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Corrine Abraham DNP, RNClinical Assistant Professor, Emory NHWSN
Coordinator for EBP & Innovation, Atlanta VAMC
Team & Aim
Map & Measure
Change
Spread Change Over Time, Transformation
Leadership & will to transform
Leadership & Alignment top to Bottom
VISION - ANALYSIS
IMPROVE
SUSTAIN
Feb 2013 July 2013 Aug 2014
National Incidence of Falls 3% - 20% of inpatients fall at least once 1
Falls are the 6th most commonly reported sentinel event. 2
Consequences of Falls 20% - 30% suffer injuries that ↑ their risk of early death.3
Leading cause of injury-related death for adults over 65 yo.4
Fractures most common and costly injury.5
Cost of Falls ↑ Length of stay, ↑ rates of discharge to institutional care, ↑
resource use 3-4,6
National ImperativeNational Patient Safety Goal - TJC 7
Serious Reportable Event - NQF 8
No reimbursement – CMS 9
Local PriorityAtlanta VAMC: Vulnerable population - many fall
related risks
Solution 1,10-11
Multifactorial assessment & management effective Success associated with multidisciplinary team Tailored interventions can prevent injury
Local Priority: Preventing falls and fall related injury will decrease expenditures and enhance patient safety as well as the organization’s accountability to provide quality care
Problem Statement: In FY2013 (through May) the hospital reported more than twice the national rate of falls with serious injury. Two units had rates that exceeded the hospital average as well as the national average of VHA hospitals of comparable acuity and size
Corrine Abraham, RN, DNP, VAQS
Sandra Thomas, RN, QA, Acute Care
Laurie Moore, RN, GNP, Long Term Care
Heather Batchelor, MD, Hospitalist
Gara Coffey, Pharm D, Long Term Care
Deshondra Green, Pharm D, Acute Care
Renee Browning, PT, Long Term Care
Beth Allen, PT, Acute Care
Kim House, MD, Long Term & Home Care
Kelly Fripps, RN, Health Promotion
Penny Gunter, RN, Education
Ken Murphy, RN, Informatics
Abebe Abera, RN, CNL, Acute Care (AC)
Casey Hill, RN, Assistant Manager, AC
Sandra Dukes, RN, DNP, CNS, AC
William Greene, RN, Mental Health
Sponsor: Sandy Leake, RN, MSN, Associate Director, Nursing and Patient Care Services and Chief Nursing Officer
The goal of the quality initiative was to decrease the rate of falls/injury by mitigating modifiable risk factors and enhancing inter-professional
collaboration.
To reduce rates of falls on 8 Palliative at Atlanta VAMC by 50% from a rate of 4.47 to 2.33 by July 2014 ◦ To have zero injurious falls on 8 Palliative at Atlanta VAMC
To reduce rates of falls on 9 Surgical at Atlanta VAMC by 50% from a rate of 1.28 to 0.64 by July 2014◦ To have zero injurious falls on 9 Surgical at Atlanta VAMC
Organizational capacity
Workflow patterns
Circumstances of falls
Pattern of fall events
Current processes
Electronic data bases
Chart audits & queries
Patient interviews (VOC)
Health team member interviews (VOC)
Direct observation of care
Surveys
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
0
2
4
6
8
10
12
14
16
18
Primary Reason
Cum
ePER Data (Jan – Feb)
Priority Area Interventions 12 - 17
Documentation of Risk
Standardize CommunicationElectronic documentation templates
Staff Education & Accountability
Monthly Resident orientationAnnual Staff EducationAccountability
Patient Education Standardize Patient Education process
Individual Risk Factors-
Modify Fall Risk Assessment processModify Post-Fall noteEnvironmental/equipment modifications
0
1
2
3
4
5
6
7
Q1 12 Q2 12 Q3 12 Q4 12 Q1 13 Q2 13 Q3 13 Q4 13 Q1 14 Q2 14 Q3 14 Q4 14 Q1 15 Q2 15
9 Surgical
8 Palliative
Injurious fall
Improvement Phase
Sustain Phase
77% Assess lower
extremity strength
62 % Initiate fall prevention in-patient referrals
58 % Evaluate
orthostatic hypotension
0 % Evaluate for osteoporosis
15 % Initiate fall prevention community
referrals
19 % Document
history of falls
35% Assess vision
N = 26
Provider Ordered Interventions
N = 81
Risk Communication:
Standardizing communication → ↑ collaboration
Electronic note template → tailored interventions
Accountability: Audits with feedback → ↑ accountability
Involvement of leaders → accountability
Patient Education:
Team involvement → ↑ patient education
Electronic version → ↑ consistency
Individual Risk Factors:
Injury Risk stratification → Identifies vulnerability
Education pamphlet → standardizes & ↑ tailoring
I would like to acknowledge team members who partnered in this initiative◦ Sponsor: Ms. Sandy Leake, CNE◦ Fall Prevention Sub-committee◦ Medical Residents: H. Batchelor, V. Pragya, A. Allen◦ MPH Student: E. Bredenberg
and colleagues who provided guidance & support◦ National Collaborative (NCPS): Virtual Breakthrough Series◦ Patient Safety Committee, Atlanta VAMC◦ VAQS: Site faculty
1.Clyburn T, & Heydemann J. Fall prevention in the elderly: Analysis and comprehensive review of methods used in the hospital and the home. J Am Acad Orthop Surg. 2011;19(7): 402-409.
