Reducing Falls with Injury on an Inpatient Geriatric Psychiatry Unit through Elevation of Nursing Support Staff: An Interprofessional Approach Lynn Ives, MSN, RN-BC Kathryn Farrell, MSN, RN John Brennan, MSN, RN, CNHA Disclosure The speakers have no conflicts of interest to disclose 2 Learning Objectives Identify strategies utilized to implement an internal falls with injury reduction program for nursing support staff Describe interventions to elevate the practice of nursing support staff Describe methods to engage interprofessional colleagues in falls with injury reduction 3 1
Nursing at Pennsylvania Hospital 989 Registered Nurses 761 Full Time 147 Part time RN Turnover below 6.5% Relationship Based Care Professional Practice Model Modified Primary Care Nursing Care Delivery Model 4 Psychiatry at Pennsylvania Hospital 2 inpatient psychiatry units 24 bed inpatient psychiatry unit 18 bed geriatric, medical, psychiatry unit Large population of dementia patients Traumatic brain injury population Only geriatric unit in the 5 hospital health system Intervention implemented on the geriatric psychiatry unit due to the unique patient population 5 Background Geriatric psychiatry patients are at the highest risk of falls and falls with injury As evidenced by a high national benchmark Patients who are frail and elderly in conjunction with decreased cognition/ mental illness are at increased risk for falls and falls with injury Age, confusion, gait instability, medications, previous fall, multiple diagnoses, psychiatric diagnoses Prior to intervention, providers at Penn Medicine used the Morse Fall Scale and the Montreal Cognitive Assessment (MoCA) but did not assess patients looking at the two scales together 6 2
Impetus for Change 7 Impetus for Change Multiple different scales used to assess multiple risk factors, but not utilized together Lack of role clarity for nursing support staff (PCTs), occupational therapists (OTs), and Physicians Inter and intraprofessional communication gaps Undefined process for falls prevention equipment utilization 8 Structures in Place Consistent Reporting Structures National NDNQI Internal Falls Debrief Team and Process Ongoing Falls Reduction Plan Monthly and Quarterly Falls Analysis Transparent Data- Unit Based Quality Boards Transparent Incident Reporting Structure Morse Fall Scale to Assess Falls Risk MoCA Scale to Assess Cognition Existing Team Meetings in Psychiatry 9 3
Intervention Interdisciplinary falls reduction team developed Physicians, Physical Therapists, Occupational Therapists, Nursing Quality, Nurse Manager, Clinical Nurses, and PCTs Examined unit based data and explored best practice interventions Developed a bundled approach to reduce falls with injury Developed a falls plus initiative ( High Morse, Low MoCA) Internally Certified PCTs as Certified Falls Prevention Advocates (CFPAs) Removed structures and barriers which contributed to breakdowns in communication Revised PT and OT assessment structure 10 Risk Identification Morse + = MoCA 11 Revised PT/OT Assessment Process All patients assess by unit based OT within 24 hours of admission Nursing and PCT staff able to provide patients with assistive devices prior to PT/OT evaluation PT/OT ensure adequate levels of assistive devices available to staff every day on all shifts Updates whiteboard daily with falls assessment and assistive devices required 12 4
Internally Certified PCTs 1 hour formal education classes for all unit based PCTs Classes included information related to scope of practice including: Identification of Lead PCT Responsibilities included gathering information from all PCTs related to falls status Identification and communication of falls risk to at daily team meeting PCT assists OT in community meeting to act as a second set of eyes in identifying at risk patients 13 Unit Based Changes Falls Plus signage on all identified patient rooms Falls Plus signage on unit based whiteboard Toileting Schedule Established PCTs joined Treatment Team Meeting PCTs initiating internal falls debrief process 14 Outcomes 5 4.5 Falls with Injury Rate Intervention 4 3.5 3 Rate 2.5 2 1.5 1 0.5 0 Feb Marc Aprl May Jun Aug Sept Oct Nov Dec Jan Feb Jul15 15 h 15 15 15 15 15 15 15 15 15 16 16 Rate per 1,000 Patient Days 4.31 1.96 4.12 0 3.95 0 3.77 0 0 0 0 0 0 15 5
Take Aways Early buy in from all key stakeholders Interprofessional Approach Elevation of PCT Autonomy Culture of Safety Transparency of Data Persistence 16 6