Wednesday, January 23, 2013 2-3p

1. Falls Program Virtual Breakthrough Series 2 Reducing Preventable Falls and Fall Related Injuries NCPS & VISN 8 PSCISession 2 Wednesday, January 23, 2013 2-3p

2. BTS2 Program Goals: Improve your organization’s infrastructure and capacity to reduce fall-related injures. Enhance environmental safety. Mitigate or eliminate modifiable fall risk factors. Assure reliable handoff communication about patients’ fall and injury risk. Integrate patient (family) as a partner in their fall prevention program. Reduce rate of repeat falls. a Quantify impact of program changes.

3. Looking Ahead Ten Sessions of Learning and Sharing • Jan 9th: Improved Organizational Infrastructure and Capacity for Fall Prevention Programs • Jan 23rd : Ensuring a Safe Environment • Feb 6th: Mitigate or Eliminate Modifiable Fall Risk Factors, Part 1 • Feb 20th : Mitigate or Eliminate Modifiable Fall Risk Factors, Part 2 • Mar 6th: Reduce Moderate to Serious Injuries for Vulnerable Populations • Mar 20th: Clinically Relevant and Reliable Handoff Communication: Let’s Talk about Falls and Fall-related Injuries • Apr 3rd: Patients/Families as Full Partners in Fall Prevention • Apr 17th: Post Fall Management: Reducing Repeat Falls • May 1st: Fall Program Evaluation • May 15th: Sharing Program Successes

4. Session 2: Ensuring a Safe Environment Objectives: • Differentiate environmental safety for preventing fall vs. reducing injuries from falls • Link environmental assessment to type of fall: accidental falls • Review strategies for environmental safety assessment

5. LEVANNE R. HENDRIX, GNP, MSN, PhD Dr. Hendrix received her BSN, Geriatric Nurse Practitioner and MSN in Psych-Mental Health Nursing from the University of Miami, Miami , Florida. She relocated to the San Francisco Bay Area in 1997 to finish her doctoral work and complete an Internship in Ethnogeriatrics at the Stanford Geriatric Education Center.  She has extensive experience in caring for culturally diverse elders in both the public and private sectors, including Acute Care, Adult Day Treatment Programs, Skilled Nursing Facilities, Adult Day Health Center program, Assisted Living, and Dementia Care.  Currently Dr. Hendrix serves our veterans as Nursing Quality Management for LTC / Extended Care Services, VAPAHCS and Facilitator for their Fall Prevention Program. She has served as the founding Chair of the Nursing Quality & Safety Council, and as Co-Chair of their Dementia Committee. Levanne also holds concurrent appointments as Asst. Clinical Professor, Dept. of Physiological Nursing, UCSF School of Nursing, and Ethnogeriatric Specialist, Stanford GEC.

6. Pat Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP Patricia Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP, 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 is also 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.

7. Before we get started, let’s hear from you, about your homework assignments Who wants to share? • Did you declare your aim for falls work organizational level and unit level program attributes. • What top 3 opportunities did you learn about to enhance your program at the Unit and Organizational Level? • Did you start to develop a strategic plan for action for each of the 3 prioritized opportunities?

8. Most effective, fall prevention interventions should be targeted at both point of care and strategic levels • Best Practice Approach in Hospitals: • Implementation of safer environment of care for the whole patient cohort (flooring, lighting, observation, threats to mobilizing, signposting, personal aids and possessions, furniture, footwear • Identification of specific modifiable fall risk factors • Implementation of interventions targeting those risk factors so as to prevent falls • Interventions to reduce risk of injury to those people who do fall (Oliver, et al., 2010, p. 685)

9. Fall Prevention • Assessment • Universal Fall Precautions • Care planning • Arm bands • Signage for high risk for injury • Veteran-Specific Interventions • Communication • Report/Assignment sheets/Handoffs -every shift • Re-assessment with Change of Condition • Intentional Rounds • Every hour or more frequently • Include equipment/intervention check • CareTracker - menu • Environmental Rounds • Video Monitoring • Courtesy of Mary Watson, MS, ARNP

