fall ambassador program - department of patient affairs at ... · the falling star logo has been...

Fall Ambassador ProgramOrientation Manual

Fall Ambassador Program

Orientation Manual

Welcome Letter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Your Role and Duties as a Fall Ambassador . . . . . . . . . . . . . . 4 - 5 Issues and Tools related to Falls. . . . . . . . . . . . . . . . . . . . . . . 6 - 14

1. The Falling Star sign . . . . . . . . . . . . . . . . . . . . . . . . . 6 What it signifies Placement on doors Correcting sign assignments and placement Replenishing inventory

2. Door/Curtain Closed . . . . . . . . . . . . . . . . . . . . . . . . . .7 - 8

The importance of “Line of Sight” Procedures when observing no “Line of Sight” Situations when closed doors/curtains are acceptable

3. Bed Alarms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 - 10 The purpose of Bed Alarms Correct placement of Bed Alarms Determing if patient’s alarm is active Procedures when noticing possible Bed Alarm issues

4. Fall Ambassador Vest. . . . . . . . . . . . . . . . . . . . . . . . . 11 Function of the Fall Ambassador Vest Where to find and return vests for your shift

5. Inpatient At-High-Risk for Fall Report. . . . . . . . . . . . 12 The function of the Inpatient At-High-Risk for Fall Report Obtaining the Inpatient At-High-Risk for Fall Report for your shift 6. The Staffing Chart. . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Obtaining the Staffing chart for your shift Heirarchy of whom to contact first, second, etc.

7. The Monitoring Audit Chart. . . . . . . . . . . . . . . . . . . . 14 The importance of your charts in improving patient safety Categories to monitor

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Table of Contents

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How to Carry Out Your Assignment . . . . . . . . . . . . . . . . . . . . . . . .15 - 20

1. Preparation for approaching your assignment. . . . . . . . .15 Backpack items (MAPS Group only) List of Units to be monitored Initial Steps

2. Preparation for Rounding. . . . . . . . . . . . . . . . . . . . . . . . . .15

3. Rounding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 4. Concentrating on Accidental Falls . . . . . . . . . . . . . . . . . . .16 5. Handling Possible Situations. . . . . . . . . . . . . . . . . . . . . . . .17 Patient trying to get out of bed unassisted Patient in an unsafe location in their room Patient needs/requests assistance

6. Example dialogues for interacting with staff members . . 17 Doors/Curtains not open Concerns about Bed Alarms 7. Patient Isolation Precautions. . . . . . . . . . . . . . . . . . . . . . . 18 Do not enter patient isolation precaution rooms Some reasons for patient isolation 8. Ending your Shift. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Submitting your Monitoring Audit Form Returning your backpack Complying with HIPAA laws (protecting patient privacy)

In Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Table of Contents

Dear Volunteer,

Thank you for your interest in participating in the Fall Ambassador program. Minimizing hospital fall risk is an important aspect of patient care. By learning about the issue and assisting in reducing falls you will acquire knowlege that will be extremely helpful in keeping your patients safe during your future career in health care.

The goal of this program is to assist the hospital in keeping patients, during their stay here, as safe and comfortable as possible. Because patients often come to our facility in weakened conditions, they are sometimes at risk for inadvertent mishaps.

One of these potential situations is the possibility of patients falling and injuring themselves. Falls during hospitalization are a serious problem. Two to 15% of inpatients experience at least one fall during their hospital stay. Preventing falls is important because about 30% of falls cause injuries, including bruises, lacerations, fractures, intracranial bleeding and even death.

Ronald Reagan Medical Center (RRMC) has implemented methods to improve patient safety and comfort while reducing falls and fall injuries. In an effort to further decrease the possibility of patient falls and fall injuries, the Falls Committee has adopted a method

to reduce falls occurrences further; by using a methodology to assess individual patient’s fall risk. A score is assigned and special protocols are followed for patients with scores above a certain threshold.

Some of the practices include:• Assigning bed alarms to certain patients. Bed alarms are designed to alert the staff when a patient is no longer in contact with the bed surface.

• Maintaining a clear line of sight to the patient. Often curtains are drawn or doors closed and any risky actions, such as getting out of bed unassisted, cannot be observed by the nursing staff.

