Agency for Healthcare Research and Quality (AHRQ) Enhancing Patient Safety AHRQ Fall Prevention Program Implementation Sharing Webinars #3 October 21, 2015 Two presentations were provided at the third AHRQ Fall Prevention Webinar on Oct. 21, 2015. The first presentation was a hospital update by Kristine Von Ruden, RN, BSN, and director of Patient Care at Mayo Clinic Health System Franciscan Healthcare. The second presentation was on post-fall huddles by Julia Neily, RN, MS, MPH, who is the associate director of the VA National Center for Patient Safety Field Office. Contributing to her presentation was Vanessa Coronel, Sue Shannon, and Amy Zemira of the VA Boston medical system. PRESENTATION 1 Kristine Von Ruden stated the pilot unit at her hospital for the AHRQ project is a 30-bed medical unit that takes a diverse patient population, such as detox patients, elderly patients failure to thrive, cardiac oncology, and neurology. We re quite the box of chocolates, she stated. We have one of the highest fall rates in the organization, because of those impulsive patients and other comorbidities that come along with their reason for admission. Hardwiring Intentional Rounding Given the amount of change that Mayo-Franciscan is experiencing as an organization, Kristine stated that staff tries to encompass many interventions that would cover a multitude of topics, such as intentional rounding, falls, patient experience, and all that. Falls Prevention Learning Network 1
We tried to hardwire intentional rounding, she stated. It s an area we struggle with because of the unit s daily turn. Our patients come and go from diagnostics, therapies, and what-not, anywhere from four to six times a day. So when managing that turn, to have someone dedicated to go in proactively is a constant struggle, Kristine stated. So staff has kind of stepped away from being proactive to being mindful, really trying to focus on asking about the four P s with every patient encounter. We have some staff that are more stellar than others, but it continues to be an effort that we continue to hardwire on that, she stated. We have actually just started documenting this in our EHR. One of the barriers was having not having what we call our patient care tech not having the same ability to document as our nurses. We just received that within the last week or two, and now are collecting data on that success. When it does work well, it does put the patients at ease and helps them to develop a more trusting relationship with staff. Kristine stated the staff feels awkward asking the same questions repetitively throughout the day, so that s where staff gets into that inconsistency. The other barrier with intentional rounding is that scripting works, role-playing or structured rehearsal works, because it s very easy to push something out, but not really understand how it should look. This is a learning process that the unit is working through, she added. The other couple things the unit is working on and has implemented is the nurse-to-nurse bedside shift report. The PCT from days to night also have taken on that format in which they go bedside to bedside, doing their introductions, making sure that bed alarms or care alarms are engaged, and that patients have everything within their reach again incorporating those four P s into the process. I wish I could say that has led to success, but even this month, we have had four falls, two of which were preventable, Kristine stated. And when I talk about preventable, there were one or more things not in place for our standard of care. No one was injured, thankfully enough, but to know that two could have been prevented speaks loudly. We can continue to work through our frustration and all of that to reduce our fall rates, but it s a very frustrating process. Falls Prevention Learning Network 2
Questions Question/Comment Michelle Tregear (AFYA) asked what Mayo-Franciscan s timeline is for implementing the changes it s working on. Michelle Tregear (AFYA) stated it sounds like Mayo- Franciscan has a lot going on, noting more questions could be asked after the next presentation. She thanked Kristine Von Ruden for sharing with everyone. Response Kristine Von Ruden (Mayo-Franciscan) responded that staff continues to address it daily, on an ongoing basis. As far as a timeline to see success, she stated one of the barriers is staff doesn t have a true benchmark for a unit, when comparing fall rates per 1,000 patient days. The benchmark is at an organization level, not a unit level. So it s really hard to determine that measure using a fall rate when the goal has been set organizationally. One of the things she s started to look into is there a fall rate for a unit of like size and population. As far as a timeline, that s kind of fluid as they learn and discover what kind of data they don t have. Once they have all the information at their fingertips, they can set a concrete goal using the PDSA language and then moving forward. PRESENTATION 2 Julia Neily introduced herself, stating she s been a nurse at the VA since 1984, having worked in various roles from staff nurse to nurse manager. For the last 15 years, she s worked for the VA National Center for Patient Safety, working with numerous teams at VAs throughout the nation that are working to reduce falls and fall-related injuries. Falls Prevention Learning Network 3
