Pat Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP · •Bathroom redesign ie raised toilet seat, relocated or new grab bars •Unit based champions 3 . Patient Falls Coaching Webinar

Pat Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP

Fall SME; Nurse Consultant

Martha Ackman BSN, MA, CPHQ, CPPS, CPHRM

Clinical Improvement Advisor, HQI

August 15, 2016

Poll #1

Who is in the room?

• Frontline RNs

• CNAs

• PT/RTs

• Management

• Senior leadership

• Other

2

Poll #2

Since participating in the Fall Coaching Webinar series we have implemented: • Identification of fall as accidental, environmental or

physiological • Post fall huddle • Inclusion of patient/family in post fall huddle • Injury reduction strategies ie floor mats, hip protectors • Proactive toileting • Bathroom redesign ie raised toilet seat, relocated or

new grab bars • Unit based champions

3

Patient Falls Coaching Webinar Series Objectives

• Extend application of fall and fall-injury prevention interventions to specific populations

• Restate critical program elements to reduce repeat falls and preventable falls

• Compose strategies to reduce barriers and enhance facilitators to short-term and long-term program implementation

4

Webinar Series

• Coaching Session 5 – Share your Experience; – Mobility Issues (Con’t) – Closure to the Webinar Series

• Coaching Session #4 – Mobility Issues, Walkers in Rooms – Postural Hypotension

• Coaching Session #3 – Proactive Toileting - Bathroom vs. Bedside Commodes; Toileting prior to Pain

Medication • Coaching Session #2

– Protection from Injury – Unit Based Champions

• Coaching Session #1 – Post Fall Management – Patient Engagement

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6

WILL MORRELL-STINSON RN-CCRN-BSN-MSN

DIRECTOR CARDIAC TELEMETRY PALMDALE REGIONAL MEDICAL CENTER

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I work at the Palmdale Regional Medical Center (in the desert of California), a 156-bed

hospital with a daily census between 110 – 130 patients. Our newly built hospital of only

6 years has a fully functional ED that sees around 72,000 patients per year. We have all

the amenities except for Labor & Delivery and Pediatrics at this stage. The top floor you

see in the picture is a shell, waiting to be built out in the future, and behind the flag on

the left is the brand new rehab unit, opening in November this year.

Our Story - What We Did

• After the workshop in April we asked ourselves – Did our staff truly understand the reason for the high fall

risk (or was it just another task)? – We tried EVERYTHING (definition of insanity……)

• We changed our approach: Presented the 3 different

‘buckets’ of high risk that we learned at the workshop to the staff in Huddles on a daily basis.

• Focus was to be proactive vs reactive.

Assess the patient – Do not simply screen

Shift Change • Care Giver Change • Condition Change • Any Change!

What are the PREVENTABLE FALLS?

Environmental • Known Risk Factors • Unknown Sudden Conditions

Update: Preventing Falls

Of Palmdale Regional Medical Center’s Nursing Department

The to

Success is Knowledge

Steps to Take When a Fall Occurs Assess the patient – do not immediately attempt to lift patient!

Get the Correct Lift Equipment to help the patient back to bed

Do a Post-Fall Assessment in Cerner

Inform MD and Family

Post-Fall Huddle – Patient • RN • C.N.A • Charge Nurse • Director / AS

Talk to the patient – What was different this time which

caused the fall and what can we do better to avoid a future fall

Talk to the Nurse – Did she / he understand the reason for the

fall, did she / he do the assessment or simply a screening

Correct Documentation – RN: RDE and Post-Fall Assessment; CN: Post-Fall Huddle and complete the Fall Audit; Director:

Directors – Check the CNO Report & Post-Fall Evaluation, see the patient, give preventative and corrective help as needed

Of Palmdale Regional Medical Center’s Nursing Department

The to

Success is Knowledge

Tips, Tricks & Tools

• Daily Huddle, all units (using the teach-back method) • Monthly fall meeting

– This month is the 1st month we can see a direct correlation between increased documented pt education and fewer falls

– At first struggled to get a unit champion • We now have the first one, a nurse whose patient fell despite all her efforts

and education etc. given to the patient – she wanted to know what else she could do!

