Join the Falls Prevention Virtual Learning Collaborative

Join the Falls Prevention Virtual Learning Collaborative

Falls Virtual Learning Session # 4 & Closing Congress Team Rapid Fire Presentation Template

Cross Cancer Institute, Edmonton, Alberta

Amy Kantor, Quality Consultant

Edmonton, Alberta

Ambulatory and Inpatient Care• 3 inpatient units• ~56 beds• ~140 RN’s plus NA’s, PT, OT, RT, Pharmacists and

MD’s

Primary Cancer Care facility, serving all of northern Alberta.

Who We Are

Team Members

Team Member Role

Nadia Kloc Inpatient Nurse Manager

Carolyn Howe-Riddell Inpatient Resources Nurse

Carole Szwajkowski Nursing Education

Judy Poon Rehab Medicine,Physiotherapy

Amy Kantor Quality Consultant

AIM

To lead and coordinate team learning, process and care improvements; to ensure our targeted goals are achieved in falls and injury reduction and that we contribute as active participants in the SHN Falls Prevention VLC.

• Reduce incidence of falls (fall rate) by 40% from baseline (to 2.4%) by March

2011.

• Reduce injury from falls by 40% from baseline (to 19%) by March 2011.

• Scope: Inpatient units (3 units, 56 beds)

Change Ideas

Changes tested during Falls VLC PDSA Cycles:

Implementation of an appropriate Assessment Tool• Initially used Schmidt tool, now working with Morse tool

Inventory of mobilization equipment and aids and storage locations• Discovered shortage of transfer belts, purchasing more and moving to a more

visible and accessible storage location

Evaluate location of majority of falls (~60% occur in the bathroom)• Planning to trial bathroom signs encouraging patients to call for assistance

Implementation of a Post-Falls Assessment Tool• Trialing and revising a tool to help discover specific reasons for falling

Implement an apple as a symbol for a patient at risk of falling• To be placed outside of patients room, used for recognition and promotional

‘materials’

Measures1: Falls Rate per 1000 Patient Days

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

5.00

Month

Fa

lls/1

00

0 d

ay

s

Fall Rate 4.74 3.71 3.29 3.90 4.46 2.00 3.29 2.58 2.76 2.48 3.00

Goal 2.40 2.40 2.40 2.40 2.40 2.40 2.40 2.40 2.40 2.40 2.40

Apr2010

May2010

Jun2010

Jul2010

Aug2010

Sep2010

Oct2010

Nov2010

Dec2010

Jan2011

Feb2011

Implemented Risk Assessment

Number of Falls per Month

Range: 4-7

Mean: 5

Change in Event Reporting System

MeasuresPercentage of Falls Causing Injury

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

Month

Pe

rce

nta

ge

of

Ha

rmfu

l Fa

lls

CCI Data 14.3% 33.3% 60.0% 0.0% 42.9% 60.0% 80.0% 25.0% 50.0% 50.0% 50.0%

Goal 19.0% 19.0% 19.0% 19.0% 19.0% 19.0% 19.0% 19.0% 19.0% 19.0% 19.0%

Apr2010

May2010

Jun2010

Jul2010

Aug2010

Sep2010

Oct2010

Nov2010

Dec2010

Jan2011

Feb2011

Implemented Risk Assessment

Number of Falls Causing Injury per Month

Range: 0-4

Mean: 2

Change in Event Reporting System

MeasuresPercentage of Completed Fall Risk Assessment on Admission

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

Month

Pe

rce

nta

ge

CCI Data 66.2% 81.7% 83.3% 82.4% 87.5%

Goal 100% 100% 100% 100% 100%

Oct2010

Nov2010

Dec2010

Jan2011

Feb2011

Number of Charts Reviewed per Month

Range: 54-82

Mean: 67

Lessons LearnedLessons Learned/Key Insights

Slow and steady wins the race

Buy in from staff is essential to success

Important to understand the foundation of the concept first

The right tool is needed: take the time to find it, don’t be afraid to change it

Follow through is required and it needs to be consistent

Ongoing compliance monitoring is key to maintaining gains

Changes to our event reporting system just prior to implementation may have affected our data

We’re still learning!

• Champions emerged from Physiotherapy department Data collection became easy with their help

• SHN Virtual Learning Series taught the team about: Quality improvement methodology (Can be applied to other projects) Data collection, analysis and trending Viewing the issue from a broader perspective: i.e. pharmacology,

special considerations for the elderly, etc. • Great connections made between departments

(Nursing, Education, Physiotherapy, Quality)• Great ideas to build on from other teams in the collaborative

Quick Wins

Next Steps

Key Sustainability Steps/Plan: Target Dates

Decide on an assessment tool 1 month

Implement bathroom signs 1 month

Finalize post falls assessment tool and decide if it is going to be used

Next 2 months

Roll out education to the staff (serve apple treats to generate recognition)

1 month

Launch the apple symbol 1 month

Amy [email protected]

Judy [email protected]

Contact Information