NYSPFP Falls Prevention: Effective Use of Assessments, Rounding, and White Boards in New York Hospitals

NYSPFP Falls Prevention: Effective Use of Assessments, Rounding, and White Boards in New York Hospitals Good afternoon everyone, and thank you for joining us. The New York State Partnership for Patients is proud to present today s web conference on fall prevention. Before we begin, I briefly need to review a couple of housekeeping items. This program is being recorded and will be made available on the NYSPFP website, along with a transcript within five business days of the program. Please contact your project manager if you need to access the recording before then. Closed captioning is available with this program. Access information can be found on the calendar of events for today's program below the login instructions, along with handouts for you to print. To access the closed captioning, click on the media viewer button located in the panel to the right of your screen. You will need to enter your name and facility inside the media viewer box and hit Submit. You will also need to click on the arrow buttons to hide message center and hide options in order to see the text. Alternatively, if you look on your screen, you may also access it by opening a new tab or window in your browser and going to www. captionedtext. com and type in the confirmation number 2097588. We have muted all your phones on our end, and there will be time at the end of the program for questions and answers. You can type and send in questions via the Q&A box located in the panel to the right of your screen, or you can raise your hand and we will call on you to ask your question out loud. Lastly, as I said before, program materials have been posted for today's event on our website. Where you access the login instructions for today, if you scroll down that s where you ll find the materials to print. And, with that, I will turn the meeting over to Cathleen Wright. Thank you, Joanie. Good afternoon. My name is Cathleen Wright and I have the distinct honor and pleasure of welcoming you to the second program in the New York State Partnership for Patients Falls Reduction Series. This event will focus on innovations and best practices. In hospitals, falls consistently make up the largest single category of reported incidents and are a common cause for the morbidity and one of the leading causes of nonfatal injuries and trauma-related hospitalizations in the United States. Preventing falls among patients requires a multifaceted approach. And the recognition, evaluation and prevention of patient falls are significant challenges for all of us. Much of the currently available research and the data on fall prevention are from long-term care facilities. However, much, if not all, is applicable for all healthcare settings. Unlike some other types of adverse events, many inpatient falls cause little or no harm. But the high overall rate of falls means that there are significant causes of hospital-acquired injury. While agreed-upon and evidence-based strategies for fall injury prevention in the hospital setting have been challenging to establish, the goal is and must continue to be to reduce fall injuries by encouraging safe mobility. Our speakers today will provide us with those strategies that have been implemented in their organizations to reduce falls and harms to their patients. Our first speaker will be Lourdes Mellino. 1

Lourdes serves in the role as Director of Professional Nursing Practice in the Center for Professional Nursing Practice at New York Presbyterian Hospital. Our next two speakers hail from Thompson Health in Canandaigua, New York. Diana Ellison is a clinical nurse leader. And Dr. Hazel Robertshaw is the vice president for patient care services and the Chief Nursing Officer. Our final speaker will be Margaret Cusumano who is Vice President of Patient Care Services and the Chief Nursing Officer at Vassar Brothers Medical Center. Details relative to their career and accomplishments have been shown on our website prior to this WebEx. So, therefore, without further ado, ladies and gentlemen, it gives me great pleasure to turn the program over to our first speaker, Lourdes Mellino. Lourdes. Yes, good afternoon, everyone. It s my great pleasure to join the webinar today and share our work in progress at New York Presbyterian to help reduce falls and falls with injury. So I will start with sharing with you our journey. Unfortunately, my slides are not advancing. You just need to click on them with your mouse. And then use your arrow keys to move forward. Got it. There you go. There you go. So I will share with you a little bit of my background only in that it gives the context in which the work that has gone on at New York Presbyterian over the last several years has culminated to some of the initiatives that we ve put in place over the last two years. So as the director for nursing practice at NYP, I lead a cross-campus team of leaders that looks at opportunities for improvement for falls reduction. New York Presbyterian, as you may know, is an academic teaching hospital, primarily based in New York City where we have four campuses, and one campus located in Westchester County. Our five campuses compose New York Presbyterian Hospital, which provides care on a broad continuum, from a small community hospital up at the Allen hospital on Northern Manhattan, along with two large academic teaching hospitals where quaternary care is provided. And our Westchester division is our primary psychiatric division. We have a children's hospital as well, the Morgan Stanley Children's Hospital. So all five campuses have a look at patient falls over the last five years to look at a strategic reduction, but our journey has gone on longer than that. Back in early 2002, we began benchmarking our falls data and pressure ulcer data with NDNQI, and for falls with the Quality Improvement Program for Behavioral Health. Throughout the year, senior leadership has been extremely supportive of our initiatives to reduce falls and falls with injury, and as a result of that strong support, we have consistently had annual quality goals that are presented to our board of trustee quality committees year after year, demonstrating our commitment to reduce falls and falls with injury. Over the last couple of years, in one of the probably more strategic moves that we did in 2011, and again last year, was to look at a formal evidence-based program evaluation. And I ll share some of that information with you today. I just want to take a moment to demonstrate that we really have looked strategically over five years at our falls and have seen, as you can tell from the slide, the strategic downward trend of our falls in total 2