Safety Huddles Overview Julia provided an overview of her discussion, stating she wanted to discuss post-fall huddles and an after-action review. The ideal way to do a post-fall huddle is within 15 minutes of the fall, as soon as possible, when it s fresh in everyone s minds. She stated it s really important to ask, What was different this time? For example, was the patient getting up to go to the bathroom or reaching for something, and why did the patient fall this time when all the other times he/she did it without falling. Many times, it s obvious why someone fell, but it s good to dig a little deeper to get to the root cause of that, she stated. And this is really about looking to see what can be done to prevent future falls of a similar nature, and it s one of the key interventions if trying to reduce repeat falls. VA Toolkit If hospitals want to practice with materials, backup information, or case studies, she recommended they go to the VA National Center for Patient Safety falls toolkit. She stated the link in the slide will take hospitals to an after-action post-fall huddle tool, where there are some case studies, typology tree, and other tools that will help hospitals determine the preventability of fall. Falls Prevention Learning Network 4
Post-Fall Essential Components and How Does This Really Work? Some teams have used an overhead page, others may use different ways to get team members there, Julia stated. It s important to have more than one person, because one colleague might see something different than another colleague, she stated. For example, after a fall, we reviewed the patient s room to look at what was happening. From a nursing perspective, a nurse is likely thinking about transfer abilities, medications, etc. In a particular incident, an environmental services person who was with Julia at a post-fall huddle spotted right away that there were long cords in the way. So everyone has a different eye, focus, and a physical therapist is going to see something different than what I would see, she stated, adding that different disciplines will bring a different eye to the event. Julia stated that it s also important to have the patient involved, asking them what was different. A Guiding Question A guiding question to ask the patient is, What was different about doing this activity, compared to all the other times you performed the same activity and did not fall? Let the patient know that you re asking so you can do what is needed to prevent them from falling again, Julia stated. She added there should be no sense of blame to the patient or the staff. Post-Fall Huddle Steps An announcement can be made. Conduct an analysis. Determine the type of fall. Julia stated she was very encouraged to hear Kristine Von Ruden of Mayo-Franciscan talk about the four falls that had occurred and that staff identified two of the falls as not preventable. That s what we re really encouraging people to do, because sometimes you can do everything within your power to prevent that fall, and for a variety of Falls Prevention Learning Network 5
reasons, it still might happen, she stated. So the post-fall huddle is a chance for people to, as a group, determine that preventability. Julia stated that many people use a form to document what they learned in the post-fall huddle, and the purpose of that is to look for tracking and trending, as well as to update the plan of care. Decision Tree for Types of Falls The slide to the right displays a decision tree, which is available on the National Center for Patient Safety Web site, Julia stated. As you can see, an unanticipated physiological fall is not going to be preventable, she stated. We really encourage people to separate out by type of fall, and to remember that not all falls are preventable. Julia noted that some falls that are accidental or anticipated physiological may not be preventable either. You may have done everything you could to have prevented that fall, she stated. Even those types of falls have their non-preventable aspects. Determine Preventability Julia encourages people to determine preventability as a group, because again, it goes both ways: Some will think the fall was preventable, and others will not. It s important to have more than one person contributing to that decision and have a group consensus. When determining preventability, there are four steps: Step 1: Conduct the post-fall huddle. Step 2: Determine the immediate cause of the fall. Step 3: Determine the type of fall. Falls Prevention Learning Network 6
Likely Preventable or Likely Unpreventable Step 4. Ask: Could the care provider have anticipated this event with the information available at the time? Julia stated this is another key aspect, because sometimes after the fall, the providers learn new things they didn t know before the fall. If looking for guidance about preventability or not preventability, refer to the Levinson source (at the slide). Again, nobody knows, Julia stated. We can t turn back the time, but nobody knows for sure if something was, so we can think of as likely preventable or likely unpreventable. Outcomes The outcomes of a post-fall huddle include: Root causes Type of fall Identifying ways to prevent reoccurrence Julia stated there was a VA site that was looking at its falls, and it found there was a trend with falls and toileting. The site then needed to look at the actions necessary to prevent patients from falling while going to and from the bathroom. To do this in an individual way, she noted that it s important to involve the patient and family in that. Formative Measures With formative measures, one of the things hospitals want to look at is who attends the post-fall huddles, and should the plan of care be changed. It s important to look at whether falls and injuries go down. Sometimes we want to implement post-fall huddles, but we re not actually doing that, Julia stated. You could take the number of falls you had, look at how many of those had a post-fall huddle, and simply to do that by observation, she stated. You can also look at how soon after the fall was the huddle occurring. Falls Prevention Learning Network 7
