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April 12, 2018
Deb Campbell, RN-BC, MSN, CPHQ, CCRN Alumna
K-HIIN Infection Prevention Improvement Advisor
Ky Hospital Improvement Innovation Network
Minimal review to tie this content to last webinar◦ Choosing what to measure
Describe process measures related to
falls prevention
*Remember, the goal is not to discuss specific
interventions in detail, but rather monitoring and feedback as prevention mechanisms!!
Quality Directors
Physical Therapists
Nurse Leaders
Falls team members
Pharmacists
Others?
They hurt!
Even minor falls can result in fear of falling and reduced activity levels->health decline!
One fall without serious injury costs hospitals $3,500
Two or more falls = $16, 500
Falls with serious injury average $27,000 in expense
Reliable Implementation-The difference between a great policy and actual best practice at the bedside consistently every day every time for every patient
Falls interventions- why is this so hard?◦ 30% of adults >65 fall yearly, 33% require medical care
◦ $12.9B were attributable to older adult falls (2017)
◦ 11,000 fatal falls occur in hospitals annually
Surveillance is the best way to ensure appropriate compliance.
◦ A sample is:
A few of many
Part of a whole
◦ A good sample is something else!
Avoid bias! (Weekends, nights)
Choosing process measures ◦ Top 10 checklist
◦ Change package/toolkit
◦ EBP articles/research
◦ RCA from last 1-5 falls*
◦ Trigger tools/chart reviews
◦ Ask the staff
◦ Top 5 diagnoses with falls at your hospital
◦ Were there any medications associated with increased falls in the last year?
Ultimately, process measures depend on yourinterventions
Oldest literature ◦ Restraints* Side rails*
◦ Staff education
◦ Risk assessment at admission
◦ Tell patients not to get up without calling for help
Next thoughts◦ Sitters
◦ Signage
◦ Yellow socks, arm bands, blankets
◦ Bed alarms
◦ Better risk assessments (add re-assessing post fall)
◦ Keep telling patients not to get up without help
Trial and Error?◦ “No one toilets alone”-> more patients not calling
◦ “Safety trumps privacy”
◦ Individualize
◦ Video monitoring?
Jury is still out!
Falls teams/committees
Post-fall huddles-> patient/family participate
Adding ‘risk for injury’ to falls risk assessment
Increasing frequency of risk assessments ◦ Q day v. Q shift
◦ After a fall
◦ With any change in status
◦ After any medication changes
Discussion at shift huddles “Who is at risk today? What is our strategy
for this patient?”
*Include in bedside huddle!
Plant ops/construction◦ Grab bars
◦ Toilet height of 17”-19”
◦ Slip resistant tubs, bathroom floors
◦ No sharp edges
◦ Colored thresholds, not raised
◦ Rubber flooring
◦ Improved lighting
Engineering/EVS◦ Room safety rounds-trip hazards, etc.
◦ Second (third) set of eyes!
◦ Environmental checklist
Is there a silver bullet?◦ Lots of good interventions*
Is there a gold standard?
Universal bundle PLUS
individualized plan and follow through/reliable implementation!
Not one perfect plan for
everyone, but there may be a
“perfect” plan for each patient
Are we there yet?
What is the evidence?◦ Effective hourly rounding
◦ Individualized risk assessment
◦ PFE v. education
◦ Early progressive mobility
If we know these are the most effective, shouldn’t we craft our auditing around these? Put our energy and resources into these?
STOP relying on a falls risk score for action
START focusing on identifying risk factors for falls and injury AND activating interventions for each risk factor
Did we avoid the “Need anything?” approach◦ Are the 3-5 P’s* addressed?
◦ Did we strongly encourage “push” an assisted trip to the bathroom?
◦ Instructions with “teach back”- not a one time task
◦ Did we assess for/correct environmental dangers?