numbers of our individual campuses. We continue to look at opportunities to hone that quality goal annually. And I ll share with you what our strategy will be this year as we look at another opportunity to demonstrate to our staff in a more simpler way how we will look at reductions of falls. So a little bit back to our program evaluation process. Last year we took a very formal approach to ensuring that our current program, and as it s articulated in our policy for fall prevention and falls with injury prevention, to ensure that we have a evidence-based program, and, frankly, to validate that we have all of the right pieces in place and to identify opportunities where we can bolster our program as well as introduce new strategies. So besides some several key literature findings on the areas of falls reduction, and as Cathleen noted, much of the work has been done in long-term care, we did hit upon a very good protocol that is published by the Institute for Clinical Systems Improvement, Prevention of Falls in Acute-Care. We actually came upon it as we generally use the GUIDELINES. GOV website for nationally accredited, if you will, guidelines on various clinical practices. We used that program or that protocol for evaluation in 2012, and again repeated that evaluation this year in January, using the same protocol, now with the updated revisions that were published mid-last year in April 2012. And, again, we used the protocol to identify opportunities. And with the addition of some additional recommendations in the guidelines, we have seen some additional recommendations that we can put forth in the year ahead. I ve listed the full reference on this slide for your use. So I just want to take a minute to go through the seven domains for intervention and practice considerations that are published in the protocol. I think the most striking item was that it really did not represent any new area that we weren t aware of, but it gave us the opportunity to hone in on opportunities through our current policies that could be strengthened. And I just want to make a connection here, because our timing of our program evaluation came very close to our recent presentation through the webinar with Dr. Quigley and her recommendations on looking at types of falls, and so we took that message to heart as well as we looked at our opportunities for the year ahead. I ll talk a little bit about that in a bit. So we looked at the seven categories and identified where we are in the organizational structure, meeting the elements. And there are many more details behind each of these seven bullets which would take way too much time to present today. So I encourage everyone to take a look at the protocol if you have not. But it was an opportunity to ensure that all the pieces to a comprehensive program that is evidence-based, and the literature behind those recommendations could be evaluated for our own program use. Some key findings that we did implement last year and will continue to work on this year under the area of communication for risk factors, we did move toward an arm alert band versus a chart label that identified a patient at risk for falls. So that was a significant change for us last year. Lastly, on the second slide, on their recommendations for practice considerations, we are looking at fall types under auditing and continuous learning and improvement because, again, based on Dr. Quigley's recommendations, it will help us look at actionable areas based on our assessment of falls data and post-fall huddle information so that we can be more strategic in the improvements that we put forth. 3

So I m going to move into some of the key areas that we have focused in on over the last year and will continue to work on this year at New York Presbyterian. Safety huddles at the start of each shift have been a recommendation and a requirement of all our inpatient units. We do safety huddles at the start of each shift with some key messaging that is posted for the leaders to emphasize and work on throughout the week. But in addition, in that safety huddle we ask that they also, as a team, identify what patients are at high risk for falls so that that information can be shared as a group and is available to the team as they go out throughout their day doing hourly rounding or intentional rounding. Because one of our implementations last year was to look at supervised toileting as a strategic way to hopefully prevent falls of high-risk patients, as it s no surprise to anyone that toileting and the high-risk patient is a lethal combination in many ways. They need to be supervised to prevent a fall during that event. We also looked at a standardization of our education around intentional rounding. One of the bigger components of that initiative last year was to look at videotaping best practices, and that s actually going to be rolled out in the weeks ahead. As we will have a formal educational program and module online for staff to view and take on intentional rounding and the best practices, which will include falls prevention. Secondly, we looked at one of the recommendations from the ICSI protocol, was the implementation of interdisciplinary committees. Each of our campuses has looked for an opportunity to engage a local physician leader and co-chairing a interdisciplinary committee that is looking at strategic data available to their population and opportunities for improvement based on their environment and their local population and services. So the key services involved, pretty much across the board, as could be imagined, is nursing, pharmacy, and rehab therapies. We have transport services at two of our main large campuses which include a number of staff that are regularly visiting patients and taking them off to procedures and test areas. So they are key in our team in preventing falls as they move patients around the organization. We have also included our environmental services so that they can be an extra pair of eyes and ears when they see and know a patient is high risk for falls. And each of these meetings are goal-driven and data-driven as we provide on a monthly basis an updated grid of the falls data for all our inpatient units. Thirdly, we have had a very organized approach to education at the unit level for our staff nurses. We held our first fall prevention resource nurse program in 2012 where over 100 staff attended. What was important to note on this first round of education for our staff nurses is that we invited support staff to partner with our staff nurses to attend the program and learn more about how they can contribute to falls prevention. And together, the RN and the support staff were asked to partner when they went back to the unit and engage the local team on opportunities for improvement and that they would work on it over the course of the year. We were going to re-offer that program this year. We have retitled it to the Fall Prevention Team Program, as we want to continue the partnership with staff, with support staff attending, and staff nurses as resource nurses. And for 2013, we will continue to look at other opportunities for improvement of education expanding it to the interdisciplinary team. One of the recommendations from or one of the takeaways from our program evaluation this past January, again, using the published protocol, was that physician, education, and interdisciplinary team engagement and education was key to the prevention of falls, 4

