Falls Injury Prevention Forum Case Study

Transcription

1 Falls Injury Prevention Forum Case Study What is/ is not best practice Prepared by those with the utmost interest and passion for falls injury prevention! March

2 PREVENTION 1

3 No prevention- what could happen? Mrs Firstfall visits her GP for her annual flu vaccine - Lowers herself into the chair using her arms - Has had a few near falls of late, but doesn t think to mention isn t that just a normal part of growing old? - GP reports that she is in tip-top shape - She grips onto the chair to lift herself to her feet 2

4 No prevention- what could happen? A little over a month later - Mrs Firstfall loses her balance down a single step and has a fall - Is taken to the emergency department for a cut that may require stitches 3

5 Best Practice Prevention Rewind to the GP consultation - GP does a Timed up and go test as he noticed her unsteadiness and difficulty getting into the chair - He tells her a fall isn t inevitable, with gentle exercise she can regain confidence and improve her strength and balance - Refers her to a gentle exercise class and will conduct falls risk assessment at her next consultation 4

6 Best Practice Prevention GP consultation, continued - Mrs Firstfall leaves the consultation happy to have talked about her fear of falling and realising that it isn t something she has to live with - GP puts a reminder in her notes to prompt follow-up at her next visit - Mrs Firstfall contacts the gentle exercise group instructor 5

7 Best Practice Prevention Fast forward 3 months (rather than having a fall and ending up at ED ) - Mrs Firstfall has attended regular exercise classes - Confidence in her stride is re-emerging - Plus she has increased social connections and is sleeping and breathing better - Occasionally still a little unsteady on her feet, but now confident she can regain her balance - She has not had a fall 6

8 ED Journey 7

9 What can happen in ED! An independently community living 76 year old woman, Ms Fiona Firstfall from Maitland presents to ED with a laceration that requires sutures. 8

10 What can happen in ED! ED data entry: laceration requiring sutures. Mrs Firstfall is asked about her tetanus immunization status Wound sutured and referral made to community health to check wound in 3-4 days time. 9

11 ED Nurse response 10 out of 10 triage nurses surveyed asked Mrs Firstfall how she had lacerated her leg and then queried the circumstances of the fall. 8 out of 10 triage nurses coded the presentation as an injury resulting from a fall. 6 out of 10 triage nurses queried the home situation 1 nurse reviewed previous ED presentations for falls and also to identify possible cases of elder abuse or history of alcohol abuse. 10

12 What is best practice in ED! Patients assessed for risk of future falls if the ED presentation is related to a fall Screening tool used to identify and guide appropriate referral for more detailed assessment Preliminary assessment of risk factors in the ED including: PMHx, falls history, medications, cognition (is it delirium), neurological and cardiovascular system, vision, gait and balance, social circumstances, current level of function. 11

13 Best Practice ED! Referral for patients who are identified as an increased risk of falling to ensure full assessment by appropriate member of the multidisciplinary team Referral can include: ASET Community Nurse GP Physiotherapist Occupational Therapist Podiatrist Medical specialist 12

14 Best Practice The Strategic goal ED data entry: Coding being reviewed at area level with Primary code being Injury caused by a fall. W19 W19 W19 W19 W19 W19 An alert in ipims will be activated to refer Mrs Firstfall to the Falls Triage Hotline. (fall, lives alone and over 70) Wound sutured and tet tox status checked. Mrs Firstfall will be advised that the Falls Triage Hotline will call her within 72 hours. 13

15 HNE Strategic Goal ED Data entry identifies that the laceration was an injury caused by a fall, -W19 That Mrs Firstfall is 76, lives alone, and requires follow-up from the Falls Triage Hotline as she is at risk of future falls. Falling is not an inevitable event of old age. The reasons for the fall need to be identified and appropriate referrals made. An appropriate and feasible screening tool for use in ED will be identified and appropriate referral responses outlined. By decreasing the risk factors and early identification, the risk of falling is reduced. 14

16 Community Journey- Part A 15

17 What can happen in Community Health! The Community Nurse visits 4 days later and notes good wound healing. No follow up of the falls risk occurs Due to lack of follow up Ms. Firstfall may be placed at even higher risk of further falls. 16

