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For You!Strategies to Strengthen a Falls Risk
and Prevention Program
Vivian Dodge, RN, BSN, MBANovember 2012
Hospice of Palm Beach County
ing
• Identify Components of a Falls Risk Prevention Program
• Integrate a Falls Program in QAPI activities• Describe Various Strategies to Integrate the
Falls Program in IDGs and Engage Staff• Identify Ways to Improve Clinical
Documentation About Patient Falls
Falls Among Seniors… Why are they Important?
• *1 in 3 adults 65 years of age and older fall each year*1
• For Seniors, falls are the leading cause of:– Injury– Hospitalization due to injury– Death due to injury
• Previous falls are good predictors for future falls*2
• Nearly 95% of hip fractures result from falls *1
• Hospice patients: Increased risk for falls as patients decline and become more debilitated & frail
• Coordination of care• *1 - AHRQ 2010• *2 – Guide to Falls in Elderly, Dannemiller Memorial Education Foundation, 2003
The Base & BranchesSteps to “Grow” Your Program
Review Standards &Regulations
Define goalsDevelop Definitions
Adopt a Falls Risk Screening Tool
Establish PIP or Committee
Collect DataReview Gaps
Educate and Engage
Ongoing Data EvaluationProvide
Feedback
Steps to get on the right track
1) Establish the components for your Falls Program
2) Structure a PIP or committee3) Identify challenges / opportunities4) PDCA !5) Evaluate data & outcomes and continually re-evaluate the effectiveness of your program
• Review standards & regulations Jt Commission, CHAPS, ACHC State regulations / standards
• Review standards of practice Related associations NHPCO, HPNA, NAHC, etc
• Review research AHRQ, CMS, OASIS, IOM, Nat’l Center for Patient Safety
Determine membership: Variety, good cross section, creative, committed
Define the purpose & goals: What do you want to accomplish
Determine frequency of meetings, data for review, other actions: How soon can data be provided? Too frequently or too little affects
momentum Determine reporting chain of command:
Who? Who are the persons/departments that have in interest in the outcomes? Various levels?
• Define goals – what is it that you want to accomplish?
• What is your organization fall rate?
• Define the elements:> What is the organization definition of falls?
• What kind of data will you collect?
• Adopt a screening tool to assess for patients’ risk for falls
Morse Falls Scale Hendrick Falls Scale
Falls Efficacy Scale Many others !!
Provides standardization in scoring
• Provides standardization among clinical staff • Assists with development of practice
standards and interventions in your organization
• Reliability• Becomes part of assessment documentation
Fall Risk Assessment Tool:
Client Factors Score Patient Score
History of Falls 15
Confusion/Disorientation 5
Age (over 65) 5
Impaired Judgment 5
Sensory deficit 5
Weakness/ impaired mobility 5
Increased anxiety/agitation 5
Altered elimination 5
Cardiovascular/respiratory disease affecting perfusion and oxygenation 5
Medications/sedatives/hypnotics 5
Dizziness/syncope 5
Attached equipment (IV poles, appliances, tubing, oxygen) 5
Total Points
Implement Fall Precautions for a total score of 15 or greater. *Source: Hartford Institute for Geriatric Nursing, Division of Nursing, New York University
• Specify when screening is completed & frequency• What actions clinical staff take if patient is
identified at risk for falls• Determine documentation expectations of falls
risk• Determine documentation expectations of any
falls• Review incident reporting forms • Communication & visual identification
• Education of patients/families/caregivers is critical
• Engage them in learning
• Education of staff is imperative
Engagement promotes :-Greater understanding-Better compliance-Improved collaboration & coordination of care-Improved outcomes
Challenges & Opportunities
Workgroup started in 2006• Lack of understanding by clinical staff what
the Falls Program really meant• Lack of documentation about the fall event• Poor reporting compliance and lack of
information on incident reports• Staff did not report falls from SNFs
Challenges & Opportunities• Staff not well versed on interventions available
nor appropriate education• Fear of Reporting• Lack of understanding of why it is important to
report• Ideas that QM department is responsible• Lack of understanding of importance related to
future clinical outcomes and regulatory compliance
• WIIFM?
