Southern Hospitals Network Falls Prevention Initiatives. Gaye Sykes - Accreditation / Quality Manager Wollongong Hospital

Transcription

1 Southern Hospitals Network Falls Prevention Initiatives Gaye Sykes - Accreditation / Quality Manager Wollongong Hospital

2 SHN Falls Prevention Working Party AIM: STANDARDISED / INTEGRATED APPROACH ACROSS 9 SHN HOSPITALS Community Health Community Acute Hospital Services Population Health Programs Aged Care Facilities Rehabilitation

3 SHN Falls Prevention Business Plan Developed a SHN Falls Prevention Plan & Implementation Plan in 2006 based on: SESIHS Falls Implementation Strategy ACHS EQuIP standards & Preventing Falls & Harm from falls Green Kit NSW Health Policy Brief Management to Reduce Injury Among Older People NSW Health Policy (2001) Preventing Falls in Older People

4 Summary of Key Result Areas Business Plan Communication & Consultation Policy & Clinical Practice Equipment Clinical Indicator / Performance Management Education Specific strategies to reduce falls

5 IIMS Reporting SHN Falls Prevention Working Party to review all Falls related IIMS Incidents within network on a monthly basis Produce a monthly report that includes all 9 Hospitals across the Southern Hospitals Network Comparison of data for Sub Acute Hospitals and Acute Hospitals Data to include Bed ratios for each hospital when reporting on the number of Falls at each site Network reports on falls rates prepared monthly by PSOs for SHN Patient Safety and Clinical Quality Meeting Also prepare 6 monthly trended reports on: Activity at time of fall and time band

6 Implementation of Business Plan Strategies Education: Annual April Falls Day Aim of the day: Have fun and learn as well! Huge promotional activity across SHN All 9 hospitals participating a real team effort! Staff morale booster Increase staff / consumer awareness of falls prevention SHN Trophy for the Best Display / activities on the day Best Display - Shoalhaven Hospital Runner Up Shellharbour Hospital Highly Commended Coledale Hospital

7 Certificates for Hospitals / Staff

8 Presentation of April Falls Day Trophy to Shoalhaven Hospital

9 SHN April Falls Day activities 846 visitors to the hospital displays in the foyers Falls Prevention Education Program CDROM s distributed to 60 wards Monitor IIM s / falls rates over the next few months to determine if a reduction in falls rates Flow-on strategies: Annual event inspired a lot of inter-hospital competition 2 hospitals month of Falls Prevention activities Introduction of Nursing Grand Rounds on Falls Prevention

10 SHN April Falls Day Coledale Hospital

11 SHN April Falls Day Coledale Hospital

12 SHN April Falls Day Coledale Hospital E - Regular Eye Checks A Increase Activity S Check Surroundings are hazard free Y Review Your Medications

13 SHN April Falls Day Wollongong Hospital

14 SHN April Falls Day Wollongong Hospital

15 SHN April Falls Day Shellharbour Hospital

16 SHN April Falls Day Shellharbour Hospital

17 SHN April Falls Day Shellharbour Hospital

18 SHN April Falls Day Shellharbour Hospital

19 SHN April Falls Day David Berry Hospital

20 SHN April Falls Day Shoalhaven Hospital

21 SHN April Falls Day Shoalhaven Hospital

22 SHN April Falls Day Shoalhaven Hospital

23 Integrating EQuIP Standards into SHN Falls Prevention Program ACHS EQuIP Standards/Criteria relating to Falls Prevention Standard: Safety 1.5 Criterion The incidence of falls and falls injuries is minimised through a falls management program. Standard: Safe Practice and Environment 3.2 Criterion Safety management systems ensure safety and wellbeing for consumers/patients, staff, visitors and contractors.

24 EQuIP Ratings for Criterion and Criterion Ratings are determined according to how well organisations can demonstrate their practices address the intent of the elements. Ratings LA SA MA requires evaluation with demonstrated results EA OA

25 Integrating EQuIP Standards into SHN Falls Prevention Program LA and SA EQuIP Elements Standard 1.5 Falls Prevention Policy Falls Risk Assessments include assessment on admission, following change of health status and after a fall and include a documented management plan. Falls Prevention Information to staff and consumers Strategies Implemented to address elements Introduced SHN Falls Prevention Policy (and site procedures in some hospitals). SHN Falls Prevention Policy and local procedures include assessment requirements. Review of Falls Risk Assessment Form for both Acute and Rehab services. E.g. Modified Stratify - Acute and Modified Schmidt Rehab - BOTH INCLUDE ASSESSMENT AND MANAGEMENT PLAN REQUIREMENTS. Staff information brochure developed and placed on SHN Intranet. Patient information brochures distributed for use at ward level. April Falls Day. Developing SHN Falls Webpage on Intranet