18 Best Practice in Community Health ED makes referral to Falls Triage hotline. Falls Triage hotline staffed by EN s contact Mrs Firstfall the day after her ED presentation. 17

19 Best Practice in Community Health This tool has been developed by the presenters as an example of the type of screening questions that could be asked. 18

20 Difference in Outcome With best practice, referral was made from ED to Falls Triage hotline Risk assessment priorities are identified through phone call from Falls Triage hotline. This identifies that this was her first fall from a trip over a step and her leg caught the edge of a rock, causing the laceration. 19

21 Difference in Outcome This results in identification as a moderate falls risk A falls risk alert is placed in CHIME A referral is completed to community nursing for a wound status check due to potential wound infection risk. The referral will also request a Quick screen assessment which is an example of a more comprehensive falls risk assessment. 20

22 Community Journey-Part B 21

23 What could happen! Relief community nurse (CN) unaware of CHIME falls risk alert prior to visiting Mrs Firstfall. Notes wound is healing well. This results in lack of follow up in regards to falls risk, for example Allied Health referral. 22

24 Best Practice CN note the CHIME falls risk alert prior to completing home visit The CN therefore has an awareness of the need to undertake an opportunistic screening assessment such as the Quick screen assessment 23

25 Best Practice 24

26 Best Practice Results from Quickscreen assessment are entered into CHIME Follow up appointment scheduled with General Practitioner(GP). CHIME generates a letter to Mrs Firstfall s GP highlighting the following risk factors: Need for medication review Referral to physiotherapist to assess home based exercise program to improve gait stability and balance as well as potential walking aids 25

27 More Best Practice Recommendation for attendance at a relevant community exercise group, e.g. Beaming Balancers (balance and strength program) auspice by HNE health Promotion as part of Active Over 50s program. OT referral to assess possible house and yard modifications, possible adaptive equipment and falls hazard risk assessment. Education booklet on falls prevention issued and explained to Mrs Firstfall at time of home visit. Note of the healing wound. 26

28 Difference in Outcome Following basic standard of care Mrs. Firstfall did not receive any follow up in regards to her falls risk which may have an impact on her risk of future falls. 27

29 Difference in Outcome Under best practice -Mrs. Firstfall would have an opportunistic fall screening assessment completed -This would then identify risk factors that are highlighted to her GP and other health professionals in a letter -Mrs Firstfall is contacted with appointment times for OT and PT. -Mrs Firstfall. is an active member of the community exercise group 28

30 Difference in Outcome Appropriate follow up, assessment and referral has meant Mrs. Firstfall is likely to have a significant reduction in her future falls risk. 29

31 Acute Journey 30

32 What can happen in hospital! Mrs. Firstfall s neighbours concerned Mrs. Firstfall is found on the floor Second time faller On floor several hours Road trip to hospital 31

33 What can happen in hospital! Bedside rails up to prevent her getting out of bed Pressure relieving mattress Bed in high position To attend Cares Call bell on locker Room at end of corridor 32

34 What can happen in hospital! Mrs. Firstfall tries to get out of bed Falls over top of bedside rail Hits head on locker No apparent injury Placed back in bed Quiet 33

35 What can happen in hospital! Night Registered Nurse noticed (Rt.) pupil fixed, dilated Medical Officer called Laboured respirations noted Hourly observations commenced Status declines 34

36 What can happen in hospital! CT Scan following morning Intracranial bleed Permanent brain damage Not suitable for rehabilitation 35

37 What can happen in hospital! Mrs Firstfall now requires permanent RACF placement 36

38 Residential Aged care journey 37

39 What can happen in Residential Aged Care! Transferred to a Residential Care facility Minimal staff 38

40 What can happen in Residential Aged care! Waiting 39

41 What can happen in Residential Aged care! Preferences 40

42 What can happen in Residential Aged care! GP unavailable 41

43 What can happen in Residential Aged care! The nurse s minute 42

44 What can happen in Residential Aged care! Gait aid 43

45 What can happen in Residential Aged care! Facility Manager/RN/physio/OT/Social worker etc 44

46 What can happen in Residential Aged care! Group exercise program no balance focus! 45

47 What can happen in Residential Aged care! Footwear they re comfy 46

48 What can happen in Residential Aged care! More comfy footwear 47

49 What can happen in Residential Aged care! Bed Rails to keep the resident safe 48

50 What can happen in Residential Aged care! Night time confusion, dark, fear 49

51 What can happen in Residential Aged care! Here we go again! 50

52 What can happen in Residential Aged care! Another life changing experience! 51

53 Best Practice in Residential Aged Care Transferred to a residential care facility Plenty of staff and a GP available within 24hrs 52

