Fall Prevention and Mobility One Systems Story Intermountain led CMMI Hospital Engagement Network...

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Fall Prevention and Mobility

One Systems StoryIntermountain led CMMI Hospital Engagement Network

June 4, 2012

Marlyn Conti, Quality and Patient Safety Consultant, Intermountain Healthcare Central Office

Vicki Spuhler, Nurse Manager Respiratory ICUIntermountain Medical Center

Disclosure

The presenters of this webinar have no financial conflict to disclose.

Objectives

At the conclusion of today’s webinar, participants will be able to:

1. List key steps to ‘getting started’

2. Identify at least 3 strategies for reducing falls

3. List at least 2 outcome and/or process measures to track/trend over time

HEN Survey Results

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

2% 3%

42%

28%

23%

IH Hospital Engagement Fall Program Status

HEN Survey Results – Learning Level

AL-Active Learner RT- Real Time Learner

PL- Passive Learner0%

5%

10%

15%

20%

25%

30%

35%

40%35%

30%26%

Fall Learning Levels

Getting Started

1• Organizational

priority

2• Risk assessment

3• Monitoring systems

4• Champions

5• Care plans

6• Plan-Do-study-Act

Getting Started

VA Center for Patient Safety

Getting Started

IHI – Best Practice

The BEST fall prevention programs are multifactorial and interdisciplinary

*AHRQ I-II,USPSTF A: LTC; Ambulatory Care; Source of Policy for JCAHO Fall Program Guidance 2007

Getting Started

Fall Assessment Tools

Morse

Hendrich II

Schmid

Others

Getting Started

Fall Assessment Tools cont.

Standard protocol

Tool in computer and paper forms

Hard code frequency of assessment

Monitor compliance

Unpublished work of authorship. Copyright © IHC Health Services, Inc. (Intermountain Healthcare). All rights reserved. 2009

Getting Started

Fall Assessment Tools cont

Hybrid tool

Criteria specific to patient population

Updated and reviewed frequently

Score General Population Post Partum Women Pediatrics

5 History of Falls (within 3 months)

History of Falls (within 3 months)

History of Falls (within 3 months)

3

Stroke/ impaired mobility (e.g. unstable gait, needs assistance with ambulation, assistive devices, post invasive procedure [e.g., post femoral access])

Impaired mobility (e.g., epidural numbness, unstable gait, needs assistance with ambulation, assistive devices?

Impaired mobility (e.g. ustable gait, needs assistance with ambulation, assistive devices, medical equipment, cerebral palsy [CP])

3

Elimination problems (e.g., diarrhea, constipation, incontinence, urgency, recent removal of indwelling urinary catheter)

Elimination problems (e.g., recent removal of indwelling urinary catheter, diarrhea, urgency when ambulating)

Elimination problems (e.g., diarrhea, constipation, incontinence, urgency when ambulatory)

3

Sensory deficit (e.g., impaired vision/ hearing/ balance, neuropathy, procedural parasthesia [e.g., post femoral access])

Sensory deficit (e.g., epidural numbness, impaired vision/ hearing, neuropathy)

Sensory deficit (e.g., impaired vision/ hearing, neuropathy, communication barrier)

2

Mental status changes (e.g., confusion, drug toxicity or alcohol)

Mental status changes (e.g., drug/ alcohol/ confusion)

Mental status changes (e.g., confusion, drug toxicity, alcohol, or developmental delay)


Getting Started

Staff Education

• Signs and posters

• Chart stickers and door frame magnets

• E-Learning

• Bed skills pass off check lists

Getting Started

Patient/Family Education Computer prompt

to print out patient fact sheet

Posters and door magnets

Enlist patient and family engagement


S

Working Harder

Fall Champion

Educate

Assess

ImplementPrevent

Monitor

Working Harder

Accountability DiagramFall Prevention

Development Team

Region Guidance

FacilityChampion Team

Nursing Safety Physical Therapy

EducationPharmacy

NOTE: Could be Safety or Quality and Patient Safety Committee

Working Harder

Teams and Champions

Empower champions

Designate teams/committee

Link to Safe Patient Handling

30% to 51% of falls have injuries

• 80% - 90% un-witnessed

• 50%-70% occur during transfer

*Measuring Fall Program Effectiveness. Nursing Quality Network

http://www.nursingqualitynetwork.org/

Working Harder

Fall Prevention Toolkits

• Signs and posters

• Assessment and charting tools

• Protocols

• References

• Education

• Skill pass off checklists


Working Harder

Monitor Rates


Working Harder

Monitor Rates cont.


Working Harder

Mobility

Ahead of the Curve

Tailor interventions to risk factors

Integrate with ‘rounding’

Assure use of bed, chair and/or toilet alarms

Use computer logic to support decision algorithms

Working Harder

ICU Risk Factors

All four legs of the stool are important for stability, mobility, sedation, delirium, and sleep are important to improve outcomes.

