Transcript Fall Prevention in the Acute Psychiatric Setting.

FALLS IN THE PSYCHIATRIC
INPATIENT POPULATION AND
PREVENTATIVE MEASURES
THROUGH MULTIMEDIA
EDUCATION
Maria Bartlett, Alisa Foote, Kylie Griffin, Laura Lazzareschi, Emily Ycasas
PROBLEM IDENTIFICATION
& EVIDENCE-BASE
Problem Identification
Patients suffer:
• Increased morbidity + mortality
• Loss of trust
• Impaired sense of safety
Problem Identification
For every fall, there are:
• Delays in throughput and access
• Unused resources
• Costs not reimbursed by Medicare
Problem Identification
“Psychiatric units are the
second most common
setting for falls in the
hospital.”
(Kerzman, Cherit, Brin & Toren, 2003)
PICO Question
In inpatient psychiatric
patients, are fall prevention
strategies more effective at
decreasing patient fall rates
than using no formal patient
strategies?
Literature Review
Lit Search Terms:
fall AND prevention AND psychiatric.
CINHAL
Cochrane
29 Articles
Found
1 Article
Found
4 Relevant
0 Relevant
“Footnote
Chasing”
11 Relevant
Articles
Found
15 Total
Articles Used
Fall Risk Factors
• Physical Environment
– Poor Lighting
– Raised Bed
– Improper Equipment
• Risky Behavior of Patient
• Others: female gender, age, abnormal
balance and gait, arthritis, blindness,
increased length of stay, h/o prior falls.
Fall Risk Factors: Psychiatric
• Psychiatric dx increased risk of falling.
– Depression + Psychotic at highest risk.
• Related risk factors include:
– Cognitive impairment
– Dementia
– Orthostatic Hypotension
– Parkinsonism
– Polypharmacy
– Sedatives
Fall Risk Factors: Meds
• Medications associated with higher fall risk:
– Benzodiazepines
– Atypical Antidepressants
– Anticonvulsants
• Fall risk rises with increasing doses of
antipsychotics, anxiolytic, hypnotics,
sedatives, and antidepressants.
• Any combination of above drugs also
increase fall risk.
Falls at SMV
• Inpatient falls = potentially preventable.
– Elimination could mean a 7% reduction in
length of stay.
• Current fall evaluation:
– Schmid Fall Risk Assessment Tool
– Get Up and Go Test (mobility assessment)
• Universal Fall Precaution or High Fall Risk
protocol then implemented.
High Fall Risk Protocol
• Interventions include:
– Yellow armbands on patients
– Falling leaf place card on room
– “Fall risk” on brain + rounds board.
– Routine orthostatic BP monitoring
– RASS scale monitoring
– Utilization of individualized interventions from
the Interdisciplinary Plan of Care (IPOC)
EBP Suggestions
• Causes of falls are multifactorial, so
prevention must be also.
– Educational programs: Written information +
one-on-one follow up
• 50% reduction in fall in people with impaired
cognitive function.
– Utilization of equipment: tab alarms, bed
alarms, other restraint-free devices.
– Hip protectors in geriatric population
– Consider Physical Therapy consult
Education
• Primary means of fall risk reduction.
• Patient:
– Video education regarding epidemiology of falls,
self reflection of individualized risk, problem
area identification, development of
preventative strategies + behaviors, goal setting,
and goal review.
– Use of multimedia: written, video, professional
follow up decreases fall rates!
Education
• Staff:
– Continuing the change in culture
• Changing attitudes
• Changing approach
– Increased visual aids, media modalities will help
staff educate patients and remain aware of the
potentially devastating consequences of falls.
CAREFUL - DON’T FALL!
SIMPLIFIED
FALL
PREVENTION
POSTER
SMV FALL VIDEO SDSU SON '12
FALL REDUCTION VIDEO
PROTOTYPE
IMPLEMENTATION
STRATEGY
Protocol for Change
• Educate staff:
–Communicate necessity
–Communicate vision
–Communicate practice
(Gesme, D., & Wiseman, M. (2010). How to implement change in
practice. Journal of Oncology Practice, 6(5), 257-259. doi:
10.1200/JOP.000089)
Necessity
25
Actual Falls
Falls with injury
20
Goal
15
15
18
SMV’s fall
rate target is
<3.4%
14
10
11
12
10
Last met:
5
3.39
0
3.88
3.48
4.38
4.46
4.98
October
2011
Vision
• Nurses and Mental Health workers are to
ensure video is shown upon admission.