which, again, was not a surprise. But it is now formally recommended in the protocol. So we will be working on that as a 2013 goal. Lastly, our risk assessment tool, back in 2004, we did have the opportunity to work with a doctoral student and had a nursing-led research initiative conducted over a course of about 18 months to look at NYP falls risk and injury assessment tool. It was developed using our patient population data and was one that stratified the patient s risk for fall and injury, giving them a cumulative score based on their risk factors. And that tool has been in effect since 2004, with some slight modifications over the preceding years. However, again, looking at the protocol that was published, we recognized that we need to, as the recommendations put forth, a formal validation of your risk assessment tool. It s recommended that organizations look at validating is the tool still providing the predictive value that you initially had either documented or had thought it would address with your patient population. So our validation chart audits will be our first step towards what we hope will be a nurse-led research proposal that will come forth in next year's goals. Lastly, I ll circle back to our quality goal. So over the course of the last many years, we have been looking at a very detailed report that looked at each of the unit s benchmark data against NDNQI. And really listed our goals is that an aggregate, 90% of our units or greater would be below their benchmark. And we ve trended in the right direction but really have stalled over the last couple of years, and felt that perhaps there was a better way of looking at an aggregate our falls. Still looking at the benchmarks and still utilizing those data, but simplifying it for our staff to understand in a more global way what the total number of fall reduction we should be targeting for the year ahead. So we re trying something new. We did this with pressure ulcers. Again, we benchmark NDNQI for pressure ulcers, and with a percentage of reduction being proposed for pressure ulcer reduction we saw a successful processing of that information by our staff and really engaged in the process. So we re going to copy that model for falls and look at a 10% reduction for falls in the course of the year ahead of unassisted falls, and basically translate that to our staff as a 10% reduction looks at accumulative reduction of 144 less falls this coming year. So that s our strategy, and we re hoping that it will be easily translatable to the unit level. We ll also continue to provide the unit dashboards so that they understand where they fall in the NDNQI database. And that s really the end of my presentation. I know we will go to some questions at the end, so I d be happy to answer any of those questions. Cathleen. Thanks so much, Lourdes. Oh, sorry, Cathy. It s Alissa D Amelio, also from the New York State Partnership for Patients. And I just wanted to jump in and say thank you so much to Lourdes for providing that very comprehensive overview of your internal falls prevention program at New York Presbyterian. I think that you very nicely tied in so many of the points that Pat quickly made in the January webinar and, you know, wanted to highlight, again, some of those for folks on the line in terms of the practice considerations that you went through and how you actually implemented the program evaluation from the Institute for Clinical Systems Improvement, their protocol as sort of a guiding tool for you. And I would encourage others to do the same. 5

