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 Establish PIP or Committee Review Standards & Regulations Adopt a Falls Risk Screening Tool 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 History of Falls Confusion/Disorientation Age (over 65) Impaired Judgment Sensory deficit Weakness/ impaired mobility Increased anxiety/agitation Altered elimination Cardiovascular/respiratory disease affecting perfusion and oxygenation Medications/sedatives/hypnotics Dizziness/syncope Attached equipment (IV poles, appliances, tubing, oxygen) 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

Score 15 5 5 5 5 5 5 5 5 5 5 5 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-

& blood pressure medications can cause hypotension and effect alertness Sleeping, pain

Psychoactive drugs (Haldol, Seroquel)

falls

-

increase risk for

• • 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 –

information How staff present

Lack of toileting routines –

sense of urgency, increased falls

• Poor eyesight, hearing –

increased falls

• Patients/families did not want equipment –

gave impression of fragility unsightly and

• 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

Paint the Picture Who?



What?



Where?



When?



Why?



How?

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

•

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

You Need a Walker

Better Way

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 1800 1600 1400 1200 1000 800 600 400 200 0

Hospice of Palm Beach County Yearly Comparisons

1805 FY 2009 1639 FY 2010 1458 1119

38% reduction

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 3,50 3,00 2,50 2,00 1,50 1,00 0,50 0,00 Falls FY 11 Fall FY 12 October November December January February 3,45 3,31 3,76 4,32 3,53 3,30 4,22 3,79 3,39 3,41 March 3,38 3,39 April 2,90 3,16 May 2,88 2,97 June 2,85 2,75 July 2,93 2,11 August 3,07 2,33 September 3,81 0,00

200 150 100 50 0 450 400 350 300 250 413 Qtr 1: Oct-Dec

Hospice of Palm Beach County Quarterly Comparison of Patient Falls FY 11-12

401 Qtr 2: Jan-Mar 317 161 Qtr 3: Apr-Jun Qtr 4: Jul - Sep YTD

5 0 15 10 30 25 20 27 12 11 6

Categories of Patient Falls July 2012

5 5 4 4

N=77

2 1 Ряд1

• • • 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]