Transcript [Team Name] - Canadian Patient Safety Institute

SunCountry Health Region
LTC Falls Prevention Program
Background

1980’s – Some Falls Prevention measures
were being done but not called “falls
prevention”:
 Baby
monitors, lowered beds, mattress on
floor, bells on side rails, and moving residents
closer to nursing station.
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22-Jul-15
1992 – District wide incident reporting
process that involved falls.
Saskatchewan Falls Collaborative
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Background
2004 – Each LTC facility became more
responsible for TLR
 2005 – TUGS started but did not happen
everywhere
 May 2008 – National Falls Collaborative
where one of our facilities took part in a
pilot project that reduced our number of
falls by 40%.
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Background
Sun Country Health Region has 18 Long
Term Care facilities and 543 LTC beds.
 Sun Country Health Regions Vision:
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 “Healthy
People in Healthy Communities”
Aim
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To decrease the number of residents who experience a fall by
20% by March 31st, 2012
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Scope & Boundaries
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Objectives:
1.
2.
3.
4.
5.
22-Jul-15
All residents of LTC who are mobile for transfer or ambulatory, and
home
Educate staff, residents and families about the initiative.
100% of LTC facilities to have inservice on falls program.
100% of facilities will have a Falls Prevention display board put up by
October 2011.
Falls Risk Assessment will be completed on admission, change in
status, after a fall and annually.
100% of all new residents will have a Fall Risk Assessment &
documented intervention on care plan.
Saskatchewan Falls Collaborative
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Goals
1.
2.
3.
4.
5.
6.
20% decrease in number of falls and fallers
20% decrease in number of injuries from falls
No increase in restraints
100% of residents are screened
100% of staff have Fall Prevention inservice
Medication audit on high risk residents (pilot)
Team Members
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22-Jul-15
Candy Bye - RN
Florie Restau – Nurse Manager, Wawota
Marnell Cornish – Nurse Manager, Tatagwa View
Debbie Obst – Nurse Manager, WSCH
Jenniene Greenbank - LPN
Laurie Cole – Nurse Manager, Gainsborough
Anna Erick – Recreation Worker
Sarah Veroba - RN
Lillian Ly - Dietician
Deb Kennett-Russill – Clinical Coordinator of Therapies
Laura Kehrig – Falls & Injury Prevention Coordinator
Amy Ryan – Quality Improvement & Patient Safety Manager
Felecia Watson - Regional Director of Strategic Planning
Saskatchewan Falls Collaborative
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Results
 We did a formal format for 3 questions and increased an
awareness to staff (was very positive).
 Falls Prevention is on our new staff orientation course.
 Every LTC facility in our region has a Falls Prevention
Display Board that has a new Falls Prevention topic on it
every month.
 Our collaborative members presented a hip protector
inservice for staff and have started Implementing them in
our facilities.
 Our Region formed a Regional Falls Prevention Working
group made up of LTC, HC, AC, Mental Health, OTs,
Nutrition, Pharmacy, EMS and Community.
22-Jul-15
Saskatchewan Falls Collaborative
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Results: Vitamin D
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A nutritionist joined our Sask.
Falls Collaborative team.
Two collaborative members
wrote a letter to the doctors in
our region to ask them to start
prescribing vitamin D to
seniors in our region.
Two collaborative members
did 2 vitamin D presentations
to staff in our region. They
were great successes.
Results
Number of Falls
Number of Falls in LTC Facilities
70
60
50
# of Falls
40
Series1
30
20
10
0
April
May
June
July
Months
August
September
October
Results
Number of Injuries from Falls
Number of Falls with Injuries in LTC Facilities
25
# of falls with Injury
20
15
Series1
10
5
0
April
May
June
July
M onths
August
September
October
Results
Number of Fallers
Number of Fallers in LTC Facilities
45
40
35
30
# of Fallers
25
Series1
20
15
10
5
0
April
May
June
July
Months
August
September
October
Results
Number of Restraints
Number of Restraints in LTC Facilities
3.5
3
2.5
# of Restraints
2
Series1
1.5
1
0.5
0
April
May
June
July
Months
August
September
October
Changes Tested
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A couple facilities in
our region put
laminated 3
question posters
above the bed in
every resident’s
room.
Sun Country Health
Region Fall
Prevention
Please ask resident these
3 questions before
leaving the room:
1. Do you need to use
the toilet?
2. Are you comfortable?
3. Can I get you
anything else?
22-Jul-15
Saskatchewan Falls Collaborative
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Changes Tested
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One facility trailed a new Falls Tracking Tool.
The facilities involved in the collaborative did
surveys to see how many residents take vitamin
D.
The Scott Tool was tested in a few facilities in
our region.
Our region has started implementing Hip
Protectors
Lessons Learned
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22-Jul-15
Staff in our region liked the 3 question posters and felt
they were very useful and relevant.
Our region is continually monitoring and training staff in
Fall Prevention.
Importance of collaborative concept is a new idea for our
region.
Summer is hard to implement changes with summer staff
working and staff on holidays.
We need to discuss the benefits of vitamin D with all
physicians in Sun Country Health Region.
Saskatchewan Falls Collaborative
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Next Steps
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22-Jul-15
Collaborative members are working on making Falls Prevention part
of every residents care plan. We are drafting a checklist of
interventions and falls prevention strategies to be part of the care
plan.
Our region is continuing making Fall Prevention a priority by bringing
it up at every staff meeting, and having Fall Prevention
presentations.
Our region will continue conducting more Fall reviews in our
facilities.
Most facilities in our region are doing or at least working on the
medication review concept to eliminate unnecessary medications
that may add to risk of falling. We are continually looking at the right
drug in the right does for the right reason.
Saskatchewan Falls Collaborative
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