One other thing that you said that struck me was your reference to the leadership support including falls prevention within your annual quality goal because I know that some others in the state have sort of struggled with that and have not been able to incorporate that as a specific component within their annual quality aims. In fact, our nursing assessment of current practices through partnership revealed that only about 80% of the hospitals in the Partnership for Patients in New York State have incorporated falls prevention into their annual organizational quality plan. And I think that your specific and targeted measurable goal of 10% reduction in the unassisted that you mentioned is such a good example for others. And so I would love to hear other feedback on that later in the program. And one other plug before we move forward, if anyone on the line has any questions as we re going through these great talks,please feel free to put them into the chat as we go and we can always stop and take questions along the way in addition to holding some until the end of the program. Cathy did you want to add anything else before we move on? Before we move on?no. Thank you. Okay, so, with that being said, I d like to pass the floor over to Diana Ellison and Dr. RobertShaw from Thompson Health. Okay. Thank you. And Hazel and I are from Thompson Health System, which is a recent affiliate of the University of Rochester Medical Center. We are 113 licensed acute-care beds, and we average around 65 occupied beds a day. We have a seven-bed ICU, three med/surg floors, a birthing center of 12 beds, and a 24-bed ED. Our journey has been similar. We started out when we realized in 2010, September of 2010, even before that, that our fall rates were increasing. So we involved our shared governance team to review our fall risk assessment. And what we had before was really just a home-grown tool. So they looked at what they could find in the literature, and we settled on the Hendrich II Fall Risk Model. So we implemented that, along with some education for the Hendrich and hourly rounding. And our hourly rounding consists of the four Ps, addressing pain, position, personal needs, including bathroom, and personal possessions. And we implemented that at the same time. At that time, we also had a brochure that we had been using in the past. We updated that, and it s How to Avoid a Fall. It s a small handout that goes to all patients on admission. We developed a new documentation tool that included interventions for all patients and interventions for high-risk patients. And the nurses using good clinical judgment would pick and choose based on that risk assessment what interventions they needed to put in place to avoid falls. We defined a fall clearly for them, which is the NDNQI definition: an unplanned descent to the floor, or an extension of the floor, with or without injury to the patient. And that s all types of patients falls are included, whether they result from physiological reasons or environmental reasons. And it does include assisted falls, when a staff member attempts to minimize the impact of the fall. We had what we call badge buddies. They re on yellow cards and they are attached right with the staff badge, and I ll review that later, but that includes what steps to include after a fall, what steps we need 6

to complete in the post-fall huddle and what we discussed in that huddle. And then in September of 2011, a year after starting the Hendrich and hourly rounding, we initiated interdisciplinary meetings to discuss falls from the past week. And that is including pharmacy, physical therapy, and nursing. Some of the initiatives from these weekly meetings in October, we implemented a Call, Don't Fall sign. These are, again, on yellow paper since that s our designated color for falls. And that is a reminder to the patient and their families to call for the nursing staff, don't fall. It s in a plastic frame that stands up on their bedside table or their over-bed table. And in January, we mandated the use of gait belts for all patients requiring assistance with ambulation and supplied them in all of the rooms, as we found that some patients possibly wouldn t have fallen had we had a gait belt on them, a place to hang onto, and eased them back down either onto the bed, the chair or the toilet. And in February, we developed a new, red bed alarm sign, and this is a magnetic sign that goes on the doorframe for a patient. And this is just a reminder to remind the nursing staff as they leave the room or as they enter the room that this patient -- there is a bad alarm in use in that room. Because we did find, as a result of some of our post-fall meetings, that the nursing staff were forgetting to reactivate the bad alarm. We already had a fall precaution time that we put on the doorframe, but this was an additional one. And then in February 2012 we initiated the transparency boards on each unit. And we ll take a look at this later, too. But this is a whiteboard, it s on each unit across from the nurse s stations, and it gives us pointers on preventing falls and pressure ulcers and infections. And we will be incorporating a discussion of the fall results during leadership rounding. In August of last year, a patient did fall sustaining a hip fracture. And as a result of that, because the patient was in a recliner chair with a small footrest, and that is just a footrest that s near the bottom of the floor. With these chairs, you can actually stand up in that chair on the footrest, and the chair won't tip. So that wasn t the issue. But the patient stepped on the footrest and then slipped off of it. So we did some mandatory education around that regarding the use of the recliner chairs that that little footrest has to be pushed in all the way before the patient stands. In November we renewed our focus on hourly purposeful rounding. And what we did was we have it on an electronic documentation, but we went back to a paper documentation to allow leadership as they are rounding to also sign the same form, and it s in the room and it s there as a reminder for the visitors, the patients, and our staff. And it does also provide us a closer monitoring so that we can provide immediate feedback if we re seeing that the rounding isn t being done as intended. And we have developed an annual fall competency. The new staff had to complete an online Hendrich training. And then annually there s a brief explanation of the Hendrich and why we chose the Hendrich and how it is evidence-based, with a 74. 9% sensitivity and a 73. 9% specificity. So it s very accurate. There s a graph over med/surg in the ICU area, some stats regarding falls. It includes the definition of the fall, just as a reminder, and the nursing responsibilities, and then our goals around fall prevention, and that is followed by a quiz. 7