• Alerting staff of high risk patients by putting a falling star sign above the patient’s door.

Two to 15% of inpatients experience at least one fall during their hospital stay

...about 30% of falls cause injuries, including bruises, lacerations, fractures, intracranial bleeding and even death

Welcome

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Your role as a Fall Ambassador

You will be improving patient safety by noticing situations that might put the patient at risk and alerting the appropriate members of the nursing staff.

Your charge as a Fall Ambassador under the MAPS Group or Nursing Volunteer Group is to take steps to assist the hospital in further reducing patient falls by:

• Heightening awareness among nursing staffYour presence on the floor with a high visibility vest marked with the program’s logo, or your yellow shirt, will serve to raise the awareness of nurses, care partners and other members of the patient care team of the RRMC’s commitment to reducing falls and fall injuries. By being a highly visible part of the team you will communicate to the staff that situations relating to falls are being monitored and reaffirm the resources the RRMC is committing to address the problem of patient falls.

• Put staff on a gentle alert that patient fall-risk reduction is a high priority.Volunteers will target safety procedures that have been put in place to minimize falls including helping the staff to:• Monitor the presence and proper functioning of bed alarms.• Monitor whether there is a clear line of sight to the patient.• Monitor whether patients’ doors have been correctly identified with the Falling Star logo*.• Assist staff in preventing falls through patient observation.• Monitor patient efforts to ambulate unassisted.• Monitor patients in a potentially unsafe position within their room and engage staff in correcting the situation.

*indicates a high fall /fall injury risk

“All patients are everyone’s patients”

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Your duties as a Fall Ambassador

Did you know thatyellow is the colornationally-recognizedin hospitals for falls?

The Fall Ambassador Program is designed to assist the hospital staff in reducing the number of patient falls and fall injuries that occur in the hospital.

Your role as a volunteer will be to raise the awareness in assigned hospital units for procedural compliance and to bring a heightened awareness of the patient fall issue to the staff.

The fall-reduction compliance issues you will be auditing are:

1) Whether high-fall /fall injury risk patients are properly identified by falling star door signs.

2) Whether these patients have doors and curtains open.

4) Whether a patient that has a bed alarm has it turned on and correctly in place while in bed.

These results are to assist the Unit Director, ANII, CNS or Unit Educator so that he/she can better evaluate some of the issues that might need to be communicated to the staff members.

You will also be there to assist the staff by being an extra resource that can assess whether any patient can be made safer by making adjustments to their physical environment. You might be enlisted to educate and explain the benefits of different strategies for keeping the patients safe.

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Issues and Tools Related to Falls

1. The Falling Star sign

An introduction to issues and tools related to falls

High-fall/fall injury risk patients are identified so that staff will know to give them appropriate precautions. One way of identifying fall risk patients is by placing a sign on their door. Based upon a nursing assessment, individual patients are assigned a fall-risk score. Scores range from 0 to 120. Those patients with an assigned score of 45 or higher are considered high fall-risk and should be identified as such with their doors being provided with a Falling Star sign.

Replenishing inventoryYou may need to replenish the inventory of signs over the course of your assignment. Some assembly may be required.

1 2 3

Cut strips of magnetic tape

For supplies, please come to Cait Walsh or Petra FritzNursing Administration, B790

Tape strips to sign with clear tape, making noteof proper positioning

(back of sign)

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Placement

The signs are placed on the door’s upper right corner.(This allows the signs to be visible from ther entire length of the hallway.)They have magnets to adhere them to the door’s metal frame.They should not be taped or crammed into crevices.

1. The Falling Star sign (continued)

Proper sign placement

* an improperly assigned sign is one that is placed on the door of a patient that doesn’t need one - or a sign is missing from the door of one that requires one.

The Falling Star logo has been used in hospitals across the US to highlight that the patient is at a high risk for a fall/fall injury.

The Falling Star door sign was created by our very ownUCLA Hospital Administration Nurse, Cait Walsh.

Issues and Tools Related to Fall Prevention

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Inability to Observe Patient

Because high fall-risk patients may try to get out of bed unassisted, there should be a clear line-of-sight from outside the room to the patient. If they can’t be seen, it is not possible to intervene when they are putting themselves in a dangerous situation.