2.ECRI Institute. Healthcare risk control: Falls. March; 2009; ECRI Institute: Pymouth Meeting, PA. www.ecri.org
3.Centers for Disease Control. Costs of falls among older adults. 2013;Author: Atlanta, GA . http://www.cdc.gov/homeandrecreationalsafety/falls/fallcost.html
4.Curry L. Fall and injury prevention. In Patient Safety and Quality: An Evidence-based Handbook for Nurses. April 2008;Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/clinicians-providers/resources/nursing/resources/nurseshdbk/index.html
5.Stevens, J A, et al. The costs of fatal and non-fatal falls among older adults. Injury prevention. 2006;12(5):290-295.
6.Wu S, Keeler E B, Rubenstein L Z, Maglione M A, Shekelle P G. A cost-effectiveness analysis of a proposed national falls prevention program. Clin in Geriatr Med. 2010;26(4):751-766.
7.The Joint Commission. Preventing patient falls. 2013; Joint Commission Resources: Oakbrook, IL http://www.jcrinc.com/Preventing-Patient-Falls/
8.National Quality Forum. Serious Reportable Events in Healthcare–2006 Update. 2006; Author: Washington, DC. www.qualityforum.org
9.Centers for Medicare & Medicaid Services. Hospital-Acquired conditions.2012;Author: Baltimore, MD. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/index.html?redirect=/HospitalAcqCond
10.Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Inpatient fall prevention programs as a patient safety strategy: A systematic review. Ann Intern Med. 2013;158:390-6.
11.Oliver D, Healey F, & Haines TP. Preventing falls and fall-related injuries in hospitals. Clin in Geriatr Med. 2010; 26: 645- 692.
12.Agency for Healthcare Research and Quality. Preventing Falls in Hospital Falls: A Toolkit for Improving Quality of Care. 2013;AHRQ: Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/fallpxtoolkit/index.html
13.Institute for Healthcare Improvement. Transforming Care at the Bedside How-to Guide: Reducing Patient Injuries from Falls. 2012;Author: Cambridge, MAhttp://www.ihi.org/knowledge/Pages/Tools/TCABHowToGuideReducingPatientInjuriesfromFalls.aspx
14.Minnesota Hospital Association. Road Map to a Comprehensive Falls Prevention Program. In Patient safety: Call to action. 2011. Author. http://www.mnhospitals.org/Portals/0/Documents/ptsafety/falls/falls-prevention-roadmap.pdf
15.National Quality Forum. Safe practice 33: Falls prevention. In: Safe Practices for Better Healthcare–2010 Update. 2010.; Author: Washington, DC. www.qualityforum.org. Accessed November 15, 2013:381.
