Pat Quigley,PhD,MPH,ARNP,CRRN,FAAN,FAANP Associate Director, VISN 8 Patient Safety Center Associate Chief for Nursing Service/Research
E-Mail: [email protected]
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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
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IOM – Crossing the Quality Chasm. Care should meet these criteria:
S - safe T- timely E - efficient E - effective E - equitable P- patient-centered
www.iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx
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
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
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
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
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
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
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
Morse Fall Scale Properties
Exposure/ Outcome
Fall + Fall – (no fall)
Sum
E+ Sensitivity TP
FP PPV a/a+b
E- FN Specificity TN
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
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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
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Interventions
Structures and Processes What interventions will you implement?
Universal Fall Precautions? Let’s look at the evidence
But first….. What is the evidence?
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)
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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
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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
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Accident Theory
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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
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
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, communication-handoff, universal and population-based fall-prevention approaches
Patient Level: exercise, medication modification, orthostasis management, assistive mobility aides, others……
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.
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Jan
Feb
Mar
Apr
May Jun
Jul
Aug
Sep Oct
Nov
Dec Jan
Feb
Mar
Apr
May Jun
Jul
Aug
Sep Oct
Nov
Dec
Falls
per
100
0 P
atie
nt D
ays
2008 2009
Falls per 1000 Patient Days
Fall Rate UCL LCL National Mean
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1
2
3
4
5
6
Jan
Feb
Mar
Apr
May Jun
Jul
Aug
Sep Oct
Nov
Dec Jan
Feb
Mar
Apr
May Jun
Jul
Aug
Sep Oct
Nov
Dec
Fall
Rat
e pe
r 100
0 P
atie
nt D
ays
2008 2009
Fall Rate by Type of Fall per 1000 Patient Days Fall Rate Anticipated Falls Unanticipated Falls Accidental Falls Intentional Falls
49
30
51
37
30
38
54
18
67
0
10
20
30
40
50
60
70
80
Jan 3 08 Feb 2 08 Mar 25 08 May 1 08 May 31 08 Jul 7 08 Aug 30 08 Sep 17 08 Nov 23 08
Day
s B
etw
een
Ser
ious
Inju
ry
Days Between Serious Injury Days Between Serious Injury Average
Annotated Run Chart
JAH VAMC Med-Surg Falls with Harm by Quarter per 1000 pt days(Includes all harm categories: Minimal, Moderate, Major & Death)
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0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Q12004
Q22004
Q32004
Q42004
Q12005
Q22005
Q32005
Q42005
Q12006
Q22006
Q32006
Q42006
Q12007
Q22007
Quarter
Fall
s w
/h
arm
per
10
00
pt
day
s
Computer Template for Morse Fall Scale
and embedded template into Adm and
Trsf notes (12/05)
Revised Post Fall Note (3-12/05)
Added Alert re-meds to Scale
(11-12/05)
Developed Education Brochure on meds
and fall risk (11/05)
Staff education on falls (1/05)
Staff education on falls (10/05)
Added handoff
form (4/06)
Red non skid socks (pilot 5S then to all
M-S 12/05)
Call-Don't Fall Signs (6-9/05)
Updated Falls HPM
(9/05)
Equipment purchased (alarms, mats, low beds 12/03-12/05)
Started AARs (safety
huddles) on test units 10-
12/06
Teachback w/pts 11/06
Put pts on high risk falls precautions w/hx of falls, osteoporosis, Morse score > 50, on anticoagulants, low
platelets 12/06Use yellow wrist bands
on high falls risk pts 1/07
Start comfort safety rounds on off-tours (evenings, nights,
weekend days) 2-3/07
Keep Thinking Out of the Box!
Leadership: Culture of Safety Fall Rounds Signage Frequency of Fall Risk Screening Measurements of Effectiveness
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Questions?