Leading Better Value

CareReducing falls and serious harm from falls by 5% in 12 months

by Intentional Hourly Rounding in the Acute Geriatric Evaluation and

Management (AGEM) unit Mid North Coast Local Health District

ACUTE

GERIATRIC

EVALUATION &

MANAGEMENT

EVIDENCE BASED INTERVENTIONS

• FALLS ASSESSMENTS ORTHOSTATIC BP

• RISK ASSESSMENTS BEDSIDE MDT MEETINGS

• COGNITION ASSESSMENT SAFE MOBILISATION

• DELIRIUM SCREEN

• MEDICATION REVIEW

• ENVIRONMENTAL MANAGEMENT

• INTENTIONAL HOURLY ROUNDING

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21 21

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en

cy #

Pareto Chart of Evidenced Based Interventions

for Falls Prevention used across 26 AGEM patients

Evidenced Based Intervention for Falls Prevention

STORY BOARD OF OUR JOURNEY

Just some

of our

hardworking

team in

action

Brain storming – a great way to start

The team put their heads together to mud map the day out to:

• Identify periods of time when patient care activity might

not be occurring.

• Determine when activities are already in place.

• When rounding could be included with other activities.

• Identify staff ’s issues and concerns with the new initiative.

Operational Definition(s)- the transformation of a

concept into something concrete, observable and measurable.

• Initial agreement – purposeful hourly rounding with each patient, and /or their carer on the

AGEM.

• Adapted from hourly to crucial points throughout each shift and by all the multi

disciplinary team.

• Three crucial points identified for each shift based around staff activity w patients and data

produced around common times of falls. At these points in time staff were to round with

intention w focus on the fundamentals of care, the patient’s specific care needs

identified risks and goals eg scheduled toileting.

• To aid this we utilized and adapted the CECs guidelines of what are called the 3 Ps –the

patient’s position, environment and personal needs and 3 Ds – discomfort/pain,

documentation and devices.

• Rounding was to be documented at each at point of activity,

Operational Definition(s)- the transformation of a

concept into something concrete, observable and measurable.

THE 3 Ps and 3 Ds

• Personal Needs Discomfort

• Position Devices

• Patient Environment Documentation

Fishbone (Cause & Effect) Diagram

Why do patients fall in our Unit?

Manual Handling

Time constraints

Clinical Handover is time consuming

Getting the team together to plan implementation

Consistency

Already Do it

Education

Toileting Comfort Pain

Insert text

Collaborative Team

Culture

Multi Disciplinary Engagement

Resources, videos, literature

PR at orientation to ward

IPR at Induction to hospital

Education

Update eMR

IPR documentation form

Documentation Falls Mats used on everyone

5pm on everyone

Desensitise staff

Alarms cause agitation

The Problem

The period from October 2016 to

November 2017, the AGEM recorded

76 Falls for a 12 bed unit.

The Aim

Reduce falls and reduce serious

harm from falls by 5% within 12

months. For our unit this

calculates to 3.8 less falls per

annum.

Primary Drivers

Gaps in fundamentals of

care

Education

Culture of change

Secondary Drivers

From the list of available

options we chose

• Documentation,

• Intentional rounding and

• Education for nurses

SMART Aim:

Reduce falls and

serious harm from

falls by 5% within 12

months (ie 3.8 less

falls)

The Problem:

In the period October 2016

to November 2017 in the

AGEM there were 76 Falls,

there were XXX serious

injuries from .

Outcome Measure:

How much: Decrease rate of

falls with harm by 5% by

October 2018.

Inclusions: Age ≥ 70 years

Inpatients in a health service

Partial and assisted falls

Exclusions: Staff, visitors.

Primary

DriversSecondary Drivers

What now?

It’s just something

else we are

expected to do!

We do this anyway!

We can’t prevent all falls

from happening!

Like the lady in this picture who is wondering what is

happening, the Visilert reminds me to go and check in on

the patient.

I feel the forms & the visilert are too much to do together.

What could enhance intentional rounding, times on the visilerts

could be adapted to suit individual patient needs, rather than

make one size fits all.

The balls remind me of the colour of the visilert…..

Yellow for the forms, and then there’s the nursing

notes, handover and the board as well…. Like having

to do extra steps for the same thing. Lots of the same

balls to juggle.

It’s like we’re always looking above the

surface. But sometimes you need to delve a

bit deeper and do all the tasks for the patient

at once. The visilert helps to do this.

It’s about leadership and walking together

as a team and listening to the team’s ideas to

shape a new practice to fit.

For me it’s about all the components that go into the know

similar to all the elements with Intentional Rounding. With all

the elements combined in Intentional Rounding. It is big and

strong, just like the strength of the safety which is in the knot

Feed Back included…..

OUTCOME MEASURES

• REDUCTION IN FALLS

• REDUCTION IN CALL BELL USE

• IMPROVED PATIENT EXPERIENCE

• IMPROVED STAFF SATISFACTION

PROCESS MEASURES:

• PERCENT OF ROUNDING FORMS COMPLETED ON

SCHEDULE – AIMING FOR 95%

BALANCING MEASURES:

• REDUCTION IN MEDICATION ERRORS

• STAFF LEAVING WORK ON TIME

• REDUCTION IN PRESSURE INJURIES

Time Data Sourced

Rat

e H

ou

rly

Inte

nti

on

al

Ro

un

din

g C

om

ple

ted

76 falls, with 1 fracture before our

initiative started from 31 October 2016 –

November 2017 (6.3 / month)

53 falls w nil fractures from 12 months

from beginning of November 2017 (4.4/

month)

21 falls from Nov 1 2018 to end April

2019 (3.5 average )

A much improved statistic

I’d like to acknowledge:

Ben Walkling Occupational Therapist and current LBVC Project Manager for the MNCLHD for his

unswerving support throughout this entire initiative.

Ann Bodill DON of Wauchope District Hospital and LBVC Lead for her vital part in this initiative.

Michelle Pope NUM of AGEM/1C for her support and direction.

Lorraine Lovitt Lead NSW Falls Prevention Program | Clinical Excellence Commission for

coaching and support.

And last by no means least

AGEM nursing and Allied Health staff. Without them this initiative would not have gotten where

it has. THANK YOU

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Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19

Num

ber

of

Fal

ls

Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19

No of Falls 4 2 7 2 6 5 7 6 6 2 6 4 5 2 2 3 2 5

Fall Rate/ 1000 bed days 11.05 5.29 18.92 5.99 16.22 13.89 18.87 16.71 16.17 5.41 16.71 10.78 13.93 5.41 5.41 8.93 5.39 13.89

PMBH AGEM Patient Falls IIMS Notifications

No of Falls Fall Rate/ 1000 bed days

Data from beginning of initiative Nov 2017to April 2019 shows a steady

downward trend and well below the state average per 1000 bed days.