Transcript HEN Readmission Affinity Call

Intermountain-led
CMS Hospital Engagement Network
Falls Prevention
July 11, 2014
Affinity Call
Marlyn Conti –Patient Safety Initiatives Manager
Intermountain Quality and Patient Safety
Outline for Discussion
• Review of data through Q1 2014
• ‘High performers’ – Identify and ask what
they are doing?
• Falls recommended metrics
• “Just-one-thing” – updated document
• 2014 plans for improvement:
– Reach out to low performers to provide assistance
– Continue Webinars for sharing
Overall Progress Through 2013
This is a 24.2% reduction from baseline which was below national benchmark
Intermountain HEN 2012- Q1 2014
submitting Inpatient Falls with Injury
Started at 0.65 Down to 0.47 in Q4, Red line is baseline
Intermountain HEN 2012- Q1 2014
submitting Inpatient Falls with Injury
Intermountain HEN 2012-Q1 2014
submitting Hospitals Inpatient Falls
Total number of falls is increasing while Falls with injury is reducing.
Might be better reporting?
Intermountain HEN 2012-13
submitting Hospitals
Inpatient Falls
Number of reporting hospitals has dropped slightly. May increase the rate
HEN Falls Measures
• Metric specification resource manual
http://www.henlearner.org/wpcontent/uploads/2012/03/HEN_measure_Feb5.pdf
• Submission schedule:
– May 20, 2014: for data through March 2014
HEN Falls Measures
Inpatient Falls
HEN Falls Measures
Falls with Injury
High Performing Hospital Highlight…
Most Improvement
Inpatient Falls
Most Improvement
Lowest Rates
OREM COMMUNITY HOSPITAL
ALTA BATES SUMMIT MEDICAL CENTER
SANPETE VALLEY HOSPITAL - CAH
ALTA VIEW HOSPITAL
SOCORRO GENERAL HOSPITAL
AMERICAN FORK HOSPITAL
PROVIDENCE SEASIDE HOSPITAL
BAYLOR ALL SAINTS MEDICAL CENTER AT FW
LOS BANOS MEMORIAL HOSPITAL
BAYLOR HEART AND VASCULAR HOSPITAL
SEVIER VALLEY MEDICAL CENTER
BAYLOR MEDICAL CENTER AT CARROLLTON
LINCOLN COUNTY MEDICAL CENTER
BAYLOR REGIONAL MEDICAL CENTER AT
PLANO
BAYLOR MEDICAL CENTER AT GARLAND
PARK CITY MEDICAL CENTER
BAYLOR MEDICAL CENTER AT WAXAHACHIE
HILLCREST BAPTIST MEDICAL CENTER
BAYLOR REGIONAL MEDICAL CENTER AT GRAPEVINE
BAYLOR MEDICAL CENTER AT IRVING
High Performing Hospital Highlight…
Most Improvement
Inpatient Falls with Injury
Most Improvement
Lowest Rates
SUTTER LAKESIDE HOSPITAL
ALTA BATES SUMMIT MEDICAL CENTER
SUTTER COAST HOSPITAL
ALTA VIEW HOSPITAL
DELTA COMMUNITY MEDICAL CENTER
AMERICAN FORK HOSPITAL
LINCOLN COUNTY MEDICAL CENTER
BAYLOR ALL SAINTS MEDICAL CENTER AT FW
PROVIDENCE PORTLAND MEDICAL CENTER
BAYLOR HEART AND VASCULAR HOSPITAL
PROVIDENCE NEWBERG MEDICAL CENTER
BAYLOR MEDICAL CENTER AT CARROLLTON
UPPER CONNECTICUT VALLEY HOSPITAL
BAYLOR MEDICAL CENTER AT GARLAND
CASSIA REGIONAL MEDICAL CENTER
BAYLOR REGIONAL MEDICAL CENTER AT
PLANO
BAYLOR MEDICAL CENTER AT IRVING
PARK CITY MEDICAL CENTER
BAYLOR REGIONAL MEDICAL CENTER AT GRAPEVINE
BAYLOR MEDICAL CENTER AT WAXAHACHIE
Just One Thing Matrix
Recommendations
Getting Started
Implement standard
Assessment tools,
protocols and prevention
strategies
(high level of evidence)
Working Harder
Ahead of the Curve
Appoint “leads” to drive
improvement & identify or
champion teams that
includes unit level nursing,
quality, patient safety,
physical therapy and
pharmacy services.