16.Neily J, Quigley P, & Essen K. Implementation Guide for Fall Injury Reduction: VA National Center for Patient Safety Virtual Breakthrough Series: Reducing Preventable Falls and Fall-Related Injuries. 2013; VA National Center for Patient Safety: Washington,DC. http://www.patientsafety.va.gov/
17.VA National Center for Patient Safety. Falls toolkit. 2004;Department of Veterans Affairs: Washington, DC. http://www.patientsafety.va.gov/professionals/onthejob/falls.asp#fallsnotebook
Standardize data reporting
Random Chart Audits Date of Audit Age Admitting Diagnosis Morse Score on Admission Fall Risks Identified Accurately Injury Risk Stratification Injury Risks Communication of Risk - DAR Documentation of Tailored
interventions Documentation of Pt Teaching -
Individual Risk Nursing Re-assessment Accurate Provider Assessment
Inter-professional Rounds Accurately report fall risk
Standardize education processVeteran Interviews Top Reasons at Risk 3 main reasons fall prevention is
important ◦ Falls for most part are preventable ◦ Falls can result in injury ◦ Falls can make hospital stay longer
3 actions to stay safe: ◦ Learn risk factors ◦ Call for help ◦ Wait for help
Two reasons to ask for help when going to bathroom ◦ Unfamiliar places increase fall risk ◦ BR are small & it is easy to lose balance or get dizzy
The main purpose to use call light is: to ask the staff for help
Locate call light: At bedside & in bathroom
The main reason to wear non-slip footwear
Patient not educated on their risk and why it is important to comply with prevention strategies leading to decreased likelihood that preventive steps taken
Lack of proper equipment e.,g., bedside commode, elevated toilet sear , prompts walk to BR and/or bending reaching that ↑ chance of falling
Overcrowded & cluttered room creates obstacles causing unsteadiness or trips that lead to falls and /or surfaces leading to injury
Six Sigma Fishbone or Cause-and-Effect for 4P’s (Plant, People, Policies and Procedure)
Vulnerabilities & Opportunities
Physician not attuned to assess and intervene to mitigate modifiable fall risk factors leading to ↑ chance of fall &/or injury
Patient behavior (confusion, impulsiveness, Unrealistic estimation of abilities) leads to unassisted ambulation
Staff not able to respond quickly (e.,g due to understaffing) leading to patient not waiting for assistance
Over emphasis on policy leading to burnout and non-adherence to best practices
Policy cumbersome to read, no method of assuring accountability, and limited resources for enforcement leading to sub-optimal implementation of fall prevention
Team members not aware of policy and not educated about the roles & responsibilities for implementing fall/injury prevention
Pt identified as at risk for fall and not stratified for injury risk decreasing likelihood that medical team is consulted about intervening to prevent injury
Fall precautions overused decreasing sensitivity and decreasing use of individualized interventions to prevent falls and/or injuries
Limited resources ,sitters to adequately supervise patients leading to unassisted position changesincreasing chance of falls
Injurious Falls
sixsigmatutorial.com
Pharmacist has not identified at risk meds- side effects that cause dizziness or confusion leading to fall
Lack of assistive PT equipment and protective equipment requiring patients to ambulate or transfer unassisted and potentially falling and getting injuried
Point Value (Risk
Level)American Hospital Formulary
Service ClassComments
3 (High) Analgesics,* antipsychotics, anticonvulsants, benzodiazepines†
Sedation, dizziness, postural disturbances, altered gait and balance, impaired cognition
2 (Medium)
Antihypertensives, cardiac drugs, antiarrhythmics, antidepressants
Induced orthostasis, impaired cerebral perfusion, poor health status
1 (Low) Diuretics Increased ambulation, induced orthostasis
Score ≥ 6 Higher risk for fall; evaluate patient
* Includes opiates.
† Although not included in the original scoring system, the falls toolkit team recommends that you include non-benzodiazepine sedative-hypnotic drugs (e.g., zolpidem) in this category.
Beasley B, Patatanian E. Development and implementation of a pharmacy fall prevention program. HospPharm 2009;44(12):1095-1102.
Provider Fall Evaluation Note
Fall Risk Evaluation• Pertinent Medical History• Identification of Risk Factors• Interventions linked to Fall & Injury risk
• PT consult• OT consult• PharmD consult• Orthostatic VS• Enhanced surveillance• Toileting assistance• Injury prevention
Post Fall Evaluation• Date of last known fall• Assessment for injury• Identification of factors contributing to fall