54 Best Practice in Residential Aged Care Welcomed by staff 53

55 Best Practice in Residential Aged Care Family 54

56 Best Practice in Residential Aged Care Preferences! 55

57 Best Practice in Residential Aged Care Assessed by physiotherapist 56

58 Best Practice in Residential Aged Care Individual exercise program with a focus on balance! 57

59 Best Practice in Residential Aged Care Group exercise programs with a focus on balance 58

60 Best Practice in Residential Aged Care Hip Protectors 59

61 Best Practice in Residential Aged Care Gait aid 60

62 Best Practice in Residential Aged Care FRAT FALLS RISK ASSESSMENT TOOL HOW TO USE THIS FORM: - Complete Parts 1 & 2 of this FRAT to establish Fall Risk. Using Parts 1, 2 & 3 document in the progress notes and care plan the appropriate fall prevention strategies for this resident Name: PART 1 DOB: AUTOMATIC HIGH RISK STATUS IF one of the following is ticked: (tick HIGH risk below) M.O. Dizziness Postural hypotension present Recent change in functional status and/or medications, which may affect safe mobility. PART 2 RISK SCORE ASSESSMENT Recent Falls History: - including number of falls and possible contributing circumstances MRN: Address: Attach Resident Label Here Falls Risk Assessment Tool Risk Factor Level Risk Score RECENT FALLS (To score this, complete recent falls history above) MEDICATIONS (Sedatives, Anti-Depressants Anti-Parkinson s, Diuretics, Anti-hypertensives, hypnotics) PSYCHOLOGICAL (Anxiety, Agitation, Depression, Withdrawn, Decreased Cooperation, Decreased Insight or Decreased Judgement esp. re mobility) none in last 12 months one or more between 3-12 months ago one or more in last 3 months one or more in last 3 months whilst inpatient/resident not taking any of these taking one taking two taking more than two does not appear to have any of these appears mildly affected by one or more appears moderately affected by one or more appears severely affected by one or more COGNITIVE STATUS Align to cognitive assessment tool used for this resident PAS Cognitive Impairment Scale Standardised Mini Mental Status PAS=0-3 m-m score 24 or more Intact PAS=4-9 m-m score mildly impaired PAS=10-15 OR m-m score 15 9 OR mod impaired PAS=16-21 m-m score 9 or less severely impaired FALL RISK STATUS Low 5-11 (Document Fall Status in the Care Plan) Medium High / 20 IMPORTANT: IF HIGH RISK, COMMENCE A FALL ALERT PROTOCOL FLOW CHART PART 3: RISK FACTOR CHECKLIST Tick and Explain Vision Reports/observed difficulty seeing objects/signs/finding way around Mobility Transfers Behaviours Mobility status unknown or is unsafe/impulsive/forgets walking aid Transfer status unknown or is unsafe i.e. over-reaches, impulsive Observed or reported agitation, confusion, outbursts of anger, disorientation, difficulty following instructions or resistive with care, constant walking or pacing ADL s Observed or reported risk-taking behaviours Observed unsafe use of equipment Unsafe/inappropriate footwear or clothing Environment Nutrition Continence Difficulties with orientation to environment i.e. areas between bed/bathroom/dining room Underweight/low appetite Reported or known urgency/nocturia/accidents Other Osteoporosis, history of fracture/s, signs/presence of pain, restraint 61