– Evidence shows multimedia education
with 1:1 follow up decreases falls.
• RN + MHW can have follow up discussions
regarding video with patients.
Practice
• Leadership can help by informing staff early
and often about new practice.
– Make video easy to access.
– Reward staff for input.
– Use email, telephone, face-to-face
communication
– Explain who, what, where, and why behind
practice change.
Protocol for Change
• Foster Team Culture:
– Develop Team aimed at common goal:
Patient Safety!
– Set clear expectations + educate staff
towards a sense of shared
accountability.
Protocol for Change
• Identify + Empower Champions
– Empower individuals to lead others
• Look for individuals with natural leadership
skills
• Identify innovators/technologically-friendly
Protocol for Change
• Provide feedback + positive
reinforcement
– Continue data collection
– Reward (WOWs!) staff proactive in implementing new
policy.
– Survey interdisciplinary team + patients for input on
video/improvements for future
– Evaluate data from before + after video implementation.
Protocol for Change
• Provide feedback + positive
reinforcement
– Continue data collection
– Reward (WOWs!) staff proactive in implementing new
policy.
– Survey interdisciplinary team + patients for input on
video/improvements for future
– Evaluate data from before + after video implementation.
Change Theory
• Seven Phases of Planned Change by Lippitt,
Watson, and Westley
– “Change Agents”: SDSU SON leadership students
• Present Change concept including benefits +
appraisal
• Cover change forces + resistance forces
• Ideally create more change agents to further
change potential
Change Theory
• Seven Phases of Planned Change
1. Becoming aware of need for change
2. Client system and change agents develop a
relationship
3. Change problem is identified
4. Change goals are set and achievement options
explored
Change Theory
• Seven Phases of Planned Change
5. Plan for change is implemented
6. Change is accepted and stabilized
7. Change entities redefine their
relationship
Wise, P. S. (2011). Leading and managing in nursing (4th ed.). St. Louis, Mo.:
Mosby/Elsevier.
Patients: Decreased
morbidity associated with
falls
SMV: Decreased length
of stay, reimbursed for all
services
Staff: New tool to
decrease falls
Stakeholders
Case Managers:
Decreased placement
issues
Insurance:
Lower bills
MD:
Healthier
patients
Strengths:
Weaknesses:
SWOT
Analysis
-Highly relevant problem
- Limited literature on aggregate
-Small margin of
cost/resource time
-Interventions supported by one
RCT
- Needs further research
Opportunities:
- Flexibility in media
options
- Room for creativity
- Could involve patients
in media development
- Sample size
Threats:
- Cost of professional video
production
- Can individualize
- Equipment needed to show
video on each unit
- Financial savings
through fall avoidance
- Ongoing support of staff and
management
Timeline
• Duration: Min 4 - max 6
months to incorporate the
multimedia fall prevention
education into the Sharp
Mesa Vista Culture.
Weeks 1-4
Furbish videos to all units. Educate staff on
new educational tools
Prepare materials
Weeks 5-8
Show videos upon admission. Show videos to
current patients.
Place posters in visible areas and pt’s rooms
Weeks 9-12
Reinforce staff implementation: Use email, phone, in person, and meetings to communicate
Weeks 13-16
See changes shown by monthly fall rates
Week 17-20
Provide positive feedback and reinforcement.
Reassess staff + patient input
Weeks 21-24
Continue to use data to document progress.
Fall Costs
Cost Benefit
7%:
Video
Production
Estimated:
$1,500 $8,000
Average
increased
length of
Inpatient stay
Viewing
Equipment
TV with DVD
player: $150
Computer:
Already
provided
Static
Media
Poster: $5$10
Handouts:
$0.03-$0.05
Staff
Resources
RN: 5 min for
video, 10 min
follow up
MHW: 10
min follow
up
(Greene et al., 2001)
$13,300:
Average
increased
cost
(Wong et al., 2011)
Potential estimated expenditure
References
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Ang, E., Mordiffi, S., & Wong, H. (2011). Evaluating the use of a targeted multiple intervention strategy in reducing patient falls in an acute care hospital:
a randomized controlled trial. Journal Of Advanced Nursing, 67(9), 1984-1992.