Julia works with a group of facilities that care for veterans, and some are doing a weekly review of falls. The post-fall huddle happens as soon as possible after the fall, Julia stated, emphasizing it s important to determine what can be done for the patient who fell right away. If we do change the plan of care, how quickly did we do that? she asked. Sometimes with repeat fallers, we might have a situation where the patient falls, but the plan of care isn t changed quickly enough, so then the patient falls again. That s definitely something we don t want to have happen. Summative Outcomes With outcome measures, repeat falls will be the first fall, and then the second fall is an entirely different root cause that might have been unpredictable, Julia stated. It s important to look at repeat falls that are the same types of the same group cause (e.g., getting up to go to the bathroom or reaching for something). Ideally, hospitals want to reduce costs with falls and fall-related injuries, but the first and primary goal is for patients to be better off as a result of reducing falls and fall-related injuries. Examples of Trends Julia discussed trends, noting that toileting had already been mentioned. She stated other trends related to falls include environmental causes, such as bumps in the floor and shower stalls. Julia stated that at a long-term care facility, staff noticed there were more falls on certain days of the week, and when staff looked into it further, they found that a barbershop was there on the days when there were fewer falls. Staff found that there were fewer falls when patients were engaged in activities, so they added more activities to decrease the falls. Falls Prevention Learning Network 8
With lunch and other breaks or shift hand-offs, Julia stated that many teams have shared how there are problems when there s not good coverage during these times. Tips for Measurements Julia asked: How do you measure post-fall huddles, and are they making a difference? She stated she encourages hospitals to keep it simple, because people can get bogged down by documentation related to the post-fall huddle. The first action is to take care of the patient and then to look at how documentation can help hospitals to track the care it s providing. She noted that observation is certainly one way to do it, and the use paper and pencil and tallying are other ways to look at data over time. Examples of Process Measures What are the percentages of patients at risk for falls and fall-related injuries with interventions in place? That s something hospitals are probably already looking at, and maybe they are already looking at that when doing intentional rounding, Julia stated. You can also look at patients with completed intentional rounding, and, as I mentioned earlier, you can look at the number of post-fall huddles that were held after a fall and, after that, how soon did that occur, she stated. Outcome Measures With outcome measures, Julia stated she thinks of this as: How do we know the patients are better off? Are major injury rates related to falls going down? Are fall rates going down? And are there balancing measures, because this shouldn t be done at the cost of a patient s independence or mobility. So it s a delicate balancing act, Julia stated. Falls Prevention Learning Network 9
VA Boston Healthcare System Julia introduced staff from the VA Boston Medical Center, where she stated there s a great program for implementing post-fall huddles. She introduced Vanessa Coronel, RN, Falls Prevention Coordinator, who would be leading the VA Boston discussion with Sue Shannon and Amy Zemira. She noted that Vanessa has been involved with the Falls Virtual Breakthrough Series for a long time, and she has presented nationally about her program. Vanessa provided a brief overview of VA Boston, stating it s a primary tertiary care referral center for five New England states with three main medical centers and five outpatient clinics. Last year, it provided care to 62,000 veterans, and about 700,000 veterans visited primary and specialty clinics across all disciplines. She stated it s a teaching hospital for Harvard Medical School and five nursing schools in the greater Boston area. In the slide, from left to right, are snapshots of the three medical centers: Brockton focuses mainly on the long-term setting. Jamaica Plain is for outpatient West Roxburry is for acute care Vanessa introduced Sue Shannon, RN, an outpatient fall champion, and nurse Amy Zemira, a falls champion for long-term care. Huddle Up! Vanessa referred to Julia s comment that to prevent falls there need to be huddles. So how do we perform the huddles the VA Boston way? She stated the slide (top of next page) shows a screensaver of VA Boston nurses, physical therapists, pharmacists, and encapsulates the huddle in three basic steps. Step 1: Find out how the fall happened. If possible, involve the patients; get their viewpoints. Step 2: Determine the root cause of the fall. Vanessa considers this to be the most important step. For strategies to be effective, the root causes of a fall must be determined. Falls Prevention Learning Network 10
