new directions in fall and fall injury prevention · medical surgical nursing conference 2019...

New Directions in Fall and Fall Injury Prevention

Medical Surgical Nursing Conference 2019Patricia A. Quigley, PhD, MPH, ARNP, CRRN,

FAAN, FAANP

Association of Rehabilitation Nurses

ANCC Accreditation Statement


Speaker Disclosure Statement

n Independent Contractor, HD Nursing, LLCn Independent Contractor, AvaSure, LLCn No off-label use will be discussed.


My Hope:n Change practice beyond usual care of prevention and

protectionn Generate Confidence in Changen Embrace Innovation n Inspire Successful Implementation


Learning Outcomesn Summarize updated national guidelines to shape fall and fall injury prevention

practices.n Challenge current practices so we can individualize fall and fall injury

preventions.n Engage the audience through compelling and interactive audience discussion

of the need to transform current practices by challenging myths of clinical practices.

n Invite discussion of barriers and facilitations to shift practice to population-based, individualized care planning.

n Explicitly showcase HD Nursing: greater clinical precision and clinical competence are required to reduce preventable fall and protect patients from injury.


National Guidelines: Shiftingn Reduce Individual Fall and Injury Risk Factors

(Individualized Care)n Integrate Injury Risk /History on Admissionn Implement Universal Injury Reduction Strategiesn Implement Population-Specific Fall Injury Reduction

Interventionn Reduce Harm from Falls


Sept 28, 2015: TJC Sentinel Alert: Preventing Falls and Fall Injuriesn Lead efforts to raise awareness of the need to prevent falls

resulting in injuryn Establish an interdisciplinary falls injury prevention team or

evaluate the membership of the team in place n Use a standardized, validated tool to identify risk factors for falls,

assess fall and injury risk factors n Ex. If reports dizziness on change of position, assess postural

hypotensionn Develop an individualized plan of care based on identified fall

and injury risks, and implement interventions specific to a patient, population or setting


SE Alert Recommendationsn Standardize and apply practices and interventions demonstrated

to be effective, including: n A standardized hand-off communication process n One-to-one education of each patient at the bedside

n Conduct post-fall management, which includes: a post-fall huddle; a system of honest, transparent reporting; trending and analysis of falls which can inform improvement efforts; and reassess the patientn Conduct a post-fall huddle n Report, aggregate and analyze the contributing factors on an

ongoing basis to inform improvement efforts.


Patient Harm… remember the news?n IOM: To Err Is Human, Shaping the Future of

Healthcare (1999)n 48,000 perhaps as much as 95,000 die each year in

hospitals as a result of medical errors that could be prevent


Dr. J. James 2013 Updaten Provided updated estimate of patient harmn Examined studies 2008-2011n MDs had to concur on final adverse events then classify

the severity of harmn True number of premature deaths associated with

preventable harm estimated at more than 400,000/yearn Serious harm 10-20 fold more common than lethal harmPatient Safety America, Houston, TX. A new, evidence-based estimate of patient harms associated with Hospital Care (2013). Journal Pt Safety, 9: 122-128.


Conclusionsn Epidemic of patient harm in hospitals must be

taken serious if to be curtailedn Fully engage patient and their advocates during

hospital caren Systematically seek the patient voice in

identifying harms n Transparent accountability for harmn Intentional correction of root causes of harm


What we know about hospital fallsD. Oliver, et al. Falls and fall-related injuries in hospitals. (2010, Nov). Clinics in Geriatric Medicine.

n 30% to 51% of falls result with some injuryn 80% - 90% are unwitnessedn 50%-70% occur from bed, bedside chair (suboptimal chair

height), or transferring between the two; whereas in mental health units, falls occur while walking

n Risk Factors: Recent fall, muscle weakness, behavioral disturbance, agitation, confusion, urinary incontinence and frequency; prescription of “culprit drugs”; postural hypotension or syncope


Hospital Best PracticesD. Oliver, et al. Falls and fall-related injuries in hospitals. (2010, Nov). Clinics in Geriatric Medicine.

