Download Fall Prevention PPT

Fall Prevention
Fareen Ahmed
Chris Chien
Zaira Masood
Mary Randolph
Tiani Tuiolosega
• An incident that results in a person coming to rest inadvertently on the
ground or floor or other lower level.
• Patient falls, defined as the rate at which patients fall during their
hospital stays per 1,000 patient days, are a nursing-sensitive quality
indicator in the delivery of inpatient services.
• Patient fall rates are perceived as the indicator that could be most
improved through nurse-led safety strategies or interventions.
• In other words, nurses assume the primary responsibility and are
somewhat liable when a patient falls in the inpatient care unit.
Definition of a Fall
• According to reports published by the Centers for
Disease Control and Prevention Injury Center
(2007), patient falls are the:
• Third most common cause of unintentional injury
death across all age groups.
• First leading cause among people 65 years and older.
Background
• Sun Coast Regional Hospital is a 500 bed, full service,
acute care facility with a medical staff of approximately
1,100 and employee base of 1,500.
Facility Information
• Number of Patient Falls / Number of Patient
Days x 1,000 = Fall Rate per 1,000 patients.
• Currently, the risk of inpatient falls is 50% per
1,000 patients annually.
Problem
• We are a quality improvement team which has been
brought in by Sun Coast Regional Hospital to help reduce
the risk of inpatient falls within their facility.
• Our goal is to reduce the risk by 90%, resulting in 10% risk
of inpatient falls per 1,000 patients annually.
Aim
Describing the Intervention
• All patients aged 65 and over.
• Younger patients at increased risk of falling, such
as those with:
•
•
•
•
History of falls
Neurological conditions
Cognitive problems
Visual impairment
Patients to be Targeted
for this Initiative
Fishbone Analysis
• 1) Screening or assessment of all older patients for risk of falling.
• 2) Education and discussion of fall-prevention risks and strategies with
all staff, older patients, and their caregivers.
• 3) Recording fall-prevention education of staff, older patients, and
their caregivers.
• 4) Establishing a person’s mobility status and ensuring that they can
mobilize safely. This can be done by several criteria.
• 5) Encouraging participants in functional activities and exercise
programs.
Fall Prevention Interventions
• 6) Instructing older patients on how to use their medications safely when they are
being discharged or transferred between departments/facilities.
• 7) Making the environment safe by ensuring several things.
• 8) Orientating the patient to the bed area, room, ward/unit facilities and how they
can obtain assistance.
• 9) Instructing and ensuring that older patients understand how to use care aids
prior to them being prescribed.
• 10) Having a policy in place to increase the use of restraints and bedside rails.
• 11) Consider vitamin D supplementation with calcium as a routine management
strategy.
Fall Prevention Interventions
• A hospital can be a
dangerous and erratic
place for inpatients
because:
• Unfamiliar physical
environment (different from
that of their home setting).
• Changes in patients' medical
conditions as related to their
physical and psychological
health and sensory systems
(e.g., pain).
Facility Design
• A better physical facility design may lead to better health care
outcomes, such as fewer patient falls in acute care hospitals.
• A patient-centered facility design should promote patient safety.
• A safety-driven design with a goal to prevent inpatient fall related
injuries should be a hospital design principle.
Facility Design
• Increase patient to
provider ratio.
• Adding information
regarding falls onto
patients’ charts.
Workforce
Patients
Staff
• Educate about how falls can
impact health.
• How and where to get
assistance when being
mobile.
• Steps to prevent falls as a
patient.
• Educate and train in the use
of various mobility aids.
• Educate about how falls can
impact health of patients.
• How to assess patients’ risk
regarding various diagnoses.
• Steps to prevent patient falls.
• Steps to take when patients
do fall.
Educating Patients & Staff
• Find an opportunity to improve
• Organize a team
• Clarify current understanding of
process
• Understanding the causes
• Select an intervention(s)
FOCUS
• Sun Coast Regional Hospital is faced with a large risk of
patients falling in the facility each year. Currently, the fall
rate is 50% per 1,000 patients annually.
• Falls can be devastating, especially for seniors. Fall-related
injuries may ensue and cause further negative health
outcomes.
• As the QI team, our plan is to reduce this number
significantly by incorporating strategies that will help
reduce the risk of patients falling.
Find an Opportunity to Improve
• The QI team will consist of:
• Team Leader: Oversees QI process and directs the team.
• Nursing Staff: Assesses patients’ risk of falling, supervise and assist
them with their mobility needs.
• Data Technician: Records and updates information and
continuously ensures team and patients are up-to-date with
intervention strategies.
• Facilities Manager: Oversees improvement of hospital design for
patient safety and facility maintenance.
