New Falls Risk Tool and Documentation

Report
Tentative Go Live Date
September XX, 2012
Falls and Injury from Falls
A Nursing Sensitive Indicator
The prevention of falls and injury from falls in patients
who are hospitalized are indicators of high quality
bedside nursing care given on a particular unit or at a
hospital.
Recognizing who is at risk and implementing
appropriate interventions aimed at minimizing the risk
is part of professional nursing practice at TJUHs, Inc.
Why we needed a New Fall Risk Tool
Background:
Morse Falls Risk Tool was not meeting our needs;
screens for Fall Risk and did not assess WHY patient
is at risk
It did not predict all of our falls
Some of our patients scored not at risk (< 50)
experienced a fall
Often incomplete/inaccurate documentation
Jefferson Fall Risk Assessment
and Intervention Tool
Goal:
To improve patient outcomes (decrease falls
and injury from falls) through targeted
interventions based on assessment
Jefferson Fall Risk Assessment and
Intervention Tool (cont)
What is different?
 Goes beyond screening – assesses WHY a patient
is at risk for fall
 No “points”/numerical values assigned to a risk
factor
 If you assess a patient to be at risk to fall due to any
risk factor – then they are at risk
 Supports clinical judgment and decision making –
re: selecting fall prevention interventions based on
the specific risk factor(s)
Timeline
Summer
2011
FRG SN
identified
WHY their
patients fell –
what put them
at risk?
Spring 2012
All units on all
campuses trialed
new Fall Risk
Assessment and
Intervention Tool.
Fall Interdisciplinary
Committee
provided feedback.
Fall 2011
FRG SN or
designee from pilot
units trialed the
assessment
criteria and
provided feedback
Summer 2011
Winter 2012
Fall Task Force
created a Fall
Risk Assessment
Tool based on a
literature review
and the Jefferson
specific risk
factors identified
by Fall Resource
Group
Task force identified
specific
interventions to
match risk factors
based on literature
and best practices
Fall
2012
Go
Live!
Summer
2012
Jeff Chart
Training and
Education
Fall Risk Assessment
 Hx of falls prior or during hospitalization
 Altered mobility/gait disturbances
 Altered elimination
 Altered balance/risk for dizziness
 Equipment
 Altered mental status &/or behavior risk
 Risk of injury
Fall Prevention Interventions
Specific Fall
Prevention
Interventions
General Fall Prevention
Interventions
(all pts at risk for Falls –
regardless of why)
General Safety Interventions
(all pts – regardless of fall risk)
Assessment
Assess Fall Risk factors through:
 Observation of patient
 Interview (completion of Nursing Admission
Assessment)
 Review of the Physician History & Physical
Falls Tab Added to Assessments
Assessment - Complete Fall Risk
Assessment in Jeff Chart.
Intervention
Implement and document General
Safety interventions for ALL patients.
Intervention
Implement and document General Fall
Prevention Interventions for ALL pts
with any risk for falls
Interventions - Specific
Select appropriate interventions based on patient
risk factors and individualized assessment.
Case Study
A 35 year old female is being admitted for wheezing and
shortness of breath.
PMH: Hypertension and asthma
Admission orders include:
 Inhalers
 Prednisone 40mg PO
 Hydrochlorothiazide 12.5mg PO
What are the Falls Risk Factors for this patient?
What Fall Prevention measures would you implement
and document for this patient?
Fall Risk Assessment
Risk Assessment Criteria
Hx of falls prior or during
hospitalization
Assessment
No risk
Altered mobility/gait disturbances No risk
Altered elimination
No risk; has been on HCTZ
Altered balance/risk for dizziness No risk
Equipment
No risk
Altered mental status &/or
behavior risk
No risk
Risk of injury
No risk
Interventions
General Safety Interventions only
 Sensory items within reach
 Call bell within reach
 Non-skid footwear
 Night Light
 Level 2 Bed Alarm at night
 Bed in low position/locked
 Pt/Family teaching
 Hourly rounding
Case Study
An 82 year old female was admitted 5 days ago, S/P fall at
home.
 PMH: Hx of falls, has generalized weakness, uses cane to
ambulate, has diabetes with neuropathy in hands and feet, is
HOH, and takes Coumadin for chronic atrial fibrillation
 Two days ago patient spiked a fever to 101.3F and became
confused; found to have a UTI
 Current orders include:
 IV fluids
Pain Medications
Oxygen at 2 liters
 Antibiotics
PT/OT consult
What are the Falls Risk Factors for this patient?
What Fall Prevention measures would you implement
and document for this patient?
Fall Risk Assessment
Risk Assessment Criteria
Assessment – from H & P, nursing
assessment, PT/OT assessment
Hx of falls prior of during
hospitalization
Hx of falls
Altered mobility/gait disturbance
Generalized weakness; hx of DM
with neuropathy
Altered elimination
Admitted for UTI
Altered balance/risk for dizziness Uses cane for balance to walk
Equipment
IV pole; Oxygen therapy
Altered mental status &/or
behavior risk
Confusion; HOH; Pain medication
Risk of injury
Coumadin with therapeutic INR
Interventions
General Safety Interventions
General Fall Prevention Interventions
Specific Fall Prevention Interventions
Altered mobility
Assist with transfers/ambulation
Altered elimination
Toilet q1 hour; stay with pt.
Bedside commode
Altered balance/risk for dizziness
Ambulate with cane at all times
Equipment
Assist with IV pole & Oxygen tubing
Altered mental status &/or behavior
risk
Room close to Nurse’s station
Self-releasing seat belt in chair
Risk of injury
Low bed
Key Points
 Falls Risk Assessment and Intervention is a
professional nursing role and responsibility
 Complete every shift, after a change in condition or
after a fall, and upon transfer to another unit.
 No “point” values are assigned to risk factors
 Having any risk factor makes the patient at risk for
falling
 Tailor your interventions to the patient’s assessment
 Communicate patient’s fall risk and interventions
via handoff, huddles, IPOC, and Teletracking.
Fall Prevention is a NurseSensitive Indicator of Quality
 As a professional nurse providing direct care,
you are in a position to make a difference in
patient outcomes.
 Your assessments and thoughtful planning will
minimize the risks for patients at risk for falls and
injury from falls

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