AHRQ Fall Prevention Program Implementation Sharing Webinars Webinar #3

Transcription

1 AHRQ Fall Prevention Program Implementation Sharing Webinars Webinar #3 October 21, 2015 Sponsored by: Agency for Healthcare Research and Quality (AHRQ) Hosted by: The AFYA Team (AFYA, Inc., ECRI Institute, and Stratis Health)

2 Today s Topics Housekeeping Updates from the AFYA Team Hospital Contact List Hospital update Mayo Clinic Health System Franciscan Healthcare Kristine Von Ruden, RN, BSN, Director of Patient Care Update on intentional rounding activities Post-fall huddles Julia Neily, RN, MS, MPH, Associate Director, VHA National Center for Patient Safety Field Office Vanessa Coronel, VA Boston Questions for presenters and open discussion Wrap-up 2

3 Webinar Tools for Interaction Raise your hand to contribute to the discussion or ask a question. OR Use the CHAT panel. 3

4 Webinar Tools - Muting Mute your audio to minimize background noise. OR Mute your phone. 4

5 Updates from the AFYA Team Connecting Outside of the Webinars Hospital Contact List December Webinar Poll regarding your availability 5

6 Presenting Hospital Mayo Clinic Health System Franciscan Healthcare 6

7 Mayo Clinic Health System Franciscan Healthcare LaCrosse, WI Bedsize: 150 Pilot Unit: Medical 7

8 7th Medical/Cardiac 30 beds; RN and PCT staff Reinforce intentional rounding one of the four initial interventions in the Implementation Plan What is the change? Who is involved? When is it done? Where is it documented? How will success be measured? Benefits: Patients RNs PCTs Learning/Measures of success 8

9 Questions 9

10 Post-Fall Huddles: Reducing Preventable Falls and Fall-Related Injuries Presented by Julia Neily, RN, M.S., M.P.H. Veterans Health Administration National Center for Patient Safety

11 A Little About Myself Work for VHA National Center for Patient Safety Have been a nurse since 1984 Have worked with numerous teams in fall breakthrough series 11

12 How to: Overview Implement post-fall huddles Use data from post-fall huddles to reduce falls and fall-related injuries Apply formative and summative evaluation methods to post-fall huddle evaluation 12

13 Safety Huddles Conducted with the patient, where the fall occurred, and within 15 minutes of the fall Post-fall analysis What was different this time? When How Why Prevention: Protective action steps to redesign the plan of care 13

14 VA NCPS Falls Toolkit Post-Fall Huddle Falls Decision Tree Falls Decision Tree Typology Post-Fall Huddle/After Action Review Case Study Number 1 Case Study Number 2 alls.asp 14

15 Post-Fall Huddle (PFH): Essential Components A brief staff gathering, interdisciplinary when possible, that immediately follows a fall event Convenes within 15 minutes of the fall event Led by clinician(s) responsible for patient/resident during the fall event Involves the patient/resident whenever possible in the environment where the patient/resident fell Requires Group Think to discover what happened Utilizes discovery to determine the root cause/immediate cause of the fall; why the patient/resident fell 15

16 Guiding Question to Ask What was different about doing this activity, compared to all the other times you performed the same activity and did not fall? 16

17 Steps of Post-Fall Huddle 1. Team leader (TL) makes announcement. 2. Convene within 15 minutes with the patient/resident in the environment where the patient/resident fell. 3. Conduct an analysis. Determine the type of fall. 4. TL summarizes information gleaned from post-fall huddle. The huddle team plans intervention(s) to prevent repeat falls. 17

18 Steps of Post-Fall Huddle 5. TL completes the Post-Fall Huddle Form and processes the form according to medical center policy and procedure. 6. TL modifies the fall prevention plan of care to include interventions to prevent repeat falls. 7. TL communicates the updated plan of care in patient/resident hand-off reports. 8. TL completes EMR Post-Fall Note. 18