Step 3: How can we prevent the fall from happening again? Implement interventions based on the root cause. If your patient is more likely to fall again, the priority is to reduce the severity of the injury, Vanessa stated. For example, in Brockton, a floor mat and the lowest beds possible are used because studies show that this reduces hip fractures and subdural hematomas. Post-Fall Huddle Form This second slide on this page is a screenshot of the VA Boston post-fall huddle form. It s electronic and embedded in the fall incident reporting system, Vanessa stated. At VA Boston, a patient safety icon is placed in every laptop and work station of which there are about 6,000. Anyone can access the patient safety icon, Vanessa stated. Making the huddle form electronic has cut down the number of steps needed to do the huddle, saving the frontline staff time, she added. Vanessa discussed the top of the form, stating the provider must note the patient s activity prior to the fall and any possible contributing factors. Underneath this, is a category to determine fall type. For the convenience of the frontline staff, a huddle recommendations section allows the providers to determine interventions. Vanessa stated there s two reason VA Boston uses a post-fall huddle tool. The first is it serves as a guide to what clinicians should be doing when doing the huddle. The second reason is it reduces the variation in how huddles are performed. Be it a new nurse or nurse with 20 years, the providers are looking at the same factors. Benefits of Post-Fall Huddle Form To reinforce what Julia stated, Vanessa elaborated on the benefits of the post-fall huddle form: To determine why the fall happened. To determine what to look for in a fall. Falls Prevention Learning Network 11
It s an opportunity to engage the patient and family, and it also builds teamwork. It could be nurse driven, but it s everybody s business from nurses to PT to family to patient. Interventions are tailored based on the root cause of the fall. Based on the root causes of the fall, the trends are reviewed every year for patient safety, and improved strategies are implemented because the real reasons for falls were addressed. Post-fall huddle recommendations are reviewed every year by patient safety, and facility wide changes are then made. Interventions, Root Causes, and Huddles Amy stated that in Brockton, a long-term care facility where she works, medication is one of the biggest reasons for repeat falls among patients who have anticipated and physiological falls. A post-fall medication review was implemented in 2013 by patient safety, and it found that polypharmacy was the root cause for some of these falls, she stated. One of the three ladies in the slide is a pharmacist who is re-doing the medication pharmacists are alerted of falls via the patient safety incident report that was previously shown. The pharmacist then follows up with the nurse to get detailed information about the fall. The pharmacist also cosigns the providers on the notes that they write, and then the provider will take the action and reduce the dosage or discontinue the medical all together if it s no longer needed. Sue Shannon stated that at the Jamaica Plain campus it s harder to assess the patient for fall risk because the facility sees a couple thousand patients a week, and staff members do not know who is coming. She stated staff noticed a trend of falls outside the building in areas where physical repairs were needed. In No. 2 of the slide, she stated there s a picture of a pothole in the parking garage. Now, the building is assessed for physical hazards, so they can be fixed or addressed in the future. In the picture to the far right under No. 2, a major injury was caused because a patient couldn t see where they were stepping off of, so part of the concrete was painted yellow to alert people Falls Prevention Learning Network 12
where the drop-off is. She also stated that ice and snow in the winter can be problematic, although there were no injuries last year, because they worked with engineering, police, EMS, etc. It was a little hard for us at first, but then we figured out who the players were who needed to be part of the huddle, Sue stated. So we all got together, checked the site to see what could be done. Courtesy Shuttles Sue stated that they also came up with a courtesy van for patients with impaired gait from parking lot to the main entrance, because patients would get short of breath or slip on the ice and snow. Now, there s a daylong shuttle that takes patients to their car after their visit. Sue s facility has more than 600 weekly courtesy drop-offs, and they are also used at the other two campuses. This has impacted slip and falls and shortness of breaths and falls dramatically, she stated. Reduction in Fall Rates Amy stated the VA system uses the five P s, noting that hourly rounding has reduced falls by about 10 percent. And based on reports by Patient Safety, there are between 25 and 35 percent fewer falls related to toileting. So as nurses do their rounds, they make sure to pay close attention to toileting needs, such as checking for incontinence, urinal assistance, call light within reach, and if they need assistance transferring. Wrap-Up Vanessa wrapped up her presentation by pointing out that falls used to be the most common adverse event from FY 2005 to FY 2013, and now it s not anymore. It s a great thing, but is always a work in progress, she stated. Vanessa stated that any hospital that would like VA Boston s screensavers, featuring nurses and falls champions, to let her know and she would be happy to share them. Falls Prevention Learning Network 13