If doors or curtains are closed and the patient appears to be unattended, please make a note of it and bring it to the attention of the nursing staff so that they may correct the situation.

2. Door Closed/Curtain Closed

Note: Doors and curtains may be closed in the interest of privacy such as when the patient is with family or is being attended to by medical or nursing staff.

Other patients may need to be isolated due to situations such as having a suppressed immune systems. The nursing staff will inform you as to whether the door needs to remain closed.


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Reasons for bed alarms

Bed alarms are placed on some high fall / fall injury-risk patients. This alerts the nursing staff when the patient’s body loses contact with the bed’s surface. In times such as when the patient tries to get out of bed, the alarm will notify the staff to immediately attend to the patient and intervene. Bed alarms do not prevent falls. They are used for timely rescue and/or planning care. Not all high fall risk patients need a bed alarm.

Determining if alarms are turned onSometimes bed alarms can be placed on the patient yet the alarm is not active. One way to determine if the alarm is active is to observe whether the green light on the top corner of the

alarm is on.

3. Bed Alarms

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Troubleshooting the alarm

Check the batteries in the alarm box. If they need to be replaced, check floor battery stock in the Clean Utility Room or order from Materials Management.Check to see if the alarm is plugged in.


4. Proper placement of Bed Alarms

It is important that the bed alarms be placed in the proper location on the patient in order to maximize their effectiveness. Placing the alarm too high on the patient can lead to false alarms. Placing the alarm too low on the patient’s body means the alarm will not activate until the patient is out of the bed.

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1.

2.

2.

3.

3.

Alarm is placed too highleading to false alarms whenthe patient moves minimally.

Alarm is placed correctly.

Alarm is placed too lowleading to no alarm untilpatient is out of bed.

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5. Fall Ambassador vest (MAPS Group only)

When rounding on your floor you will wear a vest that has been adorned with the Falling Star logo. The vest is highly visible and will alert the staff of your purpose on the floor. Of note ; if you are from the Nursing Volunteer program, you don’t have to wear the vest since your nursing uniform is yellow.

The vest with the logo will reinforce fall injury-risk awareness. It will remind all of us to be constantly diligent and proactive in order to minimize situations that could lead to patient falls and fall injuries.


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6. Care ConnectIn order to know which patients are at high risk for a fall you will obtain from the unit’s Charge Nurse a Lead Nurse Report showing the names of the patients. On that report, High Fall Risk will be identified with a score of 45 or above. The chart will be used as you monitor your assigned floors/units.

If you are unable to get the Lead Nurse Report, please ask one of the MAPS supervisors to give you an IP Patient at Risk for Fall Report (looks like report included below).

Patients on this list should have a Falling Star sign. These are the patients that need to be treated with extra attention in order to minimize their fall/fall injury risk. Patients not on this list are considered to not have a high risk of falling or sustaining a bad injury from a fall and therefore should not be given a Falling Star sign on their doors. Please remove incorrectly assigned signs.


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Patient Name

7. White Board - Staffing ChartAt the beginning of each shift, request a copy of the White Board Staffing Chart from the Charge Nurse of your assigned unit. This will be a very useful and important tool as you do your rounding. When you need help from a staff member or need to ask them about a patient, the staffing chart will tell you who is assigned to each patient. The chart also lists the contact numbers for each of the staff members. There are house phones throughout the floor that you may use to make your call to them.

Room Number

Patient Name

Contact 2nd - Primary Assistant

Contact 3rd - Backup Assistant

Contact 1st - Primary RN on

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8. Monitoring Audit FormThe Monitoring Audit Form will give the staff on your assigned unit data which will be useful in tracking both areas of concern and progress.

It gives you a tool to track the areas that need to be measured for your assignment; correct use of the Falling Star sign, how well bed alarms are being utilized and whether high-risk patients are able to be easily observed by staff.

At the end of your shift, make a copy of the Monitoring Audit Form. Leave one with the Charge RN and put the other in the mailbox of Cait Walsh (B790 - Nursing Administration Office) or slide under the door if office is closed.


