Falls Re-boot: Post-Fall Huddles. September 1, :00 2:30 PM CT

Transcription

1 Falls Re-boot: Post-Fall Huddles September 1, :00 2:30 PM CT 1

2 AHA/HRET (HEN) Falls Re-Boot Camp Webinar Day 1 repeated. Summary Disclosure & Accreditation Stmt. September 11, 2014 The planners and faculty of the AHA/HRET (HEN) Falls Re-Boot Camp have indicated no relevant financial relationships to disclose in regard to the content of this activity. This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical education through the joint sponsorship of the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) and the Health Research & Educational Trust. ABQAURP is accredited by the ACCME to provide continuing medical education for physicians. The American Board of Quality Assurance and Utilization Review Physicians, Inc. designates this live activity for a maximum of 1.50 AMA PRA Category 1 Credits. Physicians should only claim credit commensurate with the extent of their participation in the activity. The American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) is an approved provider with the Florida Board of Nursing to provide continuing education for nurses. ABQAURP designates this activity for 1.50 Nursing Contact Hours through the Florida Board of Nursing, Provider # Congress St. New Port Richey, FL Toll Free Telephone

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9 Post Fall Huddle Re-Boot Welcome! Glad you could join us. 9

10 Today s Objectives o Sharing of best practices in implementing post-fall huddles from peer hospitals. o Practical application of the model for improvement in establishing sustainable post-fall huddle practices. o Define the benefits and barriers to engaging patients in post-fall huddles when conducted at the bedside. o Examine how data from post-fall huddles can be used to identify trends and safety gaps. 10

11 What s your Post Fall Huddle Story? My Organization or Unit 1 - Has not considered post fall huddles 2 - Are planning to add Post Fall Huddles to our Plan 3 - Have implemented Post Fall Huddles and need a Re-Boot 4 - Have implemented and hardwired Post Fall Huddles Please respond to the poll 11

12 WIIFY What s in it for you? Please chat what your would like to learn today. Plus your question and comments. 12

13 State of the HEN in Falls Falls With or Without Injury Falls EOM 37 Fall with Injury Falls EOM 38 Minor or Greater Injury 76% Reporting 12% Reduction 56% Reporting 15% Reduction 13

14 Reporting Falls What are the perceived barriers to reporting Falls as part of your work with the HEN? Do you have suggestion on how the HRET HEN can reach 80% reporting on Falls? 14

15 Falls Prevented to Date Across all HRET Hospital Engagement Network Hospitals 3,672 Falls have been prevented! $2,436,000 estimated Cost Savings 15

16 Welcome to Huddle 101 Jackie Conrad RN BSN MBA RCC Improvement Advisor Cynosure Health 16

17 Types of Huddles Safety Huddle Beginning of shift Sets the focus for the shift Identifies safety risks Ensures everyone is on the same page Unit or organization level Post Incident Huddle Debrief Post event Identify what happened, what was learned and what can be improved Response teams can be used 17

18 Benefits of Post Incident Huddles Immediate drill down on factors contributing to the fall Memories are fresh Engages staff Environmental scan for contributing factors Improves communication Everyone s input matters Collects meaningful data 18

19 Data Data Data Collect Data that can be trended Time Day of week Location Diagnosis Assistive Device Medical Devices Environmental Factors Medications Interventions in place Time since last round Level of assessed fall risk When was lass fall risk assessment Activity at time of fall Toileting Reaching Walking 19

20 Huddle Up! Tina Kraft RN, BSN 20

21 Improving Harm Across the Board Fargo, North Dakota Acute Hospital 105 Beds 21

22 Our Story After achieving our targeted 40% fall reduction goals on Cardiac Tele Unit (CTU), we implemented the 3 most effective changes on our Med Surg Unit. 1. Posted # of days since our last fall 2. Preshift huddles 3. Post fall huddles 22

