Transcript Storyboard - Canadian Patient Safety Institute

Five Hills Health Region
Falls Prevention in Home Care
Background
Site:
• Moose Jaw Union Hospital
Team:
• Home Care and Community Therapies
Patient Population:
• Home Health Service Clients, Team 1 and 2
Rationale:
• These clients receive more long term service
that typically involves personal care support
• Higher needs client base, higher risk for falls
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Aim
Purpose:
• To decrease falls by 20% or more by March 2010
Goals/Objectives
• To have 100% of falls reported to Client
Service Managers
• To establish a process to identify at risk clients
• To ensure that all at risk clients have falls
prevention intervention
Boundaries:
• Exclude Team 3 home services clients
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Aim
•
-
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Challenges:
Identifying that falls have occurred
Documenting/tracking of falls reports
Communicating falls between disciplines
Implementing timely falls interventions
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Team Members
•
•
•
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Home Care
Pauline Osemlak, DNS (Team Leader)
Tracey Macfarlane, RN
Corrie Hordick, HHA
Jennifer Erbach, HHA.
Community Therapies
Lisa Benson, PT
Dana Philipation, PT
Team Sponsor
Bert Linklater, EDCC
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Results
1. BERG Score Analysis
2.5
2
1.5
Initial
FU
1
0.5
0
7
9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55
From the analysis (wilcoxon & sign tests) there is a significant
difference between initial scores and FU scores.
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Results
2. Falls rate per 1000 (%)
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Results
3. Percentage of falls causing injury (%)
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Changes Tested
1. Cards clipped to name tags:
Ask these 3 questions before you leave a client’s home:
•Have you had a slip, trip or fall since I last saw you?
•Do you have your lifeline or phone with you?
•Do you need anything before I leave
(above on the front, below on the back)
•Prevent Falls: Keep your clients safe in their homes!
•Asking these simple questions will reduce risk of falls and
injury due to falls.
•Look for environmental hazards and encourage clients to
reduce these hazards.
•Remember to report all falls to your supervisor.
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2. Falls Records
Doc Book and tracking by Client Services Managers
FALL RECORD
NAME:
HSN:
HAVE YOU HAD A SLIP, TRIP OR FALL?
DATE
OF FALL
TIME
OF FALL
LOCATION
OF FALL
INJURY CODE
1,2,3,4 SEE
BELOW
DESCRIPTION OF EVENT
REPORT TO
SUPERVISOR
DATE,TIME
INITIAL
ACTION/TEACHING
Definition of Fall An event that results in a person coming to rest inadvertently on the ground or floor or lower level, with or without injury.
INJURY CODE: Code 1 - No injury. Code 2 - Minor Injury. Requires basic first aid or short term monitoring. (e.g. skin tear, bruise) Code 3 - Adverse outcome. Major injury. (eg. Fracture, head trauma, ER
assessment, admission to hospital.) Code 4 - Tragic incident. Death.
CLIENT NAME
DATE OF FALL
LOCATION OF FALL
INJURY CODE
19-Sep-11
Home
1
16-Sep-11
Home
1
04-Oct-11
Daughter's home
1
07-Oct-11
Home
2
Home
2
12-Oct-11
Home; fell out of bed (side rail in place)
2
06-Oct-11
Slipped in shower; didn't completely fall
1
20-Oct-11
In home
2
Oct 6 & 7, 2011
07-Sep
01-Sep
1
fell in living room
1
at families in Saskatoon-fell a few times
2
at home-visit to emerg
2
home
1
bedroom
2
25-Oct-11
getting into medi chair
1
01-Nov-11
getting out of bed, slipped on rug
1
01-Nov
fell in bathroom-Bentley staff helped her up
1
07-Nov
fell in bathroom-Bentley staff helped her up
1
fell in livingroom, missed chair
1
fell in apartment, HHA arrived and sent by ambulance to hosp
2
fell in apartment.
1
fell in apartment no injury
1
Nov. 16
apartment
2
Nov. 20
apartment
1
Oct 8-11
30-Oct
29-Oct-11
Oct. 30, 2011
Nov. 7
07-Nov
Nov 8-fell 3-4 days ago
31-Oct
3. Community Therapies Falls Prevention Tracking
Client Name
Initial Berg
Score
Date
# of PTA
visits
F/U Berg Score
Date
Comments
4. Community Therapies Falls Prevention Algorithm
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5. Presentations:
To Home Health Aids, Moose Jaw EMS,
ER department at MJUH
Five Hills Health Region
Community Therapy
Falls Prevention Program
6. Moose Jaw EMS referral process
• Refer all clients with
mobility impairments that
you do not transport
• Referral process:
– Write in instruction area
that info has been given
to Therapies
– Ensure client signs form
– Fax to Therapies
694-8710
Lessons Learned
• Communication is key
• Need a process to deal with volume of
referrals/amount of falls
• Falls prevention requires ongoing support
from many disciplines and agencies:
- Quality Improvement - Epidemiology
- Primary Health Care - Home Care
- Access Centre
- Therapies
- Physicians
- EMS/ER
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Next Steps
• Review data collection processes
• Formally track the volume of falls referrals to
Therapies from all sources: ER, EMS, Home
Care, Access Centre, inpatient wards,
self/family, physicians.
• Connect with Primary Health Care and the
Falls Steering Committee?
• Presentations to local physicians?
• How do we implement timely interventions
with the same amount of staff?
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