10. Fall Detection • Alarms • Chairs • Pull cord alarms • Voice activated alarms • One arm seat belt alarms • Sensor mats- light weight • Bed • Pull cord alarms • Mattress sensor mats • Large • Small • Light Weight • 6 month pads • Built in bed alarms • Bathrooms • Call system attachment Toilet seat alarm • Clips on Emergency Cords? Courtesy of Mary Watson, MS, ARNP

11. Detection continued • Floor/Door Alarms • Floor Mat alarms • Cordless Motion Detecting Beams over bed • Passive Infrared Alarms on beds • Pull cord alarm to doors • Wander Detection Devices • Placement • Wrist/ankle • Wheelchair • Video Monitoring Courtesy of Mary Watson, MS, ARNP

12. Fall Protection • Mattresses-beveled edges • Floor mats-size? • Length • Thickness • Beveled edges • Non-slip/Hygienic • Night time glow strip • Flooring • Color • Padding • Helmets • Hard • Soft • Reusable • Available for PRN use • Hip pads • Soft pads and hard shell • External • Undergarments • Sweat pants and shorts Courtesy of Mary Watson, MS, ARNP

13. Fall Protection continued… • Low Beds • What is the patient’s height and right level? • Wheel chair • Size/features • Brake extensions • Anti -tippers • Front and • Back • Auto Brakes? Courtesy of Mary Watson, MS, ARNP • Chairs/cushions’ • Right height • Right cushion • Anti slip materials • Seat lifts • Toilet Seat elevation/lifts • Swing Away grab bars

14. OTHER CONSIDERATIONS • Keep list/spreadsheet of where products are distributed. • Shift rounds to ensure equipment is “turned on” check for patient sabotage! • Include equipment check in hourly/intentional rounds. • Maintenance and inventory checks -how will that get done? Courtesy of Mary Watson, MS, ARNP

15. From www.visn8.va.gov/patientsafetycenter/fallsTeam/default.asp • C. Environmental Safety to Reduce Severity of Injury • Hip Protectors • Floor Mats • Non-slip flooring • Height-adjustable bed (in low position, except during transfers) • Bed-rail alternatives (body pillows, assist rails) • Raised toilet seats • Elimination of sharp edges • Use of safe exit side from bed (pt transfer to unaffected side) • Use of alarms (bed, w/c) • Pt access to mobility aides (walkers, canes) as appropriate

16. Bathroom Safety • Enough Grab Bars? How about folding grab bars? • Elevated Toilet Seats- Yes or No • Toilet Alarms – clips on emergency cords • Non-skid floors with grit or traction kleen • Rubber floor mats- antimicrobial • Padded walls and sharp surfaces? • Motion Sensing Lights

17. Raised Toilet Seat: Toilets should be mounted at heights between 17 and 19 inches to eliminate the need for a raised toilet seat.Raised toilet seats are not recommended and should be used only with high need patients. These devices are high risk for the potential use as a weapon.

18. Shower Rooms • Grab Bars • Liquid soap vs. bar soap • Plenty of towels available • Grit on floors vs. floor mats • Shower chairs in working order/wheels lock? Right size? • Does water drain off quickly?

19. Evaluation of Equipment • Patient friendly • Product safety • Quantity and cost • HOW DO WE PAY FOR THIS? • Staff friendly • All Services/Departments need to evaluate • Easy to implement and clean • Distribution Courtesy of Mary Watson, MS, ARNP

20. VAPAHCS Falls Prevention Program Elements of VAPAHCS Fall Prevention: • Assessment of patient risk for fall & injury. • Application of fall reduction techniques & protective equipment. • Documentation • Coordination with all clinical units at VAPAHCS • Unit-based Falls Champions • Data collection & analysis • Fall Prevention Walking Rounds

21. VAPAHCS Falls Prevention Program 5 Point Program for all Clinical Units: 1) Hip Protectors 2) Non-Skid Socks a. Yellow – All patients needing socks & high risk. b. Red – Highest risk for fall & injury. 3) Floor Mats 4) Bed & Chair Alarms 5) CALL DON’T FALL Stop signs – Patient Rooms & Bathrooms.