(high level of evidence)
Implement decision
algorithms and/or
computerized decision
support in the electronic
medical record to target
interventions based on
patient specific risk factors
Getting Started and Keeping it going!
• Set Organizational priority
• Identify Risks and Gaps
• Develop Monitoring Systems
• Designate Champions
• Integrated Nurse Charting and Care Plans
• Repeat Cycles of ‘Plan-Do-study-Act’
Fall Event #1
Case 1: 9:13:48 AM
• Pt noted during rounding sleeping soundly @ 0200, was not woken up. Pt
found on floor by CNA @ 0240.
• Pt reports going to the bathroom on her own, took herself off the CPM,
SCD, and went to the bathroom without a walker, stated "I really needed
to go to the bathroom, that's why I didn't call," fell backwards and hit her
head on the side of the counter. Pt alert and orient before and after fall.
• Pt noted previously using the call light for help, and agreed at the
beginning of the shift to call when help is needed, but decided to be
noncompliant this time. VS done. No abnormality.
Post fall:
• Only noted injury is hematoma to left forehead. Dr. MJ notified, no new
orders given except to monitor patient during the night. Pt re-educated
about fall risks, bed alarm activated, sign on door, and monitored
frequently. Post fall: Pt re-educated about fall risks, bed alarm activated,
sign on door, and monitored frequently.
Fall Event #2
Case 2: 12:43:55PM
• Aide was sitting at desk documenting end of shift vital signs when
patient's bed alarm went off. Aide stood up look through the
doorway and saw patient on knees next to the side of the bed. Bed
alarm and side rails were in place at the time of the fall. When
asked patient reported he wanted to roll onto his side. Lift was used
to return patient to the bed, vital signs obtained RN notified, RN
assessed patient, palpated joints. Patient reports pain on palpation
of patella and anterior aspect of knees and shins bilaterally.
Post Fall:
• MD notified, Family Notified. Could have possibly been prevented if
patient had a sitter in the room. Nursing and CNA staff had
repeatedly reinforced to Patient, the hospital safety protocols for
ambulation and transfer require staff assistance.
Fall Event #3
Case 3:
• You have identified 10 patients on your unit with a high risk
for falls, what intervention do you implement?
• Based on your experience, which interventions are the most
effective?
• How would you document the assessment and intervention(s)
for the patient in your EHR?
• What type(s) of performance feedback would be available at
the unit level?
Fall Event #4
• You are a nurse manager on a 40 bed MedSurg unit with a hospital
mandate to reduce falls with limited resources.
• Issue: Identify patients at risk for falls.
• How would you identify the patients? How would you stratify the
individual patient’s risk? Who would screen the patient? What key
factors contributed to the decision?
• How would you document the assessment and intervention(s) for
the patient in your EHR?
• What type(s) of performance feedback would be available at the
unit level?
Fall Event 5
• Budget cuts have forced reduction in the
number of patient care techs (PCT) and
nursing staff. What tactics would you use to
minimize fall risk?
• How would you maintain what you have
implemented?
Fall Prevention Best Practice
• Use our HEN bundle to assess practice?
• Or use the Veterans Integrated Service
Network 8 (VISN 8) Road Map?
•
http://www.mnhospitals.org/Portals/0/Documents/ptsafety/falls/falls-preventionroadmap.pdf
2014 plans for improvement
• Reach out to low performers to provide assistance.
• Held regional workshop in Plano Texas
• Shared case studies
• Collect and share best practices across network hospitals
• Review/revise 2013 proposed prevention bundle
• Conduct participant practice survey
• Next webinar plans?
• Questions
• Issues
• barriers