1

VISN 8 Patient Safety Center of Inquiry: Journey for Change:

Innovations to Reducing Fall Incidence and Injury

Session 6: “Intervention s to Reduce Falls and Falls Harm, Part 2

Thursday, Jan 17, 2013

Program Goal

To provide VHA healthcare and quality teams with tools and strategies to reduce preventable falls incidence, injury from falls and outline key components of sustaining and spreading successfully.

2

Objectives

• Inventory tests of change in fall and injury prevention interventions

• Differentiate types of falls as a basis for analysis of program effectiveness

• Integrate injury prevention into existing fall prevention programs

• Summarize successes ready for adoption and spread

3

Looking Ahead

Eight Sessions of Learning and Sharing

• Oct 25th: State of Science of Falls and Injury Prevention• Nov 8th: Integrating Falls and Injury Assessment• Nov 29th: Interventions to Reduce Falls and Harm, Part 1 (Equipment and

Technology)• Dec 20th: Injury Risk Assessment and Communication of Risk• Jan 3rd: Sustain and Spread Improvements in Reducing Falls and Injury from

Falls• Jan 17th: Interventions to Reduce Falls and Harm, Part 2 (Intentional Rounding,

Pre-shift Huddle, Post Fall Huddles)• Jan 31st: Use of VANOD, NDNQI and SPOT Databases for Fall Program Evaluation• Feb 7th: Summary of Your Accomplishments

4

5

For Today!

• Intentional/Purposeful Rounding – Annette Galinski, RN, NM, Palo Alto; Pat Quigley

• Pre-shift Huddles – Pat Quigley• Post Fall Huddles-Levanne R. Hendrix, GNP,

MSN, PhD, Nursing Quality Management, Extended Care, and Karen Boatright,RN, ACNS-BC, Extended Care Service

• Post Fall Huddles –Charlene David, RN, ACNS, BC, Pittsburg VAMC

6

Intentional Rounding

Dr. Pat Quigley, ACNSRAnnette Galinski, RN

11

Intentional Rounding

• Clinical Rounds with specific intention: – Strategy to improve communication between the

nurse and patient– Strategy to improve patient satisfaction with care– Innovation in patient safety– Increase patient participation as active partner is

care

7

Beginnings

• Developed by the Studer Group, another way to organize existing work

• Purpose: To anticipate and meet patient needs routinely and ensure patient safety (Shaner & McRae, 2007)

• Allow information to be gathered in a structured way, addressing problems as they occur (Studer Group, 2005)

• Addresses patient needs proactively8

Performing Intentional Rounding

• Specific scripts for consistency and reliability of the content

• Defined methods to hardwire implementation• During Hand-off, explain to the patient who

would be checking on them hourly (or frequency) to enhance their safety and address personal needs

• Schedule tasks during the rounds• Before leaving the room, address the 4 “P’s”

9

The 4 “P’s”

• Pain• Personal Needs (toileting)• Positioning• Placement

Immediately before leaving the room, ask the patient if anything else was needed, emphasizing the nurse has the time to address any needs

Lastly, inform the patient when the nurse would return

10

Study Designs:

• Melnyk: Meade, et al, (2006): quasi-experimental study: hourly rounding, bi-hourly rounding, and control, no regular rounding. 46 units in 22 hospitals: hourly rounding more effective than every 2 hour rounding and the control; 2 hour rounding more effective than control

(no randomization)• Halm Article Review: 11 reports

11

Results

• Reduction in call light use • Decrease in falls • Decrease in pressure ulcers• Improved patient satisfaction and likelihood of

recommending the hospital• Improved nursing satisfaction: care is more

efficient and less stressful • Positive results exceed expectations

12

Evidence Reviews• EVIDENCE-BASED PRACTICE CENTER: MADISON WISC VA: DR.

