Corrine Abraham DNP, RNClinical Assistant Professor, Emory NHWSN

Coordinator for EBP & Innovation, Atlanta VAMC

Team & Aim

Map & Measure

Change

Spread Change Over Time, Transformation

Leadership & will to transform

Leadership & Alignment top to Bottom

VISION - ANALYSIS

IMPROVE

SUSTAIN

Feb 2013 July 2013 Aug 2014

National Incidence of Falls 3% - 20% of inpatients fall at least once 1

Falls are the 6th most commonly reported sentinel event. 2

Consequences of Falls 20% - 30% suffer injuries that ↑ their risk of early death.3

Leading cause of injury-related death for adults over 65 yo.4

Fractures most common and costly injury.5

Cost of Falls ↑ Length of stay, ↑ rates of discharge to institutional care, ↑

resource use 3-4,6

National ImperativeNational Patient Safety Goal - TJC 7

Serious Reportable Event - NQF 8

No reimbursement – CMS 9

Local PriorityAtlanta VAMC: Vulnerable population - many fall

related risks

Solution 1,10-11

Multifactorial assessment & management effective Success associated with multidisciplinary team Tailored interventions can prevent injury

Local Priority: Preventing falls and fall related injury will decrease expenditures and enhance patient safety as well as the organization’s accountability to provide quality care

Problem Statement: In FY2013 (through May) the hospital reported more than twice the national rate of falls with serious injury. Two units had rates that exceeded the hospital average as well as the national average of VHA hospitals of comparable acuity and size

TeamAimMap MeasureChange

Corrine Abraham, RN, DNP, VAQS

Sandra Thomas, RN, QA, Acute Care

Laurie Moore, RN, GNP, Long Term Care

Heather Batchelor, MD, Hospitalist

Gara Coffey, Pharm D, Long Term Care

Deshondra Green, Pharm D, Acute Care

Renee Browning, PT, Long Term Care

Beth Allen, PT, Acute Care

Kim House, MD, Long Term & Home Care

Kelly Fripps, RN, Health Promotion

Penny Gunter, RN, Education

Ken Murphy, RN, Informatics

Abebe Abera, RN, CNL, Acute Care (AC)

Casey Hill, RN, Assistant Manager, AC

Sandra Dukes, RN, DNP, CNS, AC

William Greene, RN, Mental Health

Sponsor: Sandy Leake, RN, MSN, Associate Director, Nursing and Patient Care Services and Chief Nursing Officer

The goal of the quality initiative was to decrease the rate of falls/injury by mitigating modifiable risk factors and enhancing inter-professional

collaboration.

To reduce rates of falls on 8 Palliative at Atlanta VAMC by 50% from a rate of 4.47 to 2.33 by July 2014 ◦ To have zero injurious falls on 8 Palliative at Atlanta VAMC

To reduce rates of falls on 9 Surgical at Atlanta VAMC by 50% from a rate of 1.28 to 0.64 by July 2014◦ To have zero injurious falls on 9 Surgical at Atlanta VAMC

Organizational capacity

Workflow patterns

Circumstances of falls

Pattern of fall events

Current processes

Electronic data bases

Chart audits & queries

Patient interviews (VOC)

Health team member interviews (VOC)

Direct observation of care

Surveys

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

0

2

4

6

8

10

12

14

16

18

Primary Reason

Cum

ePER Data (Jan – Feb)

Outcome MeasuresFall rate

Injury rate

Priority Area Interventions 12 - 17

Documentation of Risk

Standardize CommunicationElectronic documentation templates

Staff Education & Accountability

Monthly Resident orientationAnnual Staff EducationAccountability

Patient Education Standardize Patient Education process

Individual Risk Factors-

Modify Fall Risk Assessment processModify Post-Fall noteEnvironmental/equipment modifications

0

1

2

3

4

5

6

7

Q1 12 Q2 12 Q3 12 Q4 12 Q1 13 Q2 13 Q3 13 Q4 13 Q1 14 Q2 14 Q3 14 Q4 14 Q1 15 Q2 15

9 Surgical

8 Palliative

Injurious fall

Improvement Phase

Sustain Phase

77% Assess lower

extremity strength

62 % Initiate fall prevention in-patient referrals

58 % Evaluate

orthostatic hypotension

0 % Evaluate for osteoporosis

15 % Initiate fall prevention community

referrals

19 % Document

history of falls

35% Assess vision

N = 26

Provider Ordered Interventions

N = 81

Lessons LearnedImplications for Spread

Risk Communication:

Standardizing communication → ↑ collaboration

Electronic note template → tailored interventions

Accountability: Audits with feedback → ↑ accountability

Involvement of leaders → accountability

Patient Education:

Team involvement → ↑ patient education

Electronic version → ↑ consistency

Individual Risk Factors:

Injury Risk stratification → Identifies vulnerability

Education pamphlet → standardizes & ↑ tailoring

Relative advantage

Compatibility

Complexity

Trialability

Observability

I would like to acknowledge team members who partnered in this initiative◦ Sponsor: Ms. Sandy Leake, CNE◦ Fall Prevention Sub-committee◦ Medical Residents: H. Batchelor, V. Pragya, A. Allen◦ MPH Student: E. Bredenberg

and colleagues who provided guidance & support◦ National Collaborative (NCPS): Virtual Breakthrough Series◦ Patient Safety Committee, Atlanta VAMC◦ VAQS: Site faculty

1.Clyburn T, & Heydemann J. Fall prevention in the elderly: Analysis and comprehensive review of methods used in the hospital and the home. J Am Acad Orthop Surg. 2011;19(7): 402-409.

2.ECRI Institute. Healthcare risk control: Falls. March; 2009; ECRI Institute: Pymouth Meeting, PA. www.ecri.org

3.Centers for Disease Control. Costs of falls among older adults. 2013;Author: Atlanta, GA . http://www.cdc.gov/homeandrecreationalsafety/falls/fallcost.html

4.Curry L. Fall and injury prevention. In Patient Safety and Quality: An Evidence-based Handbook for Nurses. April 2008;Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/clinicians-providers/resources/nursing/resources/nurseshdbk/index.html

5.Stevens, J A, et al. The costs of fatal and non-fatal falls among older adults. Injury prevention. 2006;12(5):290-295.

6.Wu S, Keeler E B, Rubenstein L Z, Maglione M A, Shekelle P G. A cost-effectiveness analysis of a proposed national falls prevention program. Clin in Geriatr Med. 2010;26(4):751-766.

7.The Joint Commission. Preventing patient falls. 2013; Joint Commission Resources: Oakbrook, IL http://www.jcrinc.com/Preventing-Patient-Falls/

8.National Quality Forum. Serious Reportable Events in Healthcare–2006 Update. 2006; Author: Washington, DC. www.qualityforum.org

9.Centers for Medicare & Medicaid Services. Hospital-Acquired conditions.2012;Author: Baltimore, MD. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/index.html?redirect=/HospitalAcqCond

10.Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Inpatient fall prevention programs as a patient safety strategy: A systematic review. Ann Intern Med. 2013;158:390-6.

11.Oliver D, Healey F, & Haines TP. Preventing falls and fall-related injuries in hospitals. Clin in Geriatr Med. 2010; 26: 645- 692.

12.Agency for Healthcare Research and Quality. Preventing Falls in Hospital Falls: A Toolkit for Improving Quality of Care. 2013;AHRQ: Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/fallpxtoolkit/index.html

13.Institute for Healthcare Improvement. Transforming Care at the Bedside How-to Guide: Reducing Patient Injuries from Falls. 2012;Author: Cambridge, MAhttp://www.ihi.org/knowledge/Pages/Tools/TCABHowToGuideReducingPatientInjuriesfromFalls.aspx

14.Minnesota Hospital Association. Road Map to a Comprehensive Falls Prevention Program. In Patient safety: Call to action. 2011. Author. http://www.mnhospitals.org/Portals/0/Documents/ptsafety/falls/falls-prevention-roadmap.pdf

15.National Quality Forum. Safe practice 33: Falls prevention. In: Safe Practices for Better Healthcare–2010 Update. 2010.; Author: Washington, DC. www.qualityforum.org. Accessed November 15, 2013:381.