Some of our data, this is where we see the greatest difference was in the severity of those patients that are moderate or greater injury, and this is from our NDNQI data from September of 2012 to June of 2012. And you can see that there s a pretty good decline. We ve made a difference there in that timeframe. The next graph is of the total injuries, also from the NDNQI data. And you don't see as drastic a difference here. That dark line is our trend line and it s very softly trending down, but we re getting there for the total falls. But the biggest difference, again, is on that next graph, which is the total injuries, the moderate or greater injuries are where we see our greatest difference though. So we are making a difference. The badge buddies that I mentioned, on one side of that are the steps to be completed after a patient fall which includes getting the vital signs, doing an assessment, who to notify, initiating ongoing neurological checks if it was unobserved fall and the patient could have hit their head, reassessing the Hendrich after a fall, conducting the post-fall huddle which is on the opposite side of this badge, and what to document as far as in the chart and on the incident report. On the opposite side of that then is the post-fall huddle, and this reminds them of what they need to do right after the fall, to discuss the purpose and understand what other interventions we may need to put in place to avoid a repeat fall for this patient, what was the patient doing at the time of the fall, is the patient confused, is this new, if so, do some whys, do some investigation. Is it maybe because of a different medication?and consider involving the pharmacy at this point, although pharmacy is there at our weekly meeting when we go back and look at the falls that have occurred the past week. And does anybody in the huddle have any ideas how to prevent a repeat fall?and designate, make sure that the Hendrich is redone, and if the patient is considered at high risk that we put other interventions in place and that that ends up on the care plan. The sign that I mentioned earlier, the Call, Don't Fall, this, again, is in yellow paper and it s in the patient rooms as a standup in front of them as a reminder. The next one is what we the purpose of it was to increase transparency because this is right at the nurse s station. We update it daily, the number of days since our last fall, pressure ulcers, and infections, along with some of key things that we can do to prevent those occurrences. We did get a lot of pushback from this because the staff were very concerned about this being out there in the public where the visitors could see. We did a fair amount of education, reassurance, and the staff really have embraced it. They have difficulty when they have to go up there and change that number to a zero. We learned some lessons along the way. We did return to that paper rounding form to increase compliance for purposeful rounding, especially related to bathroom activities. Some of our new beds had a pigtail that we had to purchase so that we could find the room locate the room where the bad alarm was sounding. Without that special pigtail that hooks into the call system, we had to just use your hearing and go down the hall and figure out where that bed alarm was sounding. So this has helped too to help us quickly identify the rooms. Part of the education was that when they get to that bad alarm that they do a callout and let everybody in the area know whether the patient -- whether we re okay or we need help. We developed a harm report that also increased transparency, and this goes out to the whole system. We have an attached continuing care center in both the hospital and the continuing care center 8

information is on there, so that s the number of days since our last fall, since our last pressure ulcer, since our last clampsie, cauty, clotting, all of that is on a weekly report that goes out over our intranet along with some education. And then the results of our weekly fall meetings, at times I will e-mail some of the staff on that unit and sometimes all the units to get them feedback if it s something that the rest of us can do to help prevent falls. And we re always looking for improvement. And our next step then, we just had a joint commission visit this past week and they offered a few suggestions. And one of those was that we need to involve our physicians. And we will be doing this in the near future because we know we need their input, especially related to medications. We will be doing some Lean Six Sigma training. And there will be a number of process improvements attached to that. We ve been involved recently in this IHI expedition which is protecting your patients from injurious falls. And I have been reviewing the types of falls, whether they re anticipated, unanticipated, physiological, or accidental, but we ll be looking closer at that and putting the falls into buckets. We are considering using a different fall risk assessment tool. And we have looked at the Morse, and that is evidence-based and actually has a better track record than Hendrich, along with Stratify, according to the IHI Expedition. And we ll be looking at adding a risk for injury, if they have osteoporosis then they may be we re concerned about a fracture, or if we re concerned about bleeding and so on. And the other thing that the joint commission recommended is that we discuss the fall risk at our daily interdisciplinary meetings. We have a daily interdisciplinary meeting where everyone is involved. It s nursing, it s dietary, it s pharmacy, it s physical therapy, speech pathology. Who else, Hazel? OT, PT, social work and the provider. So we ll be discussing that fall risk at that meeting in addition. And that s all I have. Of course our real goal is no falls, but we know that that s pretty lofty, but that s a goal that we re working towards. And we ll be answering questions at the end. I think that s great. Thank you so much to Diana and Hazel for that great presentation. And, you know, it s very timely, I just actually received an e-mail in my inbox that the Agency for Healthcare Research and Quality just released, as we are having this webinar, a toolkit resource on preventing falls in hospitals. So we will absolutely make sure that everyone receives a copy or a link to that resource as well following this webinar. I just thought it was so timely, I had to raise that right now. But, you know, you brought up a lot of great points as well in terms of, linking this all together and reinforcing the importance that the best or most effective fall prevention programs are not only multifactorial, as Lourdes mentioned as well, but also interdisciplinary. So I think that incorporating falls prevention into those daily interdisciplinary meetings that you just mentioned will be also so great, and would like to offer to others to consider doing that as well in making this an interdisciplinary program, as well as multifactorial. And in the interest of time, I m going to hand the program over now to Margaret Cusumano. Hi. Thank you. Can you hear me okay? 9

