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Georgia Hospital Engagement Network. Hospital Acquired Condition Affinity Webinar Series 10/15/2014. Where we were. Quarter 1 2013 --- 1 falls with Injury per 1,587 patient day with 79 hospitals reporting CMS Estimated cost per fall $663.00 - PowerPoint PPT Presentation
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Georgia Hospital Engagement Network
Hospital Acquired Condition Affinity Webinar Series
10/15/2014
Learn. Act. Improve. Spread. Keep the Drum Beat Going.
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Where we were
• Quarter 1 2013 --- 1 falls with Injury per 1,587 patient day with 79 hospitals reporting– CMS Estimated cost per fall $663.00– Total Q1-2013 Cost of falls in Georgia HEN hospitals = $234,039– Only 32 hospitals reported “0” falls
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Learn. Act. Improve. Spread. Keep the Drum Beat Going.
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What do we look like now
• July 2014 – 1 Fall with Injury for ever 1,768 patient day with 93 hospitals reporting– That is 181 patient days without a fall with injury– 57 GA HEN Hospitals reported “0” Falls with
Injury– 70 Hospitals have met the benchmark of 0.5/1000
• Since the baseline of the focus on Falls with Injury, – we estimate that there has been a savings of over
$148,417 – 224 patient falls with injury have been prevented
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Learn. Act. Improve. Spread. Keep the Drum Beat Going.
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Where could we be?
• If we had made a 40% reduction from our baseline:
– 479 Additional Falls with Injury could have been prevented
– $317,445 in preventable cost could have been avoided
– There would have been 1 fall with injury for every 2,652 patient days
– That adds up to an additional 884 patient days without a fall with injury
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Stories of Falls Prevention Champions
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Coliseum Medical Centers
Falls AnalysisJanuary – June 2014
Analyze Falls Based on Collected Data/Metrics
Day of WeekTime of DayConfusedAmbulationAssistive DeviceAgeGender
Days from Admission
ToiletingMedicationsFamily PresenceStaffingRisk Assessment
Slide 8
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0.0%
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Falls: Time of Day vs. Alert/Confused
Alert-%Confused-%
% T
ota
l Falls
Confused Patients – 42% of falls occur from Midnight to 5 AMAlert Patients – 19.4% of falls occur between 4 AM – 7 AM.Common Peak Fall Times for both Groups: Midnight, 5 AM and 6 PMShift Change – 20.6% of falls occur during “shift change” of 6 – 7 AM/PM.
TOILETING43% = Falls related to toileting17% = Family was present at time of all falls25.4% = Patients who fell during toileting had family present at the timeToileting/Gender:
◦ Men = 35% of falls are associated with toileting
◦ Women = 55% of falls are associated with toileting
Toileting / Gender/ ConfusionConfused males = 25% of falls are associated with toileting
Confused females = 61% of falls are associated with toileting
Interventions1. Increased vigilance for confused patient after midnight
2. Mandatory “potty trips” during high risk times
3. Coordinate “potty times” to precede or immediately follow other activities on the unit such as laboratory phlebotomy or meal tray delivery.
4. Availability of bedside urinal may account for lower toileting-related falls in men.
5. Maintain coverage for bathroom requests during shift change
6. Amend Post-Fall Huddle Form to include prompts for interventions.
7. Mandatory Sitters after second fall
Slide 11
POTENTIAL IMPACT – 35% Reduction
13% Reduction: By eliminating repeat fallers
11% Reduction by convincing alert men to call for help when going to the bathroom.