Determine detail of dataNumber of fallsAttended / UnattendedInjury status: No injury, Minor injury, Fractures, Death911 callsTime of eventCategory of fallFrequent FallersTeam & RegionTreatment
Diagnosis Fall Risk Score Disposition of patient Year to date data Quarterly Fall Rate Fiscal Year Comparisons
Most falls occur during the day Top 4 categories:
Found on FloorRolled out of Bed
Bathroom / toileting relatedAmbulation
Majority of falls - No injury Majority of falls in home environment or ALFs Inpatient units – low fall rates Lack of documented follow up for falls with injuries to the
head
• Hospice patients with polypharmacy – interactions, efficacy
• Types of medications: Diuretics & laxatives – sense of urgencyAnti-hypertensive meds, sedatives, narcotics- Sleeping, pain & blood pressure medications can cause hypotension and effect alertnessPsychoactive drugs (Haldol, Seroquel) - increase risk for falls
• Chronic pain and musculoskeletal pain in 2 or more joints & pain interfering with ADLs – more likely to fall• Delirium- more likely to fall
• Staff not well versed on DME available – products, knowledge
• Lack of collaboration with facilities to implement interventions for fear of ‘stepping on their toes’ – What is allowed? Education needed of how hospices can assist?
• Language used by clinical staff – How staff present information
• Lack of toileting routines – sense of urgency, increased falls
• Poor eyesight, hearing – increased falls
• Patients/families did not want equipment – unsightly and gave impression of fragility
• Missing hand off communication – contributes to lack
of clinical follow up
Reviewed ongoing gap analysis Provided monthly feedback to teams on falls Discussed at Quarterly Quality Meetings Developed audit tools Developed yearly initiatives for Falls Workgroup Attended IDGs Reviewed medical records and provided feedback to
supervisors and nurses Evaluated data Developed patient teaching handouts Developed staff teaching handouts Provided education to staff
Keeping “Falls” activities on staff radar has been challenging but became a successful endeavor
Data is boring
Workgroup was committed to having fun
PREVENT YOUR PATIENT FROM BECOMING A
FALLING STAR
Remember To:•Use the Fall Stickers•Use the Fall Stickers on the patient folders in the home•Update Care Plans•Educate Patient / Family / Caregiver
Patient safety begins with HPBC’sFall Prevention Program
FALLS AMONG SENIORS•1 of every 3 people over the age of 65 fall a year•For Seniors, falls are the leading cause of:• -Injury
-Hospitalizations-Death due to injury
HPBC Facts
Average 115-130 falls per monthFall Rate Less than 1% of HPBC Patients
(That’s Good!)
February Facts:
•54% of February 08 falls occurred during the day
14% occurred in the evening25% occurred during the nightMost Falls Occurred Unattended in the HomesOnly 6 Serious Injuries (Fractures –Mostly Hip FX’s)
Remember To:
Use the Fall Stickers
Use the Fall Stickers on Patient Folders in the Home
Update the Care Plans
Educate the Patient / Family / Caregiver
Patient safety begins with HPBC’s Fall Prevention Program
Summer Star GazingLooking for Falling Stars
GOAL: Keep HPBC fall rate to < 1% of patient days :Currently at 0.41%
Paint the Picture
Who?
What?Where?When?Why?How?
•Educate, Educate, Educate! Proper Body Mechanics
•How to use DME Equipment Safely
Fall Prevention Tips
Good Job To All On:
Updating the Care Plans
Good IR reporting
Patient safety begins with HPBC’s Fall Prevention Program
How do you know when to contact the Medical Examiner’s Office if there was a fall?
Simple Rule of Thumb
•Did the fall/trauma contribute or hasten an unnatural death?•Did the patient’s status, or mentation change as a result of the fall?Example: Patient was ambulating, talking prior to fall; now patient is unresponsive Example: patient active prior to fracture of hip. Since fracture, patient is bedridden•Was the patient’s lifestyle changed due to the event?•Did the fall result in fractures from which patient did NOT recover? (Fx hips, femurs, etc) •Did the patient die of complications from the fracture or fall?Example: Pt developed pneumonia or embolism post fall•Important: Was patient already declining or pre-imminent prior to the fall? If yes, then may not be a ME case.