Perfectly. Okay, great. So I m representing Vassar Brothers Medical Center where I m the CNO. And Vassar Brothers is part of a three-hospital system known as Health Quest in the beautiful Hudson Valley. And I have overall responsibility for our fall prevention program, but I don t do it alone. I have a tremendously committed and passionate team of people, all disciplined, who are committed to accept the fact that we may have falls because they re inevitable, but we are committed to reducing injuries and increasing the number of assisted falls. And that s really what, as you ll see, all of our initiatives have really been geared for. Okay. Margaret, just click on the presentation with your mouse and then you can use your arrow keys. Okay, great. Thank you. So even though fall prevention has always been part of our mantra, we probably got really formal and serious about it back in 2010, early on, when we started to see what we were very uncomfortable with was a trend for injuries and an increase in falls. We really all focused on it, recognizing that it was one of our patient safety goals. And we recognized, too, that we needed more information. If we were going to develop initiatives to prevent injuries, then we really needed to look at what were some of the causative factors. We started with, of course, basic education for all nursing, as well as our ancillary staff. Because so many people touch patients and have their eyes on them at different points in their stay, we wanted to make sure that it was something the entire organization was focused on. We certainly were using hourly rounding to improve our patient experience, but we really started to imbed the use of hourly rounding to help us prevent falls and doing safety checks when we re in the room and making sure that all of the elements were in place. We also recognized that patients themselves and their families really had to be actively engaged in this procedure and this process and have their commitment to understanding what those prevention mechanisms were and that they were committed to working with us to do that. We looked at our patient safety environment. We have Hill-Rom beds that have bed alarms, but we found we weren t using the alarm setting consistently. So one of the things we did is we make sure that all the beds are set on either the second or third most sensitive highest volume. We started to do unit fall audits. They were random and unannounced. And we looked at whether or not high-risk patients were indeed having all of the elements in place, such as the yellow socks. And I ll go into that in a minute. Those results were shared very publicly with everyone. And we recognized good improvement and good achievement. And we worked with those that were struggling to make sure that, again, the staff were fully engaged. One of the other, I would say, very significant changes we made in our approach to patient falls prevention was the use of what we call contact guard. It is a physical therapy term, and what it basically means is that we remain with all high-risk patients at all times including during toileting. We keep hands on the patient, not just in the vicinity but hands on the patient making contact. And this was a fairly significant challenge for us, not just for our patients who now needed to have staff with them at all times, even while toileting, but certainly for our staff who wanted to preserve patient's dignity and 10

privacy. But helping them understand that by doing that we would prevent a patient harm. So that took some time to incorporate into our culture. But now it is very accepted and it is done fairly consistently. So part of our whole program of identifying our high-risk fall patients is the yellow. We started with the yellow armband, part of the colors of safety. And we proceeded to use the yellow skid-resistant socks, the yellow sign that s above the bed that lists out all the fall preventions, details. We have a magnet outside the door so anybody passing, if they see a patient starting to get out of bed they can identify the patient and come to the rescue, so all of that yellow program elements. Health Quest did adopt the standardized Morse high-risk fall scoring tool and we did embed that in our EMR, which we ve been at now for about two-and-a-half years. So it is part of the electronic record. We do conduct a fall debrief immediately after every fall with everybody that was involved, as well as everybody else in the department, all staff. And we do that whether there was an injury or not, or whether it was assisted are not. And the reason we do that is because we also want to publicly recognize the catches. So if a staff member was assisting a patient, maintaining contact during toileting and the patient suddenly felt weak and started to fall, and even though they may have been lowered to the ground, that patient was assisted. So we use that to very publicly recognize the individual that really literally caught the patient and prevented harm. But, certainly, if that was not done or the patient fell without somebody being with them, maybe out of bed or in some other way, it gives everybody on the unit a chance to raise awareness of what we could have done differently if anything. And really make everybody a part of that change. Continuing with the elements of our fall prevention program, anytime we do have a major injury, we conduct a quality-driven multidisciplinary in-depth analysis. We bring everybody that was involved with the fall, as well as other quality administrative folks, if it s a pharmacy potentially related issue, we ll bring them to the discussion. And everybody, in a very non-punitive way, gets together and reviews what happened, and more importantly, what are some of the things we could learn from this so that it doesn t happen again. And, lastly, I spoke about a number of things regarding our program and whether the patients are involved with that, and while I have to say the majority of our patients go along with the elements of fall prevention, there are those who choose not to. They don't want the bed alarm going off when they move. They don't want anyone taking them to the toilet. So they actually signed something that we developed which was a waiver. So once in a blue moon we do have a patient who wants to sign that waiver. And it is interesting, last year in 2012 we had two patients who had fallen who had actually signed the waiver, and in both cases the patient rescinded the waiver after the fall. But it something, and by doing that it actually raises the awareness back to the patient to say, Are you sure you want to not have all this safety in place so we can prevent you from getting hurt? So it s one more opportunity for the staff and leadership to have that conversation with the patient and hopefully talk them out of signing the waiver. So all patients certainly have some risk for falling for different reasons, whether it s accidental or physiologic. And so many of those elements that I spoke to are provided for all patients, whether they re scoring high or normal on the fall risk. And you can see some of those that are there. And a lot of it is environmental, making sure that they have the blue non-skid footwear, making sure the room is clutter- 11

