Preventing Patient Falls Coaching Webinar Series Pat Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP Fall SME; Nurse Consultant Martha Ackman BSN, MA, CPHQ, CPPS, CPHRM Clinical Improvement Advisor, HQI May 26, 2016
Patient Falls Coaching Webinar Series Objectives Extend application of fall and fall-injury prevention interventions to specific populations Restate critical program elements to reduce repeat falls and preventable falls Compose strategies to reduce barriers and enhance facilitators to short-term and long-term program implementation 2
Snapshot of Patient Falls Today Each year 1 million patients fall in American hospitals (AHRQ 2013) Close to 1/3 of those falls can be prevented (AHRQ 2013) Serious injury from falls are almost always preventable (NQF) Falls continue to be the most frequently occurring adverse event reported in hospitals (Spoelstra, et al. 2012) 3-20% of inpatients fall at least once (Oliver et al 2010) 30-50% of falls in hospitals result in injury (Oliver et al 2010) Falls with injury added 6.3 days to the hospital stay (CDC) 3
CalHEN 2.0 Harm Events Reporting Period: October 2015-April 2016 11% Falls with Harm, N=1,567 89% Total Patient Harm Events Reported (excluding Falls), N=12,382 Source: HRET S CDS 5.16.2016 4
55 CalHEN 2.0 Total Number of Falls with Harm Reporting Period: October 2015- April 2016 50 45 40 35 30 25 Tot 20 15 Bottom Quartile 12 10 5 0 Source: HRET s CDS 5.16.2016 CalHEN 2.0 California Hospitals N=160 hospitals reporting this measure Median Top Quartile 5 5 2
Coaching Session #1 Post Fall Management: Types of Falls Determining Preventability Post Fall Huddles Patient Engagement: Engagement Education 6
Poll #1 Who is in the room? Frontline RNs CNAs PT/RTs Management Senior leadership Other 7
Subject Matter Expert Patricia Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP, Nurse Consultant, Retired Associate Director, VISN 8 Patient Safety Center of Inquiry, is both a Clinical Nurse Specialist and a Nurse Practitioner in Rehabilitation. As Associate Chief of Nursing for Research, she was a funded researcher with the Research Center of Excellence: Maximizing Rehabilitation Outcomes, jointly funding by HSR&D and RR&D. Her contributions to patient safety, nursing and rehabilitation are evident at a national level with emphasis on clinical practice innovations designed to promote elders independence and safety. She is nationally known for her program of research in patient safety, particularly in fall prevention. The falls program research agenda continues to drive research efforts across health services and rehabilitation researchers. 8
Post Fall Management - Getting to Types of Falls, Repeat Falls, and Determining Preventability: Post Fall Huddles Pat Quigley, PhD,MPH,ARNP,CRRN,FAAN,FAANP Nurse Consultant Retired Associate Director, VISN 8 Patient Safety Center Retired Associate Chief for Nursing Service/Research E-Mail: pquigley1@tampabay.rr.com
Post Fall Practices Post Fall Huddle Post Fall Assessment Patient/Resident/Family Education Staff Education 10
Safety Huddles Pre-Shift Huddles Post Fall Huddles Conducted with the patient/resident where the fall occurred within 15 minutes of the fall Post Fall Analysis What was different this time? When How Why Prevention: Protective Action Steps to Redesign the Plan of Care 11
Accident Theory 12
Post Fall Huddle (PFH): Essential Components A brief staff gathering, interdisciplinary when possible, that immediately follows a fall event. Convenes within 15 minutes of the fall event Clinician(s) responsible for patient/resident during fall event leads the PFH Involves the patient/resident whenever possible in the environment where the patient/resident fell Requires Group Think to discovery what happened. Utilizes discovery to determine the root cause / immediate cause of the fall: why the patient/resident fell. Guiding question to ask: What was different this time you were doing this activity, compared to all the other times you performed the same activity (and did not fall), but this time you fell? 13
Steps to the Post Fall Huddle 1. TL makes announcement 2. Convene within 15 mins with the pt/resident in the environment where the patient/resident fell 3. Conduct Analysis; Determine type of Fall 4. TL summarizes information gleaned from PFH and intervention(s) for prevention of repeat fall are decided by the huddle team. 5. TL completes of the Post- Fall Huddle Form and processes the form according to medical center policy and procedure. 6. Modifies the fall prevention plan of care to include interventions to prevent repeat fall 7. Communicate updated plan of care in patient/resident hand-off reports. 8. Complete EMR Post Fall Note 14
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Determine Preventability Step 1: Conduct the Post Fall Huddle. Step 2: Determine the Immediate Cause of the Fall. Step 3: Determine the Type of Fall. Step 4. If Accidental and Anticipated Physiological Falls, determine Preventability: Could the care provider (direct care provider) have anticipated this event with the information available at the time? If the Answer is NO, the fall is Not preventable. If the answer is YES, the provider must ask another question: Were appropriate precautions taken to prevent this event? Answer: No, Clearly or likely Preventable; Yes, Clearly or likely Unpreventable Levinson, D. R., (2010, Nov). Adverse events in hospitals: National incidence among Medicare beneficiaries. DHHS. OEI-06-09-00090 16
