Using a Neuroscience Diagnosis as the Patient’s Primary Risk Factor

for Falling

Darlene Bailey, PCTDarlene Bailey, PCTLeslie Barna, Manager 2 NEWilliam Benedict, MDBarbara Buturusis, Administrative DirectorBarbara Buturusis, Administrative DirectorJose Biller, MDMary Healey, Manager 2 S/2 Neuro ICUMeri Hix, PharmDMeri Hix, PharmDCorrie Husak, RNCorrie Husak, RNBresha Mc Clain, RNBresha Mc Clain, RN

Neuroscience Fall Prevention and Safety Performance Improvement Team

Judy Mc Hugh, NQI, Team LeaderJudy Mc Hugh, NQI, Team LeaderLisa Millsap, APNLisa Millsap, APNMartina Notovny, PharmDMartina Notovny, PharmDVikram Prabju, MDVikram Prabju, MDKaren Potoki, APN, Karen Potoki, APN, Risk ManagementDevra Romick, PTJoanne Scharnak, Nurse Educator, Team FacilitatorTheresa Schwenkel, RN LiaisonKate Steinhable, Physical Therapy EducatorAzucena Uy, RNAzucena Uy, RN

Opportunity Statement

Reduce inpatient falls on the 2 NE Neuroscience Unit and increase staff knowledge related to patient safety

Potential Cause of Falls

Environment People

Materials Patient Decreased Sensorium

Patients At Risk

For Falls

Documentation

Clutter Admitting Issues Bedroom

Frequent transfersInappropriate AdmFast Turn-over

IV PolesChairs

Unfamiliar Room Patient Transfers

EducationAge

Patient Staff History Of Falls(7-13-05, 8-10-05)

Over Estimate Strength & Ability Long Length of Stay

Staff CommunicationLack of Reg RoundsNot Using EquipmentFall Risk (8-10-05)

Gait Belt (7-13-05, 8-10-05)

Medications (7-13-05, 8-10-05)

Elimination

Medication (7-13-05, 8-10-05)

Cannot reach call lightCall light too complicatedFamily assists patient to bathroom

Not Answering Call Lights

Plan of CareNot Documented(8-10-05)

HX of FallsNot in EPIC(7-13-05, 8-10-05)

Flowsheet Fall SectionIncomplete(7-13-05, 8-10-05)

Call Light Issues Bed Alarm Door Reminder Risk Levels

Not onLost in covers

Confusion/Altered Mental Status (7-13-05//8-10-05)

Weakness

Medication(7-13-05/8-10-05)

BalanceGait

Postural Hypotension

Stroke

Don’t Realize They Need Assistance

Sundowner

SedationNarcoticsSleepers

Post Fall Analysis(1/06)

Gait Belt(8-10-05)

Confidential: For Quality Improvement Purpose Only

Not available 7/05

Multidisciplinary Staff Educationo New fall assessment flowsheetso Fall extrinsic and intrinsic factorso Appropriate Bed Alarm Useo Gait belt use and transfer competencyo Fall risk associated with neurologic impaired patiento Monthly fall prevention updates

Solutions Implemented

Neuroscience Safety Awareness Week

o Falls in the Elderlyo Is Polypharmacy Causing Acute Confusiono Touch Therapyo Guided Imageryo Gait Belt Use and Transfer Competencyo Massages for staff

Solutions Implemented

Designed a Level 3 Fall Prevention Interventions

o All neuroscience patients are at risk for falls o Increased elimination rounds to include mealtime and bedtimeso Observe patient activity ever hour or moreo Implemented Bathroom Buddy- staff stays with patient during elimination o Bathroom Buddy- nursing staff stays with patient during eliminationo Place patient on a BedCheck Classic bed alarm and chair alarmo Consult pharmacy regarding medications that can cause altered mental statuso Repeatedly reinforced limits and safety needs to patient and familyo Assign bed that enable patient to exit towards stronger side whenever possible

and transfer patient toward stronger side.o Provide comfort rounds- repositioning, back rub with PM care, assisted

ambulation before bedtime. o Developed Post Fall Assessment Environment Study

Neuroscience Safety AwarenessNeuroscience Safety AwarenessWeek of September 26, 2005Week of September 26, 2005

Monday, September 26, 2005Monday, September 26, 2005 Message of Touch Massage & Guided Imagery by Fran Message of Touch Massage & Guided Imagery by Fran

Glowinski, Glowinski, MPS, OSSMPS, OSS 2 Neuroscience Unit2 Neuroscience Unit 11:00 to 13:00 18:00 to 20:00

Tuesday, September 27, 2005Tuesday, September 27, 2005 Lunch and Learn -Falls in the Elderly by Dr. Jose Lunch and Learn -Falls in the Elderly by Dr. Jose BillerBiller