Furniture, debris, blankets, towels, backpacks, purses
Glasses, hearing aids, water, call light
Intangibles◦ Caring attitude
◦ Willing and ABLE to help
◦ Touch, smile
*No Passing Zone/”I stop for lights”
What does the data look like?◦ # pts rounded on hourly/# pts on unit
◦ # correct rounding events*: Out of 40 interactions observed, 18 addressed all of the 3 or 5 Ps = 45%
◦ Subjective measures harder- caring approach, unhurried manner
◦ Patient feedback
can be gathered
via interview or
survey
Not just “have you fallen?”, but what were the circumstances around the fall(s)?
Delirium scale used? bCAM?
Tethers present?
Risk for injury – ABCS◦ Age>85
◦ Bones: osteoporosis, metastasis, hx of fracture
◦ Coagulation: bleeding disorder or anticoag therapy
◦ Surgery: Post-op
Med review by pharmacy
Did we act on the assessment findings?
What does the data look like?◦ # pts assessed for risk of injury/# pts audited
◦ # bCAM assessments/# of eligible patients
◦ # pharmacy reviews/# of pts with >3 meds
◦ # PT consults/# of at risk patients*
◦ # low beds, floor mats, hip protectors/# patients at risk for injury
◦ # pts with delirium
prevention actions/
# positive bCAM
Autonomy “We report…you decide”
Choice: to call or not to call? Overtly stated◦ Provide consequences of each: injury, may not be
able to go home as planned
Repetition of specific risk
Teachback is then different: ◦ What puts you at risk?
◦ What can you do to prevent a fall?
◦ Why is this so important?
Contract
Get Up campaign◦ Cross cutting
Mobility teams- calculate ROI◦ Use PCAs, sitters, volunteers
Intense engagement of Physical Therapy
Nursing buy-in◦ Time found to be greatest barrier in a nursing survey
◦ Education -> change in prioritization
Order set/protocol *Are medical staff engaged?*
• Progressive mobility is defined as a series of planned movements in a sequential matter beginning at a patient's current mobility status with goal of returning to his/her baseline
(Vollman 2010)
Vollman, KM. Introduction to Progressive Mobility. Crit Care Nurs. 2010;30(2):53-55.
24
Elevate
HOB
Manual
turning
PROM
AROM
CLRT and
Prone
positioning
Upright /
leg down
position
Chair
position
Dangling
Ambulation
25
• Determine pre admission ambulation status
• Don’t assume a frail appearance means
weakness
• Use Get Up and Go or Timed Get Up and Go test
to assess ambulation skills
Gait Belts in every room
Patients and staff have access to mobility devices
Safe mobilization and patient handling training for staff
* Gait belts are used to
help control the patient’s
center of balance.
Track mobility: document frequency, distance
Create a culture of mobility
Make it visible
27
Walk of Fame Ambulation Board instructions can be accessed in file pod
What does the data look like?◦ # patients PT evaluations/# at risk patients
◦ # rooms with gait belt/# rooms
◦ # of times patient is up/ambulated
◦ # of patients up at least 3X/day/ # of pts audited
◦ How far patient walked; pedometer
◦ # pts reassessed/
# pts who fell/had a
med or status
100% v. incremental goals
Use competition◦ Compete against your past performance
◦ Compare units/departments/disciplines
Celebrate success!
Share it- not just the numbers/not just on dashboards and at meetings!!
What issues are you seeing? Use for training and re-training!
Regular agenda item to keep topic top of mind to get resources needed
Discover (and work to overcome) barriers!! Poor assessment tool
Over-reliance on score
Culture of “bedrest”
Responsibility silos
Outcomes matter, but processes drive them!
Today’s slides
3 presentations from the Quality Conference
“Stop to Start” document
Also available:◦ HRET Falls with Injury Change Package
◦ AHRQ Falls Toolkit
◦ AHRQ Fall Prevention in Hospitals Training Program
◦ Kentucky Safe Aging Coalition www.nofalls.org
PLEASE let us help if this is new for you or you would just like a second opinion or advice from someone outside your everyday work flow!!
502-992-4383
Process measure webinar # 6
Readmissions process measures
Thursday, May 10, at 11am ET (10am CT)