Room #Patient’s fall risk

CorrectStarPlacement?

PrimaryAssistantPhoneExtension

Correct useof bed alarm?

Line of sightto patient?

Reason patientnot observable Notes

Bedalarmin use?

Reason for not using bed alarm

Date: Lead/Charge nurse: Shift:

Yes/No Yes/No Yes/No Yes/No

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Carrying out your assignment

1. Preparation for approaching your assigned unit

(MAPS Group)

There is a prepared backpack with the items you will need. It contains:• Bright Yellow Fall Ambassador vest• Extra Falling Star signs• A clipboard• 2 pink Highlighters• 2 red pencils• Packet of Lead/Charge Nurse Sheets• Audit sheets• Backpack checklist and sign off sheetPlease don your vest before you are on the Unit!

(Nursing Volunteer Group)• Audit sheets from the Nursing Volunteer sign-in binder on the unit.

At present, this program targets these Units:

5E (Medicine)6N (Neuro)6W (Vascular, Plastics, Ortho/Epilepsy)7N (Cardiac)7W (Cardiac)

Note: More units may be added in the future.

2. Preparation for rounding

Proceed to your assigned unit and introduce yourself to the front-desk greeter. (MAPS Group only)Please let the greeter know of the reason for your visit and ask to be directed to the Charge Nurse. After explaining the reason for your visit request from the Charge Nurse the Care Connect Lead Nurse Report and White Board Staffing Chart for the shift. You will then identify and record the room numbers for the patients with a Fall Risk score of 45 and above. You are now ready to begin your rounds.

The following is a summary of the steps to carry out your assignment

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7E (Medicine)8N (Liver Transplant)8E (Medicine/Surgery)8W (Surgical)

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3. Rounding

Using your audit sheet, you will record the different categories defined on the sheet. Are patients’ doors correctly identified? (Falling Star when needed on doors of patient with an Acuity Score of 45 or above). Take down Falling Star when not needed (an Acuity Score of less than 45), Is the Falling Star placed correctly on the door? (Fix if not), Are patients’ doors and curtains unnecessarily closed? Are there bed alarms on patients that need them? The RN needs to critically think of why the bed alarm is needed. Some reasons are: cognitively impaired patients, expressive aphasia after a stroke, fail teach back education. If an alarm is used,does the staff know if the bed alarms are properly placed on the patient? You will be an extra set of eyes for the staff focused on falls. You can be very helpful in noticing things regarding fall-risk that a busy staff person might miss. By working as a team, you and the rest of the staff can improve the experience and safety of patients in the hospital.

4. Concentrating on Accidental Falls

Accidental Falls can be prevented. Below is a list of items to check on while you are rounding and trying to prevent falls. This list does not include everything. Be on the look-out for other items that could cause an accidental fall.

Cords that a patient can trip over.Call light not within reach of patient.Bed table not next to patient.Upper bed rails not in up position.Patient not wearing non-slip socks or shoes when patient is up.Towel or chux not under patient’s feet when up in a chair.Patient sliding down in chair and not sitting up straight.No chair binder with Velcro facing forward or security belt, when patient in cardiac chair (pink chair).Food/Water not near patient if patient can eat and drink.Patient on the commode alone.Pajama bottoms should not be below the ankle.Spills in patient area.Syringe tops, paper towels, trash, etc. are on the floor.Luggage, bags and other items on the floor. (These are a trip hazard).



5. Handling Possible Situations

If you see a patient trying to get out of bed unassisted and there is a Falling Star on the door, please ask him/her to sit back down. (State: “You are important. I do not want you to fall. Please sit down. I will get you assistance”.) Then turn to any staff member that comes by or is in the vicinity and ask them to help the patient. Do not leave the patient until assistance has arrived.

• Patient in an unsafe location in their roomIf you see a patient is in an unsafe location in his/her room– (Examples: sitting on the commode alone, in a chair without a call bell close by, close to falling out of a chair) , please get the nearest staff member to evaluate situation. (For Nursing Volunteer Group follow the directions of what you can and cannot do - You may be able to intervene without getting a staff member involved).