63 Best Practice in Residential Aged Care Fall Alert Strategy Fall Alert Protocol Flow Chart Resident identified as HIGH Risk Falls using a Falls Risk Assessment Tool Initiate Fall Alert Strategies Highlight below the Fall Alert Strategies that are to be implemented for this resident Name: MRN: Address: DOB: M.O. Attach Resident Label Here Place green sticker on appropriate locations to alert staff of high fall risk: o Bed head o Care plan o Progress notes o Handover sheets o Communication sheet/book o Mobility aid o Dining room table o Resident s chair o Bathroom if appropriate o Inside wardrobe door o Other Commence resident on fall alert check form: o Day o Night o Day & night o Other To monitor for: o Pain/comfort o Need to change location o Need to toilet o Need for food & drink o Behaviour suggesting an unmet need o Other Commence resident on movement alarm/alert system: o Day o Night o Day and night o Other Injury Prevention Strategies Is the resident using: o o Vitamin D Hip protectors Commence resident on a Log of Falls form Keep on file with the Resident Mobility Care Plan and review as part of the Mobility Care Plan and after a reassessment with a Falls Risk Assessment Tool as per facility protocol 62

64 Best Practice in Residential Aged Care Falls Log Aim: This log is to be completed for residents for whom it has been determined that there is a benefit from logging a falls record for further analysis of their falls history Page Number: Log of Falls Name: MRN: Address: DOB: M.O. Attach Residents Label Here Date Time Location of Fall Description Describe what the resident was doing at the time of the fall, include possible contributing factors and whether hip protectors were being worn Injuries from fall Referred to GP Falls Prevention Strategies What falls prevention strategies have been implemented as a result of the fall Signature 63

65 Best Practice in Residential Aged Care Fall Alert Check Form How to use this form: This form is to be used to record the checks that occur for a resident who is high risk for falling and been assessed as requiring frequent monitoring as a strategy of their falls prevention intervention Name: MRN: Address: DOB: M.O. Attach Resident Label Here Frequency or times for checks Date Time What was the resident doing / where were they? Comments Fall Alert Check 64

66 Best Practice in Residential Aged Care GP Communication 65

67 Best Practice in Residential Aged Care Easy to find, comfy footwear 66

68 Best Practice in Residential Aged Care Information on safe footwear Safe Footwear Checklist This checklist may be used in the resident s admission package or to assess safety of current footwear or purchase of new footwear. The requirement for safe, well-fitting shoes varies depending on the individual and their level of activity. The features outlined may assist in the assessment of an appropriate shoe. This is a general guide only. Some people require the specialist advice of a podiatrist for the prescription of appropriate footwear for their individual needs. The shoe should have the following features: Safe Feature Name: MRN: Address: DOB: M.O. Attach Resident Label Here Tick Heel Low & broad (<2.5cm) Straight through sole Firm heel collar to provide support Sole Weight Toe box Cushioned, flexible, non-slip Lightweight Adequate width, depth & height for natural spread of toes Have a one centimetre space between longest toe and end of shoe Fastenings Uppers Laces, buckles elastic or velcro that hold securely Accommodating material Smooth seam-free interior Safety Shape Purpose Orthoses Protect feet from injury Same shape as the feet, without causing pressure or friction on the foot Appropriate for the activity being undertaken Comfortably accommodating orthoses Recommendations /Plan: Podiatrist or physiotherapist advice 67

69 Best Practice in Residential Aged Care New safer footwear 68

70 Best Practice in Residential Aged Care Bed mobility 69

71 Best Practice in Residential Aged Care Vision assessment, single lens glasses 70

72 Best Practice in Residential Aged Care Settling in 71

73 Best Practice in Residential Aged Care A life changing experience! 72

74 Best Practice in Residential Aged Care An unbalanced load 73

75 Best Practice in Residential Aged Care Balancing that load!! 74

76 Acute Journey-Best practice! 75

77 Best practice in Hospital! Post operative confusion anticipated Increased risk factors for delirium targeted Given room near nurses station Bed in lowest position when not receiving direct care Bedside rails down Use of Special considered for 1:1 monitoring 76

78 Best practice in Hospital! Volume depletion noted in OT Resident consulted to increase IV rate 77

79 Best practice in Hospital! Falls prevention management plan commenced Sign above bed indicating falls risk Falls arm band in place Noted in handover as High Falls Risk 78