Implementation of safer environment of care

Identification of specific modifiable fall risk factors

Implement interventions targeting those risk factors so as to prevent falls

Implement interventions to reduce risk of injury to those people who do fall


Where are we? Change in HACs, 2011-2015 (Total = 3,097,400)

National Scorecard Estimates from Medicare Patient Safety Monitoring System, National Healthcare Safety Network Healthcare Cost and Utilization Project.


Let’s Bust Mythsn Challenge current practices so we can individualize fall

and fall injury preventions.


Prevention Myth Busters

What is prevention?

n The act of preventing, forestalling, or hindering

Myths:1) You can prevent all falls2) You can predict the likelihood of

all falls3) Patients are going to call for help4) Strategies to prevent all falls are

the same


Protection Myth Busters

What is protection?

Shield from exposure, injury or destruction (death)Mitigate or make less severe the exposure, injury or destruction

Myths:1) Assessing fall risk is the same as

assessing injury risk2) All patients have the same risk for

injury3) Interventions to prevent falls are the

same as interventions to prevent injury


Current Staten Overall lack of robust falls evidence has led to the

development of bad habits• Over reliance on practices contrary to evidence• Patients minimized to a score• Working harder, applying more pressure• Patients and families seen as the problem


Let’s Share!n What are your barriers to shift practice to population-

based, individualized care planningn What are your facilitators to shift practice to

population-based, individualized care planning


Current Interventionsn Are not workingn Are not individualizedn Can be reconsidered to revise clinical

practices and tools for prevention and protection

n Can be refocused to increase your safety net at the point of care


What can we change to move faster?n Current situation:

n Over-reliance on Fall Risk Screening

n Insufficient Risk Assessmentn Lack of Differential Diagnosis:

Pathophysiology Underlying Fall Risk Factors

n Undetermined Range of Severity – Don’t know vulnerability – Level of Risk

n Understand that just about everyone is at risk for a fall

n Let’s STEP UP our game!n Set and be accountable for

achieving bold goals. In our care:n No one dies from a fall n No one breaks a hip

n Mitigate or eliminate patients' modifiable fall risk factors


Screening to Assessmentn History of Falls

n Screen: yes or non Assessment: based on positive or negative screen responsen History of fall injury

n Assessment must be comprehensive n Pre-Mobility (postural hypotension, sensory neuropathy;

proprioception)n Mobility Status (gait, balance, assistive devices)

n Required for rest of nursing processn Assessment must involve interdisciplinary team (nursing referrals

to PT, PharmD, etc)


Fall Risk Scales/Toolsn Morse Fall Scale- 1989n Schmid Fall Risk Assessment Tool - 1990n Hendrich I - 1995n Conley Scale for Med Surg - 1999n Hendrich II- 2003n Johns Hopkins Fall Risk Assessment Tool (FRAT) - 2005n HD Nursing - 2013


HDNursingFallsManagementSolution

ü Improves patient outcomesü Reduces hospital costsü Reduces hospital re-admissions and institutionalized careü Automated work flow for care providersü HD Falls Program has been implemented in over 100 + Hospitalsü The HD Nursing Program has helped reduce falls by an average of

43% and falls with injury an average of of 65% in 2017 (*clients reporting data through 2017)

Predictive Analytic Program to predict and prevent falls and injuries across the

continuum of care.

www.hdnursing.com


HD Nursing’s MissionInject the science of falls management across the care continuum so that individuals can safely transition through disease and wellness management without falls and injury confounding their journey.


The HD Nursing Solution

Ø Predict: Hester Davis Fall Risk Assessment Scale©

Ø Prevent: HD Falls Care Plan©

Ø Sustain: HD Falls Tool Kit©

With a comprehensive, individualized falls management program, providers will have the tools needed to improve patient safety outcomes and address the growing costs associated with falls.