BEVERLY PREIFER• Since the publication of the Meade article, there have been other

studies examining hourly rounding and fall prevention. • Additional Researchers found

– no difference in fall rates after one year of hourly rounding. – decrease in call light use but no difference in falls after implementing

hourly rounding.• Hourly rounding presents no harm to patients, • Nurses / Teams need to clearly understand why they are

implementing hourly rounding: what are the expected outcomes, and decide on your have the capacity for implementation.

13

Additional Actions

• Toilet before giving pain medication• Test patient knowledge (and skill) about fall and

injury prevention• If prescribed hip protectors and /or helmet, inspect

to ensure they are on• If floor mats required and patient in bed, observe

for floor mat• Observe height of the bed (relevant to patient

activity: if patient resting, is it in low position; if patient out of bed, is the bed raised-up)

14

Answers

– Accidental Falls– Anticipated physiological Falls– Unanticipated physiological Falls– Intentional Falls

15

Is your approach likely to be successful?

16

WE’VE GOT THE SPIRITAT CLC2 IN LIVERMORE

ANNETTE GALINSKI, NURSE MGR.

IMPLEMENTATION STRATEGIES

OUR CURRENT ACRONYM FOR OUR FALL PREVENTION PROGRAM IS S-P-I-R-I-T -- WE’VE GOT THE SPIRIT TO MAKE FALL REDUCTION A PRIORITY, ESPECIALLY AFTER WE HAD ONE MONTH OF 11 FALLS IN OCTOBER.

WE NEEDED SOMETHING FRESH AND NEW TO GET STAFF INTERESTED AGAIN.

WE ROUND HOURLY ON THE RESIDENTS WHO ARE THE HIGHEST FALL RISK, UTILIZING THES-P-I-R-I-T GUIDELINES.

REASONS BEHIND SPIRIT AND WHAT IT STANDS FOR:

SAFETY: SAFETY OF THE ENVIRONMENT IS KEY.

PAIN: ESPECIALLY IN OUR HOSPICE RESIDENTS, PAIN CAN LEAD TO FALLS

INGESTION: OFFERING FOOD AND FLUIDS OFTEN WORKS TO PASSIFYRESIDENTS WHO ARE FIDGETING IN THEIR CHAIRS

RESTLESSNESS: TERMINAL RESTLESSNESS IS SEEN IN HOSPICE RESIDENTS AS WELL. STAFF NEED TO OBSERVE TO ASCERTAIN THE CAUSE

INVOLVEMENT: RESIDENTS NEED TO BE INVOLVED IN ACTIVITIES

TOILETING: MANY FALLS SURROUND TOILETING ISSUES. STAFF NEED TOBECOME AWARE OF HABITS OF THEIR RESIDENTS.

CHANGES WE HAVE MADE

SOME DAY SHIFT STAFF AGREED TO ROTATE INTO A SPLIT SHIFT TOUR SO THAT THERE WOULD BE MORE STAFF SUPPORT ON EVENINGS THROUGH THE DINNER HOUR AND THE EXPECTED TOILETING RITUAL SOON AFTERWARD.

“STOP” SIGNS HAVE BEEN POSTED ON BATHROOM DOORS.

WE ARE AGGRESSIVELY ENCOURAGING RESIDENTS TO USE HIP PADS.

WE HAVE OBTAINED A LARGE BULLETIN BOARD FOR QM MONITORS AND HAVE A VERY VISIBLE MONTHLY CALENDAR IN WHICH WE POSTEACH FALL A ND WHAT TOUR IT OCCURRED ON. THIS IS A GREATPEER PRESSURE TOOL.

WE STARTED A NEW PRACTICE IN PEER TO PEER HAND OFFS AT CHANGE OF SHIFT. HANDOFF WILL INCLUDE WHAT HAS BEEN GOING ON WITH THE RESIDENTS, WHAT WORKED AND WHAT FALL MEASURES DID NOT WORK.

PM SHIFT STAFF MAKE SURE THAT WHEN THEY ASSIST A RESIDENT TO BED THAT THEY AUTOMATICALLY PUT ON NON-SKID SOCKS.

FOR RESIDENTS WITH A CHANGE IN CONDITION, THE EXPECTATION IS TO HAVE STAFF TAKE TURNS IN CLOSE MONITORING.

