Transcript Falling For You! Strategies to Strengthen a Falls Risk and

ing
For You!
Strategies to Strengthen a Falls Risk
and Prevention Program
Vivian Dodge, RN, BSN, MBA
November 2012
Hospice of Palm Beach County
• 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 & Branches
Steps to “Grow” Your Program
Define goals
Develop
Definitions
Adopt a Falls Risk
Screening Tool
Establish PIP or
Committee
Review Standards &
Regulations
Collect Data
Review Gaps
Educate and
Engage
Provide
Feedback
Ongoing Data
Evaluation
Steps to get on the right track
1) Establish the components for your Falls
Program
2) Structure a PIP or committee
3) Identify challenges / opportunities
4) PDCA !
5) Evaluate data & outcomes and continually
re-evaluate the effectiveness of your
program
Branch 1:
• 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
Branch 2:
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?
Branch 3:
• 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?
Branch 4:
• 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
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
Medications/sedatives/hypnotics
5
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
Patient Score
Branch 5:
• 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
Branch 6:
• 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 data
Number of falls
Attended / Unattended
Injury status: No injury, Minor injury, Fractures, Death
911 calls
Time of event
Category of fall
Frequent Fallers
Team & Region
Treatment
 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 Floor
Rolled out of Bed
Bathroom / toileting related
Ambulation
 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 urgency
Anti-hypertensive meds, sedatives, narcotics- Sleeping, pain
& blood pressure medications can cause hypotension and
effect alertness
Psychoactive 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
information
staff present
• 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
Patient safety begins with HPBC’s
Fall Prevention Program
PREVENT YOUR PATIENT FROM
BECOMING A
FALLING STAR
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
Remember To:
•Use the Fall Stickers
•Use the Fall Stickers on the patient folders in the
home
•Update Care Plans
•Educate Patient / Family / Caregiver
HPBC Facts
Average 115-130 falls per month
Fall 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 evening
25% occurred during the night
Most Falls Occurred Unattended in the Homes
Only 6 Serious Injuries (Fractures –Mostly Hip FX’s)
Remember To:
Patient safety begins with HPBC’s
Fall Prevention Program
 Use the Fall Stickers
 Use the Fall Stickers on Patient Folders in the Home
 Update the Care Plans
 Educate the Patient / Family / Caregiver
Summer Star Gazing
Looking for Falling Stars
GOAL: Keep HPBC fall rate to < 1% of patient days :Currently at 0.41%
•Educate, Educate, Educate!
Proper Body Mechanics
Paint the
Picture
Who?
What?
Where?
When?
Why?
How?
•How to use DME Equipment
Safely
Fall Prevention Tips
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 deaths
There 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 False
From your HPBC Falls Workgroup
TT
FF
 Our Fall Rate has decreased!
FY 2010
Apr-10
May-10
Jun-10
# of Falls
137
131
139
FY 2011
Apr-11
May-11
Jun-11
# of Falls
106
109
103
%↓
23%
17%
26%
 Our staff is doing a great job in reporting witnessed falls
and unwitnessed falls
 Good follow-up from SNF teams on reported falls
 Sapphire/After hours/ Weekend Staff:
Kudos for RADT 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
Fall Prevention Tips
 Assess for BSC needs and recommend usage
From
The Falls Workgroup
Old Way
Better Way
You 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
2000
Hospice of Palm Beach County
Yearly Comparisons
1805
Number of Patient Falls
1800
1639
1600
1458
1400
38%
reduction
1119
1200
1000
800
600
400
200
0
FY 2009
FY 2010
FY 2011
FY 2012-Year to
Date
Hospice of Palm Beach County
Fall Rate Comparison Chart
(Fall Rate per 1000 Pt. Days)
FY 2011 vs. FY 2012
5.00
4.50
4.00
Fall Rate per 1000 Pt. Days
3.50
3.00
2.50
2.00
1.50
1.00
0.50
0.00
October
November December
January
February
March
April
May
June
July
August
September
Falls FY 11
3.45
3.76
3.53
4.22
3.39
3.38
2.90
2.88
2.85
2.93
3.07
3.81
Fall FY 12
3.31
4.32
3.30
3.79
3.41
3.39
3.16
2.97
2.75
2.11
2.33
0.00
Hospice of Palm Beach County
Quarterly Comparison of Patient Falls
FY 11-12
450
413
401
400
350
317
300
250
200
161
150
100
50
0
Qtr 1: Oct-Dec
Qtr 2: Jan-Mar
Qtr 3: Apr-Jun
Qtr 4: Jul - Sep YTD
30
27
N=77
Categories of Patient Falls
July 2012
25
20
15
12
11
10
6
5
Series1
5
5
4
4
2
0
1
• Little comparative data on falls in the hospice
industry
• Home health, acute hospitals collecting data
for years
• Future? Required reporting?
• NHPCO initiatives
Establish process/protocols
Educate
Engage
Question
Quantify
Quality check
References:
-National Quality Measures Clearinghouse, www. qualitymeasures.ahrg.gov
-Agency for Health Research and Quality (AHRQ), www.ahrg/qual
Institute 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
-
Questions?
Vivian Dodge, RN, BSN, MBA
Hospice of Palm Beach County
Office: 561-227-5171
Email: [email protected]