Questions and Discussion Question/Comment Ashley Frederick commented that the presenters had great information to share before asking Julia Neily how to make convening a post-fall huddle within 15 minutes after a fall when there are many other priorities. Ashley Frederick asked Julia Neily about Step 6 to the postfall huddle, wanting to know if a fall wasn t preventable does a plan of care always have to be modified. Ashley noted that she doesn t want to create busy work. Ashley Frederick asked Julia Neily about steps 7 and 8, asking: How do you guarantee everyone knows about the fall and any of the changes. Sometimes it s easy to pass to the next shift but not always to the shifts afterward. Ashley Frederick asked about reporting huddle information back to the staff. How do you make it meaningful? A question by an unidentified individual asked: Are there key differences in the post-fall huddle for the inpatient setting vs. the outpatient setting. Ashley Frederick asked if there are hospitals on the call that do assess the patient in the outpatient setting. If so, what does that process look like? Ashley Frederick asked a question related to the five P s and hourly rounding. She stated that some of the feedback she s gotten from staff on the unit about why they don t want to comply with the hourly rounding has to do with scripting. Response Julia Neily stated Ashley s question was a great one. In the Breakthrough Series, they do an overhead page, noting the 15 minute standard is a guideline. Obviously if there s a code going on at the time, you have to balance out with what the most urgent need is at the time. The idea is to do it as soon as possible so that it s fresh in people s minds. Julia Neily stated she always encourages people to save their time for care at the bed. If there s not something that needs to be documented, then spend the time with the patient instead. Julia Neily stated this is the question to ask. One of the things that Vanessa brought up is standardizing processes and using cognitive aids to provide care in the same way each time; to help us not forget steps. It s tough and not easy, but that s why we use cognitive aids or standardized processes whenever possible. Amy Zemira stated that at her facility, it s initially passed off via report after the huddle. From report, it goes into rounding on Monday, Wednesday, and Friday. And from rounding, it will go to the interdisciplinary meeting, where it can be discussed with the whole team everybody s there to cover all of the bases. It is discussed multiple times through the day and week. And it s also care planned. Vanessa Coronel stated that s a great question. When we look at the forms for outpatient and long-term care setting, it s very different because in the long-term care setting you usually check for the five patient needs, and for outpatient, the post-fall huddle team players would be her, Sue, engineering, police, and Safety. In outpatient, you look at the architectural issues the patient is facing, whereas in longterm care it s mostly anticipated physiological two different kinds of settings, but at the same time, with the huddle form we have, you could check the check boxes and list the unique reasons for the fall. Sue added that the majority of falls were unfixable. The huddle depends on where the fall was. The inside ones are more EMS, Vanessa, or myself, and the outside ones are more engineering, the police, etc. Sue added that she and Vanessa hunt down who should be on the huddle, depending on the where the fall is at. Sue noted that people balked when they first pulled them into the huddles, but as they saw that falls were being prevented, they became more responsive. They don t call us nags anymore. Michelle Tregear stated no one raised their hand to answer the question. Amy Zemira stated that on the Brockton campus, her unit is broken down into three different pods. Instead of a nursing assistant going around and asking everybody, they have between nine and 11 patients on their pod. And there are Falls Prevention Learning Network 14