DAY STAFF TAKES OWNERSHIP IN MAKING SURE FALL PREVENTION SUPPLIESARE READILY AVAILABLE.

UNIT BASED COUNCIL HAS TAKEN ON FALLS AS ONE AREA OF CHANGE ANDMEMBERS ARE BRAINSTORMING NEW IDEAS FOR FALL PREVENTION.

CC

CHANGES WE HAVE MADE

CHANGES WE HAVE MADE

WE ARE ENCOURAGING STAFF ON ALL SHIFTS TO TAKE OWNERSHIP OF OUR PROGRAM.

WHEN THERE IS A FALL, THE GROUP OF STAFF ON THAT SHIFT DISCUSSES IT AND NOT ONLY GOES OVER THE FALL DURING THE POST FALL HUDDLE, BUT TRY TO COME UP WITH NEW IDEAS OR RESOLUTIONS TO HELP PREVENT A SIMILAR EVENT FROM HAPPENING. THIS INFORMATION CANGO INTO THE POST FALL HUDDLE NOTE.

WE HAVE ALSO DIVIDED BREAK TIMES INTO 3 DIFFERENT TIMES ON DAY SHIFT TO MAKE MORE STAFF AVAILABLE ON THE FLOOR DURING LUNCH.WE ARE ENCOURAGING THE EVENING STAFF TO DO THE SAME.

RELIABILITY CHECKS

FALLS CHAMPIONS AND CHARGE NURSES ARE MAKING SURE THATASSIGNMENTS ARE MADE EACH SHIFT AND THAT THE ROUNDINGTOOL IS BEING FILLED OUT EACH HOUR. WHEN ROUNDING, STAFFARE ASKING THE RESIDENTS IF THEY NEED ANYTHING WHILE THEYARE IN THE ROOM.

SOME RESIDENTS HAVE EXPRESSED SATISFACTION WITH HOURLYROUNDING AND APPRECIATE THE EXTRA ATTENTION.

OUTCOMES

SINCE WE HAVE JUST BEGUN THIS NEW “WE’VE GOT THESPIRIT” PROGRAM, WE HAVE ONLY ONE QUARTER OF DATA.OCTOBER 11 FALLS, NOVEMBER 3 FALLS, DECEMBER 2 FALLS

WE CAN SAY THAT WE HAD ONLY ONE FALL WITH INJURYOVER THE PAST YEAR.

OUR FALL DATA FOR 2012 WAS 47 FALLS AS COMPARED TO2011 IN WHICH WE HAD 59 FALLS SO OUR FALLS ARE DECREASING.

WE ARE WORKING VERY HARD TO HAVE LESS FALLS IN 2013.

Challenges

• Use of formal scripting• Hardwiring• Sustainability• Accepting rounds are value added

25

Other Outcomes

• What Type of Falls would be sensitive to intentional rounding? Your choices are:– Accidental Falls– Anticipated physiological Falls– Unanticipated physiological Falls– Intentional Falls

26

27

Pre-shift Huddles – Pat QuigleyStandardize Safety Communication

• High Fall Risk communication in hand-offs:– Nurse-to-nurse hand-off (including unit-to-unit)– Charge-nurse-to-charge-nurse hand-off– Purple hand-off form (Ticket to Ride) for off-unit

movement• Best Practice: Safety Huddles (at shift change

or on rounds) verbally tell the whole team who is vulnerable, at greater risk for falls and Injury and WHY

40

28

The Proactive Safety Huddle

Goals:• To make entire staff aware of which patients

are at risk for fall and injury and WHY• To create awareness of specific prevention

measures in place for each patient• To create team vigilance for all unit patients at

risk• To reduce anticipated physiologic falls

41

29

Method: Pilot Unit

• On 5 South: After nurse-to-nurse hand-off, the entire unit comes together for a brief (10-15 minute) shift huddle. Each patient who is at even greater risk for falls and injury is discussed: what is their fall risk level (score)? Reason for risk level (age, condition, meds, history of falls, mental status, etc).

