagnosis (2) Axis 3 Diagnosis (6) Asthma Hypertension Diabetes Back Pain All individuals were physiologically and medically stable. All were on psychotropic medication. All had multiple medication changes during their hospitalization.

78 Analysis of incident: Where (bathroom, nurses station, room, etc.)? When (shift and time)? Involved in an activity? Environmental hazard (lights, wet floor, etc.)? Were other patients involved? Staff assessment/hunches?

79 Admission Last Recorded Data Data Date Date of Fall BP (sitting) (standing) BP (sitting) (standing) Alert Yes No Unit Pulse Pulse Oriented Time Yes No MR# Respirations Respirations Oriented Place Yes No Age Temperature Temperature Oriented Person Yes No Gender Height ECT Yes Confused No Yes No History of Falls: Weight Date of last Confusion Mild Yes No treatment Mod Severe

80 Functional Health Vision: Hearing: Aided? Glasses/lenses? Weakness: None Mild Mod Severe Gait: Steady Slight Mod Severe Impair Impair Impair Ambulation: Unassisted Partial Full Assist Assist Toileting: Unassisted Partial Full Assist Assist Showering: Unassisted Partial Full Assist Assist Rising: Unassisted Partial Full Bed/chair: Assist Dressing: Unassisted Partial Full Assist Assist Current Medication (include PRN s) 24 hour dosage 48 hour dose 72 hour dose

81 Individual Case Analysis Cross Case Analysis

82 Age & Gender Axis 3 Diagnosis Number of Antipsychotics Titrations/Additions Sleep Medication Vital Signs 49 F Low Back Pain 3 (Clozaril, Abilify, Trilafon) Clozaril, increase 25 mg/day X s 3 days Trazadone 50 mg qhs Pulse rate > 100 within 24 Hours Total past 24 Total past 48 Total past 72 Ativan Clozaril Abilify Trifafon 0 0 4

83 Age & Gender Axis 3 Diagnosis Number of Antipsychotics Titrations/Additions Sleep Medication Vital Signs 26 M None 2 (Risperidone & Haldol) On haldol 7.5 mg bid, Risperidone being tapered down from 5mg bid to 1 mg bid, Depakote 1500 mg & Inderol 10 mg added 5 days prior at current dose.** Trazadone 200 mg qhs Pulse rate > 100 within 24 Hours Total dose 24 hrs Total dose 48 hrs Total dose 72 hrs Haldol Risperidone Depakote Inderol

84 Age, Medical issues, Number of antipsychotic medications, Number of psychotropic drugs, Medication changes, Loading doses of mood stabilizer, Postural VS over 72 hour period Patient or staff complaints/concerns

85

86 Fall Rate 6.0 for the 3 month period Only 1 patient had a slight impairment in gait (shuffling). Thirteen were steady and unassisted in ambulation & ADL s. Most patients were on complex drug regiments (3 or more psychotropic drugs) (N=12). Many had experienced titrations upward over a short period of time (9), All were on drug combinations which can increase negative side effects (sedation, dizziness and light headedness).

87 Yes Postural BP 2 (minor, < 10mmhg) Postural Pulse (incr. 5-9) 3 No 12 8 Postural Pulse (incr. >10 ) Pulse >100 Preceding 24 hrs 3 9 5

88 Number Antipsychotic Drugs Number Patients

89 Number Psychotropic Drugs Number Patients

90

91 Discussed findings: Program Director, Psychiatrists, and Nurses. Developed and implemented interdisciplinary Quality Improvement Plan. Evaluated 3 month fall rate.

92 Heart rate > 100. Greater than 2 antipsychotic drugs. Greater than 10 medications overall. Greater than 2 Mood Stabilizers. Loading dose Mood Stabilizer. First psychiatric admission. Poor compliance. Variations require Program Director consultation.

93 Night RN s review record and complete data tracking form daily. Form is easy to complete, it is included in shift report. Content is discussed in interdisciplinary rounds daily. Program Director alerted to variations in practice for consultation.

94 Fall Risk Assessment Patient Age DATE (Check for MD assessment) Vital Signs Postural BP > 20 mmhg Pulse >100 in past 24h Observations or Complaints Confused Sleepy Tired Sedated Dizzy Medication Number meds > 10 Antipsychotic > 2 Mood Stabilizer >2 Beta Blocker New Admit; prior compliance problem Acute Loading: Mood Stabilizer

95 Fall Rate Reduced to 0.46 in subsequent 3 month period. Cumulative Fall Rates have remained at or below 1.3 per 1000 hospital days

96

97 Healthy, non-elderly individuals with acute psychiatric problems are at risk for falls. Typical risk factors are not present. Complex medication regimens may play a role.

98 Tachycardia was present in 64% of individuals who experienced a fall. Only Clozaril has been linked to tachycardia. Elevated heart rate may increase risk for arrhythmia s.

99 Mandate rapid management of symptoms. Often call for rapid titration or change in medication for acutely ill patients. Sedation, dizziness and light-headedness can manifest suddenly. Individuals who have been non-compliant or who are drug naïve may be at greater risk.

100 What role if any does acuity play? Is tachycardia one indicator of physiological instability? Is tachycardia an ongoing health concern for individuals who take psychotropic medication long term to manage symptoms? Is any one medication implicated?

101 Conley D, Schultz AA, Selvin R. (1999). The challenge of predicting patients at risk for falling: development of the Conley Scale. MEDSURG Nursing, 8(6), Knight M, Coakley C. (2010). Fall risk in patients with acute psychosis. Journal of Nursing Care Quality, 25(3), Morse JM, Black C, Oberie K, Donahue P. (1989). A prospective study to identify the fall prone patient. Social Science Medicine, 28(1), Oliver D, Britton M, Seed P, et al. (1997). Development and evaluation of an evidence based risk assessment tool (STRATIFY) to predict which elderly inpatients will fall: Case controlled and cohort studies. British Medical Journal,315,