80 Best practice in Hospital! Consult with Dementia/Delirium CNC Post operative delirium suspected Check hydration Fluid intake and out put Bowel function Appetite Pain / relief scheduled Infection 79

81 Best practice in Hospital! By treating risk factors post op delirium resolving : Less confused Physiotherapist able to commence exercises Non-slip socks placed over TED stocking Mrs. Firstfall able to stand out of bed 80

82 Best practice in Hospital! Gradually Mrs. Firstfall regains strength Increased participation in self care Suitable for Rehabilitation Transferred to Rehabilitation unit ten days later 81

83 Rehabilitation journey! 82

84 What can happen in Rehabilitation 10 days post op Mrs Firstfall is transferred to a rehabilitation unit in Maitland She appears well and staff note that assessments from acute care had been attended and utilise these same assessments to plan her care. No falls risk identification or individual plan is put into place 83

85 What can happen in Rehabilitation Mrs Firstfall does not want to call the nurses for assistance to go to the toilet. Her bed is a bit high due to staff attending to her hip dressing a few moments before. As she attempts to get from sitting to standing she slides forward for her feet to touch the floor and with her TED stockings on she continues to slide when her feet meet the linoleum. 84

86 What can happen in Rehabilitation She falls to the floor on her non surgical side and she hears a crack. Staff assess Mrs Firstfall and note the external rotation of her foot and shortening of her leg She is hoisted to the bed and awaits X-ray 85

87 What can happen in Rehabilitation X-ray reveals a fractured NOF which requires surgery. Mrs Firstfall requires major surgery for the second time in less then two weeks No IIMS record is made and there is little documentation made in the notes pertaining to the fall. 86

88 What can happen in Rehabilitation Due to her weakened state, blood loss and dehydration, she arrests during surgery and cannot be resuscitated. This results in a coronial inquest. 87

89 Best Practice in Rehabilitation On admission to rehabilitation Mrs Firstfall has a comprehensive multidisciplinary assessment completed Nursing-initial patient assessment includes: 1.Falls risk screen 2.Review of vision and hearing 3.Mobility assessment eg: sit to stand and aid used 4.Hydration and nutrition 5.Orientation and cognition 88

90 Best Practice 6.ADL function- manual dexterity, limb movement and education based on surgical requirements 7. Medication management and pain management review 8.Continence 89

91 Best Practice Falls screen denotes Mrs Firstfall as a high falls risk Strategies that are put in place include: 1.Attaching arm band that denotes falls risk 2.Educating Mrs Firstfall on falls prevention and restrictions to her mobility, including footwear 3.Orientating Mrs Firstfall to the new area she is in, including call bell use 4.Having all equipment within reach 90

92 Best Practice 5.Locating Mrs Firstfall close to nurse desk and close to ward bathroom 6.Instituting falls care plan and documenting risks 7.Educating family members on falls risk 8.Frequent checks on Mrs Firstfall,supervision and encouragement with her mobility 91

93 Best Practice 9.Pain management 10.Adding a night light to increase night vision and Highlighting risks to other staff at handover 92

94 Best Practice Multidisciplinary team falls prevention Occupational therapy- assess cognition, self care, home assessment. Physiotherapy- assess mobility, bed mobility, transfers, strength and balance, and gait. Social work- social situation, service provision and emotional state. 93

95 Best Practice Medical- review of medication management including pain medication and commencing Vitamin D and calcium if appropriate. Dietician- assess nutritional status and provide education. Pharmacist- review of medications and instruct patient on use. 94

96 Best Practice Mrs Firstfall becomes more independent with her mobility aide each day and her strength and balance improve considerably. Mrs Firstfall is sent for bone density testing and is commenced on a bisphosphanate. She is competent in self medication, small meal preparation and requires supervision with self care. 95

97 Best Practice A home visit is attended by the OT at Maitland who suggests some rails be put in the bathroom and toilet and front entrance, the height of the bed adjusted and removal of floor hazard. The OT will refer to community Physiotherapy(TACP) for ongoing mobility safety and allow for Mrs Firstfall to regain independence both indoor and outdoor. 96