22. RESOURCES • Alimed Catalog: www.AliMed.com • Care-view.com • Carroll Healthcare Low Beds: www.carrollhospitalgroup.com • Comfortex Landing Strips: www.comfortex.com • Elcoma.com…swing away grab bars • Hill Rom Low Beds: www.hill-rom.com/ • Hip Savers: www.hipsaver.com • Courtesy of Mary Watson, MS, ARNP

23. Resources • Sammons Preston Catalog: www. pattersonmedical.com/ • Plum Enterprises Helmets/Hip Pads: www.FallsSafety.com • Posey: www.posey.com • Satech Floor Mats: www.satechinc.com/ • Span America: contoured mattresses: www.spanamerica.com • Courtesy of Mary Watson, MS, ARNP

24. TECHNOLOGY and equipment • ADJUNCT to ASSESSMENT • Related to individual abilities & disabilities • One size does NOT fit all….

25. Types of Falls • The types of falls will be reviewed, with special emphasis on accidental falls, the type of fall linked to environmental safety issues.

26. Types of Falls • Failure to Differentiate Type of Fall • Accidental • Anticipated Physiological • Unanticipated Physiological (Morse 1997) • Intentional Falls • Failure to Link Assessment with Intervention

27. Environmental Checklists • Examples of interventions to improve environmental safety will be provided,

28. Environmental Assessment Tool Or any design of your own vs. VISN 8’s Injurious Fall Prevention Assessment Tool

29. Environmental Assessment-do you need equipment or repairs? • How often? • Develop a schedule • Who rounds? • Areas of concern? • Safety Huddles during shift change

30. Strategies to Increase Environmental Safety • Focusing on the patient room & bathroom • Addressing the patient's interaction with both the room and the bathroom • Environmental Assessment Checklist: http://www.patientsafety.gov/SafetyTopics/fallstoolkit(interventions • Environmental Safety

31. Strategic Planning Framework • See handout

32. Overview of Next Session 3 2/6/13, 2-3 PM Eastern Presentation: Mitigate or Eliminate Modifiable Fall Risk Factors – Part 1 • The roles of risk screening vs. assessment • Emphasis for multifactorial comprehensive fall risk assessment. • In-depth review of the AGS/BGS guidelines • New framework for individualized care planning that links the specific fall risk factor to a treatment intervention required to mitigate or eliminate specific fall and injury risk factors. • Open discussion to share clinical warning systems within current EMRs to alert others about patients fall and injury history.

33. Homework Assignments from this Session to report at Session 3 • Complete environmental safety assessment specific to risk for falls and risk for injury, on one unit, including patient room and bathroom. • Discover at least two environmental/equipment safety changes that could reduce fall risk. • Discover at least two environmental/equipment safety changes that could reduce injuries should a fall occur. • Develop a strategic plan to implement the proposed environmental safety changes and integrate hip protectors and floor mats into patient care. • Review the last 10 falls from one unit, classify the fall by type of falls. For those falls that are accidental falls, examine the root causes for trends.

34. Next Session Session 3 – 60 minutes – 2/6/13, 2-3 PM Eastern Presentation: Mitigate or Eliminate Modifiable Fall Risk Factors - Part 1 Faculty: • Tatjana Bulat, MD, Director, VISN 8 PSCI • Amanda Olney, PhD, PT, Seattle VAMC • Pat Quigley, PhD, ARNP, CRRN, Assoc. Director, VISN 8 PSCI