Laws Governing Medical Examiner Cases: •FLA Statute 406.11; Gives authority to Medical Examiner to do an autopsy in suspicious deaths •FLA Statue 406.12: Duty to Report – specifies health care workers have a duty to report suspicious deathsThere are many reasons patients are M.E. cases…. But today, we are only focusing on Falls and M.E. cases What to do?
What to do? •Discuss with team physician events surrounding the fall •If uncertain: Always good to discuss case with ME office.•Use the Medical Examiner Worksheet as a guide and place in chart•Document all calls and conversations with the ME office.•Remember: ME office has final jurisdiction•Discuss patient’s condition pre and post fall
Guess what’s coming your way?TT / FF
Hint: It’s not True and FalseFrom your HPBC Falls Workgroup
TT FF
Our F all R ate has decreased!
Our staff is doing a great job in r epor ting witnessed falls
and unwitnessed falls
Good follow-up fr om SN F teams on repor ted falls
Sapphire/ A fter hour s/ W eekend Staff:
K udos for RA DT notes, Triage notes and submitting IR’s
Reminders:
Encourage patients and families to use night lights in
bathrooms and throughout the house
Educate patients, families, and facility staff on
F all P revention Tips
A ssess for BSC needs and recommend usage
FY 2010 # of Falls FY 2011 # of Falls % ↓ Apr-10 137 Apr-11 106 23% May-10 131 May-11 109 17% Jun-10 139 Jun-11 103 26%
From
The Falls Workgroup
Old Way Better WayYou Need a Walker You may want to consider using a walker
(cane). It will give you a little more support & perhaps you may be able to
go outside.I am ordering you a hospital bed A hospital bed will help your spouse
get you out of the bed when we are not here.
You are going to fall, you are not safe
Give it some thought… it will help you stay more independent.
Don’t >>>>>>> What do you think may be of help to you
Fear Changing what is familiar
Wanting to stay independent
Not aware of DME options and how it can benefit
Afraid of appearing old or frail
Afraid of what appears new or confrontational
Not ready to accept decline/mortality
Do not like how DME takes up space in the home
• Stay patient with your patients
• Engage a family member, caregiver
• Teach how to operate equipment or transfer patient: Use the teaching techniques!
• Staff too!
• Clinical staff education > DME possibilities: Hi/lo beds, mats, transfer boards,
etc
> Feedback on audits> Feedback on Plan of Care expectations> Feedback on documentation
Outcomes:Continued Reduction in Falls Rate
38% reduction
• Little comparative data on falls in the hospice industry
• Home health, acute hospitals collecting data for years
• Future? Required reporting?
• NHPCO initiatives
Establish process/protocolsEducate
Engage
Question Quantify
Quality check
References:-National Quality Measures Clearinghouse, www. qualitymeasures.ahrg.gov-Agency for Health Research and Quality (AHRQ), www.ahrg/qualInstitute of Medicine National Academies, IOM, www.iom.edu-The Joint Commission of Healthcare Organizations, CAMH, 2012-National Center for Patient safety, Department of Veterans Affairs, www.patientsafety.gov-National Institute on Aging, www.nia.nih.gov-”Engaging patients and Families in the Quality and Safety of Hospital Care”, AHRQ, June
2012-Guide to the prevention and management of Falls in the Elderly, Dannemiller Memorial
educational foundation & McMahon Publishing Group, 2003-“Etiology of Falls among Cognitively Intact Hospice Patients”, Schonwetter, Kim, Kirby,
Martin, Henderson, Journal of Palliative Medicine Vol. 13, No. 11, 2010
-
Questions?Vivian Dodge, RN, BSN, MBAHospice of Palm Beach CountyOffice: 561-227-5171Email: [email protected]