23 Our Huddles Pre Shift Huddles All staff included Discuss fall risks Safety issues Who leads? 5 minutes 23

24 Our Huddles Post Fall Huddles Led by Resource RN on unit Nurse assigned to patient Staff who found the patient Patient Care Tech Huddle tool used to collect data that is trended Patient Family interviewed 24

25 Lessons Learned after Spread After 4 months our fall #s were getting worse, we underestimated the differences in the CTU vs Med Surg The culture of the Med Surg floor was very different from CTU We started over by customizing the changes to Med Surg unit. 25

26 Finding clues in the Data 4 months of post fall huddle data showed the majority of our patient falls were associated with: toileting ortho patients 26

27 Confirming a Theory Are we REALLY rounding with a purpose??? 27

28 Data Driven Solutions Post fall worksheet for Med Surg created to help collect data that could identify trends Pre Op Teaching on fall prevention for ortho patients Call don t Fall patient contract Signs on the ceiling above the bed call don t fall Re-launched hourly rounding to address falls related to the toileting 28

29 Our results Med / Surg vs Hospital Fall Rate MS 3rd MS 5th Hospital Fall Rate Linear (MS 3rd) Linear (MS 5th) Linear (Hospital Fall Rate) Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 29

30 Wins Recognize the progress We bring up the fact that the # of falls is going down at every meeting and even the daily huddles and praise the staff for their efforts Celebrate success! For floors achieving 100 days since the last fall we announce over head and bring cookies and refreshments. We take a picture in front of the Days since sign with all the staff that and post it in our organizational news paper 30

31 Pearls of Wisdom Pull any data previously to help identify some trends Start a committee that includes frontline staff, managers, therapy, and a champion if possible Start by making 1-2 changes at first so you can measure your progress and decide what changes made an impact Continuously identify any trends that you notice and investigate them 31

32 Question / Discussion Tina Kraft, RN, BSN House Supervisor Essentia Health nd Ave S. Fargo, ND Phone: Tina.Kraft@essentiahealth.org 32

33 What s on your Mind? 33

34 Post Fall Huddles Sarah Wood RN, MSN, CMSRN Nurse Manager/Fall Committee Chair 34

35 St. Elizabeth Healthcare Facts about hospital 6 Facilities in Northern Kentucky Approx. 1,200 licensed beds Multiple specialty services Greater Cincinnati/ Northern Kentucky area St. Elizabeth Healthcare is sponsored by the Diocese of Covington 35

36 Our Story St. Elizabeth vision statement: We will be a national leader in healthcare excellence. Most quality indicators are very good, but fall scores above national average. Goal: involve staff in reducing fall rates 36

37 Our Story Model for improvement of patient safety: Set goal for all units fall rates Initiated Fall Huddle Procedure, post Fall Turn form into Department Manager Ensure use of chair/bed alarms on all high fall risk patients Biweekly fall meeting to review all falls Make staff aware of unit fall scores and goal. Quarterly newsletter addressing current fall rates and any strategies gleaned from huddles or review. 37

38 The who what where when Post Fall Huddle: conducted within 30 minutes after fall Everyone (nursing and non nursing) who is on the unit when the fall occurs attends huddle. Nurse Manager(NM) & shift supervisor attend when available. The charge nurse leads and documents Fall Prevention strategies solicited from all present. Huddle is conducted in the nurses station 38

39 The who what where when Fall Review Meeting: Standing biweekly meeting led by Patient Safety Attended by the Fall Committee Chair, VP Nursing, Risk Management, and any manager or assistant manager who has had a fall in the last 2 weeks. (includes outpatient such as PT, cardiac rehab, imaging ) Every fall is discussed including strategies that could have prevented the fall. 39

40 Fall Huddle Form 40

41 What have you learned from the data collected? What system wide issues have been identified and fixed? Lack of personal/chair alarms system wide Purchased alarms - one in every room and toilet Lack of gait belts for ambulation Gait belts purchased - available in every room Patients with high Morse Fall Scores included in change of shift huddle. Use of bed/chair/toilet alarms as well as gait belts expected on all these 41

