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

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Questions?Vivian Dodge, RN, BSN, MBAHospice of Palm Beach CountyOffice: 561-227-5171Email: vdodge@hpbc.com