• Also shared in the huddle is any other change or event that wasn’t already identified in the shift report (increased agitation, addition of diuretics, etc)

42

30

Items for Change of Shift Huddle(s) updated 10-6-2010• PATIENT ITEMS• UPDATES ONLY – around the room. Please, do not read your whole report.• DNRs• High acuity patients• Patients at risk for FALLS – Patients at risk for HARM from falls (h/o Osteo, low platelets,

h/o falls, on anticoagulants, fall scale score of 50 or greater, 85 or older). Check for bed alarm activation.

• Hip protectors, yellow arm bands are in supply room.• HIP PROTECTORS ON PATIENTS WITH H/O HIP SURGERY, BONE DISEASE, ETC.• Patients receiving chemotherapy• Identify patients to be turned every 2 hours (even hour).• Patients at risk for skin breakdown.• Discharge appointments times• PRN effectiveness list printed every 2 hours automatically. Please check list.• Patients on tele• STAFF ITEMS_________________________________________________________

43

31

Method: Test Unit Two

• On 6 South: An hour into the tour, the charge nurse conducts a huddle of all the unit staff to discuss patients who are at higher risk for falls and injury and other safety issues (restraints, name-alerts). The charge nurse asks: “What makes this patient a high fall risk?” (previous fall, confusion, anemia, syncope, etc)? What is the plan to keep the patient safe?

44

32

DATE:

Proactive Safety Huddles The Proactive Safety Huddle focuses on: Preventable physiologic falls, near misses on the off-going shift and addresses potential safety concerns for the upcoming shift. Huddle is held at the beginning of each tour by the Charge Nurse and lasts no more than 10 minutes.

PATIENT NAME/ ROOM #

WHAT MAKES THIS PATIENT A HIGHER FALL

RISK? History of falls? Confusion? Post-op? Polypharmacy? Dehydration? DX: Anemia, Syncope, etc.?

WHAT I S THE PLAN TO KEEP THE PATI ENT SAFE?? (Orthostatic BPs; huddle with MD team; meds adjustment; nursing close obs, etc.)

Charge Nurse Notes

45

33

Benefits of Proactive Safety Huddle

• Better customization of care for vulnerable patients • Enhanced staff learning about fall contributing and

prevention factors• Improving “systems thinking” among the staff• Better sense of “community”; everyone is involved

in keeping all the patients safe, not just “theirs”• Building upon one another’s knowledge of the

patients individual needs and issues• Decrease in anticipated physiologic falls

46

34

Veterans Affairs Palo Alto Health Care SystemNursing Quality & Safety Council

Falls Prevention Team

Levanne R. Hendrix, GNP, MSN, PhDNursing Quality Management, Extended CareKaren Boatright,RN, ACNS-BC, Extended Care Service

35

VAPAHCS Fall Prevention Team

About Us:VAPAHCS has 833 operating beds, 360 are CLC, 94 acute med-

surg, 92 acute psychiatry, 43 spinal cord injury, 32 blind rehab, and 30 traumatic brain injury beds.

We consist of 3 inpatient divisions at 3 sites, and 7 outpatient clinics (CBOC’s).

We have over 3,660 full time employees.

36

VAPAHCS Falls Prevention Team

POST FALL HUDDLE GUIDELINE

BACKGROUND – (Refer to Guideline)FY 2011 – VAPAHCS had 850 inpatient falls

• 355 of the falls were repeat falls (3+)• All except 7 of the repeat falls (3+) were in CLC’s• There was only one serious injury of the repeat

falls (3+)• Acute care inpatient areas had veterans who fell

only once or twice.

VAPAHCS Falls Prevention Program

5 Point Program for all Clinical Units:1) Hip Protectors2) Non-Skid Socks

a. Yellow – All patients needing socks & high risk.b. Red – Highest risk for fall & injury.

3) Floor Mats4) Bed & Chair Alarms5) CALL DON’T FALL Stop signs – Patient Rooms

& Bathrooms.