free, cords and wires are kept out of where the patient might want to walk. And, again, every patient and family is provided that education. So in addition to all of the basic elements of fall prevention, when we identify a high-risk patient, these are the additional steps we take. Again, we keep those bed alarms on the second or third settings so that it will go off quickly. We institute the yellow fall program. We maintain the contact guard. We make sure that we look even more diligently during hourly rounding for keeping the patient safe. We review all of the fall prevention opportunities. When possible, we try to move very agitated patients closer to the nurse s station. And one additional element that we used last year, and to a fairly good success, is something we found from another hospital, and they are called Forever Friends, and they re little stuffed animals that purr and make noises, either a cat or a dog or even a sheep, and they make little noises. And by keeping that with the elderly on their lap, for instance, when they re sitting in a chair, they actually don't want to get up and cause the little animal to fall and get hurt. So they keep the little animal on their lap and it has been shown to prevent those patients from falling. Additional strategies, our council, which is made up of nursing leaders as well as those from quality and ancillary departments, do come together regularly to look at all of the falls and other additional opportunities to prevent falls or also to prevent injuries. So that does happen. We installed breakaway cables on all of our beds because what we found was the little pins that were keeping the beds plugged into the walls, because the beds were moving in and out constantly, the cables were actually causing the pins to break. And that is how the alarm goes into the staff s Vocera, which is our wireless devices, and that s how the staff gets the bed alarm. So we identified that, actually, as a result of a couple of falls, and so we did some mechanical changes to the beds. We are looking at, again, from another hospital, an idea of using the Adirondack type chairs versus the sort of easy chair where you can just pull the chair up and have the little footrest because we found patients can push the footrest down and slide right out of the bed. The chair alarms, we do use them. Every time a high-risk patient is out of bed to a chair they sit on their own personal ped, it s per patient admission. That s attached to an alarm that has a very piercing sound, different than the bed alarm, different than the IV alarm, and the staff know to make a quick response into that room. We re constantly talking about it with the staff. We celebrate success. We really try to hardwire their accountability. We found that in the ER, because Morse didn t really apply, they came up with their own high-risk criteria, and so they used the yellow program based on different criteria. That make sense for the ER. We do continue the fall rounding. The leaders, as they do their leader rounding, continue to look at safety checks and make sure the elements are in place. And we re continuing to look at the medication involvement. Morse currently doesn't really speak to medications in a good way or a big way, I should say, to contribute to a score. And even though we have identified medications as contributing to the potential for patient s, you know, dizziness and falls, we are looking at an overlay of how we can embed medication that the patient's might be on that would contribute to their risk of falling. So at this point, after all of the work that we ve done, where have we come?and we absolutely have seen a reduction in falls with injuries year over year. I will tell you, we had one major injury in all of 2012. We continue to remain below the tenth percentile for both all falls as well as falls with injury. And 12

this is the one I m probably most proud of is that we ve increased our assisted falls from being 10% of the falls we had in 2010 to now a full third of all of the falls that we had in 2012. That s it. Thank you so much, Margaret. And I think I speak for everyone when I say congratulations on your great results from your fall prevention program as well. Thank you. It takes a village. So I think, you know, we are so honored to have these three fall prevention program strategies highlighted on today s call. I think that you all really talked through some very comprehensive strategies that folks can consider to implement in their own institutions if they aren t already. Again, I keep going back to Pat Quigley s mention about the fact that, you know, in order to be really effective, it has to be something that s multifactorial and involves many different disciplines in your institution, not just nurses. And, you know, I m glad, Margaret, that you also mentioned the importance of linking medications to this because, you know, I think we all know that medication review and management, given that patients medications sometimes increase the risk of falls, it s important to consider when you re instituting a fall prevention program, and especially some of the high-risk medications that we re addressing through the Partnership for Patients. I just sort of loops it around and emphasizes that this is all so linked, including our focus on opioids and insulin as well. So thank you for bringing that up. There s a couple of questions coming in through the queue. And I also sort of wanted to throw one out there to the attendees based on something that our speakers from Thompson Health brought up. We absolutely love your poster, the transparent poster that you list on the units, where you can actually write in there the number of days since your last fall or your last pressure ulcer or your last infection. You know, through the New York State Partnership for Patients, and I think as a nation, through this initiative are looking at how we can get to zero across the board and get to no harm across the board. And we love this sort of transparency and think that it s such a great idea and a great concept to draw people's attention to the fact that this is all something we re working on. So I just wanted to say that we love this poster concept. And I m wondering if anyone else does the same thing. So if you could, just chat into the Q&A box, yes or no, you have something similar to the poster that Thompson presented on earlier today. And while you re doing that, I ll ask a couple of the questions that have come in through the queue. Any of the speakers can feel free to jump in for these. One attendee is asking, How are you, in the emergency department and outpatient clinic, patients assessed for falls, and what fall risk model do you use, so looking not only at the inpatient setting, but also in the emergency department?. Here at Vassar we took a lot of the elements from Morse and developed our own that were specifically for our outpatient clinic or wound care center or ER. But sort of taking off a lot of the elements from Morse. 13