98 Best Practice Towards end of time in rehab Mrs. Firstfall s son comes to visit from WA in order to meet with staff to ascertain what is required to enable Mrs. Firstfall to return home It is decided that her son will return home with her to see how she is managing. 97

99 Best Practice Referrals are made to TACP for ongoing review of patient care needs. Mrs Firstfalls son and daughter are educated on her mothers care requirements and informed of service providers and the referral system. Mrs Firstfall is aware that her GP will have information pertaining to her admission sent to him and to see her GP within one week of d/c. 98

100 Best Practice Mrs Firstfall is discharged home with her daughter and son who will assist community services to increase their Mums independence The referral made to community services in Maitland will assess and identify what services will be required for Mrs Firstfall to live independently 99

101 Community Journey c) 100

102 Support to return home CAPAC Services TACP Client Journey 101

103 CAPAC Umbrella CAPAC HAH Pre-Hospital Health / COPs Partnership 6 week program HITH Anticoagulation Cellulitis IV Other Orthopaedic Elective Orthopaedic Falls Risk Heart Failure COPD Other TACP Post - Acute Enablement / ACF avoidance 12 week program 102

104 CAPAC-Why? Goal to prevent admission to hospital and facilitate early discharge by providing: front end care to avoid ED presentations and unplanned admissions (HAH) Quick turn around at the Emergency Department (HITH) Early discharge (Acute) 103

105 CAPAC Follow-up to prevent representation (Post-acute / TACP) Multidisciplinary team-based approach Holistic approach Seamless and integrated care, complementary to existing services As effective as in-patient care for selected conditions 104

106 TACP- overview Jointly funded program by both the Commonwealth and State Governments Only for current inpatients (5 local public hospitals) Slow-stream rehabilitation, Capturing elderly patients in an acute/subacute setting who have the potential to be rehabilitated to the point where they can care for themselves in the home; or Can be admitted to an Aged Care Facility at a higher level of functioning and independence Funding for 12 weeks with potential for a 6 week extension 105

107 TACP Process Mrs. Firstfall identified as suitable for enablement by multidisciplinary inpatient team Referral to TACP attended via CAPAC phone intake Reviewed / assessed by clinician (CAN / CAAH) whilst in Rehabilitation ACCR completed for transitional care (valid for 4 weeks ) 106

108 TACP Process Mrs. Firstfall agrees to enter Transitional Aged Care Program and is willing to enter into an agreement, which may include making a financial contribution GP informed at time of discharge She is visited daily for the first week and goals established, contact is reduced depending upon need (multidisciplinary) Review at 4 and 8 weeks 107

109 Primary Goals for TACP Ensure that client and family are actively involved in goal setting and planning for clients treatment Improve clients mobility and physical functioning generally and assist in returning to daily living skills following hospitalisation Enable the client to remain at home wherever possible. Work toward establishing community services to be organised to meet the clients ongoing care needs upon discharge from the program 108

110 Goals Identified for Mrs Firstfall Shower and dress independently Attend to small meal preparation, light domestic tasks. Return to independent mobility indoors and walk to local shops 109

111 Program for Mrs Firstfall Reconditioning and mobility were the major focus of rehabilitation Initially daily visits. TACP nurse - personal care enablement and medication supervision. TACP Physio home based exercise program and outdoor mobility. TACP OT -Follow up with home modifications, encouragement to remove floor hazards, initial meal prep supervision,encourage socialisation. 110

112 Outcome Physio identified that Mrs Firstfall was continuing to improve with intensive therapy and an extension of 6 weeks on the program would enable her to fully return to her previous level of functioning. Mrs Firstfall is encouraged to attend the local Active over 50s program OT encouraged socialisation and Mrs Firstfall joined the local charity group and spends time with her friends. Community Options have been arranged to assist with transport and heavy domestic chores. 111

113 Outcome Mrs Firstfall discharged from programme at an increased level of independence. - Independent with personal care. -Independent with light domestic tasks and meals. -Independent with indoor mobility and uses a cane for outdoor mobility. -Increased socialisation and exercise tolerance. 112

114 Best Outcome!! 113