• Gave us the down-to-earth needs (see next slide)

– We adjust as we get feedback* • E.g. We will put out a Huddle about the adjustable commodes *

• What is the most important piece of learning from this experience

that other hospitals can use? – Stop ‘blaming’ the patient (uncompliant, etc.) and make it our own, ask the patient what can we do better so that next time you do not fall

RDE: Document When a Fall Occurs • Did the RN on duty (prior to the fall) know the reason

for the high risk fall (during SBAR handoff)

• Was a fall assessment done (vs screening)

• Is the IPOC based on the reasons for the high fall

risk prior to the fall

• Was any education documented by the RN prior to

the fall, what was the patients’ response

• Post fall assessment done; Huddle done, PT eval…

• Categorize: Environmental; Known Risk Factors; or

Unknown Risk Factor

Of Palmdale Regional Medical Center’s Nursing Department

The to

Success is Knowledge

Aim – To improve both patient and nursing’s

understanding of the risk of falls.

To decrease the total number of falls, and

decrease falls with injury.

Aim Statement

Interventions

Next Steps

Lessons LearnedRun Charts

Implemented and Tested: New Huddle describing the

different areas of risk for falling, and appropriate

education to the patient in understanding the risks.

Discussed on a daily basis prior to every shift, with

teach-back.

During handoff the patient is educated (each shift) of

the reasons for the high fall risk

Slogan: Call, don’t fall!

Post Fall Huddle: Asking the pt what happened this

time, so that we can understand the reason behind

the fall and prevent it moving forward

Questions to ask:

• Did the RN know the reason for the high risk

• Was it documented and discussed in handoff

• Was the Care Plan addressing the risk

The staff needed to understand the reasons

for a high fall risk. Until then, it would

simply be another task to be done

As the understanding improves, so does

the teaching of the patient improve

Monthly Run chart to show where the actual

fall risks came from

Continue to educate the staff on a daily basis

Monitor the progress – At this stage it is

simply too soon to tell.

Conference and initial changes in 4/27/2016

Team Members

Project Champion – Will Morrell-Stinson

Senior Leader Sponsor - Steve Owens

Team Members - Mary Siemantel & Roy

Miser (Quality); Debbie Cockerham-

Slaughter (Risk); Daisy Dorotheo, Cindy

Damboise, Rick Smith (Nursing Directors)

Ann Dexter (PT); Teresa Mendoza (IT);

Jody Pienta; Diane Morrow; Jennifer

Garcia

Falls with injury

Palmdale Regional Medical Center

Palmdale, CA

Background & Problem Overview

Our fall numbers did not decrease despite all

the signs we posted, education and even

corrective actions taken

0

0.1

0.2

0.3

0.4

Bas

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e

Oct

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No

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Dec

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Jan

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Feb

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Mar

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Ap

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May

-16

Jun

-16

Rat

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er 1

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P

ati

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ays

Falls with Injury

Rate per 1,000 Patient days Improvement Target

Start of Interventions .

.

.

.

.

.

.

.

.

.

.

.

..

.

Thank You!

Will Morrell-Stinson RN-CCRN-BSN-MSN

Director of Cardiac Telemetry Palmdale Regional Medical Center Office: (661) 382-5813

Fax: (661) 382-6161

[email protected]

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Reducing Patient Falls Creating a Culture of Safety

In Bloom July 18, 2016 Palomar Health:

Escondido, CA

Standardizing Practice: Identifying Fall Risk Patients

Yellow Falls

Wrist Band Yellow Socks

Sunflower on door

(placard in GPU/MHU)

1 2 3

Behavior Expectations

L

E

A

F

Look into the room

Evaluate/Enter

Alert the Nurse

Follow through

Code Sunflower

• Emergency Code with patient fall

• Rapid Response Nurse Respond; support bedside RN with patient assessment

• One month pilot

Sunflowers in Bloom July 18 Kick off of Code Sunflower and

Fall Prevention

Thank you!

Bunny Krall APRN MSN ACNS-BC CDE CMSRN

Clinical Nurse Specialist Quality and Patient Safety

Palomar Health

[email protected]

442-281-4268

22

EILEEN JENSEN RN MSN FNP CLINICAL SPECIALIST SANTA ROSA MEMORIAL HOSPITAL CONTACT: [email protected]

23

Faculty

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Patricia Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP, Nurse

Consultant, Retired Associate Director, VISN 8 Patient Safety

Center of Inquiry, is both a Clinical Nurse Specialist and a Nurse

Practitioner in Rehabilitation. As Associate Chief of Nursing for

Research, she was a funded researcher with the Research Center of

Excellence: Maximizing Rehabilitation Outcomes, jointly funding by

HSR&D and RR&D. Her contributions to patient safety, nursing and

rehabilitation are evident at a national level – with emphasis on

clinical practice innovations designed to promote elders’

independence and safety. She is nationally known for her program of

research in patient safety, particularly in fall prevention. The falls

program research agenda continues to drive research efforts across

health services and rehabilitation researchers.