Predict: Hester Davis Falls Risk Assessment Scale©

Ø AssessHDS © goes beyond screening - to identify level of risk (safe environment) and specific modifiable risk factors

Ø AnalyzeRisk factors in HDS © mapped to specific interventions in the HD Care Plan ©


Hester Davis Falls Risk Assessment Scale © (HDS) Validation• Tested and scientifically validated over 4

years at University of Arkansas for Medical Sciences (UAMS) in Little Rock, AR

• Peer-reviewed published results: Journal of Neuroscience Nursing, Oct 2013

aMorse, OberlebWilliams,Szekendi,ThomascHendrichdHester, DaviseBane, Hester

Psychometric Statistics of Commonly Used Adult Inpatient Fall Risk Prediction Tools

Screening Tools Assessment Tools

MORSEa JohnsHopkinsb

HENDRICHIIc

HDSc d, e

Sensitivity

73% Not Validated 75% 91% paper90% EMR

HDS identifies the RIGHT at-risk

patients.

15-18% More Sensitive than

other commonly

used validated

tools!


Prevent: HD Falls Care Plan©

Ø Take ActionIndividualized HD Care Plan© generated by specific risk factors selected in HDS©

Ø TreatIndividualized HD Care Plan© adjusts based on patient’s real time condition


Sustain: HD Falls Toolkit©

Ø Train & EducateTraining, education, nurse competency, audit and compliance toolsØ ReportQuality and performance improvement tools and templates for JC & CMS documentation and compliance


Results: UAMS Case StudyOne year after implementing (2011) the HD Falls Program™ at UAMS:n Experienced a 60% reduction in injurious fallsn Improved from 98th to 11th percentile in falls injury ranking

on NDNQIn Saved $1.27 million on falls related costs the 1st year 1

n Saved an additional $330k by eliminating “patient sitters” –an ineffective and costly intervention

n Saw an overall savings of $1.6M per year

All occurring during a time when the hospital was significantly reducing staff.

2013, 2016 Top Performer in Falls and Injury Prevention (University Healthsystem

Consortium)

2014 Top Hospital Saving Money in Innovative Ways

(Becker’s Healthcare)

In 2013, UAMS achieved the lowest falls and falls injury rates in it’s history and was recognized as a national leader. In 2016, the fall rates at UAMS were half the national average.


HD Nursing’s Competitive Advantage

n Developed separately –interventions not linked

n Screening tools too general to identify specific modifiable risk

n All patients are treated the same regardless of risk factors

n Approach rarely changes during patient stay

n Developed, tested and validated together

n HDS© /HD Care Plan© target specific modifiable risk factors

n All patients are treated individually based on specific risk factors

n Care Plan changes with patient condition

Care Plan

HD Scale™

HD Falls Care

Plans™

HD Falls Tool Kit™

Common Approach HD Falls Program™

Screening Tools


EHR Program Integrationn HD Falls Program© can be easily integrated into any EMR

system n In 2014 release: HDS© integrated in Epic EMR foundation

system as default Falls Assessment Tooln HD Care Plan© & HD Toolkit© available for Epic integration direct

from HD Nursingn Integration of the HD Falls Program © leverages workflows

within the EMR including but not limited to:n Best Practice Alertsn Work lists/ Task lists/ Overdue itemsn Content mapping between flow sheets and the HD Care Plan ©n Content mapping with other workflows (i.e. mobility scores)

34


HD Nursing: Advances Functional OutcomesMitigating / Eliminating Fall Risk Factors

n Mobilityn Medications

n Toileting Needsn Communication Sensory Deficits

n Behavioral Issues


HD Nursing Integrates Bedside Floor Mats


HD Nursing Integrates Hip Protectors


Test Clinical Judgmentn Expert Nursing Judgmentn You know who is “at risk for falling”n Do you know who is “at risk for injury”? n Do you know which patients on your unit have a history of

hip fracture?n Do you know which patients in your care are receiving

chronic anticoagulation?n Who has orthostasis?


