Corrine Abraham DNP, RN Clinical Assistant Professor, Emory NHWSN Coordinator for EBP & Innovation, Atlanta VAMC

Transcription

1 Corrine Abraham DNP, RN Clinical Assistant Professor, Emory NHWSN Coordinator for EBP & Innovation, Atlanta VAMC

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3 IMPROVE VISION - ANALYSIS SUSTAIN Leadership & will to transform Team & Aim Map & Measure Spread Change Over Time, Transformation Leadership & Alignment top to Bottom Change Feb 2013 July 2013 Aug 2014

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5 National Incidence of Falls 3% - 20% of inpatients fall at least once 1 Falls are the 6 th most commonly reported sentinel event. 2 Consequences of Falls 20% - 30% suffer injuries that their risk of early death. 3 Leading cause of injury-related death for adults over 65 yo. 4 Fractures most common and costly injury. 5 Cost of Falls Length of stay, rates of discharge to institutional care, resource use 3-4,6

6 National Imperative National Patient Safety Goal - TJC 7 Serious Reportable Event - NQF 8 No reimbursement CMS 9 Local Priority Atlanta VAMC: Vulnerable population - many fall related risks Solution 1,10-11 Multifactorial assessment & management effective Success associated with multidisciplinary team Tailored interventions can prevent injury

7 Local Priority: Preventing falls and fall related injury will decrease expenditures and enhance patient safety as well as the organization s accountability to provide quality care Problem Statement: In FY2013 (through May) the hospital reported more than twice the national rate of falls with serious injury. Two units had rates that exceeded the hospital average as well as the national average of VHA hospitals of comparable acuity and size

8 Team Aim Map Measure Change

9 Corrine Abraham, RN, DNP, VAQS Sandra Thomas, RN, QA, Acute Care Laurie Moore, RN, GNP, Long Term Care Heather Batchelor, MD, Hospitalist Gara Coffey, Pharm D, Long Term Care Deshondra Green, Pharm D, Acute Care Renee Browning, PT, Long Term Care Kelly Fripps, RN, Health Promotion Penny Gunter, RN, Education Ken Murphy, RN, Informatics Abebe Abera, RN, CNL, Acute Care (AC) Casey Hill, RN, Assistant Manager, AC Sandra Dukes, RN, DNP, CNS, AC William Greene, RN, Mental Health Beth Allen, PT, Acute Care Kim House, MD, Long Term & Home Care Sponsor: Sandy Leake, RN, MSN, Associate Director, Nursing and Patient Care Services and Chief Nursing Officer

10 The goal of the quality initiative was to decrease the rate of falls/injury by mitigating modifiable risk factors and enhancing inter-professional collaboration.

11 To reduce rates of falls on 8 Palliative at Atlanta VAMC by 50% from a rate of 4.47 to 2.33 by July 2014 To have zero injurious falls on 8 Palliative at Atlanta VAMC To reduce rates of falls on 9 Surgical at Atlanta VAMC by 50% from a rate of 1.28 to 0.64 by July 2014 To have zero injurious falls on 9 Surgical at Atlanta VAMC

12 Electronic data bases Chart audits & queries Patient interviews (VOC) Health team member interviews (VOC) Direct observation of care Organizational capacity Workflow patterns Circumstances of falls Pattern of fall events Current processes Surveys

13 % 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Primary Reason Cum eper Data (Jan Feb)

14 Outcome Measures Fall rate Injury rate

15 Priority Area Interventions Documentation of Risk Standardize Communication Electronic documentation templates Staff Education & Accountability Patient Education Monthly Resident orientation Annual Staff Education Accountability Standardize Patient Education process Individual Risk Factors- Modify Fall Risk Assessment process Modify Post-Fall note Environmental/equipment modifications

16 Injurious fall 9 Surgical 8 Palliative Improvement Phase Sustain Phase Q1 12 Q2 12 Q3 12 Q4 12 Q1 13 Q2 13 Q3 13 Q4 13 Q1 14 Q2 14 Q3 14 Q4 14 Q1 15 Q2 15

17 77% Assess lower extremity strength 62 % Initiate fall prevention in-patient referrals Provider Ordered Interventions 58 % Evaluate orthostatic hypotension 35% Assess vision N = 81 0 % Evaluate for osteoporosis 19 % Document history of falls 15 % Initiate fall prevention community referrals N = 26

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20 Lessons Learned Implications for Spread

21 Risk Communication: Accountability: Patient Education: Individual Risk Factors: Standardizing communication collaboration Electronic note template tailored interventions Audits with feedback accountability Involvement of leaders accountability Team involvement patient education Electronic version consistency Injury Risk stratification Identifies vulnerability Education pamphlet standardizes & tailoring

22 Relative advantage Compatibility Complexity Trialability Observability

23 I would like to acknowledge team members who partnered in this initiative Sponsor: Ms. Sandy Leake, CNE Fall Prevention Sub-committee Medical Residents: H. Batchelor, V. Pragya, A. Allen MPH Student: E. Bredenberg and colleagues who provided guidance & support National Collaborative (NCPS): Virtual Breakthrough Series Patient Safety Committee, Atlanta VAMC VAQS: Site faculty

