A Interprofessional Approach to Falls Prevention

A InterprofessionalApproach 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 Licensed beds 413 Employees 4,432 Physicians 1,216 Admissions 19,424 ED visits 65,515 Clinic visits 224,769 Surgery cases 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 Interprofessionalapproach 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 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 interprofessionalfalls 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 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

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 ED – Three question fall assessment Consistently communicate individualized information about patients at risk for injury from falls to all caregivers and hospital staff Verbal and visual cues Consistently communicate in handoffs those patients with a history of falls Intensive Reviews of falls with staff Implementation plan 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: fallhmc@uw.edu 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 Not a post fall debrief Chart review followed by discussion of patient and possible interventions/opportunities for future prevention Outcomes 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 • 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” • 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 • 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

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

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 QI- Confidential Presented at Washington State Hospital Safe Table, 2/20/2013

Current Project – Post Fall Assessment 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 Communication post fall 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 Interprofessionaltask 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?

A Interprofessional Approach to Falls Prevention