42 Challenges & Solutions Barriers Staff compliance Patient/Family Compliance How we overcame Staff education on Morse fall scale and unit fall rates Constant reminders to use alarms/gait belts Patient family education on admission in regard to assistance when getting out of bed Now call bed/chair/personal reminder not to get up without assistance Failures & what you learned Huddle form on 5th revision to ensure best information obtained 42

43 Fall Newsletter 43

44 Wins/ Turning Point Proven results; better compliance with policy and fewer falls. Staff holding themselves accountable They know their unit scores, and the hospitals Compete to have lowest scores Quick response to alarms Unit celebrations for lower rates: Some had pot luck celebrations, days to wear special clothing etc Awards Certificates for No Falls 1 month, 3 month, 6 month, 9 month, 12 month. 44

45 Award 45

46 Percent Improvement in Falls 46

47 Lessons learned Advice to a hospital just starting down this path It takes time to change a culture. Solicit staff input they are the best source for strategies that will work Be flexible if something isn t working, be ready to revise your plan. Try to make it fun, celebrate any successes. 47

48 Question / Discussion Contact information Sarah.Wood@Stelizabeth.com Phone:

49 49

50 Post Fall Huddle Stop the Line Ann Allison, MSN, RN, ACNS-BC Critical Care/Progressive Care Clinical Nurse Specialist IU Health Arnett Lafayette, Indiana 50

51 Indiana University Health Arnett We Opened 10/2008 Facts about hospital 191 Beds Full Service Hospital Open Heart NICU Trauma Oncology Community Population of Tippecanoe County is 175,000 Home to Purdue University Boilermakers: Go Boilers 51

52 Our Problem-Falls Prevention We were not making progress Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 # of Actual Falls falls/1000 patient days 52

53 Engaged Staff-Utilized Lean Methodology Reviewed Data Reviewed Best Practice recommendations Identified Current State and Ideal State 53

54 Engaged Staff-Utilized Lean Methodology Brainstorm session- Gaps Grouped & Prioritized the brainstorm ideas Realized progress will not happen without a culture shift..to one with Urgency 54

55 Leveraging Post Fall Huddle to Sustain Culture of Urgency When a fall happens, first priority is the patient Next is to trigger the Post Fall Huddle process Responding staff dial 77 -our Code Blue line Operator initiates the phone tree 55

56 Leveraging Post Fall Huddle to Post Fall Huddle Participants Sustain Culture of Urgency Associate Administrator Leads the huddle, fills out the form; submits the event report. 24/7 availability Nurse Managers respond when available Clinical Nurse Specialist respond when available Staff involved Patient/Family Copies to lead of Fall Prevention Team, Unit Based Fall Champion & Manager 56

57 Culture of Urgency and Discovery Goal is to conduct Post Fall Huddle within 1 hour Our reality is 5-10 minutes We have Urgency 57

58 Engaging Patient and Families in Post Fall Huddles Benefits First hand experience from patient; gain better insight Patient and family are involved in the patient s plan of care (specifically related to safety) Reassures family Educational opportunity Urgency of staff demonstrates significance of fall to patient and family Barriers Can be difficult to get feedback of fall when patient is cognitively impaired Patient can be embarrassed about fall, does not want to engage or minimizes significance of fall 58

59 Fall Number and Repeat Fall Number Trends 16 Adult, In Patient Falls 3 Repeat Falls 14 Number of Falls Apr-12 Jul-12 Oct-12 Jan-13 Apr-13 Jul-13 Oct-13 Jan-14 Apr-14 Jul-14 Total IP Adult Falls Linear (Total IP Adult Falls) 0 Q Q Q Q Q Q

60 Lessons learned Advice to a hospital just starting down this path Don t give up!!! It is important work!!! There is no magic bullet Engage the entire team Give feedback to entire team 60