Question/Comment Do you encourage staff to assess every hour for those five P s? She states that staff worries that going in every hour can get annoying and redundant for the patients. Is there some kind of scripting you provide to the staff to make it less annoying to the patient or more helpful? Ashley Frederick asked Amy Zemira if the five P s were being addressed every hour by someone, and if so, have patients complained about it. Ashley Frederick asked Amy Zemira if her process is on paper or computer. Ashley Frederick asked if that was part of the permanent medical record. Betsy Jeppensen (Stratis Health) thanked Kristine Von Ruden (Mayo Clinic Health System Franciscan Healthcare) for sharing the challenges her staff has encountered with intentional rounding. She asked, knowing that you ve got a unit where folks are coming in and out frequently, could you speak to what were some of the findings you found that led to folks not being able to follow the standard. What were they encountering? Betsy Jeppensen (Stratis Health) stated that would be fine, noting it s one of the challenges that any hospital can appreciate, when you re setting up something in place and you re hoping folks will follow it, and then when they don t, trying to find out what got in the way of preventing them from doing part of the process that we thought was feasible. Rose Peterson (Mayo Clinic Health System Franciscan Healthcare) asked a question about preventable. When it is determined that falls were preventable? How is that brought forward to the staff and organization as a whole. Response stations in each pod with a computer. They spend most of their time in the hallway, so there s always dual contact with the patients and staff providing care. This cuts down on the five P s when rounding is done because they are always checking in, but cutting the pod into different responsibilities by different people seems to help instead of having one person responsible for the entire unit. Amy Zemira stated there s a nurse and nursing assistant in each pod. She stated when the nursing assistant is busy, then she herself will take the responsibility to do it, and she and the nursing assistant communicate; they keep a clip board in the hallway between them. One of us will do it. Amy Zemira stated it s on paper. It s on a clipboard. They write in all the residents names on it in the morning. She uses her initializes when she does her assessment, and we go from there. Amy Zemira stated she knows they save them and keep track. They turn them in at the end of their week. Vanessa Coronel added that it s not part of the permanent medical record, but if a patient falls, and it turns into a lawsuit, the documentation system shows hourly rounding was done. Otherwise, the records are not kept, but rather the checklists serve as guides. Julia Neily added that if it s too much, because some patients are getting annoyed, then there s looking at individualizing the frequency and intensity of the rounding for each patient. It s more complicated, but there may be a patient that needs it more. If everyone gets it every hour, then it s easier for staff to remember. Rose Peterson (Mayo Clinic Health System Franciscan Healthcare) stated that Kristine Von Ruden had to leave the meeting, but she didn t know if she could answer that. It s a great question though. She might have to get back to the group. Julia Neily stated that what she finds to be helpful when determining whether falls are preventable or not preventable is then to look at what the reasons might be and are there any trends within that. For example, the one team that found a high percentage of preventable falls were anticipated physiological falls related to toileting. Then the team as a whole can focus on making toileting safer to have the greatest impact. She stated that it s important that staff not be made to feel guilty or that they did something wrong because it won t help anything. It s a balancing act. Is there Falls Prevention Learning Network 15
Question/Comment Michelle Tregear (AFYA) asked how frequently units should measure the processes around falls and sharing that data back with the hospital so they are aware of what s going on and whether their activities have helped. Michelle Tregear asked for tips on the process measures related to the post-fall huddle. Response anything the falls team can come up with to help you prevent falls or ask them what they might think will help in the future? It s a delicate balance looking at causes and not wanting staff to feel blamed. Vanessa Coronel stated that as a falls prevention nurse, if something on the floor happens, an incident report is made. If it s a major or moderate injury, the first contact is the floor itself. They already did the huddle. The nurse managers are great with sharing information with the staff and in trying to determine how to improve the process in terms of falls prevention. As a patient safety manager, all falls in all three centers are required to be reported. For example, when we presented to the medical center director the falls occurring in the outpatient clinic, at first they didn t want to grant funding for the construction. Once administration and engineering saw that fall rates and rates of major injuries are high because of the uneven walkway, they decided to get funding. At the same time, we improved our processes from an engineering perspective. It really depends in the frontline, where the fall happens; we tend to give them the feedback and recommendation within a day, and then the nurses do the post-fall huddle. From an administration perspective, if you really want facility wide changes, we do a falls aggregate review quarterly and every year. Usually whatever the recommendations are, the administration will approve it because they see the numbers. Julia Neily stated she looks at it like this: If I want to be able to run faster, how many times a week am I going to the gym? Well, the gym s not working, but I m not going. I have to look at my process. As far as frequency, she agrees with Vanessa Coronel, that if we do it sooner than later then we might find out why it might not be working and can solve the problem. Falls Prevention Learning Network 16