pat quigley, phd, mph, arnp, crrn, faan, faanp · •bathroom redesign ie raised toilet seat,...
TRANSCRIPT
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
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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
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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 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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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
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Falls with Injury
Rate per 1,000 Patient days Improvement Target
Start of Interventions .
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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
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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
442-281-4268
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EILEEN JENSEN RN MSN FNP CLINICAL SPECIALIST SANTA ROSA MEMORIAL HOSPITAL CONTACT: [email protected]
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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 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!
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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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