Pat Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP · Patricia Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP, Nurse Consultant, Retired Associate Director, VISN 8 Patient Safety Center of

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

Fall SME; Nurse Consultant

Martha Ackman BSN, MA, CPHQ, CPPS, CPHRM

Clinical Improvement Advisor, HQI

July 25, 2016

Poll #1

Who is in the room?

• Frontline RNs

• CNAs

• PT/RTs

• Management

• Senior leadership

• Other

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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

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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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Poll #2

Does your mobility assessment include:

1. Gait evaluation?

2. Transfer evaluation?

3. Lying to Sitting status?

4. Ability to lift legs on and off bed?

5. Sensory Neuropathy?

6. Proprioception?

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Poll #3

Do you assess older adults/patients or those with hypertension for:

1. Postural Hypotension on admission?

2. Postural Hypotension after change in HTN medications?

3. Routinely for patients admitted on mental health units?

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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 4

Mobility Issues, Walkers in Rooms

Postural Hypotension

Normal Aging

Balance-function of vision, balance and

sensory systems

Increased postural instability due to

changes in your inner ear (increased

sway)

Awareness of body position and

feedback decreases and interferes with

proper foot placement

Normal Aging con’t

Posture changes with wider base

Shorter steps, decreased velocity, decreased steppage height and decreased arm swing

Vision changes with increased sensitivity to glare and adapting environmental lightning

Risk Factors are many and complex –

◦ Intrinsic Risk Factors

◦ Extrinsic Risk Factors

Risk Factors-Intrinsic

Cognitive impairment (delirium, dementia,

depression)

Previous falls, fear of falling

Cardiac arrhythmias, transient ischemic

attacks, stroke

Parkinson’s disease

Acute and subacute medical illness

Orthostatic hypotension, dehydration,

hypoglycemia

Intrinsic Factors – con’t.

Musculoskeletal conditions, problems with gait and mobility, ADL impairment

Incontinence (bowel or bladder)

Vision (both contrast sensitivity and acuity) or auditory impairment

Sensory impairments (proprioception), vestibular dysfunction

Foot problems, ankle dorsiflexion

Extrinsic Risk Factors

Polypharmacy vs. polymedicine- more

then 4 medications

“No risk factor for falls is as potentially preventable or reversible as medication

use” (Leipzig RM et al. JAGS, 47:30-39, 1999.)

benzodiazepines, diuretics, psychotropics

Extrinsic Risk Factors – con’t.

Use of restraints

Environmental factors-dim lighting, glare,

inappropriate footwear, uneven flooring,

loose rugs, wet, slippery floor, old and

unstable furniture, etc.

Imperative that health care providers

routinely assess risk factors and inquire

about falls

Connecting SPH to Falls:

At the Point of Care

Patient Handling

◦ Bed Mobility

◦ Transfers

◦ Toileting

◦ Gait

ADL Tasks ◦ Toileting Transfers

Clothing Management

Reaching to clean and wipe

◦ Dressing ◦ Grooming ◦ Bathing

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SPMM: Patient Handling Injury

Barriers to prevent

injury

Float Nurse pulled to Med/Surgical

Care area Mobility Assessment of Patient not completed according to Policy

FRD not returned from Laundry and placed in patient room

Staff in a hurry and did not reinforce the use of the Mobility Assessment or the use of the FRD when repositioning

Injury

Employee sustained a Lumbar injury

requiring LWD and Medical intervention

Fall Event: Fall Risks

Fall Risk Factors

Universal Fall Precautions

Fall Risk Assessment of Patient not completed according to Policy

Postural Hypotention: Pt NOT Symptomatic

Impaired Gait and Balance and Walker not within Reach

Fall &

Injury

Employee sustained a Lumbar

injury requiring LWD and

Medical intervention

Manage and Reduce Risk

Patient: Screening and Assessment

Environment: Infrastructure and

Capacity

Interaction between Both: Consider

Cognitive and Mobility Function

Role of Autonomy

Normal Aging

Balance-function of visual, vestibular and proprioceptive sensory systems

Increased postural instability due to vestibular dysfunction (increased sway)

