The Post Fall Clinical Pathway

Kate Smith

Manager

Patient Safety Initiatives

Patient Safety Quality Improvement Service

Clinical Excellence Division

Queensland Health

Acknowledgements

Development

Dr Paul Varghese1, Rebecca Bell1, Heidi Atkins1, Kate Smith1, Alex Black3, Kristina O’Dwyer1, Joanne Kinnane1, Natalie Obersky1, Site Project Managers1, Sandy Brauer1,2

Review

Dr Paul Varghese1. Kate Smith1, Sue Hazenberg1, Shyam Inglis1, Stephanie Gettens1

1Queensland Health, Brisbane, QLD, Australia 2 University of Queensland, St Lucia, QLD, Australia 3 Queensland University of Technology, QLD, Australia

Post Fall Clinical Pathway

• Why did we develop and how did we implement the post fall clinical pathway

• What is the clinical usage of the post fall clinical pathway

• Has the post fall clinical pathway made a difference to post fall management and patient care

Types of services

182 – Hospitals, Primary and

multipurpose health services, out

patient Dept, youth detention, rehab,

nursing service

Hospital and Health Services

Patient Safety Initiatives Team

2 Principal Project Officer

1 x Principal Project Officer 1 x Part-time Senior Project Officer

1 X System Admin Support

Manager

Why did we develop PFCP? Case study

• Mental health patient was walking through the car park outside the ED had an unwitnessed fall

• Taken into Emergency Department

• CT head done – NAD

• No post falls pathway

• No neurological observations

• Pt admitted to acute ward with chest infection

• 2nd fall in the ward – unwitnessed

• No CT head

• No post falls pathway

• No neurological observations

• No electronic incident report logged

Day 2 post 2nd fall:

• Documentation in medical chart notes that Pt mobility and cog function declined, ?delirium

Day 3

• Displaying stroke like symptoms –no further documented neurological observations

Day 4

• CT head reveals - massive acute bleed with midline shift - Patient palliated

Outcome

• Pt died

Falls Tools & Strategies Survey

Would you like to see a statewide standardised approach to falls prevention?

87%

4%9%

Yes

No

Unsure

inconsistent documentation and follow up of the patient was

resulting in patient harm.

limited or no neuro obs were being done post

a fall

RCA’s and review of clinical incidents

identified:

Root Cause Analysis Themes Post fall

• Most falls unwitnessed

• In some cases Drs were not being notified

• In cases of suspected head injury neurological observations were not being undertaken

• Minimal consideration of anticoagulant therapy

• Coronial interest and inquiry

Coronial inquiries and reports • Queensland Northern Coroner researching post falls

management

• Coronial report Margaret Winter, Darwin Hospital [2008] NTMC 049

– neurological observations were not completed post fall and it was stated that this is –“unacceptable practice”

• Victorian State Coroner’s Office released a Coroner’s “Investigation Standard”: Fall-related deaths in hospital (2009).

Incident Data • 2012 - 13,636 falls-related clinical incidents reported

• Breakdown by Severity Assessment Codes (SAC):

– 30 SAC1—0.2% of all falls related incidents resulted in death (22 incidents) or likely permanent harm (8 incidents)

– 435 SAC2—3.1% of all falls related incidents resulted in temporary harm

– 13,171 SAC3—96.6% of all falls related incident resulted in minimal harm (5,617 incidents) or no harm (7,554 incidents).

– Falls represented 15.5% of all incidents and 8.4% of all SAC1 events.

Cost of inpatient falls

• In-hospital falls resulting in injury

• patient average increased LOS eleven days

• Costs $12,287 per patient

• Over $5.4million statewide,

• exclusive of costs for surgery or wound care

• Cost to person, family and staff

*based on average cost of $1,117 per day

– Statewide consultation, clinical experts, literature

– Pre and Post:

– Staff Surveys – demographics, attitudes and tools

– Client Surveys – satisfaction with care

– Chart Audit – focused on documentation of interventions

– Other qualitative feedback

Development and Evaluation

Staff Survey Results

> Total of 49 staff completed the post-trial survey

> Majority agreed that PFCP was an effective clinical tool:

> Increasing consistency in post-fall actions (80%);

Results

> Assisting in post-fall documentation (80%)

Results

Facilitating actions within 15 minutes of a fall (82%); Assisting correct observations after a fall (80%);

Results

and developing a post-fall management plan (78%).

Results Most staff found the flow chart useful (73%)

Most staff would continue to use the tool (67%);

Results found the tool was easy to use (67%); and

found the tool assisted them to know when to undertake specific investigations (67%).

Results

I feel this tool helped me improve my care of patients (63%)

Qualitative Results

Theme 1 – Clear pathway or action plan

• The most commonly cited way in which the tool was deemed useful was that it provided a clear pathway or action plan to follow after a fall, including timeframes.

“It did not take away my clinical judgment, but gave me cues, prompts...”

Chart Audit 298 Falls audited across 14 Hospital facilities – identified through incident reports

243 patient charts audited. Median 1 fall.

118 items reviewed in every chart.

Number of charts audited by hospital in intervention (red, n =263) and control (blue, n =35)

0

10

20

30

40

50

60

No.

Initial action taken There was an increase in frequency of documenting some initial

obs immediately after finding a fallen patient in the intervention group post, compared to pre trial

MO notified

Post fall general observations

Observations for witnessed falls –improvement from pre to post

> Obs: 43% pre to 54% of charts post

> Obs done hourly: 33% pre to 68% of charts post

> Obs done two hourly: 0% pre to 47% of charts post

> Obs done four hourly: 89% pre to 68% of charts post

> For all – family notified in 14% cases pre and 24% post

Outcomes - PFCP > There was a significant increase in :

> the frequency of recording the temperature of the patient after a fall (26% to 44%),

> pulse (44% to 57%),

> Glascow Coma Scale (GCS) (26% to 43%)

> blood glucose levels (3% to 23%).