16.Neily J, Quigley P, & Essen K. Implementation Guide for Fall Injury Reduction: VA National Center for Patient Safety Virtual Breakthrough Series: Reducing Preventable Falls and Fall-Related Injuries. 2013; VA National Center for Patient Safety: Washington,DC. http://www.patientsafety.va.gov/

17.VA National Center for Patient Safety. Falls toolkit. 2004;Department of Veterans Affairs: Washington, DC. http://www.patientsafety.va.gov/professionals/onthejob/falls.asp#fallsnotebook

Baseline assessments Examples of interventions Audit results

Standardize data reporting

Random Chart Audits Date of Audit Age Admitting Diagnosis Morse Score on Admission Fall Risks Identified Accurately Injury Risk Stratification Injury Risks Communication of Risk - DAR Documentation of Tailored

interventions Documentation of Pt Teaching -

Individual Risk Nursing Re-assessment Accurate Provider Assessment

Inter-professional Rounds Accurately report fall risk

Standardize education processVeteran Interviews Top Reasons at Risk 3 main reasons fall prevention is

important ◦ Falls for most part are preventable ◦ Falls can result in injury ◦ Falls can make hospital stay longer

3 actions to stay safe: ◦ Learn risk factors ◦ Call for help ◦ Wait for help

Two reasons to ask for help when going to bathroom ◦ Unfamiliar places increase fall risk ◦ BR are small & it is easy to lose balance or get dizzy

The main purpose to use call light is: to ask the staff for help

Locate call light: At bedside & in bathroom

The main reason to wear non-slip footwear

Patient not educated on their risk and why it is important to comply with prevention strategies leading to decreased likelihood that preventive steps taken

Lack of proper equipment e.,g., bedside commode, elevated toilet sear , prompts walk to BR and/or bending reaching that ↑ chance of falling

Overcrowded & cluttered room creates obstacles causing unsteadiness or trips that lead to falls and /or surfaces leading to injury

Six Sigma Fishbone or Cause-and-Effect for 4P’s (Plant, People, Policies and Procedure)

Vulnerabilities & Opportunities

Physician not attuned to assess and intervene to mitigate modifiable fall risk factors leading to ↑ chance of fall &/or injury

Patient behavior (confusion, impulsiveness, Unrealistic estimation of abilities) leads to unassisted ambulation

Staff not able to respond quickly (e.,g due to understaffing) leading to patient not waiting for assistance

Over emphasis on policy leading to burnout and non-adherence to best practices

Policy cumbersome to read, no method of assuring accountability, and limited resources for enforcement leading to sub-optimal implementation of fall prevention

Team members not aware of policy and not educated about the roles & responsibilities for implementing fall/injury prevention

Pt identified as at risk for fall and not stratified for injury risk decreasing likelihood that medical team is consulted about intervening to prevent injury

Fall precautions overused decreasing sensitivity and decreasing use of individualized interventions to prevent falls and/or injuries

Limited resources ,sitters to adequately supervise patients leading to unassisted position changesincreasing chance of falls

Injurious Falls

sixsigmatutorial.com

Pharmacist has not identified at risk meds- side effects that cause dizziness or confusion leading to fall

Lack of assistive PT equipment and protective equipment requiring patients to ambulate or transfer unassisted and potentially falling and getting injuried

Point Value (Risk

Level)American Hospital Formulary

Service ClassComments

3 (High) Analgesics,* antipsychotics, anticonvulsants, benzodiazepines†

Sedation, dizziness, postural disturbances, altered gait and balance, impaired cognition

2 (Medium)

Antihypertensives, cardiac drugs, antiarrhythmics, antidepressants

Induced orthostasis, impaired cerebral perfusion, poor health status

1 (Low) Diuretics Increased ambulation, induced orthostasis

Score ≥ 6 Higher risk for fall; evaluate patient

* Includes opiates.

† Although not included in the original scoring system, the falls toolkit team recommends that you include non-benzodiazepine sedative-hypnotic drugs (e.g., zolpidem) in this category.

Beasley B, Patatanian E. Development and implementation of a pharmacy fall prevention program. HospPharm 2009;44(12):1095-1102.

Provider Fall Evaluation Note

Fall Risk Evaluation• Pertinent Medical History• Identification of Risk Factors• Interventions linked to Fall & Injury risk

• PT consult• OT consult• PharmD consult• Orthostatic VS• Enhanced surveillance• Toileting assistance• Injury prevention

Post Fall Evaluation• Date of last known fall• Assessment for injury• Identification of factors contributing to fall