Anonymous. (2010). Multimedia patient education prevents falls. Irish Medical Times, 44(49), 41.
Blair, E., & Szared, B. (2008). Exploring relationship of psychotropic medications to fall events in an inpatient geriatric psychiatric population.
International Journal Of Psychiatric Nursing Research, 14(1), 1698-1710.
Centers for Medicare & Medicaid Services. (2008). Changes to the hospital inpatient prospective payment systems and fiscal year 2009 rates. Baltimore,
MD: Centers for Medicare & Medicaid Services.
De Carle, J., & Kohn, R. (2001). Risk factors for falling in a psychogeriatric unit. International Journal Of Geriatric Psychiatry, 16(8), 762-767.
doi:10.1002/gps.40
Fontenot-Miller, C., Lee, T., Mendoza, C., Ray, M. (2011). Results of Sharp Mesa Vista’s current fall protocol versus their previous fall protocol in
reducing patient falls. San Diego State University: School of Nursing.
Greene, E., Cunningham, C.J., Eustace, A., Kidd, W., Clare, A.W., & Lawlor, B.A., (2001). Recurrent falls are associated with increased length of stay in
elderly psychiatric inpatients. International Journal Of Geriatric Psychiatry, 16(10), 965-968. doi:10.1002/gps.463
Haines, T. P., Hill, A-M., Hill, K. D., McPhail, S., Oliver, D., Brauer, S… Beer, C. (2011). Pt education to prevent falls among older hospital inpatients.
Archives of Internal Medicine, 171(6), 516-524.
Kerzman, H., Chetrit, A., Brin, L., & Toren, O. (2004). Characteristics of falls in hospitalized patients. Journal Of Advanced Nursing, 47(2), 223-229.
doi:10.1111/j.1365-2648.2004.03080.x
Knight, M., & Coakley, C. (2010). Fall risk in pts w/ acute psychosis. Journal of Nursing Care Quality, 25(3), 208-215.
Lavsa, S. , Fabian, T. , Saul, M. , Corman, S. , & Coley, K. (2010). Influence of medications & diagnoses on fall risk in psychiatric inpatients. American
Journal of Health-system Pharmacy : AJHP : Official Journal of the American Society of Health-System Pharmacists, 67(15), 1274-1280.
Neyens, J., Dijcks, B., Twisk, J., Schols, J., van Haastregt, J., WJ, & de Witte, L. (2009). A multifactorial intervention for the prevention of falls in
psychogeriatric nursing home pts, a randomised controlled trial (RCT). Age & Ageing, 38(2), 194-199. doi:10.1093/ageing/afn297
Poe, S., Cvach, M., Gartrell, D., Radzik, B., & Joy, T. (2005). An evidence-based approach to fall risk assessment, prevention, & management: lessons
learned. Journal Of Nursing Care Quality, 20(2), 107-118.
Semin-Goossens, A., van der Helm, J. M. J., & Bossuyt, P. M. (2003). A failed model-based attempt to implement an evidence-based nursing guideline
for fall prevention. Journal of Nursing Care Quality, 18(3), 217-255.
Sharp Mesa Vista (2011). Fiscal Year Report Sheet. (Unpublished fiscal year report). San Diego, CA.
Spoelstra, S. , Given, B. , & Given, C. (2012). Fall prevention in hospitals: An integrative review. Clinical Nursing Research, 21(1), 92.
Sterke, C., van Beeck, E., van der Velde, N. , Ziere, G. , Petrovic, M. , et al. (2011). New insights: Dose-response relationship between psychotropic drugs
and falls: D study in nursing home residents with dementia. The Journal of Clinical Pharmacology.
Tzeng, H. (2011). Nurses' Caring Attitude: Fall Prevention Program Implementation as an Example of Its Importance. Nursing Forum, 46(3), 137-145.
doi:10.1111/j.1744-6198.2011.00222.x
Vaughn, K., Young, B., Rice, F., & Stoner, M. (1993). A retrospective study of pt falls in a psychiatric hospital. Journal Of Psychosocial Nursing & Mental
Health Services, 31(9), 37.
Wong, C. A., and others. The cost of serious fall-related injuries at three Midwestern hospitals. The Joint Commission Journal on Quality and Patient
Safety. 37(2):81-87, February 2011
DISCUSSION QUESTIONS