Ross Ehrmantraut Slides - Washington State Hospital Association

Report
A Interprofessional Approach
to Falls Prevention
Ross Ehrmantraut, RN, CCRN
Patient Safety Officer
Elizabeth Phelan, MD, MPH
Harborview Medical Center – UW Medicine
Seattle, WA
Presented at Washington State Hospital Safe Table, 2/20/2013
Harborview Medical Center
Harborview Medical Center is owned by King County,
governed by the Harborview Board of Trustees, and
managed under contract by the University of Washington
Confidential – QI
Presented at Washington State Hospital Safe Table, 2/20/2013
WAMI Region
 Only
Level I adult and pediatric trauma
and burn center in region

Washington, Alaska, Montana and Idaho.
Confidential – QI
Presented at Washington State Hospital Safe Table, 2/20/2013
Harborview Medical Center


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Licensed beds
Employees
Physicians
Admissions
ED visits
Clinic visits
Surgery cases
413
4,432
1,216
19,424
65,515
224,769
13,455
Approximately $190 million in charity care
in 2011
Confidential – QI
Presented at Washington State Hospital Safe Table, 2/20/2013
Thanks
 Pat
Blissitt, RN
 Elizabeth Phelan, MD
 Joni Herrington, RN
 Abdelhak Abdou
 Debra Page, PharmD
 Nurse managers and frontline staff
Presented at Washington State Hospital Safe Table, 2/20/2013
Issue
 Falls
are a leading cause of injury in
hospitalized patients
 Has historically been a single discipline
approach to prevention
 Fall Risk assessment tools are not
consistently good predictors of fall risk

Studies indicate clinical judgment is
equivalent to tools – neither is predictive
• Webster, Courtney, et al, Journal of Clinical Epidemiology, Feb 2009
Confidential – QI
Presented at Washington State Hospital Safe Table, 2/20/2013
NPSF/AHA Fellowship Project
 12
month Patient Safety Leadership
Fellowship



Action learning project focused on
Interprofessional approach to falls prevention
and reduction of harm from in hospital falls
Focus on what we do and improve on it
Provide increased awareness of falls
prevention and reduction of harm from falls
across all disciplines
Confidential – QI
Presented at Washington State Hospital Safe Table, 2/20/2013
Falls Taskforce
 Subset
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of hospital wide falls committee
MD - Geriatrician
Patient Safety Officer
Nurse Manager
Nurse Educator
Neurosciences Clinical Nurse Specialist
Pharmacist
Confidential – QI
Presented at Washington State Hospital Safe Table, 2/20/2013
Hypothesis
A
interprofessional falls assessment and
intervention will reduce the incidence of
falls and harm from falls in inpatients at
high risk
Confidential – QI
Presented at Washington State Hospital Safe Table, 2/20/2013
Clinical Objectives

Decrease fall rate by 20%
 Decrease severe injuries from falls to < 1/month

Harm score of six or higher
• Harm score of six = Temporary harm – bodily or
psychological injury, but likely not permanent

Develop a systematic approach to assessment
and intervention
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Involve all disciplines
Bundle
Lower threshold for identifying patients at risk
Involve family/patient
Confidential – QI
Presented at Washington State Hospital Safe Table, 2/20/2013
Implementation plan

A interprofessional approach, using Team STEPPS
concepts

Develop a “stop the line” mentality

Build the belief among staff that injuries from falls can be
eliminated
 Incorporate fall assessment discussion in daily rounds
 Develop an order form for patients at risk for falls
 Implement the falls bundle for those patients identified at
risk for falls
 Transparency – unit and hospital wide
Confidential – QI
Presented at Washington State Hospital Safe Table, 2/20/2013
Implementation plan
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Review medications for fall risk and adjust as indicated
Post falls data monthly on all care units – be transparent
Consistently use a valid falls risk assessment tool and
track compliance – MFS

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Consistently communicate individualized information
about patients at risk for injury from falls to all caregivers
and hospital staff

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ED – Three question fall assessment
Verbal and visual cues
Consistently communicate in handoffs those patients
with a history of falls
Intensive Reviews of falls with staff
Confidential – QI
Order Form
Presented at Washington State Hospital Safe Table, 2/20/2013
Bundle
Presented at Washington State Hospital Safe Table, 2/20/2013
HMC CARES about Fall Prevention
Communicate fall risk to all providers
Visual Fall Alerts Yellow armbands and blankets, Falling Stars & Fall Plan on
white board, Discuss fall/ harm risk and prevention plan at hand-off.
Audible Alerts/Assess Mobility
Bed exit alarms or sitter select and assess ability to easily get out of bed/chair
Reduce Harm/Review Medications
Low Beds, Floor Mats and increased observation ie chart in room, patient at
front desk, sitter, consider revising medications
Educate Patient and family/Evaluate for Delirium
Provide written and verbal information, use teach back, document fall
prevention education in the detailed assessment, assess patient’s level of
awareness and screen for delirium.
Standardize Intentional rounding
Focus on the 4 P’s: prompted toileting, positioning, pain & placement of items
(call light & personal items such as eyeglasses)
To get involved or make suggestions about Fall Prevention initiatives
e-mail: [email protected]
Confidential – QI
Presented at Washington State Hospital Safe Table, 2/20/2013
Transparency
 Tied
to annual evaluations for managers
 Dashboard shows fall rates by unit and by
service
 Rates presented at board of trustees
meetings
Presented at Washington State Hospital Safe Table, 2/20/2013
Intensive Reviews

