Patient Education and Falls Prevention Clinical III Project Proposal Rose Posadas RN, BSN 1
History Falls have been the largest reported incident in hospitals. Quality improvements and research have been ongoing to prevent falls. Hospital falls occur for a variety of reasons, including a patient s condition and lack of staff supervision 2
History Falls can increase hospital stays and add to healthcare costs Patient and family education are identified as one of the action plans for the UCIMC fall prevention program A fall prevention brochure is available to educate nurses Patients may differ in learning styles 3
Goal The purpose of this project is to provide education to patients and their families about the importance of fall prevention. Also, to supply nurses with a source of reference for fall prevention guidelines. 4
Why is the project important? Nurses don t have enough resources to educate patients and families UCIMC was unable to identify an educational video to use on the closed circuit television Will save nurses time 5
Objective TL10EOf, Patient Education and Falls Prevention Clinical III Project Proposal.pdf Method/Project Components Outcome/ Measurement Assess patient knowledge of risk and how to prevent falls Diagnose those at risk for falls and high risk for injury Overarching goal: decrease falls Develop interview questions to survey patients at risk for falls Is the tool appropriate and is the patient at risk? Create a new tool? Appropriate patient/family education using different teaching methods and tools Pre and post implementation comparison Evaluation: data to analyze CALNOC benchmarking Plan Create audio video Completion of video Patient Education: improve patient knowledge of risk for falls Provide in-services for all nurses Audit teaching plans 6
Video http://vimeo.com/25322915 7
References Poe, Stephanie S. et al The Johns Hopkins Fall Risk Assessment Tool post implementation evaluation. J Nursing Care Quality Vol. 22, No. 4, pg.293-298 Sullivan, R. Recognize Risk factors to prevent patient falls. Nursing management May 1999 Joint Commission (2009) Hospital National Safety Patient Goals retrieved from http://www.unchealthcare.org/site/nursing/servicel ines/aircare/additionaldocuments/2009npsg 8
3T Nurses Pre and Post In-service (1) 9
3T Nurses Pre and Post Inservice (2) 10
3T Nurses Pre and Post Inservice (3) 11
3T Nurses Pre and Post Inservice (4) 12
3T Nurses Pre and Post Inservice (5) 13
Falls Prevention Survey Results 3Tower May 19, 2011 All 3Tower patients surveyed on a single day by Rosemarie Posadas, RN Results 27 total patients. 85% (23 patients) identified at risk to fall Patient Interviews of the At Risk Patients 26% (6 of the 23 patients) unable to participate in interview 35% (6 of 17) unaware they are at risk to fall 47% (8 of 17) unaware of why they were at risk to fall 24% (4 of 17) did not say that the most important thing they could do to prevent a fall was to call for help before getting up Fall Prevention Interventions not in Place 22% (5 of 23) were not wearing Red Sox 9% (2 of 23) did not have a Falling Stars Sign 4% (1 of 23) did not have bed in low position Hand-off Communication 39% (9 of 23) did not have Fall Risk Status communicated RN to RN at shift change 48% (11 of 23) did not have Fall Risk Status communicated to SHA at shift change Bed Exit Alarms 59% (16 of 27) beds were not equipped with Bed Exit Alarms No Bed Exit Alarms were in use 14
Falls Prevention Survey Results 3 Tower November 9, 2011 Results 26 total patients. 92% (24 patients) identified at risk for fall Patient Interviews of the At Risk Patients 4% (1 of 24 patients) unable to participate in the interview 22% (5 of 23) unaware they are at risk for falls 30% (7 of 23) unaware why they were at risk for falls 30% (7 of 23) did not say that the most important thing they could do to Prevent a fall was to call for help before getting up Fall Prevention Intervention not in Place 25 %( 6 of 24) not wearing red socks; in which 1patient prefers not to wear It because of severe edema 16% (4 of 24) did not have a Falling Stars Sign 0% (0 of 24) did not have bed in low position Hand off Communication 100% (24 of 24) Fall Risk status communicated RN to RN at shift change 100% (24 of 24) Fall Risk status communicated to SHA at shift change Bed Exit Alarms 23% (16 of 26) beds were not equipped with Bed Exit Alarms No bed exit alarms were in use 2 Portable bed alarms were in use 15
John Hopkins Fall Risk Tool Survey Based on trial using John Hopkins Fall Assessment tool Day Shift 24 patients. Low- 13 patients Moderate 8 patients High- 3 patients Night Shift 27 patients Low -8 patients Moderate- 17 patients High-2 patients 20 patients were identified to be at risk using our tool. 16
3 tower falls vs CalNOC 17