Pat Quigley,PhD,MPH,ARNP,CRRN,FAAN,FAANP. Associate Director, VISN 8 Patient Safety Center Associate Chief for Nursing Service/Research

Transcription

1 Pat Quigley,PhD,MPH,ARNP,CRRN,FAAN,FAANP Associate Director, VISN 8 Patient Safety Center Associate Chief for Nursing Service/Research patricia.quigley@med.va.gov 1

2 Overview Formulate measurable fall-related outcomes that build upon NDNQI data Differentiate types of falls as a basis for analysis of program effectiveness at patient, unit and organizational levels Compare Proactive vs Reactive Approaches to Fall and Injury Prevention 2

3 IOM Crossing the Quality Chasm. Care should meet these criteria: S - safe T- timely E - efficient E - effective E - equitable P- patient-centered Chasm-A-New-Health-System-for-the-21st- Century.aspx

4 Types of Measures Processes Structures Outcomes Balancing Measures: Impact of change on other parts of our system; i.e., as fall and injury rates decline, did other measures improve or decline

5 Types of Outcomes Quality (QOL, Satisfaction, Function, M&M) Financial (Cost Savings, ROI) Access (Access to Treatment) Timeliness (Care in timely manner) Nurse-Sensitive Outcomes

6 Core NDNQI Data Age, Gender Fall Risk: Assessment prior to fall ; Scale score; Time since last risk assessment; At risk for Falls (y/n) Fall Prevention Protocol in Place Falls Assisted Fall Repeat Falls Injury Physical Restraint Prior Fall this Month

7 Fall Prevention Program vs. Falls Outcomes Fall Prevention Program Falls Fall-related Injuries Days without a fall Staff Involvement- Unit-based Champions Falls QI Committee Cost of Program (ROI) Falls Outcomes Actual Numbers of Falls (event, rate, percent) Fall Type Repeat Falls Fall-related Injury

8 Formulate Measurable Fall- Related Outcomes Structure, Process, Outcomes Reduce preventable falls by 20% in 1 year Requires data collection for type of fall What are the types of fall? Others Eliminate serious fall-related injuries in 1 year

9 First Step: Types of Falls Accidental Falls Anticipated Physiological Falls Unanticipated Physiological Falls Morse, J. (1997). Preventing Patient Falls. Thousand Oaks, CA: Sage Intentional Falls

10 Second Step: Link to Fall Risk Assessment Fall Risk Screening Tools Validity, Reliability Sensitivity, Specificity Likelihood of which Type of fall? Comprehensive Fall Risk Population-based Individualized

11 Morse Fall Scale Properties Exposure/ Outcome E + Fall + Fall (no fall) Sensitivity FP TP E - FN Specificity TN Sum PPV a/a+b NPV d/c+d a/a+c d/b+d Total Sensitivity: 78% (a/a+c) (proportion of those who fall and identified at risk by test) Specificity: 83% (d/b+d) (proportion of those who are free of fall and identified not at risk by test) PPV 10.3% (proportion of those with risk who fall) NPV 99.2% (proportion of those with no risk who are free of fall) 100 falls, 4,000 control (due to fall rate X 1,000 pt days of care); 82.9% of cases classified correctly 11

12 Differentiate Screening from Assessment Screening Disease Detection Who should undergo diagnostic testing for confirmation- Cut off point to be negative or positive Over-reliance on screening tools What tool are you using? Assessment Data for differential Diagnosis 12

13 Interventions Structures and Processes What interventions will you implement? Universal Fall Precautions? Let s look at the evidence But first.. What is the evidence?

14 Best Practice Approach in Hospitals: Most effective, fall prevention interventions should be targeted at both point of care and strategic levels Implementation of safer environment of care for the whole patient cohort (flooring, lighting, observation, threats to mobilizing, signposting, personal aids and possessions, furniture, footwear) Identification of specific modifiable fall risk factors Implementation of interventions targeting those risk factors so as to prevent falls Interventions to reduce risk of injury to those people who do fall (Oliver, et al., 2010, p. 685) 14

15 Third Step: Expand Evaluations Methods Prevalence Studies Formative and Summative Evaluation Methods Type of Falls Severity of Injury How are you assessing for injury? Duration? Extent of Injury? Repeat Falls Survival Analysis Annotated Run Charts 15

16 Fourth Step: Prevent Repeat Falls: Safety Huddles? Post Fall Analysis What was different this time? When? How? Why? Prevention: Protective Action Steps to Redesign the Plan of Care 16

17 Accident Theory 17

18 Outcomes of Post Fall Huddles Specify Type of Fall Specify Root Cause (proximal cause) Identify actions to prevent reoccurrence Changed Planned of Care Summative Outcome: Prevent Repeat Fall: Same Root Cause and Same Type of Fall

19 Formative Outcomes Structures: Who attends: Nursing and others Count them Add actions to your run-chart: Annotated run chart; Capture interventions Processes: Timeliness of Post Fall Huddle (number of minutes) Timeliness of changing plan of care Time to implemented changed plan of care

20 Program Effectiveness: Fall Prevention Organizational Level: Expert interdisciplinary all team, program evaluation, leadership, environmental safety, safe patient equipment, anti-tippers on wheelchairs Unit Level: education, communicationhandoff, universal and population-based fall-prevention approaches Patient Level: exercise, medication modification, orthostasis management, assistive mobility aides, others

21 Program Effectiveness: Protection from Serious Injury Organizational Level: available helmets, hip protectors, floor mats, height adjustable beds; elimination of sharp edges Staff Level: education, adherence, communication-handoff includes risk for injury Patient Level: adherence with hip protector use, helmet use, etc.

22 Falls per 1000 Patient Days Fall Rate UCL LCL National Mean Falls per 1000 Patient Days Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

23 6 Fall Rate by Type of Fall per 1000 Patient Days Fall Rate Anticipated Falls Unanticipated Falls Accidental Falls Intentional Falls Fall Rate per 1000 Patient Days Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

24 80 Days Between Serious Injury Days Between Serious Injury Average Days Between Serious Injury Jan 3 08 Feb 2 08 Mar May 1 08 May Jul 7 08 Aug Sep Nov 23 08

25 Annotated Run Chart JAH VAMC Med-Surg Falls with Harm by Quarter per 1000 pt days (Includes all harm categories: Minimal, Moderate, Major & Death) Falls w/harm per 1000 pt days Equipment purchased (alarms, mats, low beds 12/03-12/05) Staff education on falls (1/05) Updated Falls HPM (9/05) Call-Don't Fall Signs (6-9/05) Revised Post Fall Note (3-12/05) Computer Template for Morse Fall Scale and embedded template into Adm and Trsf notes (12/05) Added Alert remeds to Scale (11-12/05) Developed Education Brochure on meds and fall risk (11/05) Red non skid socks (pilot 5S then to all M-S 12/05) Staff education on falls (10/05) Added handoff form (4/06) Put pts on high risk falls precautions w/hx of falls, osteoporosis, Morse score > 50, on anticoagulants, low platelets 12/06 Use yellow wrist bands on high falls risk pts 1/07 Start comfort safety rounds on off-tours (evenings, nights, weekend days) 2-3/07 Started AARs (safety huddles) on test units 10-12/06 Teachback w/pts 11/06 0 Q Q Q Q Q Q Q Quarter Q Q Q Q Q Q Q2 2007

26 Keep Thinking Out of the Box! Leadership: Culture of Safety Fall Rounds Signage Frequency of Fall Risk Screening Measurements of Effectiveness 26

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28 Questions? 28