Mobility

Delirium

SedationSleep

Working Harder

ICU Mobility Affinity Diagram

SLEEP

SEDATIVES

MOBILITY

DELIRIUM

Makes It Worse

Makes It Better

Courtesy of Terry Clemmer MD

Ahead of the Curve

ICU Mobility

24

“Improving long-term outcomes after discharge from intensive care unit: Report from a stakeholders’ conference” Critical Care Medicine. 40(2):502-509, February 2012.

Post Intensive Care Syndrome (PICS)

Family (PICS-F)

Mental HealthAnxiety/ASD

PTSDDepression

Complicated Grief

Survivor(PICS)

Mental HealthAnxiety/ASD

PTSDDepression

Cognitive ImpairmentExecutive Function

MemoryAttention

Visuo-spatialMental Processing Speed

Physical ImpairmentPulmonary

NeuromuscularPhysical Function

Working Harder

Average Cost/ Patient Day

Adjusted for 2010 costs

Ahead of the Curve

Average ICU LOS

8.5

14.5

Ahead of the Curve

ICU Discharges

27

Ahead of the Curve

Monitor Fall Rates

2007 2008 2009 2010 20110.0

0.5

1.0

1.5

2.0

2.5

Falls with Injury

Average Falls with Injury LCL UCL

Falls

Rat

e pe

r 100

0 Pa

tient

Day

s

Falls Risk Training

Safe Patient

Handling

System

Board Goal

Bed Alarm

Inspection

Unpublished work of authorship. Copyright © IHC Health Services, Inc. (Intermountain Healthcare). All rights r12erved. 2009

Ahead of the Curve

Patient HandlingQ

1-07

Q2-

07

Q3-

07

Q4-

07

Q1-

08

Q2-

08

Q3-

08

Q4-

08

Q1-

09

Q2-

09

Q3-

09

Q4-

09

Q1-

10

Q2-

10

Q3-

10

Q4-

10

Q1-

11

Q2-

11

Q3-

11

Q4-

11

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.57

0.40

0.43

0.33

0.17

0.21

0.290.27

0.23

0.28 0.290.32

0.17

0.30 0.31

0.37

0.33

0.38

0.280.29

Patient Falls Related to Transfer/Lifting

Rate per 1000 Patient Days


Ahead of the Curve

Drive Improvement

• System Board goal 2011 and 2012

• Mandatory education

• Connect with safe patient handling

• Connect bed alarms to nurse call systems (smart beds)

Ahead of the Curve

Drive Improvement cont.

• Post-fall tool

• Care team huddles

• Additional prevention

• Gait belts for ambulation

Ahead of the Curve

Drive Improvement cont

• Tell your stories!

• Engage frontline staff and middle management

Ahead of the Curve

Forcing Functions

• Computer logic

AND

• Safety Rounds

Outcome Measures

Falls per 1000 patient days

Numerator: Count of falls by inpatient unit. All severity levels, assisted or unassisted. Outpatient and visitor falls are excluded.

Denominator: Count of patient days based on midnight room charges for inpatient units. Outpatient units are excluded.

Source - NDNQI

Outcome Measures cont

Falls with injury per 1000 patient days

Numerator: Count of falls by inpatient unit. Severity levels greater than “No Harm” also excludes “Emotional Injuries Only”, assisted or unassisted. Outpatient and visitor falls are excluded

Denominator: Count of patient days based on midnight room charges for inpatient units. Outpatient units are excluded

Source: NDNQI

Process Measures

Assisted and unassisted falls as a % of falls

Numerator: Count of falls by inpatient unit. All severity levels. Stratified by assisted or unassisted. Outpatient and visitor falls are excluded.

Denominator: Count of falls by inpatient unit. All severity levels. Outpatient and visitor falls are excluded.

Source: NDNQI

Optional Process Measures

Fall by risk level Count of falls by inpatient unit. Stratified by severity

level. Includes assisted or unassisted falls. Outpatient and visitor falls are excluded.

Source: Medical Record Review

Fall during transfer per 1000 patient days. Numerator: Count of falls by hospital that occurred

during transfer. All severity levels, assisted or unassisted. Outpatient and visitor falls are excluded.

Denominator: Count of patient days based on midnight room charges for all inpatient units. Outpatient units are excluded.

Source: Medical Record Review

Questions?

What tools would you like posted?

Who would be willing to share improvements and/or best practice?

Keep the Conversation Going!

Patient Falls and Immobility Affinity Group Call

2nd Friday of each month

First call – Friday, July 13th at 11:00 am MST

Info posted on calendar at HENLearner.org

http://www.henlearner.org/

Acknowledgements

Thanks to the hard work and continuing efforts by the Intermountain Fall Prevention Team Quality and Patient Safety Staff Quality data Analyst Educators, etc.

Fall Prevention and Mobility One Systems Story Intermountain led CMMI Hospital Engagement Network...

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