VAPAHCS Falls Prevention Program

FALLS With SERIOUS INJURY:FY2011 - 23 FallsFY 2012 – 9 Falls Reduction of 61 %

FALL PREVENTIONIs Everyone’s Business!

39

VAPAHCS Falls Prevention Team

POST FALL HUDDLE GUIDELINE

IMPLEMENTATIONFalls Team Goal for FY 2012 – Standardize the Post Fall

Huddle Process• Developed & refined by the Falls Prevention Team• No duplicate documentation• Focus Analysis on individual falls • Stimulate Critical Thinking• Collection of Data by types of Fall (Anticipated,

Unanticipated, Accidental)• Encourage integration of ABCS for risk of injury• Guideline introduced by unit-based Falls Champions

40

VAPAHCS Falls Prevention Team

POST FALL HUDDLE GUIDELINE

SUSTAINABILITYForm is purposefully de-identified Used for individual analysis and aggregate review at

unit level (new).Information is used for monthly reporting.Guideline forms and monthly reports used to

perform a written quarterly analysis and report (new).

Quarterly reports are shared with the interdisciplinary VAPAHCS Falls Prevention Team.

41

Post-Fall Huddle: Acute Care Side

Great tool for the Manager , staff nurses, and Falls Champions to have open discussions for other preventive measures.

Guides the Staff Nurse in interventions and critical thinking when a fall occurs.

Feedback from staff: easy checklist Visually helpful: post-fall huddle paperwork compiled

into a binder.Courtesy of Evamarie De Mayo, RN Staff Nurse

42

Roll out of the Post Fall Huddle Guideline in the CLCs

• Training & Buy-in

• Critical thinking

• Documentation

• Communication

43

How Are We Doing Thus Far?

Successes: Challenges:• Staff that fully utilized the

Huddle Guideline revealed:– more thorough documentation– collaboration with team– improved written and verbal

communication– awareness and follow-through

for risk for injury interventions

• Staff that have not fully utilized the Huddle guideline revealed:– incomplete documentation – Key risks factors not addressed – Opportunities for individualized

interventions missed – Did not incorporate critical

thinking with ABCS and Morse results

44

Challenges for FY2013

• Recent audits indicate that information (fall prevention interventions and injury prevention interventions) from the Post Fall Huddle Guideline is not being documented in CPRS notes and the care plan.

• There is inconsistent use across clinical units.• Action: We will review the documentation

process for usability & duplicate documentation.

45

What’s next?

• Continue audits of all Fall reports and huddles

• Education- 1:1 and as a group with in-services and through the monthly Falls Team meetings

• Advocate for a CPRS Post Fall Template

Safety Huddle/Fall Consult for Repeat Fallers

Charlene M. David, RN, ACNS, BCVA Pittsburgh Healthcare System

What is it?

• In depth examination of veteran’s fall risk factors, risks of injury, history of falls, and environment.

• The huddle/consult ‘s sole purpose is to ensure Veteran’s risk factors are matched with interventions to reduce risk.

Who is involved?

Varies depending on availability of caregivers & veteran’s needs: – Care givers closest to the veteran i.e. RN’s, NA’s, NP,

physician– Veteran and significant other – Specialty services if needed– Unit administration– Pharmacist– Staff member dedicated to fall reduction i.e. CNS, fall

coordinator, unit fall champion.

When is it completed?

• Soon as possible after 2nd fall• May be delayed d/t:

– Admission to acute care– Availability of essential staff

Where is it completed?

• In the Veteran’s environment

First Step: Come to Huddle/Consult Prepared by Listing Risk Factors

• In depth review of Veteran’s:• Interventions currently in place and attempted to reduce risk

– PT, OT, Restorative, safe exiting side, hip pads, mats alarm, est.• History of falls

– Actions, environment, time, participating factors, devices in use/or not, injuries with falls• Physical ability

– SPH equipment needed, Rehabilitation Therapy opinion, ambulatory aids used, hx of ADL functionality

• Medical history– Acute/chronic illness; Medication history including recent changes, sedatives, poly

pharmacy, ; Cognition including safety awareness, anxiety issues, agitation, confusion; Sensory deficits.