• Patient needs/requests assistanceIf patient needs/requests assistance, state: “I am not trained for patient care, but I will get someone immediately that can assist you. Your request is important to me and the staff that work here.” (For Nursing Volunteer Group follow the directions of what you can and cannot do - You may be able to intervene without getting a staff member involed).

6. Some example dialogues for interacting with staff members

You may be uncomfortable approaching the staff with your concerns and observations. This is natural. It will become easier with practice. Think of this as a great opportunity to learn from the staff and to protect patients by preventing a fall.

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Here are some sample dialogues, should you need helpin getting the conversation started.

• Doors/Curtains not open “Excuse me, I noticed that the door for room 6137 was closed. Would it be okay to open the door and curtain? There are concerns about being able to observe the patient should he/she attempt to do something that might lead to a fall.”

•...followed by “the patient wants it that way” “Yes I could see how the patient might prefer a closed door. Would it be possible to explain to the patient the it is safer for him/her if you are able to observe him/her from outside the room?”

7. Patient Isolation Precautions

If you are a MAPS Group Member,Do Not Go Into Isolation Precaution Rooms – Rooms are clearly marked with signs. You need to go through a competency regimen to be able to know about isolation precautions. Nursing Volunteers have an Isolation Precautions Competency so these volunteers are permitted in all Isolation Rooms - except ones with an airborne precaution sign.

Some reasons for patient isolation precautions are: • A microorganism that can spread to other patients if personal protection equipment (PPE) is not worn/disposed of correctly. Some organisms are: C-diff (Clostridium difficile). It is a spore-type organism and can live on a surface for up to 3 months if the surface is not cleaned correctly. VRE (Vancomycin-Resistant Enterococci) is another problematic organism. MRSA (Methicillin-Resistant Staphylococcus Aureus) is a third. TB (Tuberculosis) is a fourth. This organism affects the lungs. There are others. But these are the most common. Door signs do not include exact organism since this would be a Health Information Patient Privacy Act (HIPPA) violation.

• Neutropenia: This is a condition where the patient has no or very little neutrophills. The patient’s immune system is severely compromised and the door to the patient’s room needs to be closed at all times unless the patient is wearing a mask.


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8. Ending your Shift

• Submitting your paperworkXerox your Lead/Charge Nurse Form. Ask person at front desk to Xerox. Submit one to the Lead/Charge Nurse before you leave the Unit. Put the other in the mailbox of MAPS Director Cait Walsh (Nursing Admin B790A- mailbox room) If office is closed, slide audit sheet under door.

• Returning your monitoring kit (MAPS Group only)Bring the backpack with all the items back to the MAPS CHS Office or at night to the satellite MAPS Office (In Nursing Staffing on the B Level of Ronald Reagan Hospital). E-mail Cait Walsh ([email protected]) immediately after your shift if you leave the backpack in the satellite office.Perform a backpack check to make sure all the contents are in the backpack. If you are short of any item or missing anything, E-mail Cait Walsh ([email protected]) immediately. Sign off and clearly print name on backpack checklist which is in the front pocket of the backpack. By signing you are insuring accountability that you performed this task.

• Protect patient privacyAny documents printed out with patient names on it need to be placed in the containers that are used for shredding. It is important - and it is the law - that you do place the pages in these containers.


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Thank you for your time and commitment to the Fall Ambassador Program. We hope your efforts here will be as valuable to you as to those patients you serve. Your dedication to helping patients stay safe while in the care of others is admirable.

Regardless of your ultimate destination in the field of health care,there are some important lessons available to learn here:

• The need for constant vigilance and attention. You will be in in an environment in constant flux. A situation which is currently okay may change in an instant. You must always be alert and observant

• The necessity of working as part of a team. Healthcare is is a complex field. No individual can do it all. Any weakness in the chain can have serious consequences. It is important to observe and speak up if you notice anything which could put a patient or any other individual at risk.

• An understanding of how health care is provided in a hospital setting. With your experience working side-by-side with a variety of health care professionals you will get a sense of procedures and the kinds of protocols put into place to insure a safe and efficient environment for those being cared for.

• The satisfaction of making a difference in the lives of others.

In Conclusion

fall ambassador program - department of patient affairs at ... · the falling star logo has been...

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