Your Rehab Patient: Mr. Veterann CC: Dizziness and Fell face forward, at Home Getting

Up from Toilet n 82 year old accompanied by 2 daughters and son-in-

law using 4 wheel walkern in good health and active until one year agon 1 fall in the last 3 months


Falls hx.n 4 falls ever (this fall)n First fall October -fell twice with sugar in low 50’s n March - fall-returning from bathroom at night –

climbed into bed over the foot of the bed and lost balance-sustained L1 comp. fx.

n Frequent stumbling and loss of balancen Family noticed dragging L foot and tendency to lean

to the side since Marchn Not using an assistive device at the time of falls


HPI/PMHn 8 hospitalizations in 2014n treated for lung cancer with LUL resection; no

chemo or radiation tx. n had AAA repair, f/u by bilateral FEM/POP bypass

and DVT with IVC filter placementn significant weight loss over the last year n at least 2 episodes of hypoglycemia


PMHx.n Compression Fx. following

a falln Paroxysmal atrial fibrillation

on warfarinn HTNn CAD/CABG x 3 1981n DM II n TIAn Dementia

n GERDn Low back painn AAA- Repair 3/2006 n PVD-s/p fem-pop bypass

3/2006n DVT with IVC filter

placement 3/2006n CHF


HistoryFunctional Hx:Independent in basic ADL’s except bathing, ambulates

with a 4 wheel walker most of the timeUnable to get up unassistedNeeds assist with bathing, meals preparation and

medicationsFamily hx: non-contributory


Pertinent ROS and VSn Denies syncope, palpitations, hx of kidney stonesn Has constant chronic low back pain 5-9/10n Denies lower extremity weakness or numbnessn VS: 106/69 HR 76 Sitting

91/59 HR 85 standing immediate94/61 HR 86 Standing one minute93/60 HR 80 Standing 3 minutes

n *Pt denied dizziness (13mm drop in SBP)


Physical Exam n Gen: in NADn HEENT: PEERLA, EOMI, no nystagmusn Neck: no JVD, no bruitsn Heart: irregular, S1, S2, Systolic murmur III/VIn Lung: clear, Abd: benignn Ext: L ankle 1+edema


Physical Exam cont.n Neuro exam: MMSE 25/30, GDS 7/15n CN II-XII grossly intact, VA L 20/30, R 20/100

uncorrected, gross depth perception intact, fine impaired

n Motor: R ankle DF 4+, Lt 2-.R knee ext 4+, Lt 3+R hip flex 4, Lt 4


Results of Your Assessmentn Share Risk Factorsn Start Care Plan


HD Nursing: Advances Functional Outcomes and Patient Safety

Mitigating / Eliminating Fall Risk Factorsn Mobility

n Toileting Needs


Assessment/Identification of Fall and Injury Risk Factors

n Deconditioningn Episodes of hypoglycemian Chronic low back pain secondary to lumbar DDD and

DJD, and compression fracture of L1, n Lt foot weakness and sensory impairment most likely

multifactorial (lumbar spine DJD, r/o spinal stenosis, residual effects of CVA?)

n Borderline hypotension with 15mm drop in SBPn Anticoagulant therapy with Warfarinn Assist with ADLs


Plan Continues

n Create a Safe Environmentn Protect from Injury: Floor Matsn Safe Exit Siden Bed Side Commoden Virtual Surveillance


Your Turnn Share Your Patientsn Let’s Discuss


You Can Always Reach Me!n Patricia Quigley, PhD, MPH, ARNP, CRRN, FAAN,

FAANP, Nurse Consultantn [email protected]


Thank You

If you Fall Tell

Someone


I Fall A lot! Why?

Oreo

Jethro Mr. Goober

new directions in fall and fall injury prevention · medical surgical nursing conference 2019...

Documents