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Transcript of Kate Smith - Clinical Excellence Division, Department of Health Queensland - Development,...
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
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
Facilitating actions within 15 minutes of a fall (82%); Assisting correct observations after a fall (80%);
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%).
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
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
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: [email protected]