11% Reduction by getting families to call for help instead of helping patients to the bathroom themselves
POST- FALL HUDDLE FORM
Admitting Diagnosis: _______________________________ Date Admitted: _______________ FALL: Date of Fall: _______________ Time ___________ Prior Falls Date: None 1st Fall ______________ 2nd Fall ___________ 3rd Fall __________ Description of Fall: ______________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
FALL TYPE FALL OUTCOME Ambulating, slip, trip, stand or walk Non-Ambulating – fell from bed, chair Unknown
No Injury Minor: Bumps, Skin Tear, Scratch, Bruise Major: Broken bone/Stitches
PRE –FALL CONDITION – POTENTIAL ROOT CAUSE Yes No Fall Assessment Complete for current shift Patient Fall Risk assessed as “High” Patient had previous fall or admission was associated with a fall. Mental Status: Patient confused, dementia, unable to use call light Patient uses an Assistive Device – Walker, Crutches, Cane Patient on any of the following medications: Sleep Medication Benzodiazapenes, Narcotic, Anti- convulsive Diuretic/ Laxative,
Hourly Rounding: Evidence of patient contact within the past hour Interventions in place prior to fall such as Non-Skid Socks Lower Bed side rails up Call Light within reach Fall Bundle
Bed Alarm in Use at the time Related to toileting/ bathroom: If yes – Last Time Toileting Offered ____:____ Family present at the time of the fall Staff/ Sitter present at the time of the fall Nurse Assignment < 6 patients (Med/Surg) or < 2 for ICU. CNA/ Tech Assignment < 16 patients at the time
POST-FALL INTERVENTIONS Added Bed Alarm Arranged Sitter / Family Member Patient / Family Instruction Move closer to Nurse’s Station
Revised Fall Risk Assessment Fall-Bundle (Slippers – blanket) Occurrence Report Filed Post-Fall Assessment Post-Fall Huddle Form
Fax to Quality Department: 478-765-4174 and turn-in original to the Unit Manager 305-600 6-14
1-Jan 1-Feb 1-Mar 1-Apr 1-May 1-Jun 1-Jul 1-Aug 1-Sep 1-Oct 1-Nov 1-Dec0
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2014 - Number of Falls
What is your Story?
Learn. Act. Improve. Spread. Keep the Drum Beat Going.
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Georgia Top Guns in Fall PreventionHospitals reporting no falls with injury since Q3-2013 (4 quarters)
• Coliseum Northside Hospital• Cook Medical Center – A Campus of Tift Regional Med
Center• Hutcheson Medical Center• Jefferson Hospital• SGMC Lanier Campus • Morgan Memorial Hospital• Perry Hospital• Pioneer Community Hospital of Early
Learn. Act. Improve. Spread. Keep the Drum Beat Going.
Hospitals Reporting less than one fall with injury per month since Q2-2013
• Bacon County Hospital and Health System• Barrow Regional Medical Center• Chatuge Regional Hospital, Inc.• Chestatee Regional Hospital• Clearview Regional Med Ctr • Coliseum Medical Centers• Coliseum Northside Hospital• Colquitt Regional Medical Center• Cook Medical Center – A Campus of Tift Regional
Med Center• DeKalb Medical At Hillandale• Dodge County Hospital• Effingham Health System• Elbert Memorial Hospital• Emanuel Medical Center• Hutcheson Medical Center• Evans Memorial Hospital, Inc.• Hamilton Medical Center• Houston Medical Center• Jasper Memorial Hospital
• Jeff Davis Hospital• Jefferson Hospital• SGMC Lanier Campus• Miller County Hospital• Monroe County Hospital• Morgan Memorial Hospital• Murray Medical Center, Inc.• Northridge Medical Center• Perry Hospital• Phoebe Worth Medical Center• Pioneer Community Hospital of Early• Floyd Polk Medical Center• Southeast Georgia Health System Camden Campus• Southern Regional Medical Center• Southwest Georgia Regional Medical Center• Spalding Regional Medical Center• St. Francis Hospital, Inc.• St. Mary's Health Care System, Inc.• Stephens County Hospital• Ty Cobb Regional Medical Center• Upson Regional Medical Center
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Questions or Comments?
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Learn. Act. Improve. Spread. Keep the Drum Beat Going.
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Recommended Resources
• Characteristics and Circumstances of Falls in a Hospital Setting http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1492485/
• AHRQ Falls Prevention Toolkit
• Campaign Zero Flyer
• Department of Defense Falls Prevention Toolkit
• Using
a Computerized Fall Risk Assessment Process to Tailor Interventions in Ac
ute Care
• Road Map to a Comprehensive Falls Prevention Program19
Remember the Meeting Evaluation
Due October 21 at 5 pm
Enter Link Here
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