Changing focus from repetitive screening for Falls Risk to a model that supports Falls Prevention Historically for each new issue addressed, weve added.

9N Safety/Falls Pilot – SSS guide

Changing focus from repetitive screening for Falls Risk to a model that

supports Falls Prevention

Historically for each new issue addressed, we’ve added a new section or

Tab to HED – not sustainable and adds complexity to documentation

Framework developed to identify and address all safety risks efficiently

Falls/Safety Documentation Changes – Why change?

Pilot focuses on: ◦ Falls Risk portion of new Safety Build

Other New features that will be addressed:

◦ Role/Communication documentation

◦ Changes in documentation of Patient/Family education &

engagement

◦ Changes in Restraint, CIWA, and some other safety-related

documentation

Pilot: 9N September 18th

RNs complete hands-on check off on documentation and workflow

associated with new Falls/Safety HED build

Practice Scenario:

o Determine the Morse Falls Risk Score

o Identify safety risk factors and safety problems ; Start Safety or Restraints Priority

Problem, if warranted

o Document, Care Interventions, Patient/Family Teaching, and any Notifications &

Care Coordination

o Document shift goals/outcomes for Safety Priority Problems & response to safety

interventions

TRAINING

1. Assess2. Care3. Educate 4. Notify

Safety Risk AssessmentSafety PlanResponse to Interventions

Safety Risk Assessment Tab

Morse Falls Risk Screen

Education Tab Role Communication Section

(caregiver contact info)- nurses to document caregivers contact info once and if any phone number changes

Education Categories – categorized in similar fashion to Priority Problems

9N Pilot: What’s Changing Safety assessment on every patient every shift. Alsoo 9N: Morse Falls screen on admission & with change in status/condition (e.g.

Transfer to different level of care, change in mental status, etc.)

o 6A/B: PEWS screen documented q4h (will be moved from Falls/Safety Tab at conclusion of pilot before VCH-wide rollout)

Safety Problems (Injury Risk, Violence Risk, Substance Abuse, and others ) will be identified. o If they are a priority, also initiate this as a Priority Problem

Safety Interventions will be documented – things you: o Assess/Monitor/Evaluate/Observeo Care/Perform/Provide/Assisto Teach/Educate/Instruct/Supervise o Manage/Refer/Contact/Notify

New Education Tab:

Caregivers’ contact information (“Care Contacts”) – will be documented

in new Role/Communication section

Patient/Family Education & Engagement

Some other Safety documentation (eg. Restraints) streamlined.

9N Pilot: What’s Changing

Plan of Care documentation

Priority Problems – continue to create and evaluate goals

Pathway, Nursing Summary, and Plan Priorities documentation in HED

Continue to assign e-docs pathway

Education Record tab still visible for pilot until further discussion as to whether to

blend the new Education tab with current one

Admission History documentation of substance screening and caregiver

contact information will still be recorded until further evaluation with pilot

What’s NOT Changing

Admission

• Morse Falls Risk screen • Safety assessment as part of head-to-toe assessment; Identify problems

& Plan Interventions; Start Priority Problem if warranted

Beginning of Shift

• Safety assessment; Identify problems & Plan Interventions

• Document expected Short Term Goals for Safety Priority Problems

End of Shift

• Start/End Safety Priority Problems if warranted • Document Short Term Goal Status or outcome for Priority Problems • Document Response to all Safety Interventions

Condition/ Status

Change

• Morse Falls Risk screen• Repeat other Safety Assessment & Revise Planned Interventions as

appropriate

What to Do & When

Admission

• Morse Falls Risk screen • Safety assessment as part of head-to-toe assessment; Identify problems

& Plan Interventions; Start Priority Problem if warranted

Click on HED Train tab and select the Safety Falls/ Risk tab

Locate and complete the Morse Falls Risk Section – bottom of screen

Complete Safety Risk Assessment

Admission

• Morse Falls Risk screen • Safety assessment as part of head-to-toe assessment; Identify problems

& Plan Interventions; Start Priority Problem if warranted

How would you assess the patient’s:◦ Ambulation aid◦ Gait

Hover over boxes with HED Upgrade on many fields

Continue to document:◦ Nursing Summary, Plan Priorities, and Goal Status

Include from Safety/Falls tab end of shift documentation on: ◦ Response to Safety Interventions

• Start/End Safety Priority Problems if warranted • Document Short Term Goal Status or outcome for Priority Problems • Document Response to all Safety Interventions End of Shift

Re-Assessment of Morse Falls Risk Screen and Safety Assessment with:

◦ Change in level of care (unit-to-unit)

◦ Status Change

◦ Fall or injury

◦ Increased monitoring of patient’s condition due to status

change

Condition/ Status

Change

• Morse Falls Risk screen• Repeat other Safety Assessment & Revise Planned Interventions as

appropriate

Day of go-live

also9N Go Live – Sept 18th

New Safety/Fall Risk tab will replace the old Falls Risk section in

assessment tabs

New Education tab will appear- old Education Record tab will still be visible

Restraints documentation moved from Restraints tab to Safety/Fall Risk tab

Past data will be viewable for the Restraints tab, and Fall Risk section but

will not contain charting boxes.

CIWA tab released

Resources:◦Super Users – in-staffing◦Educator◦Unit Resource Manual- contains issue log, pocket aides, staff& support schedule, and pocket aides

Implementation Support◦ SuperUsers◦ SSS/CAPS: 9a-5pm and 9pm to 5am, Sept. 18, 19, 20, 21st ◦ Issues Log on unit

Training and Implementation Plan