61 Question / Discussion Ann Allison, MSN, RN, ACNS-BC (765) Aallison1@iuhealth.org Sally J Lowrey RN, MSM, NE-BC lowreys@iuhealth.org

62 What ideas are you generating? What questions do you have? 62

63 Downstream Benefits: Data, Knowledge, Engagement Emily C. Piercy, EdD(c), MSN, RN, CNE Baptist Health Lexington September 10,

64 Objectives Examine how data from post-fall huddles is used to identify trends and plan improvement strategies Relate the use of post-incident huddles in reducing future harm. 64

65 Baptist Health Lexington Facts 383-bed, full service, acute care, major medical research and education center in Lexington Magnet re-designated Joint Commission Top Performer Part of a statewide, multi-hospital, healthcare system NDNQI 65

66 Fall risk assessment Communication is Key Handoff communication SHARED S Situation H History A Assessment R Request E Evaluate D Document 66

67 Close to You Bed alarms Chair alarms Workstations in the hallways close to patients Hourly Rounding (5 P s) Pain Potty Position Possessions Protection 67

68 More Communication Concurrent investigation of fall incidents Staff meeting presentations Post incident huddles 68

69 Fall Prevention Awareness Week 2013 Activities each day of the week including: Changing daily table display with information PT/OT Muscle Tone and Strength HealthwoRx Balance and Flexibility, Vision Wheel of Education Medication Safety Employee/Visitor Fall Prevention Home Safety Contests and prizes Demonstrations What s wrong with this picture? Daily to all employees Tent cards on cafeteria tables Hospital newsletter puzzle Staff bathroom signage Parking lot shuttle signage 69

70 Director Huddles Weekly Director meetings What happened? What could have been done differently? Focus on process rather than people 70

71 Findings from Huddles 71

72 No, no! Bad chair! 72

73 Toileting No patient requiring help to get to the bedside commode or bathroom shall be left unattended in either of those places. 73

74 Patient/Family Education Orientation to room and how to call for assistance Patient education video 74

75 Other Behavioral assessment study Nurse call system to phones November 2013 Third Annual Fall Prevention Awareness Week in September

76 Trendline 8.0 Fall Rate/1000 Patient Days Baseline = Mean = 3.66 Jan-11 Mar-11 May-11 Jul-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12 Sep-12 Nov-12 Jan-13 Mar-13 May-13 Jul-13 Sep-13 Nov-13 Jan-14 Mar-14 May-14 76

77 Outcomes 41% reduction in annual patient falls since % reduction in annual patient falls with injury since

78 Key Takeaways Engaging the entire patient care team is important to a successful fall prevention program. If at first you don t succeed, try, try again. Use your data; know the problem; communicate! 78

79 Reference Corley, D., Brockopp, D., McCowan, D., Merritt, S., Cobb, T., Johnson, B., Stout, C., Moe, K., & Hall, B. (2014). The Baptist Health high risk falls assessment: A methodological study. Journal of Nursing Administration, 44(5),

80 Questions / Discussion Emily Piercy, EdD(c), MSN, RN, CNE PI Coordinator Baptist Health Lexington emily.piercy@bhsi.com Denise McCowan, MSN, RN Director of Nursing Baptist Health Lexington denise.mccowan@bhsi.com 80

81 Recap of Key Takeaways 81

82 National Fall Prevention Awareness Day is Tuesday, September 23 rd? 82

83 Fall Resources Other Harm List Serv HRET Falls Change Packet and Top 10 Checklist w=article&id=5&itemid=130 83

84 Our patients thank you for keeping them safe! 84

85 Reminders Instructions on how to claim CEUs will be sent via . To join the Other Harm LISTSERV, log in to and click the red button in the top left hand corner of the screen. An evaluation survey on this boot camp will appear when you close out of the WebEx platform. Please let us know how we are doing! Register now for tomorrow s session at under the Events page. 85