Falls Committee Meeting MHE Command Center and DGH Boardroom via Videoconference June 27, 2012 Presiding:, RN, Director Acute Care and, RN, Director of Clinical/ Financial Nursing Resources Present: Martha Clark; Kim Billingslea; Tracie Nolan; Anne Shannahan; Steve Pittman; Jeannie Brower; Denise Chodnicki; Janet Wilson; Deb Van ; Barbara Excused: Cindy Beemer; Dona Benford; Teresa Blem; Bev Anders; Erin Jones; Debbie Medford; Anna-Marie Bertics Howard; Tammy Bradshaw Recorder: Jennifer Kaminskas, Secretary Guest: Jen Miles Approval of Minutes The minutes were approved as written. Approved Review of UMMS Fall Committee The Committee will be meeting with the members of 2 of the subgroups on Thursday June 28, 2012. Kim Billingslea is on the Patient and Family Involvement subgroup. Denise Chodnicki will attend for fall huddle subgroup. Susan Siford s sub group will be discussing trying to do a pilot in 2 hospitals on medication records for patients with high falls. / Journal Club Behavioral Health (BH) Fall Risk Tool informed the group of the study done by Deborah Edmonson, RNBC, BSN; Sherry Robinson, RN, PhD; and Larry Hughes, PhD. ("Development of the Edmonson Psychiatric Fall Risk Assessment Tool" Journal of Psychosocial Nursing, Vol 49, No. 2, 2011). The study was based on different populations. A number of the members from the BH unit have read the study. Susan Deichert felt the tool in the study was a substantial tool. The BH group had questions regarding the process of implementation. explained the process to Deb Van. Ruth Ann recommended first taking it to the unit based council and trying a small test of change. Use the tool with the next couple of admissions and try it, time how long it takes staff to use, is it difficult to use, is it easier or more difficult to use than the to take tool to unit based council and do a small test of change. to send the information about license to and Ruth Ann Jones. to bring 1
Hendrichs II is, etc. If the unit wishes to use the new tool, Deb will have to check with Jo Anne Thomson to see if it is possible to build into Meditech for a specific unit to use a specific tool. would like the two tools to be compared by the BH unit. If this is a licensed tool, SHS will need to know the cost. If Deb needs any help, call or Ruth Ann. information about tool to the next Falls Fall Education Plan for FY13 explained last year fall education was done for all clinical and non clinical staff on Healthstream. Fall huddle education is occurring now. Ruth Ann asked the group what they felt this group needs to do to move forward with fall education for clinical and non clinical staff for FY13? Ruth Ann discussed a handout from previous meeting about modules from UMMS similar to the program SHS had on Healthstream for FY12. brought up discussion of bedside commodes. Recommended using alarms under the commode seat. Group discussed benefits and different scenarios. Steve Pittman is available to attend any unit meeting if staff requires help with occurrence reports. described a key note speaker at a Falls Conference she attended. The speaker spoke on geriatric patients and the importance of balance. did an exercise with group to show balance problems with the age group of attendees. The majority of the group had trouble with the simple exercise. The group asked if this speaker would be interested in speaking to this group. Barbara recommended having this speaker come and present for an hour during the Research Presentation. Contact hours can be offered to staff. discussed ideas for Fall Month during the month of September 2012. Professional Nursing Practice could help organize. Ruth Ann asked for volunteers to be on the group., Denise 2 would like the group to go back to teams and ask questions about why put commode at bedside, alarm issue, etc. will lead the team organizing for Falls Month.