19 Decision Tree for Types of Falls 19

20 Determine Preventability Step 1. Conduct the post-fall huddle. Step 2. Determine the immediate cause of the fall. Step 3. Determine the type of fall. 20

21 Determine Preventability Step 4. If physiological falls are accidental and anticipated, determine preventability: Could the care provider (direct care provider) have anticipated this event with the information available at the time? If the answer is NO, the fall is not preventable. If the answer is YES, the provider must ask another question: Were appropriate precautions taken to prevent this event? Answer No: Clearly or likely preventable Yes: Clearly or likely unpreventable Source: Levinson, D. R., (2010, Nov). Adverse events in hospitals: National incidence among Medicare beneficiaries. DHHS. OEI

22 Outcomes of Post-Fall Huddles Specify root cause (proximal cause). Specify type of fall. Identify actions to prevent reoccurrence. Change plan of care. Involve patient (family) in learning about the fall occurrence. Prevent repeat falls. 22

23 Structures Formative Measures Who attends (nursing and others) count them Changed plan of care add actions to your run chart: annotated run chart; capture interventions Processes Timeliness of post-fall huddle (number of minutes) Timeliness of changing plan of care Time to implemented changed plan of care 23

24 Summative Outcome Prevent repeat falls. Same root cause and same type of fall. Reduce costs associated with falls and fall-related injuries. 24

25 Examples of Trends Preventable falls related to toileting Notification Observation Falls related to environmental causes Doorways Shower stalls Long bedspreads Lunch and other breaks or shift hand-off Days of the week (barbershop/activities) 25

26 Tips for Measurements Seek usefulness, not perfection. Use sampling (e.g., 10 charts per week). Don t wait for the information system. Report percentages and rates, not absolute numbers. Take outcome measures at least 1X/month. Take process measures at least 2X/month. Plot data over time, and run charts. 26

27 Examples of Process Measures Percentage of: Patients at risk for falls and fall-related injuries with interventions in place Patients with completed intentional rounding Observation and chart review Process measures answer the question: Are we doing the things we think will lead to improvement in outcome? 27

28 Outcome Measures Major Injury Rate Fall Rate Balancing Measures 28

29 Post Fall Huddle Vanessa Coronel, RN, Falls Prevention Coordinator Gilda Cain, RN, Long Term Care Fall Champion (Brockton Medical Center) Susan Shannon, RN, Out patient Care Fall Champion (Jamaica Plain Medical Center) Christa Wertz, RN, Acute Care Fall Champion (West Roxbury Medical Center) 29

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32 Benefits of Post-Huddle Form 1. Answers the important question of WHY did the patient fall. Determine the root cause. 2. Reduces variation in what is reported (checklist of what to look for after a fall) new nurse vs. expert nurse vs. non-clinician. 3. Patient is engaged and reinforces team approach to falls prevention. 4. Interventions are tailored based on the root cause of the fall. 5. Trends are identified, and facility-wide changes are recommended during annual falls review. 32

33 Interventions based on Root Cause from Post-Fall Huddles 1. Long-term care setting: Post-Fall Medication Review by Pharmacists targets anticipated physiological fall (orthostatic, low blood sugar, drowsiness) 2. Outpatient setting: Engineering fixes such as repair of sidewalk, standardizing the deployment of ice/snow team target accidental falls (uneven road, icy walkway) Before After Paint Steps- Visual Cue 33

34 Interventions based on Root Cause from Post-Fall Huddles 3. Inpatient Setting and Outpatient: Courtesy shuttle for patients with impaired gait from parking lot to main entrance 4. Reinforce hourly rounding (25-35% of all falls are related to toileting). 34

35 6/12- electronic Postfall Huddle form, early stages of hourly rounding From FY 2005 to FY falls used to be the #1 adverse event in VA Boston but not anymore 35

36 Questions/Discussion 36

37 Next Session: November 18, 2015 Please complete the Webinar evaluation survey. Thank you! 37