Hello. It s Lourdes Mellino. I ll comment on that as well. We took our inpatient risk assessment tool and modified it for the ED environment. Okay, great. Thank you. This is Hazel Robertshaw. In our family practice offices, as part of their assessment of the patient, they ask just a simple question, if the patient has had any recent falls, as a simple screening tool to see if there is somebody who presents with a trending of recent falls. This is Diana at Thompson. In our ED, they use the Hendrich risk assessment if it s a patient that s to be admitted. They don t do it routinely on every patient in the ED. That s a really good idea. Okay, thank you for that. Another question that s come through is, Can you explain how to perform a validation audit for determining whether the risk assessment tool is being used appropriately? This is Lourdes Mellino again. So at New York Presbyterian, what our initial thoughts were that we were going to -- working with our director of nursing research, we were going to first do a chart audit that looks at 50 fallers and 50 non-fallers, and apply the tool, and see how predictive it was for that sample. And, clearly, we ll need to scope it out further. But we re looking at using a predictive validity methodology for our tool as we move forward towards a more research-based approach to validating our current tool to our patient population. I hope that helps. Yeah, that is helpful, I think. Any of the other speakers want to answer that? This is Diana at Thompson. We really don t have an audit that we do. But we look at the falls. Any patient that has fallen, we look at the Hendrich score before and after and see what the differences are and why, so it s a retrospective kind of audit. Okay. Another question that s come in is, Do you have any recommendations for bed alarms that are found to be most effective in the absence of a centralized system? The chair alarms that we use actually can be used on beds. For instance, we use them in our critical care area, just because the types of beds they have don't have the different alarms on them. So we actually bought -- and you can use them for stretchers, you can use them for beds, and then they make a smaller pad for a chair. Okay, anyone else? This is Diana at Thompson. We have the same, but our newer beds have the alarm system right in the bed. Okay, one question has come in specifically for Margaret. It sounds like folks are interested in the Forever Friends concept. And one attendee in particular was asking whether or not those stuffed 14

animals you are referring to go home with the patient and how do you keep it clean to keep in compliance with infection control? February 6, 2013 Right. No, that s one per patient, so it s our gift to them when they go home, certainly, if families want to use them or the nursing home. So just like the chair pad, it s one per patient because they are furry, have to keep it clean. Okay. And then Can I go? Yeah, go ahead. You can get them through Toys "R" Us. Okay. Good to know. It s a great concept, one that I hadn t heard of before preparing for this conference. So thank you for bringing that up. We have another question coming in with regard to fall benchmarks. And I know that most of our hospitals are using the NDNQI other benchmarks. Obviously we have data coming in through the NYSPFP portals in terms of our process measures and the outcome measures, which do align with NDNQI. I will say that through the CMS national partnership for patient initiatives, they also are asking the hospital engagement networks to evaluate the hospitals based on some scoring criteria. And you ve probably heard us talk about that in the past. But just for this one person who is asking, what CMS was looking for in terms of -- and this is for a high-performing hospital, a fall rate of them 2. 15, or a falls with injury rate of 0. 5, to be held within that high-performing hospital standard criteria. Cathy, have I missed any questions coming in on your end, do you see that I don t, because I m not seeing anymore in the queue at this point? No, I m not seeing anymore, Alissa. Okay. And before we close out, I just wanted to make a couple of reminders. Our next falls prevention webinar is scheduled for March 6 at 1:00 in the afternoon. And this call in particular will be focusing on leveraging health information technology for quality improvement, and the use of data for improvement as well, in addition to some tips on how to sustain your internal fall prevention efforts. So please stay tuned for some more information about that over the next coming weeks. But do mark your calendars for March 6 at 1:00 p. m. Also, you may have seen in our NYSPFP weekly email update, a mention of a national CMS Partnership for Patients call on effectively engaging patients and their families in quality improvement efforts. We do encourage you, if you are interested and available, to join that call as well. It was mentioned in last week's weekly e-mail update, and we ll also include a mention of it again this week. And that call is scheduled for Monday, February 11, at 3:00 p. m. 15