Transcript Using a Neuroscience Diagnosis as the Patient`s Primary Risk

Using a Neuroscience Diagnosis
as the Patient’s Primary Risk Factor
for Falling
Neuroscience Fall Prevention and
Safety Performance Improvement Team
Darlene Bailey, PCT
Leslie Barna, Manager 2 NE
William Benedict, MD
Barbara Buturusis, Administrative Director
Jose Biller, MD
Mary Healey, Manager 2 S/2 Neuro ICU
Meri Hix, PharmD
Corrie Husak, RN
Bresha Mc Clain, RN
Judy Mc Hugh, NQI, Team Leader
Lisa Millsap, APN
Martina Notovny, PharmD
Vikram Prabju, MD
Karen Potoki, APN, Risk Management
Devra Romick, PT
Joanne Scharnak, Nurse Educator, Team
Facilitator
Theresa Schwenkel, RN Liaison
Kate Steinhable, Physical Therapy Educator
Azucena Uy, RN
Opportunity Statement
Reduce inpatient falls on the 2 NE Neuroscience Unit
and increase staff knowledge related to patient safety
Potential Cause of Falls
Environment
Documentation
People
Post Fall
Analysis
Clutter
Admitting Issues
Frequent transfers
Inappropriate Adm
Fast Turn-over
IV Poles
Chairs
Age
Education
Patient
Staff
Bedroom
Unfamiliar Room
Patient Transfers
Call Light Issues
Bed Alarm
Not on
Lost in covers
Door Reminder Risk Levels
Not available 7/05
Staff Communication
Lack of Reg Rounds
Not Using Equipment
Fall Risk (8-10-05)
Gait Belt (7-13-05, 8-10-05)
Medications (7-13-05, 8-10-05)
Not Answering Call Lights
Patient Decreased Sensorium
Confusion/Altered
Mental Status
(7-13-05//8-10-05)
Stroke
Don’t Realize They
Need Assistance
Sundowner
Confidential: For Quality Improvement Purpose Only
Plan of Care
Not Documented
(8-10-05)
History Of Falls(7-13-05, 8-10-05)
Over Estimate Strength & Ability
Elimination
Long Length of Stay
Medication (7-13-05, 8-10-05)
Cannot reach call light
Call light too complicated
Family assists patient to bathroom
Materials
(1/06)
Medication
(7-13-05/8-10-05)
Sedation
Narcotics
Sleepers
Balance
Gait
Gait Belt
(8-10-05)
Weakness
Postural
Hypotension
Flowsheet Fall HX of Falls
Section
Not in EPIC
Incomplete
(7-13-05, 8-10-05)
(7-13-05, 8-10-05)
Patients At
Risk
For Falls
Solutions Implemented
Multidisciplinary Staff Education
o New fall assessment flowsheets
o Fall extrinsic and intrinsic factors
o Appropriate Bed Alarm Use
o Gait belt use and transfer competency
o Fall risk associated with neurologic impaired patient
o Monthly fall prevention updates
Solutions Implemented
Neuroscience Safety Awareness Week
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Falls in the Elderly
Is Polypharmacy Causing Acute Confusion
Touch Therapy
Guided Imagery
Gait Belt Use and Transfer Competency
Massages for staff
Designed a Level 3 Fall Prevention Interventions
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All neuroscience patients are at risk for falls
Increased elimination rounds to include mealtime and bedtimes
Observe patient activity ever hour or more
Implemented Bathroom Buddy- staff stays with patient during elimination
Bathroom Buddy- nursing staff stays with patient during elimination
Place patient on a BedCheck Classic bed alarm and chair alarm
Consult pharmacy regarding medications that can cause altered mental status
Repeatedly reinforced limits and safety needs to patient and family
Assign bed that enable patient to exit towards stronger side whenever possible
and transfer patient toward stronger side.
o Provide comfort rounds- repositioning, back rub with PM care, assisted
ambulation before bedtime.
o Developed Post Fall Assessment Environment Study
Neuroscience Safety Awareness
Week of September 26, 2005
Monday, September 26, 2005
Thursday, September 29, 2005
Message of Touch Massage & Guided Imagery by Fran Glowinski,
Lunch and Learn –Healing Touch by Ann O’ Malley , RN., C.H.T.P.,
MPS, OSS
2 Neuroscience Unit
11:00 to 13:00
18:00 to 20:00
EMS Bldg. Room 3284
11:00 to 12:00
Tuesday, September 27, 2005
Lunch and Learn -Falls in the Elderly by Dr. Jose Biller
Bldg. 105 Maguire, Room 2812.
11:00 12:00
Bed Check Bed Alarm Use Inservice by Bill Saemann,
Macon Company
Bed Check Bed Alarm Use Inservice by Dick Tedesco, Macon Company
2 Neuroscience Unit
6:00 to 8:00
10:00 to 11:00
18:00 to 20:00
Gait Belt Training by Kate Steinhable, PT, MPT.
08:00 to 09:00
Friday, September 30, 2005
2 Neuroscience Unit
6:00 to 8:00
10:00 to 11:00
18:00 to 20:00
Message of Touch & Guided Imagery by Fran Glowinski, MPS, OSS
Wednesday, September 28, 2005
Lunch and Learn –Is Polypharmacy Causing Acute Confusion In
Your Patient?
by Martina Novotny, Pharm. D
Seated Back Massage by Loyola Health and Fitness Club
2 Neuroscience Unit
6:00 to 7:00
16:00 to 17:00
2 Neuroscience Unit
6:00 to 8:00
EMS Bldg. Room 3284
11:00 to 12:00
Posey Restraint Use and Other Restraint Alternatives by Fred
Demshar, Posey Company
2 Neuroscience Unit
11:00 to 12:00
14:00 to 15:00
Nursing Performance Improvement Fall Prevention Initiative 2005
2NE Monthly Falls
I ndi vi dua l s
Set 2: UCL=9.97, Mean=4.04, LCL=-1.89 (not shown) (11-20) (mR=2)
UCL = 11.30
11
UCL = 9.97
10
Stroke Unit Opened
9
New Manager
8
Fall Reduction Education
3 Pt fell due to extrinsic factors
2 NE Fall Reduction Project
7
1 PT fell twice
Gait Belt Implemented Stroke
6
Cause & Effect-Fall
Gait Belt T raining
Fall Reduction Edu
Mean = 5.32
Safety Week
5
Post Fall Assessment
Hourly Rounds
Level III Pilot
Staff 1 to 1
Bed Alarm Implementation
Mean = 4.04
4
Bed Alarm T raining
Confidential: For Quality Improvement Purpose Only
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NEXT STEPS
o Develop monthly education poster series for Medications Contributing to
Mental Status Changes
o Design patient and family safety education to neuroscience population
o Partner with the Loyola Niehoff School of Nursing to introduce the
Neuroscience Level III Fall Prevention Program into student curriculum
o Integrate fall risk factors and history of fall into the Electronic Medical Record
o Produce and videotape Lunch and Learn Safety Programs
o Improve patient care handoff utilizing SBAR Situation, Background,
Assessment, and Recommendations
Catching the Safety Culture