Fall & Injury Preven/on: Demen/a + Hospitals = The Perfect Storm Tiffany E. Shubert, PhD, PT Carolina Geriatric Educa/on Consor/um UNC School of Medicine June 11, 2014
Acknowledgements This work was supported by the Bureau of Health Professions (BHPr), Health Resources and Services Administra/on (HRSA), Department of Health and Human Services (DHHS) under grant #UB4HP19053, Carolina Geriatric Educa<on Center. This informa/on, content and conclusions are those of the author and should not be construed as the official posi/on or policy of, nor should any endorsements be inferred by the BHPr, HRSA, DHHS or the U.S. Government.
Demonstra/ng Value Our funders (HRSA) value numbers and demographics (who is a[ending our trainings) To demonstrate value, we ask all a[endees click on this link and complete the online demographic form now or in the next 3 days: h[p://www.aheconnect.com/cgecahec/ user3.aspx?admin=1
Objec/ves Describe the impact of cogni/ve dysfunc/on on fall risk for pa/ents in the hospital Discuss three key strategies to minimize falls and risk of injury from a fall for individuals with cogni/ve impairment Present implementa/on strategies
Why do people fall?
Why do people fall in hospitals? History of falls Mobility problems/use of assis3ve devices Medica3ons Mental status Con3nence Other pa3ent risks
What to do about it? Universal fall precau/ons Standardized assessment of risk factors Tailored care planning and interven/ons Posball procedures (h[p://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/)
Universal Fall Precau/ons Familiarize the pa/ent with the environment. Personal possessions within pa/ent safe reach. Handrails in bathrooms, room, and hallway, hospital bed in low posi/on when a pa/ent is res/ng in bed Hospital bed brakes and wheelchair locked. Nonslip, comfortable, well- fifng footwear Night lights or supplemental ligh/ng. Floor surfaces clean and dry. Pa/ent care areas unclu[ered. Follow safe pa/ent handling prac/ces.
Cogni/ve Dysfunc/on Delirium Acute state of severe confusion; waxes and wanes Confusion Assessment Method www.hospitalelderlifeprogram.org/pdf/ TheConfusionAssessmentMethodTrainingManual.pdf. h[p://consultgerirn.org/resources/media/? vid_id=4361983#player_container.
EVALUATOR: DATE: I. ACUTE ONSET AND FLUCTUATING COURSE BOX 1 a. Is there evidence of an acute change in mental status from the pa3ent s baseline? b. Did the (abnormal) behavior fluctuate during the day, that is, tend to come and go or increase and decrease in severity? No Yes No Yes II. INATTENTION Did the pa3ent have difficulty focusing asen3on, for example, being easily distrac3ble or having difficulty keeping track of what was being said? III. DISORGANIZED THINKING Was the pa3ent s thinking disorganized or incoherent, such as rambling or irrelevant conversa3on, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? IV. ALTERED LEVEL OF CONSCIOUSNESS Overall, how would you rate the pa3ent s level of consciousness? No No Yes BOX 2 Yes Alert (normal) Vigilant (hyperalert) Lethargic (drowsy, easily aroused) Stupor (difficult to arouse) Coma (unarousable) Do any checks appear in this box? No Yes
Interven/ons Prevent delirium if at all possible! Infec/ons, medica/ons, electrolyte imbalances Maintain consistent environment Address all risk factors Intense supervision No restraints or bed alarms
Cogni/ve Dysfunc/on Demen/a Pre- exis/ng state of cogni/ve impairment Mini- Cog 1. Dictate three items, ask to repeat 2. Clock Drawing Test 3. Ask to recall the three items MMSE Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The mini- cog: a cogni/ve vital signs measure for demen/a screening in mul/- lingual elderly. Int J Geriatr Psychiatry. 2000;15(11):1021-1027. Borson S, Scanlan JM, Chen P, Ganguli M. The Mini- Cog as a screen for demen/a: valida/on in a popula/on- based sample. J Am Geriatr Soc. 2003;51(10): 1451-1454. McCarten JR, Anderson P Kuskowski MA et al. Finding demen/a in primary care: the results of a clinical demonstra/on project. J Am Geritr Soc. 2012;60(2): 210-217.
Interven/ons Universal fall precau/ons Intense supervision Medica/on review/revision NO Restraints or Bed Alarms! Safety Zones Low beds, mats on either side of the bed, night light, gait lights, STOP sign
Interven/ons Consistent schedule to minimize anxiety Appropriate ligh/ng Music, aromatherapy
Implementa/on Strategies All pa/ents screened upon intake and also daily for delirium/cogni/ve impairment Once a dysfunc/on iden/fied, standardize interac/on with all staff Family/caregiver educa/on
What does this look like? Propose a scenario and let s apply!
Thank you!!! Ques/ons? More informa/on? tshubert@med.unc.edu
Data Overview" For the 2014 Falls Learning Network, hospitals are no longer being asked to report Falls with Injury (using the NDNQI definition). " In order to encourage participation in the learning network, NoCVA is utilizing the data available from the CMS Falls HAC (claims-based) data set." The data is available for >90% of NoCVA hospitals and account for conditions that are present-on-admission (POA)" Using this data source means a reduced burden on hospitals to collect and submit data" The downside to claims-based data is a reporting lag (approximately 6-9 months)"
Outcome Measure CMS Falls HAC" Note: Baseline includes 6 quarters of data (2010Q4 through 2012Q1). Each of the 97 hospitals in the baseline contributed only one quarter of data, which varies from hospital to hospital. Baseline selec/ons were made based on a percentage of valid POA codes found for Falls HAC in our claims based dataset. In general, baselines selected corresponded to when a hospital first reached 90% valid POA codes.
Comparison of Measures" Falls with Injury CMS Falls HAC Data Point Timeframe # Hospitals Measure # Hospitals Measure Baseline 1/1/13 74 0.61 107 0.52 1 4/1/13 74 0.62 106 0.43 2 7/1/13 72 0.62 106 0.36
Hospital Improvement 2013 vs. 2012" % Improvement Number of Hospitals > 40% 39 (36.8%) 0 40% 11 (10.4%) In addition, 25 hospitals (23.5%) have maintained a rate of 0 from 1/1/12 9/30/13. This means that 71% of NoCVA hospitals have shown improvement or maintained their performance during this time period.!