Chodnicki, Tracy Nolan, and Barbara will be on the group. Ruth Ann informed group of the Jeopardy games in the Nursing Administration office along with questions from UMMS which can be held in Cafeteria or HEC. Ruth Ann recommended repeating the clinical and non clinical education modules using the newer modules for FY13 on Healthstream. Types of falls and levels of falls would be included. Should NDNQI, rl Solutions, or UMMS be used for levels of falls? Jen Miles would like to see NDNQI used for staff. Ruth Ann reviewed the modules developed by UMMC Falls Group and asked the group which ones they would like to use: Interventions Involving patient and their families identifying the risks Plan of Care- how to change it and why it is needed Resources available Set of 6 scenarios and quizzes to along with them Jeanne explained how she and Stephanie came up with an algorithm for a fall and a fall risk. Martha Clark would like the families oriented and better educated about the hospital and hospital life. Ruth Ann explained that later today, she,, Kim Billingslea, Karen Twigg, and a gentleman from USH will be meeting at the Medical Office Building to discuss putting together a plan on patient and family education. The orange fall forms in the patient room will be replaced with blue and yellow laminated form Call Don t Fall. Group discussed making the print larger on legal size paper. Ruth Ann mentioned other ideas to the group, such as book marks, table cards, lapel buttons, magnet, stickers, etc Group discussed sticky labels for cups or water pitchers. Ruth Ann will take to the larger UMMS meeting on Thursday. Steve Pittman suggested laminated tags for the TV arms. Group thought wall posters for elevators and high traffic areas was a good idea. Group would like 3 Barbara and Jeanne Brower will ask new members if they are interested in being on group. and Jen Miles to get together about NDNQI and bring back to next will work on algorithm and bring back to next will take sticky label idea to Thursday s UMMS and Barbara
Fall Huddle Education Plan posters to include CARE information. An outpatient flyer in English and Spanish was distributed to Anne Shannahan for her review. Having a branding on the SHS patient education channel was suggested. Group liked the idea, but Wynne Aroom will need to be contacted. Verbal scripts would be good for unit based education. discussed the post fall huddle sheet with the group. The education is 75% completed. Jeanne has been going to ancillary staff meetings. She will be visiting with radiology June 28, 2012 and EVS in July 2012. Jeanne showed the group the board she has been using for education. Jeanne requested contact information for person who developed the UMMS Fall Huddle handout. She would like to discuss possible problems that they may have run into or ones she has not anticipated. Jeanne will speak with the Nursing School when they are back in session. Amy Stafford and Stacey Kram will build it into the orientation for staff. Mary Kate Williams-Feldman made a flyer for staff s mailboxes. Anne Shannahan to review and get back to group next will take idea to Wynne Aroom to see if it is possible. to get contact information to. Barbara will follow-up with Stacey Kram and Amy Stafford. Anne Shannahan Barbara Group discussed path of the fall huddle form. Once the form is completed it goes to the managers of the unit for review and is then forwarded to and and filed for review and will be used in the future for educational purposes. Steve Pittman recommended scanning the form as an attachment to the incident report. Group will discuss the idea of scanning form at the next Ruth Ann explained Nurse Pharmacy discussed the issue of what if the pharmacist cannot get to the fall huddle in the middle of the night. The pharmacist will make a note in the note section in the emar within 8 hours of the fall for medication review. Denise Chodnicki will ask Kevin Chapple to inform the Pharm D s. Do not document post fall huddle but do document medications reviewed post fall. Denise Chodnicki will speak with Kevin Chapple. Denise Chodnicki Presentation of a Fall Jen Miles discussed a fall MHE 2 East had on June 22, 2012 involving a 61 year old male. The circumstances and the situation of the case were Jen Miles 4
described to the group. Jen explained what was done prior to the fall along with the patient s medication history. The group discussed possible recommendations. Attachment NK6mm, Falls Committee Meeting minutes 6-27-12 Ruth Ann would like Barbara to look into orientation of staff regarding the calling of help based on a conversation she had with a new orientee. Jen Miles mentioned Terri Ross asking her to remove the 1:1 so that Terri s group could place the patient in a nursing home facility. Jen expressed concern. Barbara to speak with Stacey Kram and Amy Stafford about the calling of help in orientation. will speak with Terri Ross about 1:1 situation legalities. Barbara Ruth Ann would like Jen Miles to print a medications list for this patient so she can present it to the UMMC Falls meeting on Thursday June 28, 2012. Jen Miles to copy patient s medication list for Ruth Ann Jones. Jen Miles Open Discussion Meetings in the future will include a challenging falls for the group to discuss and offer other recommendations/ interventions. Steve Pittman- Asked the group if an RCA should be held for the two significant falls from April 2012. The group decided moving forward with all future issues, but these two falls are too far past. Significant falls are reported to the state. Group agreed discussing a challenging fall monthly would be beneficial. RCA to be done soon after a significant fall. Next Meeting The next meeting is July 25, 2012 @ 0730 in the MHE Command Center and the DGH Boardroom by videoconference. 5