Proprioceptive feedback decreases and interferes with proper foot placement

Decline of central integration of visual, vestibular and proprioceptive senses

Normal Aging con’t

Gait: flexed posture and wider base-

men;narrower base and tendency to

waddle when walking-females

Shorter steps, decreased velocity,

decreased step height and decreased arm

swing

Vision: Greater sensitivity of aging eye to

glare, slower adaptation to changes in

environmental lightning

Normal Aging cont.

Decline in depth perception (step edges, curbs)

Baroreflex activity-progressive decline-blunted heart rate response to postural change resulting in transient hypotension

Musculoskeletal- relative decrease in muscle mass-muscle strength (proximal muscles), rapid deconditioning

Risk Factors

Intrinsic

Extrinsic

Risk Factors-Intrinsic Cognitive impairment (delirium, dementia,

depression)

Previous falls, fear of falling

Cardiac arrhythmias, transient ischemic attacks, stroke

Gait and balance deficits

General weakness / debility

Parkinson’s disease

Acute and subacute medical illness

Orthostatic hypotension, dehydration, hypoglycemia

Intrinsic Risk Factors, con’t.

Musculoskeletal conditions, problems with gait and mobility, ADL impairment

Incontinence (bowel or bladder)

Vision (both contrast sensitivity and acuity) or auditory impairment

Sensory impairments (proprioception), vestibular dysfunction

Foot problems, ankle dorsiflexion

Peripheral neuropathy

Extrinsic Risk Factors

Polypharmacy vs. polymedicine- more then 4 medications

Benzodiazepines, psychotropics, antihypertensive medications

Environmental Risk Factors

“No risk factor for falls is as potentially preventable or reversible as medication use” (Leipzig RM et al. JAGS, 47:30-39, 1999.)

Postural Hypotenson

Known Fall Risk Factor

◦ decrease in systolic BP >20mmHg; or diastolic 10 mmHg: supine, Immediate standing or

within 1 min standing, then 3 min after

standing

◦ assess compensatory elevation of pulse and

◦ if patient is symptomatic

Medications which may cause postural

hypotension include: Antihypertensives,

Diuretics, Nitrates, Antypsychotics,

Tricyclic antidepressants, L-dopa

Extrinsic Risk Factors, con’t.

Use of restraints

Environmental factors-dim lighting, glare, inappropriate footwear, uneven flooring, loose rugs, wet, slippery floor, old and unstable furniture, etc.

Imperative that health care providers routinely assess risk factors and inquire about falls

Environmental Considerations

Let’s Share!

Your experiences with Mobility

Assessment and Modification

Plans to enhance mobility assessment?

Experiences with assessing postural

hypotension?

◦ Revised Toileting Protocols

◦ Post Fall Huddles?

◦ Patient Engagement and Teach Back?

◦ Population-based approach to injury reduction?

◦ Peer Leaders?

Thank you for sharing!

Together we accomplish more!

Closing Remarks

• What are your questions?

• What are you going to do by next Tuesday?

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Fall Coaching Webinar Series 12:00 – 1: 00 PM

• 5/26/16 Session 1: Post Fall Huddle, Involving the Patient; Patient Engagement

• 6/13/16 Session 2: Protection from Injury: Injury Reduction Environmental Assessment, Floor Mats, Hip Protectors, Helmets; Implementing Population-based approach to Injury Reduction (A, B, C, and S); Unit-based Champions: Resources for Peer Leaders

• 7/5/16 Session 3: Proactive Toileting - Bathroom vs. Bedside Commodes; Toileting prior to Pain Medication

• 7/25/16 Session 4: Mobility Issues, Walkers in Rooms; Postural Hypotension

• 8/15/16 Session 5: Accelerate Improvement- Share your Experience; Closure to the Webinar Series

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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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