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Inside Out: A Comprehensive Nurse-Led Initiative to Prevent Trauma From Falls
Gia RamseyViktoriya Fridman
Kelly ReillyThomas Smith
Maimonides Medical Center
• Established January 1911
• 711 Bed Tertiary Hospital
• Academic Medical Center
• Robust Geriatric Care
• NICHE member since 2011 (Exemplar Status)
• Heart & Vascular Center
• Cancer Center
• Bone & Joint Center
• NYS and Joint Commission Advanced Comprehensive Stroke Center
• Joint Commission Certification: Ventricular Assist Device
• Infants and Children’s Hospital (within a hospital)
• Provisional Level I Adult, Level II Pediatric Trauma Center
Background
• The Joint Commission recommendation of evidence-based fall prevention program across the continuum of care
• Mandatory programming for Adult Level I Trauma Status– The American College of Surgeons, Committee on Trauma
requires trauma injury prevention and evidence-based programming
• Gap analysis showed need for outpatient fall prevention program
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Fall Prevention Performance Improvement Plan
Phase 1• Gap analysis to identify fall prevention practices
Phase 2• Stakeholder and community support
Phase 3
• Implementation of inpatient fall prevention program and adapt for outpatient and community setting
Phase 4• Longitudinal evaluation of implementation and appropriate outcomes
Trauma
• Provisional Level I Adult, Level II Pediatric Center
– August 1, 2016
Trauma Injury Prevention
• “Trauma centers must have an organized and effective approach to injury prevention and must prioritize those efforts based on local trauma registry and epidemiologic data (CD 18-1).”
• Levels of trauma designation
Resources for Optimal Care of the Injured Patient (2014). Chapter 18: Prevention
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Trauma Data
• Adult Admissions
– 2017= 1090 admissions
• 1034 had a fall as the mechanism of injury (MOI)– 95% of all admissions
• Average age of trauma patients
– NTDB (National Trauma Database)
• 54 years
– Maimonides Medical Center Trauma Registry
• 66 years
Falls by Age
3%
12%
11%
74%
15-24 years 25-49 years 50-64 years 65+ years
Gap Analysis
• Analyzed policies, procedures, and practice
– Inpatient units
– Outpatient/Ambulatory settings
– Community programming
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Medical Cost of Falls
Stakeholder/Community Support
Inpatient Fall Prevention
Outpatient Services
Organizational/Leadership Support
Trauma Injury Prevention
2012 2013 2014 2015 2016
Monthly multidisciplinary fall prevention core-team meetings
July, 2012
Fall Prevention Nursing StandardsSeptember , 2012
Detailed Fall Data AnalysisJanuary, 2013
Team STEPPS & Post Fall HuddleDecember, 2014
Reassessment Hendrich II Fall Risk Assessment
May- September, 2014
TodayApril, 2018
Hendrich II Fall Risk Assessment September, 2012
Fall Prevention Investigation Form November, 2012
Interdisciplinary Team EducationNovember, 2012-August, 2015
Standardized LIP assessment tool via EMRMay, 2014
Purposeful Rounding
January 2015
Target Interventions via EMRNovember 2014
Organizational-Wide Culture Message Around Fall SafetyJuly, 2012 - Present
Auxiliary StrategiesDecember, 2012
Interventions Framework- PDSA cycle
Hourly RoundingJanuary, 2012
Organizational Falls Prevention Programming
2017
Started Accepting Trauma patients
ACSCOT Trauma Consultation Visit
August 2016
October 2017
Outpatient ProgrammingSTEADI
August 2017
August 2017
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Outpatient Programming
• Fall risk assessment upon sign in
– Wrist bands
• Education in waiting room
• CDC STEADI Program
– Risk assessment
– Education
• Nursing, Physicians
– Referral to community resources
Fall Prevention Video
STEADI
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STEADI Toolkit-Algorithm
STEADI Toolkit-TUG Test
STEADI Algorithm
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STEADI Toolkit-Education
Community Programming
• Monthly ThinkFirst fall prevention presentations
• Programming at senior centers and community organizations
• Grandparent Safety Day event
• Fall Prevention Day/Week events
Community Programming
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Evaluation
3.28
2.402.52
2.34
2.51
2.282.36
1.911.99
2.33
1.73
1.93
2.302.45
2.58
2.35
1.69
2.06
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
2013 Q3 2013 Q4 2014 Q1 2014 Q2 2014 Q3 2014 Q4 2015 Q1 2015 Q2 2015 Q3 2015 Q4 2016 Q1 2016 Q2 2016 Q3 2016 Q4 2017 Q1 2017 Q2 2017 Q3 2017 Q4
Hospital total falls rate per 1,000 patient days
MMC Rate Median Percentile 50 Linear (MMC Rate)
Evaluation (cont.)
0.93
0.70
0.57
0.390.43
0.50
0.39
0.48
0.91
0.42 0.400.38
0.56
0.35
0.44
0.24
0.38
0.32
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
2013 Q3 2013 Q4 2014 Q1 2014 Q2 2014 Q3 2014 Q4 2015 Q1 2015 Q2 2015 Q3 2015 Q4 2016 Q1 2016 Q2 2016 Q3 2016 Q4 2017 Q1 2017 Q2 2017 Q3 2017 Q4
Hospital falls with injury rate per 1,000 patient days
MMC Rate Median Percentile 50 Linear (MMC Rate)
Program Results-Outpatient
• Adapted JCAHO and ACSCOT required evidence-based fall prevention program across the continuum
• STEADI implemented
– Health Coaches implemented to support healthcare team in education efforts
• Staff and healthcare team satisfaction
• Policy/procedure implementation
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Conclusion
• The comprehensive implementation of a nurse-led falls prevention through the hospital-community continuum improved fall rates thereby improving the independence and quality of life for NYC elders through the reduction of trauma from falls
References
• Aging, N. C. (Director). (2015). 6 Steps to Prevent a Fall [Motion Picture].• Brooklyn. (n.d.). Retrieved April 4, 2018, from Wikipedia The Free Encyclopedia:
https://en.wikipedia.org/wiki/Brooklyn• Florence CS, B. G. (March 2018). Medical Costs of Fatal and Nonfatal Falls in Older
Adults. Journal of the American Geriatrics Society.• (2016-2018). Maimonides Medical Center Community Health Needs Assessment
and Community Service Plan . Brooklyn.• Registered Nurses: Partners in Transforming Primary Care. (2016, June 15-18).
Josiah Macy Jr Foundation Conference Recommendations. Atlanta, Ga.• Resources for the Optimal Care of the Injured Patient. (2014). Chicago: American
College of Surgeons.• ROBIN LEE, P. M. (2017 Aug 15). The CDC's STEADI Initiative: Promoting Older
Adult Health and Independence Through Fall Prevention. Am Fam Physician, 95 (4):220-221.