A thorough review of patients who had an in-hospital fall
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Not a post fall debrief
Chart review followed by discussion of patient and possible
interventions/opportunities for future prevention
Outcomes

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Better use of bed alarms
Better maintenance of bed alarms
Better communication
• Leading to better assessment of risk


Establish awareness
Default on MFS for history of fall
Presented at Washington State Hospital Safe Table, 2/20/2013
Patient Smith
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Admitted with history of UGI bleed. On CIWA with most
recent score of 20 before fall
Fell twice while hospitalized
Recently admitted prior to first fall
Patient had received Ativan and diazepam for high CIWA
score – lethargic at last check. Found on ground in
melena, disoriented and delirious. Blood “gushing from
face”

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Patient transferred to ICU due to fall and GIB
2nd fall patient angry waiting for discharge and jumped
out of bed and fell to knee – no injury
Patient on waist restraints the night before second fall
QI - Confidential
Presented at Washington State Hospital Safe Table, 2/20/2013
QI - Confidential
Presented at Washington State Hospital Safe Table, 2/20/2013
Patient Jones
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Patient admitted on 6/5 for alcoholic pacreatitis.
Fell twice - on 6/23 and 6/25
History of ETOH abuse – not on CIWA
Using walker/wheel chair to get around
Frequent reminders to ask for assistance
Ambulated to nurses station and fell
Impulsive behavior at time of falls
QI - Confidential
Presented at Washington State Hospital Safe Table, 2/20/2013
QI - Confidential
Presented at Washington State Hospital Safe Table, 2/20/2013
Patient Anderson
 Pt admitted with diagnosis of SDH –

Extensive PMH – COPD, mental illness
 A & O x 3, but did not know why she was in
hospital
 Frequent reminders to ask for help before
getting up
 Found sitting at beside the night before
 Incontinent of urine
 Bed alarm not functioning at time of fall
QI - Confidential
Presented at Washington State Hospital Safe Table, 2/20/2013
QI - Confidential
Presented at Washington State Hospital Safe Table, 2/20/2013
Results to Date


Significant reduction in fall rate from
baseline throughout hospital since 2010
30% decrease in fall rate and sustained
decrease in falls with harm in pilot unit
• 29 months without a fall with severe injury on
pilot unit

Falls with severe harm are <1/month
• Nearly 50% reduction in falls with harm
• 60% reduction in Administrative Adjustments
Confidential – QI
Presented at Washington State Hospital Safe Table, 2/20/2013
QI - Confidential
Presented at Washington State Hospital Safe Table, 2/20/2013
QI - Confidential
QI- Confidential
Presented at Washington State Hospital Safe Table, 2/20/2013
Current Project – Post Fall Assessment
Post Fall Assessment - Inpatient
Patient Label
Section 1 – To be completed by RN/Therapist
1)
2)
3)
4)
Admitting Diagnosis: Date and time of fall: (date and time box)
Brief Description of Fall: (free text)
Location: bed, chair, bathroom, hallway, other (freetext)
Nursing/Therapist Assessment:
Y N Witnessed or assisted fall?
Y N Did patient hit head?
Y N Did patient lose consciousness?
Y N New neck or back pain or new motor or sensory deficits?
Y N New lacerations?
If yes, where: (free text)
Y N Evidence of new skeletal injury?
If yes, where: (free text)
Y N New complaint of pain?
If yes, where: (free text)
5) Date and time provider called:
6) Family notified (Time and Date):
N/A: patient declined or called family
Section 2- To be completed by provider
Date and time patient assessed: (date and time box)
Y N Laceration Assessment: (free text) closure
Y N Suspected spine injury (new numbness of extremities or new neck or back pain, pain on
palpation of spine). Consider or Order: cervical collar and immobilization, spine series.
Y N Concern for intracranial bleed (on anticoagulation therapy, coagulopathy, new focal neuro
findings) Consider or Order : CT head, increased frequency of neuro checks)
Y N Suspected musculoskeletal injury (chest wall pain, complaint of sternal pressure,
decreased ROM, severe extremity pain, edema, discoloration, cannot bear weight)
Consider or order radiology exams
Family notified: (Time and Date):
N/A patient declined:
Annotation (free text)
Section 3 – Interventions
Hourly rounding, scheduled toileting
Medication review- stop or decrease: Narcotics, sedatives, anti-cholinergics, sedative/hypnotics, antipsychotics, other: (free text)
Decrease tethering: discontinue Foley, Saline Lock IV, discontinue SCD’s, discontinue restraints, other:
(free text)
ORDERS: Fall prevention orders, Delirium Order set, PT-inpatient, PT outpatient, Fall prevention clinic,
other: (free text)
Presented at Washington State Hospital Safe Table, 2/20/2013
Reason for Success to Date
 Sense
of urgency
 Executive support
 Physician support
 Outside agency involvement
 Interprofessional task force
 Very little new interventions
 Increased awareness and reporting
Presented at Washington State Hospital Safe Table, 2/20/2013
Barriers
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Communication post fall
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Family
Staff
Some push back on interprofessional approach
Consistent use of order form
Consistently including nurses in daily rounding
Difficult to implement hourly rounding on a
consistent basis
Sustaining results
Confidential – QI
Presented at Washington State Hospital Safe Table, 2/20/2013
Summary
 Program
has been well received by
providers
 The bundle and order form continues to
evolve
 Interprofessional task force has been
instrumental in early successes
 An increased awareness has significantly
contributed to a decrease in falls and falls
with harm
Confidential – QI
Presented at Washington State Hospital Safe Table, 2/20/2013
Thank You
Questions?

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