– Determine risk of injury» Bone disease» Hx of fractures» Advanced age» Liver disease» Cancer’s or cancer therapy that compromised bone marrow» Anti-coagulant use

Second Step: Staff interview

• Ask specifically why they feel the Veteran is at risk and how they can help reduce his/her risk

• Interventions are often unique:– Ensuring clock is in view to decrease anxiety

regarding time of activities– Using foam pool floaties to cover hard sink edges– Ensuring room objects are always in same place to

aid in decreased anxiety

Third Step: Conduct Huddle/Consult

• All available care givers should be involved in the assessment including the significant other and the Veteran

• What is done during evaluation:– Evaluation of environment

• w/c, bed, pathways, lighting, est.

– Veteran/Significant other conversation • Tell me what happened? Why? What can we do to keep you safe

from falls? • Provide education including plan to keep veteran safe from falls

– Veteran demonstration of skills• Gait, transfer, stand, sit, est.

Step Four: Implement Plan based on Risk

Examples of a few very generic risks and matched interventions: Mobility impairment

Consult OT, PT, w/c consult, Restorative Care Safe exiting side of bed Ensure Veteran has proper ambulation device

Sensory deficit Educate Veteran to look through bottom lenses while walking Consistent lighting

High risk for hip fracture Hip pads, low bed while resting

Anxiety Consult geriophyscology Decrease stimulation Alternatives i.e. music, lavender

Final Step: Documentation

• Should include:– Caregivers present (include Veteran & significant

other)– Hx of Falls– Risk Factors for falls and injury– Unit staff input– Veteran Input (if available)– Veteran education given– Evaluation and Recommendation (match risks)

Huddle/Consult Aids with…

• Veteran Education• Staff Education• Reducing Risk of falls/injury• Liability

57

AAR Part 2: Types of FallsSelect which type of fall occurred. Select only one of the first four types of falls. Part 1. Fall Type• Accidental Fall: Fall due to extrinsic environmental risk factors: spill on the floor, clutter, tubing / cords

on the floor, etc. Or

• Anticipated Physiological Fall: Factors associated with known fall risks as indicated on the Morse Fall Scale: loss of balance, impaired gait or mobility, impaired cognition/confusion, impaired vision. Falls that we anticipate will occur to the patients’ existing physiological status, history of falls, and decreased mobility upon assessment. Or

• Unanticipated Physiological Fall: Factors associated with unknown fall risks that were not predicted on a fall risk scale: unexpected orthostasis; extreme hypoglycemia; stroke; heart attack.Or

• Intentional Fall: Patient who voluntarily positions his/her body from a higher level to a lower level. Part 2. Additional Fall Information

Select the following items if the fall was assisted by staff or a repeat fall for this patient:• Assisted Fall: Patient was physically assisted to the floor by a staff member.• Repeat Fall: A fall has already occurred for this patient

Morse J. (1997). Preventing patient falls. CA: Sage.

38

58

Benefits of Post-Fall Huddle

• Identify root cause of fall • Prevent recurrence• Update the care plan• Define type of fall that occurred• Educate patient and family about causes

of fall and prevention, protection strategies

39

Outcomes

• Intentional Rounds: Reduce accidental and anticipated physiological falls

• Pre-shift Huddles: Reduced anticipated physiological falls

• Post-fall Huddles: Eliminate repeat falls (same type and root causes), Changed Plan of Care, Reduce Accidental and Anticipated Physiological Falls

59

60

Assignments for Next Week

• Test intentional rounding on one or more of your patients at high risk for falls or injury

• Test the pre-shift huddle • Test the post-fall huddle • Examine strategies to hardwire these practices

60

61

Looking Ahead• Next Session

–Jan 31st: Use of VANOD, NDNQI and SPOT Databases for Fall Program Evaluation

• Feb 7th: Summary of Your Accomplishments