Inpatient Fall Prevention. Genesis Health System Davenport Iowa

Transcription

1 Inpatient Fall Prevention Genesis Health System Davenport Iowa

2 Fall Facts The average cost of a fall with injury is $33,785 Fractures following falls account for 35% on non fatal injuries, but 61% of the costs By 2020, the cost of fall related injuries may reach $32.4 billion nation wide. One study demonstrated that the higher the inpatient satisfaction levels with the quietness of the hospital environment, the lower the injurious fall rates.

3 Reason for action A3 Reason for Action: Burning Platform Increase in Falls and Severity of Injury Initial State Genesis Tool 1999 Homegrown Risk Assessment blurry Risk Assessment and Interventions confusing Yellow versus Red

4 Initial State A3 Qualitative Confusion on Policy Emotional Distress Inconsistent Hand-Off communication Inconsistent Quantitative 271 Falls No Harm 85 Falls required intervention 59 temporary harm and intervention 6 temporary harm- prolonged hospitalizaton 2 deaths 250/424 could be related to lack of prescribed interventions

5 Target State A3 Reduce falls by 50% No Serious Safety Events Related to Falls

6 Gap Analysis A3 Root Cause: Confusion in policy and management of patients at risk for falling Stoplight tool Communicates "red" as high risk- new tools all "yellow", confusing Admission assessment 'loose' Assessment does not clearly I.D. interventions Trip ticket to radiology unclear Poor decisions- 2 person transfer 1 person set-up Lack of knowledge on use of bed alarms Lack of use of chair/bed alarm/bathroom supervision together Yellow gown initiated without linking Hurried/busy staff General lack of knowledge

7 Solution Approach A3 Revise policy Evidence based tool for Risk Link interventions to Risk Education on Fall Prevention Interdisciplinary/Ancillary Educaton Healthstream Module/Rapid Regs Inpatient and Outpatient Competencies

8 Solution Approach A3 Teach tool for Critical Policy Safety Observation Rounding Article for newsletters Patient and Family brochures Yield Sign replaces Stop sign Banner Bar Chair alarm availability

9 Solutions Approach Standard interventions Moderate interventions High Risk Interventions - Bundled Electronic Risk Assessment in EHR

10 Risk Assessment Tool Literature review Other Tools Johns Hopkins Risk Assessment Tool Copywrited Permission Electronic

11 Completion Plan: Risk Assessment Tool John Hopkins Risk Assessment Tool (Part 1)

12 Completion Plan: Risk Assessment Tool John Hopkins Risk Assessment Tool (Part 2)

13 Rapid Experiments A3 Review validity and assessment of Johns Hopkins Tool Trip Ticket Transporter responsibilities

14 Completion Plan: Interventions A3 Standard Tied to all patients no matter the risk Built on NIC

15 Completion Plan: Standard Interventions Call light within reach at all times Bed in low position when unattended Non-slip footwear Use of proper techniques for transfer or ambulation such as gait belt, walker, and lift devices Assessment for side effects of medication that may cause vertigo Observe frequently (rounding)

16 Completion Plan: Standard Interventions Use proper techniques for transfer or ambulation such as gait belt, walker, and lift devices Use soft touch call light as appropriate Orient to surroundings Instruct/teach patent and family to use of call light for assistance with mobility Place personal articles within reach of patient. Lock wheelchair and or bed when moving patient. Remove clutter Teach patient and family fall prevention interventions

17 Completion Plan: Moderate Interventions Moderate Risk Tied to Score of 6-13 Supervise all mobility Teach patient and family to call Discuss with Physician referral to therapy Evaluate need for elimination Schedule

18 Completion Plan: High Risk Interventions High Risk tied to score of >13 Bundle Signage

19 Completion Plan: Fall Signage v

20 Completion Plan: Education Roll Out March 4, 2013 Each Campus All Day Walk through

21 Completion Plan: Education Campaign

22 Completion Plan: Quality Observations Fall Prevention - High Risk patient Yellow triangle on door Fall Prevention - High Risk patient Yellow triangle on patient wristband Fall Prevention High Risk patient Yellow gown on Fall Prevention High Risk patient - bed and chair alarm on

23 Completion Plan: Yellow Gown

24 Completion Plan: Trip Ticket

25 Completion Plan: Challenges IT build in Cerner competing priorities How to do Education Constant BR supervision Yellow Gown Rehab and Skilled Triangle on Bracelet Policy Revision

26 Outpatient Tool 4 Questions 1. Do you have trouble standing or walking on your own? 2. Do you currently use a wheelchair, walker, cane, or anything else that assists you to walk? 3. Have you fallen in the past 6 months? 4. Do you feel that you re at risk to fall for any reason Interventions Yellow Wrist Band Wheelchair or assist

27 Moving Forward Outpatient Risk Tool/Policy All areas ED Risk Tool and Interventions Revisions to Electronic Tool Patient/Family EducationBrochure Revised policy Updated the Bundle to include gait belt Behavioral Health???

28 Confirmed State A3

29 Confirmed State A3

30 Confirmed State: A3 1.56/1000 to 1.18/ day per month for total campuses to 8.89 falls/month 2.03 reduction of $35,000/fall Monthly reduction of $71,050 Annual Reduction $852,600

31 Insights: Positive Education plan Visibility for staff IT Johns Hopkins Tool Fall Bundle Team of 4-5 A3 Challenges Large Scope IT multiple projects Copywrited Tool ED Involvement Outpatient Involvement

32 Safety Heroes - Oncology

33 Questions Maggie Dubin Wanda Haack