Poll #2 & Poll #3 Do you do Post Fall Huddles? Yes No Sometimes 17
Poll #3 Who is part of your Post Fall Huddle? Patient Visitor/Family present at time of fall Frontline staff Manager/charge nurse PT/OT Senior leadership other 18
Let s Share! Actions taken to plan and implement post fall huddles Experiences with involving the patient Experiences with PDSA cycles: barriers and facilitators to implementation and/or change Lessons learned to increase adoption and spread 19
Patient Engagement: Health Literacy Health Literacy Definition: The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. (Ratzan and Parker, 2000) According to the research, about 52% of patients understand what we tell them or give them to read 1 in 3 patients have inadequate health literacy skills IOM Report: Health Literacy: A Prescription to End Confusion 2004 healthliteracy@ama-assn.org 20
Partnering Patients Need support and education to make good choices Benefit from easy to use directives Need to be accountable Need practical examples to put principles into place Family Partners in Care Advocates, Information Gatherers Messengers Provide ongoing assessment in the home Teach clinicians about their safe practices 21
Autonomy Self Determination 22
Teach Back Teach Back Testing: what are the trends in patients difficulty to understand what is taught? Ask the patient to describe or repeat back in his or her own words what has just been told or taught. Return demonstration is a similar technique used by diabetic educators, physical therapists, and others. When the health professional hears the patient s description in her/his own words, further teaching can be accomplished to correct misunderstandings. Never ask whether patients understand; they always say yes. 23
When Teach Back Is Especially Important: New medications A new diagnosis Instructions for calling for help to BR Instructions for self care e.g. ask, How can you stay safe from falling in the hospital? Patients are cautioned on how to prevent falls in the hospital e.g. young male patients who suddenly have high doses of pain meds but want to toilet themselves. Ask, How will you best prevent yourself from falling when you are given this powerful drug for pain that is known to cause falls? 24
Ask Me 3 Adapted for Falls How many patients understand what we teach them? Teach patients with this format: Their main problem putting them at fall risk What they need to do to keep from falling in hospital Why is it important for them to do this Check the family s understanding: What is the patient s main problem? What can the patient to do to stay safe from falling in the hospital? Why it is important for the patient to do this? 25
Teaching: After a Fall Reframe patient education curricula to include "what happens after a fall". What can we learn from this event? How can we work together to prevent this again? 26
Best Practice Patient Education Brochure Anticoagulation: Preventing Injurious Falls Risk for falls Practical strategies to prevent injuries Actions to take if one falls Fall prevention strategies 27
What to do When you Fall 28
Poll #4 The actual purpose of teach back is: Determine if my teaching was effective. Assess if the patient understand what I said. Listen to the patient / family repeat back in their own words what I said. Learn if the patient will read the materials I am sending home with him/her. 29
Evaluation of Learning Design patient education program evaluation as a knowledge and skills checklist for cognitive and psychomotor domains of learning Include Health Literacy Assessment to check ability to comprehend and use health information 30
Let s Share! Actions taken since conferences to plan and implement including patients & families as partners in care Experiences with involving the patient and family: prevention, protection, detection Lessons learned to increase adoption and spread 31
Thank you for sharing! Together we accomplish more! 32
Closing Remarks What are your questions? What are you going to do by next Tuesday? 33
Fall Coaching Webinar Series 12:00 1: 00 PM 5/26/16 Session 1: Post Fall Huddle, Involving the Patient; Patient Engagement 6/13/16 Session 2: Protection from Injury: Injury Reduction Environmental Assessment, Floor Mats, Hip Protectors, Helmets; Implementing Population-based approach to Injury Reduction (A, B, C, and S); Unit-based Champions: Resources for Peer Leaders 7/5/16 Session 3: Proactive Toileting - Bathroom vs. Bedside Commodes; Toileting prior to Pain Medication 7/25/16 Session 4: Mobility Issues, Walkers in Rooms; Postural Hypotension 8/15/16 Session 5: Accelerate Improvement- Share your Experience; Closure to the Webinar Series 34
Thank You! For further questions: Martha Ackman mackman@hqinstitute.org Pat Quigley pquigley1@tampabay.rr.com Shweta Krishnan skrishnan@hqinstitute.org 35