> improvements in documentation immediate post falls Mx

> Improved family notification pre-trial 14% to 24% of cases post.

> More thorough reporting incident reporting systems.

How did we implement

> Statewide Falls Injury Prevention Collaborative

> Clinical Lead

> Site coordinators

> Education packs

> Provide trial forms

> Private hospitals requests

> Clinical incident report

> Assists to comply with National Standards

Support implementation > Printed tools made available free statewide

> Developed falls prevention model policy and implementation standard https://www.health.qld.gov.au/stayonyourfeet/for-professionals/resources-prof.asp

> Online learning

> Coroner member of the FIPC

> Reporting to Learning on falls

> Chairs of Falls Working Group – monthly, bi-monthly

> Education sessions via video conference

Has the post falls clinical pathway made a difference to

post falls management and patient care?

2014 - PFCP Tool Review

> Consultation clinicians, human factors, graphic designer, form specialist’s.

> response recommendations root cause analysis

> EOI Chairs of Falls Working Group

> Literature review

> Feedback via videoconferences

> Rounds of review

> Minor changes made to formatting

> Feedback from clinicians on the working group very positive.

> Completed – education session via video conference

Post Fall Clinical Pathway

• When a patient falls there must be an immediate and urgent response to ensure the clinical wellbeing of the patient .

• The Post Fall Clinical Pathway assists in the implementation of a consistent and thorough response to a fall

• The recommended immediate response to a fall is highlighted in the red bordered box.

• Details of the fall and the patients vital signs are recorded on the PFCP and observation chart as soon as possible

• It is a recommendation that a medial officer be notified of the fall within 15 mins. It is important to record who was notified and at what time

• Medical Assessment is used to record the results of the assessment, initial diagnosis and recommendations

• Investigations/observations guide the care plan for the patient over the next 8 hours, depending on the seriousness of the falls related injury.

• Observations are recommended for a suspected head injury or unwitnessed fall and for no head injury. These observation will be recorded in the patient observation chart.

• Management Plan within 24 hours prompts the clinician to undertake ongoing tasks as the result of the fall

• Every person documenting in the clinical pathway must supply their details and signature in the signature log

Stock Long Description

STK_APN

_NUMBE

R

Jun-

15

May-

15

Apr-

15

Mar-

15

Feb-

15

Jan-

15

Dec

-14

Nov

-14 Oct-

14 Sep-

14 Aug-

14 Jul-14

Total 12 months

INPATIENT POST FALL CLINICAL PATHWAY V2

SW135 PK/100 INPATIENT POST FALL CLINICAL SW135

82 199 81 31 19 24 50 12 3 10 0 4 51500

RESIDENTIAL CARE FACILITY POST FALL

CLINICAL PATHWAY V2 SW137 PK/100 SW137 12 24 12 10 3 3 16 7 0 3 2 0 9200

POST FALL CLINICAL PATHWAY FLOWCHART

V3.00 - SW330 (PACK 100) SW330 9 7 2 4 51 0 2 2 0 0 3 23 11200

71900

Clinical Form Usage

Post Falls Clinical Pathway

Facility Name Use PFCP PFCP Stored

Hervey Bay Yes medical notes

Gladstone Hospital Yes End of bed notes

Townsville Yes End of bed notes

TPCH Yes End of bed notes

QE11 Yes End of bed notes

Chinchilla Yes End of bed notes

Esk Yes End of bed notes

PAH Yes End of bed notes

Cairns Yes End of bed notes

Caboolture Yes End of bed notes

Sunshine Coast HHS Yes End of bed notes

Torres & Cape HHS Yes End of Bed notes

RBWH No

Clinical Form Usage

Preliminary review 2014 incident data

Severity Assessment Code 1 and 2 falls 2014

• Total 24

• PFCP present - 70%

• No PFCP - 26%

• Not enough info 4%

• If PFCP not used it was recommended to be used

Case Study:

• Pt. fell in Mental Health – • CT head done - NAD

• Patient transferred to Acute Ward with ? delirium

• Deteriorated

• 2nd fall unwitnessed – no Post Fall Pathway completed, no CT head, no neuro obs, no PRIME

• Pt deteriorated further - no CT head to investigate ↓GCS, one set of neuro obs

• CT head – massive acute bleed with midline shift - Patient palliative - died

Could the Patient outcome have been different if PFCP completed?

– Flag CT head

– Reminder to do Neuro obs

– Reminder to complete Incident Report

• Don’t think of the PFCP as ‘just another form’ we have to do

• Think of it as evidence that you have provided optimal care for YOUR patient

• Easy to miss something – PFCP a guide to help remind you to “tick all the boxes”

Where to from here

• Seeking further information on PFCP usage

• Investigating PFCP included in QBA 2016

• Repeat - Falls Review of incidents

• Integrating working groups – falls and PIPP

• Update online education

• IeMR

• HEAPS electronic analysis tools

Summary The Post Fall Clinical Pathway was: positively received had positively influenced their delivery of post-fall care to

patients in hospital chart audit significant improvement in documentation of post

fall observations

provide best available care for our patients

provide for timely and accurate documentation

tool to assist clinicians

Assists HHS comply with the recommendations outlined within Standard 10 of the NSQHS Standards

Contact us: Queensland Stay On Your Feet

Web: http://www.health.qld.gov.au/stayonyourfeet/

Go to professional resources

https://www.health.qld.gov.au/stayonyourfeet/for-professionals/resources-prof.asp

Email: stayonyourfeet@health.qld.gov.au