Bldg. 105 Maguire, Room 2812. Bldg. 105 Maguire, Room 2812. 11:00 12:00

Bed Check Bed Alarm Use Inservice by Bill Saemann,Bed Check Bed Alarm Use Inservice by Bill Saemann,Macon CompanyMacon Company

2 Neuroscience Unit2 Neuroscience Unit 6:00 to 8:006:00 to 8:00 10:00 to 11:00 18:00 to 20:00

Wednesday, September 28, 2005Wednesday, September 28, 2005 Seated Back Massage by Loyola Health and Fitness ClubSeated Back Massage by Loyola Health and Fitness Club 2 Neuroscience Unit2 Neuroscience Unit 6:00 to 7:006:00 to 7:00 16:00 to 17:00

Posey Restraint Use and Other Restraint Alternatives by Posey Restraint Use and Other Restraint Alternatives by Fred Demshar, Posey CompanyFred Demshar, Posey Company

2 Neuroscience Unit2 Neuroscience Unit 11:00 to 12:00 14:00 to 15:00

Nursing Performance Improvement Fall Prevention Initiative 2005

Thursday, September 29, 2005Thursday, September 29, 2005 Lunch and Learn –Healing Touch by Ann O’ Malley , RN., Lunch and Learn –Healing Touch by Ann O’ Malley , RN., C.H.T.P., C.H.T.P.,

EMS Bldg. Room 3284EMS Bldg. Room 3284 11:00 to 12:00

Bed Check Bed Alarm Use Inservice by Dick Tedesco, Macon Bed Check Bed Alarm Use Inservice by Dick Tedesco, Macon CompanyCompany

2 Neuroscience Unit2 Neuroscience Unit 6:00 to 8:006:00 to 8:00 10:00 to 11:00 18:00 to 20:00

Gait Belt Training by Kate Steinhable, PT, MPT.Gait Belt Training by Kate Steinhable, PT, MPT. 08:00 to 09:00

Friday, September 30, 2005Friday, September 30, 2005 Message of Touch & Guided Imagery by Fran Glowinski,Message of Touch & Guided Imagery by Fran Glowinski, MPS, OSSMPS, OSS 2 Neuroscience Unit 6:00 to 8:00

Lunch and Learn –Is Polypharmacy Causing Acute Lunch and Learn –Is Polypharmacy Causing Acute Confusion In Your Patient? Confusion In Your Patient?

by Martina Novotny, Pharm. D by Martina Novotny, Pharm. D EMS Bldg. Room 3284 11:00 to 12:00

2NE Monthly Falls

Confi dent i al : For Qual i t y I mprovement Purpose Onl y

Individua lsSet 2: UCL=9.97, Mean=4.04, LCL=-1.89 (not shown) (11-20) (mR=2)

3

4

5

6

7

8

9

10

11

UCL = 11.30

Mean = 5.32

UCL = 9.97

Mean = 4.04

Fall Reduction Education

Post Fall Assessment

Bed Alarm Implementation

Stroke Unit Opened

3 Pt fell due to extrinsic factors

New Manager

2 NE Fall Reduction Project

Gait Belt Implemented Stroke

Hourly Rounds

Cause & Effect-Fall

1 PT fell twice

Fall Reduction Edu

Safety Week

Level III Pilot

Staff 1 to 1

Gait Belt Training

Bed Alarm Training

2NE Monthly Falls

Confi dent i al : For Qual i t y I mprovement Purpose Onl y

Individua lsSet 2: UCL=9.97, Mean=4.04, LCL=-1.89 (not shown) (11-20) (mR=2)

3

4

5

6

7

8

9

10

11

UCL = 11.30

Mean = 5.32

UCL = 9.97

Mean = 4.04

Fall Reduction Education

Post Fall Assessment

Bed Alarm Implementation

Stroke Unit Opened

3 Pt fell due to extrinsic factors

New Manager

2 NE Fall Reduction Project

Gait Belt Implemented Stroke

Hourly Rounds

Cause & Effect-Fall

1 PT fell twice

Fall Reduction Edu

Safety Week

Level III Pilot

Staff 1 to 1

Gait Belt Training

Bed Alarm Training

o Develop monthly education poster series for Medications Contributing to Mental Status Changes

o Design patient and family safety education to neuroscience population

o Partner with the Loyola Niehoff School of Nursing to introduce the Neuroscience Level III Fall Prevention Program into student curriculum

o Integrate fall risk factors and history of fall into the Electronic Medical Record

o Produce and videotape Lunch and Learn Safety Programs

o Improve patient care handoff utilizing SBAR Situation, Background, Assessment, and Recommendations

NEXT STEPS

Catching the Safety Culture