26 Integrating EQuIP Standards into SHN Falls Prevention Program LA and SA EQuIP Elements Standard 1.5 Appropriate falls prevention strategies Use of validated Falls Risk Assessment tools Consumers/patient involvement in falls prevention/ management plans Strategies Implemented to address elements Developed SHN Falls Prevention Business Plan and SHN Falls Prevention Implementation Plan which include numerous evidence based strategies. Review of Falls Risk Assessment Form for both Acute and Rehab services. E.g. Modified Stratify - Acute and Modified Schmidt Rehab. Awaiting validated Falls Screening tool for ED. Currently reviewing ASET Screening Tool. Plan to introduce Quickscreen in all Community Health Centres April Falls Day 846 visitors attended. Patient involvement with nursing, physiotherapy (gym) and occupational therapy staff (div therapy). Falls Clinics at 4 hospitals.

27 Integrating EQuIP Standards into SHN Falls Prevention Program LA and SA EQuIP Elements Standard 1.5 Falls Injury Prevention equipment D/C Planning for high risk patients Staff are educated on falls injury risk Strategies Implemented to address elements Equipment Trade Display in 2006 Purchase of Murphy Lo Lo Beds Review of equipment needs across the network Litegait equipment purchased at Port Kembla Hospital Introduced new referral pathways from D/C patients from ED to Falls Clinics and Better Balance Programs for assessment. Established a working party to introduce #NOF pathway from ED. Falls Clinics established including Domiciliary Clinic at Port Kembla Hospital Staff information brochure developed and utulised in all hospitals. April Falls Day SHN Quality Forum October 2007

28 Integrating EQuIP Standards into SHN Falls Prevention Program MA & EA EQuIP Elements Standard 1.5 MA - Falls and fall injury data are analysed and improved as required. MA - Falls and falls injury prevention and management education program is evaluated and improved as required. Strategies Implemented to address elements SHN IIMS Falls Incident Reports Falls rates, falls by age band and time band and SAC 1, SAC 2 Falls related incidents. Falls Prevention Audits conducted at PKH, Coledale Hospital resulting in improvements to delivery of care. Survey of Falls prevention site programs in 2007 across the network. ACHS Clinical Indicators reviewed no includes falls indicator to be collected as mandatory indicator across SHN. SHN Compliance Audit against SHN Falls Prevention Policy to be conducted in July Education program evaluated at network level. Outcomes included: April Falls Day Falls Education Disc to all wards across SHH SHN Falls Prevention Forum planned for October 2007

29 Integrating EQuIP Standards into SHN Falls Prevention Program MA & EA EQuIP Elements Standard 1.5 EA - The organisation undertakes research into falls and falls injury prevention EA Falls Management Program communicated to other organisations. EA Falls data management systems reviewed Strategies Implemented to address elements Falls Prevention Research 5 current projects. NSW Falls Forum 2006 NSW Falls Forum 2007 CEC Presentation 2007 CEC Rural Telehealth 2007 Representation on SESIH Falls Injury Steering Committee and SESIH Falls Injury Acute/Sub Acute Working Party IIMS Reports developed for Network/Sites Benchmark against peer sites Bed ratio reporting introduced Introduced ACHS Clinical Indicator for Falls as mandatory for collection across SHN

30 Integrating EQuIP Standards into SHN Falls Prevention Program LA & SA & MA EQuIP Elements Standard 3.2 Manual Handling Strategies Implemented to address elements Manual Handling Flipcharts introduced at Port Kembla Hospital and Coledale Hospitals and evaluated (MA). Litegait Equipment purchased at Port Kembla Hospital. Manual Handling education provided to staff - part of mandatory training across the network. Safety/Injury Management Falls Prevention part of the Network Injury management - inclusion as one of 6 Key Clinical Priority Areas in SHN Clinical Quality Managers role. WH Accreditation/QM - key priority areas at Wollongong Hospital. Site representation from all 9 hospitals and Community Health - implement Falls Prevention strategies at site level.