Webinar 5

Mobility Issues Con’t

Accelerate Improvement- Share your

Experience;

Closure to the Webinar Series

Etiology of Falls

Accident / environment

Weakness, balance / gait

Dizziness / vertigo

Orthostatic hypotension

Other (acute illness, confusion, poor eyesight, drugs)

Combination of environmental hazards and increased susceptibility to falls related to aging and disease

Causes of Mobility Disorders

Hip fractures

Arthritis

Neurological disorders

Systemic illnesses

Amputations

Normal Balance Balance-need to maintain our COG over a

narrow BOS (area of contact between the support surface and feet); once the COG deviates beyond the perimeter of the BOS, a rapid step, stumble or external support is required to prevent a fall

Limits of stability-a family of COS sway angles

A variety of ankle, knee and hip movements are used to actively control COG and keep it in BOS-hip, ankle or stepping movement strategies

Normal Gait

Stance phase (double limb support), swing

phase (single limb support)

The integration of postural control with

movement is necessary for all locomotion,

including initiation, turning and stopping

Stride length, cadence (steps/min), velocity

Abnormalities of Gait and Posture

Spastic hemiparesis

Scissors gait

Steppage gait

Sensory ataxia

Cerebellar ataxia

Parkinsonian gait

Antalgic gait

Visual Acuity and Depth Perception

Visual acuity-Rosenberg chart; test with and without correction

Depth perception (with correction)

Stereo Fly test-gross depth perception

Stereo Circles Test- fine depth perception

Lord SR, Visual contributions to postural stability in older adults. Gerontology 46(6):306-10,2000.

Physical Examination

General

Head, eyes, ears, nose and throat

Neck

Chest (heart and lungs)

Abdomen

Back

Extremities

Neuro

Observational gait

Observational Gait

No deviations

Trunk lateral lean

Trunk forward flexion

Hip hiking

Hip circumduction

Scissoring

Trandelenburg (R or L)

Knee hyperextension (R or L)

Foot drop (R or L)

Ataxic gait pattern

Antalgic gait pattern

Festinating

Shuffling

Decreased gait speed

Widened base of

support

Other…

Mobility Assessment

Bed Mobility

Lying to Sitting

Sitting Balance

Muscle Strength

ROM

Timed Up and Go

Chair Sit to Stand

Test

Multi-directional

Reach Test

Backwards

Release

m-CTSIB

Neurological exam

Mental status

Cranial nerves

Motor

Sensory – Sensory Neuropathy

Proprioception

Tone, EPS

Reflexes

Fall History

How long have you had this problem with

falling down?

How many falls have you had in the past 3

months? In the past year?

Do you stumble and lose your balance

but catch yourself? (“near falls”)

SPLATT

Symptoms

Previous Falls

Location

Activity

Time

Trauma

Environmental Assessment

Uneven ground

Uneven ground in yard

Stairs to get into home

Ramps

Stairs inside home

Clutter

Throw rugs

Electric cords on floor

Bright lighting

Nightlights

Slick slippery floors

Nonskid bathmats

Grab bars in bathroom

Shower stall or tub

Bath chair or bench

Handheld showerhead

Raised toilet seat

Other…

Current Assistive Devices Used

Orthotics/specialty shoes

Cane

Walker

Braces

Wheelchair

Electric wheelchair and/or scooter

Prosthesis

Cruise furniture

Assistive & Protective Devices

Management of mobility disorders

Medical

Gait and balance training

Strengthening exercises

Environmental modifications

Use of assistive devices-canes, walkers, hip

protectors etc.

Algorithms: Traditional

Suggested Care Pathway

Safe Patient Handling Program

Ergonomic Algorithms

Transfer To and From: Bed to Chair, Chair to Toilet, Chair to Chair, or Car to Chair

Lateral Transfer To and From: Bed to Stretcher, Trolley

Transfer To and From: Chair to Stretcher, Chair to Chair, or Chair to Exam Table

Reposition in Bed: Side to Side, Up in Bed

Reposition in Chair: Wheelchair or Dependency Chair

Transfer a Patient Up from the Floor

Causes of Immobility

Hip fractures

Arthritis

Neurological disorders

Systemic illnesses

Amputations

Fear of Falling

Thank you for Participating!

Together we accomplish more!

46

Poll #3

Enhancements to this webinar series would include:

• More ‘real experience’ sharing by participants

• Shorten length of webinar to 30 minutes

• Other – please type in chat box

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Poll #4

The coaching series of breaking down one topic into a series of focused webinars was an effective format:

• Yes

• No

• Too long

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Thank You!

For further questions:

• Martha Ackman [email protected]

• Pat Quigley [email protected]

• Shweta Krishnan [email protected]

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