For You! Strategies to Strengthen a Falls Risk and Prevention Program

1
For You!Strategies to Strengthen a
Falls Risk and Prevention Program
ing

• Vivian Dodge, RN, BSN, MBA
• November 2012
• Hospice of Palm Beach County

2
Objectives

• 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

3
Falls Among Seniors Why are they Important?

• 1 in 3 adults 65 years of age and older fall
  each year1
• For Seniors, falls are the leading cause of
• Injury
• Hospitalization due to injury
• Death due to injury
• Previous falls are good predictors for future
  falls2
• 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

4
Where to Begin?What is Needed?
5
The Base BranchesSteps to Grow Your Program
Adopt a Falls Risk Screening Tool
Define goals Develop Definitions
Collect Data Review Gaps
Educate and Engage
Establish PIP or Committee
Ongoing Data Evaluation
Provide Feedback
Review Standards Regulations
6
Steps to get on the right track

• Establish the components for your Falls Program
• Structure a PIP or committee
• Identify challenges / opportunities
• PDCA !
• Evaluate data outcomes and continually
• re-evaluate the effectiveness of your
• program

7
Branch 1 Requirements

• 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, Natl Center for Patient
  Safety

8
Branch 2 The Workgroup or PIP is Essential

• 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?

9
Branch 3 Specifications

• Define goals what is it that you want to
  accomplish?
• What is your organization fall rate?
• Define the elements
• gt What is the organization definition of falls?
• What kind of data will you collect?

10
Branch 4 The Screening Tool

• 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

11
Screening Tools

• Provides standardization among clinical staff
• Assists with development of practice standards
  and interventions in your organization
• Reliability
• Becomes part of assessment documentation

12
Fall Risk Assessment Tool    
Client Factors Score Patient Score
History of Falls 15  
Confusion/Disorientation 5  
Age (over 65) 5  
Impaired Judgment 5  
Sensory deficit 5  
Weakness/ impaired mobility 5  
Increased anxiety/agitation 5  
Altered elimination 5  
Cardiovascular/respiratory disease affecting perfusion and oxygenation 5  
Medications/sedatives/hypnotics 5  
Dizziness/syncope 5  
Attached equipment (IV poles, appliances, tubing, oxygen) 5  
     
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    
13
Branch 5 Protocols Interventions

• 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

14
Branch 6 Education

• Education of patients/families/caregivers is
  critical
• Engage them in learning
• Education of staff is imperative

Engagement promotes -Greater understanding -Bett
er compliance -Improved collaboration
coordination of care -Improved outcomes
information
REINFORCEMENT
15
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

16
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?

17
Data

• 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

18
Data

• Diagnosis
• Fall Risk Score
• Disposition of patient
• Year to date data
• Quarterly Fall Rate
• Fiscal Year Comparisons

19
Heres What We Found

• 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

20
Heres What We Found 5Falls Risk

• Hospice patients with polypharmacy
  interactions, efficacy
• Types of medications
• Diuretics laxatives sense of urgency
• Anti-hypertensive meds, sedatives, narcotics-
  Sleeping, pain blood pressure medications can
  cause hypotension and effect alertness
• Psychoactive drugs (Haldol, Seroquel) -
  increase risk for falls
• Chronic pain and musculoskeletal pain in 2 or
  more joints
• pain interfering with ADLs more likely
  to fall
• Delirium- more likely to fall

21
Heres What We Found

• 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 How staff
  present information
• Lack of toileting routines sense of urgency,
  increased falls

22
Heres What We Found

• Poor eyesight, hearing increased falls
• Patients/families did not want equipment
  unsightly and gave impression of fragility
• Missing hand off communication contributes to
  lack
• of
  clinical follow up

23
PDCA Plan, Do, Check, ActAway We Go!

• 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

24
Keeping the Momentum

• Keeping Falls activities on staff radar has
  been challenging but became a successful endeavor
  
• Data is boring
• Workgroup was committed to having fun

25
Patient safety begins with HPBCs Fall Prevention
Program

Falling For You!
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

26
Into Action!

• HPBC Facts
• Average 115-130 falls per month
• Fall Rate Less than 1 of HPBC Patients
• (Thats 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
  FXs)

Patient safety begins with HPBCs Fall
Prevention Program
Remember To ? Use the Fall Stickers ? Use the
Fall Stickers on Patient Folders in the Home ?
Update the Care Plans ? Educate the Patient /
Family / Caregiver
27
Summer Star Gazing
Looking for Falling Stars
GOAL Keep HPBC fall rate to lt 1 of patient
days Currently at 0.41

• Educate, Educate, Educate! Proper Body Mechanics
• How to use DME Equipment Safely
• Fall Prevention Tips

• Paint the Picture
• Who?
• What?
• Where?
• When?
• Why?
• How?

Good Job To All On ? Updating the Care Plans ?
Good IR reporting
28
(No Transcript)
29
FALLS TO M.E. OR NOT TO M.E.
How do you know when to contact the Medical
Examiners Office if there was a fall?
Simple Rule of Thumb

• Did the fall/trauma contribute or hasten an
  unnatural death?
• Did the patients 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 patients 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.

30
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 patients condition pre and post fall

31
Guess whats coming your way?TT / FFHint Its
not True and FalseFrom your HPBC Falls
Workgroup 

• FF

• TT

32
(No Transcript)
33
Learn to Speak Their Language
Old Way Better Way
You Need a Walker 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.
Dont gtgtgtgtgtgtgt What do you think may be of help to you
34
Barriers to Changing Patient Behavior

• 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

35
Positive Reinforcement Goes a Long Way

• Stay patient with your patients
• Engage a family member, caregiver
• Teach how to operate equipment or transfer
  patient Use the teaching techniques!
• Staff too!

36
Other Actions

• Clinical staff education
• gt DME possibilities Hi/lo beds, mats,
  transfer boards, etc
• gt Feedback on audits
• gt Feedback on Plan of Care expectations
• gt Feedback on documentation

37
So How Did We Do?

• Outcomes
• Continued Reduction in Falls Rate

38 reduction
38
(No Transcript)
39
(No Transcript)
40
(No Transcript)
41
Benchmarking

• Little comparative data on falls in the hospice
  industry
• Home health, acute hospitals collecting data for
  years
• Future? Required reporting?
• NHPCO initiatives

42
Our Falling Stars

• Establish process/protocols
• Educate
• Engage
• Question
• Quantify
• Quality check

43

• 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
• -

44
Thank you!

• Questions?

Vivian Dodge, RN, BSN, MBA Hospice of Palm Beach
County Office 561-227-5171 Email vdodge_at_hpbc.com