• Compliance Officer: Ensures the team is complying within safe
practices for patients when implementing interventions.
Organize a
• The current process at Sun Coast is very poor and is often
a reactive step which only takes place once patients have
already suffered from a fall.
• Falls are recorded and any fall-related injuries are then
treated promptly.
• There are minimal preventative practices and procedures
along with an insufficient amount of patient to provider
ratio.
• With such a poor process, the number of falls will
continue to increase and no improvements will be made.
Clarify current Understanding
• There are multiple causes that may trigger patients to fall
during their stay in the hospital, and without proper
oversight and preventative practices, falls will likely occur
often.
• As the quality improvement team, we have identified three
(3) sources that contribute highly to the annual fall rate and
which we shall address with interventions.
• Materials (education of patients & staff)
• Physical environment (facility design)
• Workforce (staff increase)
Understanding the Causes
Materials
• Education and discussion of fall-prevention risks and strategies with all
staff, patients, and their caregivers.
Physical Environment
• Making the environment safe by ensuring several things (i.e., install
more hand rails, clean and hazard-free floors, well-lit rooms, etc.).
Workforce
• Orientating the patient to the bed area, room, or ward/unit facilities and
how they can obtain assistance.
Selecting the Intervention(s)
PDSA Cycle
PDSA
• Quarterly auditing of the implementation process.
• Formula used:
• The percentage of patients who received all fall prevention
interventions can be calculated by:
• Number of patients observed having ALL appropriate fall
prevention strategies in place / Number of patients at risk
reviewed x 100% = % Results.
Measurement
Auditing Fall Prevention
Auditing Fall Prevention
• First quarter assessment: reduction of inpatient falls by
40%
• Derived from formula: 200 / 500 x 100 = 40% of patients received
all falls prevention interventions.
• Second quarter assessment: reduction of inpatient falls by
50%
• Third quarter assessment: reduction of inpatient falls by
70%
• Fourth quarter assessment: reduction of inpatient falls by
90%
Results
• Notice less improvement between first and second
quarter assessments.
• This was due to:
• Patients not wearing proper footwear.
• Patients not wearing blue wristbands.
• Patients not seeing a physiotherapist for check-ups.
Outcomes
• Enforce stricter rules regarding use of footwear
and blue wristbands – check patients daily to
make sure they have it on.
• Schedule monthly routine check-ups with a
physiotherapist for patients.
Solution Implementation
• Failure Mode and Effects Analysis (FMEA)
• Proactive risk assessment
• Prevents an adverse event
• Close examination of a process
• To help determine where improvements are needed
• Reduces likelihood of adverse affects
• Process in terms of:
• What could go wrong?
• If something does go wrong, what will be the result?
• What needs to be done to prevent a bad outcome when something
does go wrong?
• Hospitals and nursing facilities that are accredited by The Joint
Commission are required to periodically conduct a prospective
risk assessment for patient safety improvement.
Risk Assessment
• Narrowed focus to three (3) main areas:
• Materials:
• Education for patients about falls
• Education for employees
• Physical environment:
• Keeping the beds low under a certain degree
• Open floor plan in bedrooms
• Workforce:
• Patient to provider ratio
• Adding information to charts regarding falls
• Annually conduct risk assessment with every department:
• Set goals:
• Current: Reduction of 90%
• Ultimate: No falls
• Audit charts
Process
2012: Risk Assessment Preventing Patient Falls
Department:
Department lead:
Staff meets with
patient before and
extended stay and
2 provide education
Staff will use new
chart formation to
indicate that the
proper education
3 was provided
Charge nurses will
work with QA and
secret shoppers to
perform audits on
4 charts
Random ized
audits will
takeplace befor
patients departure
to see if patients
felt the received
adequate
knowledge about
falls and
5 prevention
Effect
Criticality Score
Risk
Assessment
Template
Provide staff with
education about
1 falls prevention
Potential Failure
Detection
Step
Severity
Goal:
No patient falls
Looking at all patient charts to ensure that patients are being provided with the proper
Audit descrption:education about patient falls and prevention. Each chart should have a signature by an
attending nurse of physician in the chart that indicates that they did discuss fall
prevention with patients, paying special attention to higher risk patients
Frequency
Date:
Audit Tool: Questionnaire
Audit Tool: Diagram
• Sun Coast RH faces a high risk of patient fall rate of 50% per 1,000
patients annually.
• The QI team aims to reduce the risk by 90%.
• Conduct a fishbone analysis to find multiple causes and settled on
three (3) that were of great significance.
• Completed the FOCUS-PDSA model.
• Conduct a risk assessment of patients.
• Measured results using a formula and obtained outcomes of the
interventions.
• Reinforce interventions for patient falls and continued with QI
process.
Conclusion