24 1.Clyburn T, & Heydemann J. Fall prevention in the elderly: Analysis and comprehensive review of methods used in the hospital and the home. J Am Acad Orthop Surg. 2011;19(7): ECRI Institute. Healthcare risk control: Falls. March; 2009; ECRI Institute: Pymouth Meeting, PA. 3.Centers for Disease Control. Costs of falls among older adults. 2013;Author: Atlanta, GA. 4.Curry L. Fall and injury prevention. In Patient Safety and Quality: An Evidence-based Handbook for Nurses. April 2008;Agency for Healthcare Research and Quality, Rockville, MD. 5.Stevens, J A, et al. The costs of fatal and non-fatal falls among older adults. Injury prevention. 2006;12(5): Wu S, Keeler E B, Rubenstein L Z, Maglione M A, Shekelle P G. A cost-effectiveness analysis of a proposed national falls prevention program. Clin in Geriatr Med. 2010;26(4): The Joint Commission. Preventing patient falls. 2013; Joint Commission Resources: Oakbrook, IL 8.National Quality Forum. Serious Reportable Events in Healthcare 2006 Update. 2006; Author: Washington, DC. 9.Centers for Medicare & Medicaid Services. Hospital-Acquired conditions.2012;author: Baltimore, MD. Payment/HospitalAcqCond/index.html?redirect=/HospitalAcqCond

25 10.Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Inpatient fall prevention programs as a patient safety strategy: A systematic review. Ann Intern Med. 2013;158: Oliver D, Healey F, & Haines TP. Preventing falls and fall-related injuries in hospitals. Clin in Geriatr Med. 2010; 26: Agency for Healthcare Research and Quality. Preventing Falls in Hospital Falls: A Toolkit for Improving Quality of Care. 2013;AHRQ: Rockville, MD Institute for Healthcare Improvement. Transforming Care at the Bedside How-to Guide: Reducing Patient Injuries from Falls. 2012;Author: Cambridge, MA 14.Minnesota Hospital Association. Road Map to a Comprehensive Falls Prevention Program. In Patient safety: Call to action Author National Quality Forum. Safe practice 33: Falls prevention. In: Safe Practices for Better Healthcare 2010 Update ; Author: Washington, DC. Accessed November 15, 2013: Neily J, Quigley P, & Essen K. Implementation Guide for Fall Injury Reduction: VA National Center for Patient Safety Virtual Breakthrough Series: Reducing Preventable Falls and Fall-Related Injuries. 2013; VA National Center for Patient Safety: Washington,DC VA National Center for Patient Safety. Falls toolkit. 2004;Department of Veterans Affairs: Washington, DC.

26 Baseline assessments Examples of interventions Audit results

27 Standardize data reporting Random Chart Audits Date of Audit Age Admitting Diagnosis Morse Score on Admission Fall Risks Identified Accurately Injury Risk Stratification Injury Risks Communication of Risk - DAR Documentation of Tailored interventions Documentation of Pt Teaching - Individual Risk Nursing Re-assessment Accurate Provider Assessment Inter-professional Rounds Accurately report fall risk Standardize education process Veteran Interviews Top Reasons at Risk 3 main reasons fall prevention is important Falls for most part are preventable Falls can result in injury Falls can make hospital stay longer 3 actions to stay safe: Learn risk factors Call for help Wait for help Two reasons to ask for help when going to bathroom Unfamiliar places increase fall risk BR are small & it is easy to lose balance or get dizzy The main purpose to use call light is: to ask the staff for help Locate call light: At bedside & in bathroom The main reason to wear non-slip footwear

28 Six Sigma Fishbone or meds- Cause-and-Effect side effects that cause for dizziness 4P s (Plant, People, Policies or confusion leading to fall and Procedure) Injurious Falls sixsigmatutorial.com Pharmacist has not identified at risk Physician not attuned to assess and intervene to mitigate modifiable fall risk factors leading to chance of fall &/or injury Patient behavior (confusion, impulsiveness, Unrealistic estimation of abilities) leads to unassisted ambulation Staff not able to respond quickly (e.,g due to understaffing) leading to patient not waiting for assistance Vulnerabilities & Opportunities Overcrowded & cluttered room creates obstacles causing unsteadiness or trips that lead to falls and /or surfaces leading to injury Lack of proper equipment e.,g., bedside commode, elevated toilet sear, prompts walk to BR and/or bending reaching that chance of falling Limited resources,sitters to adequately supervise patients leading to unassisted position changes increasing chance of falls Lack of assistive PT equipment and protective equipment requiring patients to ambulate or transfer unassisted and potentially falling and getting injuried Over emphasis on policy leading to burnout and non-adherence to best practices Policy cumbersome to read, no method of assuring accountability, and limited resources for enforcement leading to sub-optimal implementation of fall prevention Team members not aware of policy and not educated about the roles & responsibilities for implementing fall/injury prevention Pt identified as at risk for fall and not stratified for injury risk decreasing likelihood that medical team is consulted about intervening to prevent injury Patient not educated on their risk and why it is important to comply with prevention strategies leading to decreased likelihood that preventive steps taken Fall precautions overused decreasing sensitivity and decreasing use of individualized interventions to prevent falls and/or injuries

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30 Point Value (Risk Level) American Hospital Formulary Service Class 3 (High) Analgesics,* antipsychotics, anticonvulsants, benzodiazepines 2 (Medium) Antihypertensives, cardiac drugs, antiarrhythmics, antidepressants Comments Sedation, dizziness, postural disturbances, altered gait and balance, impaired cognition Induced orthostasis, impaired cerebral perfusion, poor health status 1 (Low) Diuretics Increased ambulation, * Includes opiates. induced orthostasis Score 6 Higher risk for fall; evaluate Although not included in the original scoring system, the falls toolkit team recommends that you include patient non-benzodiazepine sedative-hypnotic drugs (e.g., zolpidem) in this category. Beasley B, Patatanian E. Development and implementation of a pharmacy fall prevention program. Hosp Pharm 2009;44(12):

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33 Provider Fall Evaluation Note Fall Risk Evaluation Pertinent Medical History Identification of Risk Factors Interventions linked to Fall & Injury risk PT consult OT consult PharmD consult Orthostatic VS Enhanced surveillance Toileting assistance Injury prevention Post Fall Evaluation Date of last known fall Assessment for injury Identification of factors contributing to fall

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