making the number of falls fall
DESCRIPTION
Mara Aronson , MS, RN, GCNS-BC, FASCP, CPHQ Director of Nursing. Making The Number of Falls Fall. Spaulding Nursing & Therapy Center, North End Boston, MA. Objectives :. By the end of this presentations, participants will be able: Identify characteristics that increase fall risk - PowerPoint PPT PresentationTRANSCRIPT
Making The Number of Making The Number of Falls FallFalls Fall
Mara AronsonMara Aronson, MS, RN, GCNS-BC, FASCP, CPHQ
Director of Nursing
Spaulding Nursing & Therapy Center, North EndBoston, MA
ObjectivesObjectives::
By the end of this presentations, participants will be able: Identify characteristics that increase fall risk
Describe the value in individualizing care plans to reduce the risk of falls
Compile, analyze, and trend data to determine patterns of falls
Discuss how trending data can be used to reduce risk of future falls
Definition “FALL”Definition “FALL”
“An event which results in a person unintentionally coming to rest
on the ground or another lower level,
not as a result of a major intrinsic event
(such as a stroke) or overwhelming hazard.”Tinetti et al., 1988
Who fallsWho falls??
#1 risk factor
Confused
Medicated
Impaired senses
Incontinent/Urgency
Use of adaptive devices
Elderly
= History of = History of fallsfalls
Falls are often multifactorial.Falls are often multifactorial.
Where do they fallWhere do they fall??
In the Community:
35%-40% all 65+ y fall once or more/yr25% of 70+ years fall/yr
35% of 75+ years fall/yr
20%-30% of falls result in severe injuries
(ex. hip fx, head injuries)
A leading cause of death amg cmty elders
Where do they fallWhere do they fall??
In Hospitals: 0.6-2.9 falls/year per bed
4-12 falls per 1000 pt bed days
Where do they fallWhere do they fall??
In Nursing Homes: A 100-bed SNF typically has 100-200 falls/yr
Bwt 50%-75% all SNF residents fall/yr
Avg is 2.6 falls per person/yr
4-12 falls per 1000 pt bed days
1800 die/yr from falls in nsg homes1800 die/yr from falls in nsg homes
Trend but considerTrend but consider::
Some falls may not be preventable without jeopardizing the elder’s
dignity &/or compromising function.
Trend but Trend but considerconsider::0% fall rate is a problem0% fall rate is a problem
Under reporting? Are residents immobile?
Hey! I think he just moved, add one more!
Who fallsWho falls??
#1 risk factor
Confused
Medicated
Impaired senses
Incontinent/Urgency
Use of adaptive devices
Elderly
= History of = History of fallsfalls
Falls are often multifactorial.Falls are often multifactorial.
Medicalconditions
Impaired vision & hearing
Psychiatricconditions
Environment
Medications
Assistive Devices
Multifactorial FallsMultifactorial Falls
Intrinsic FactorsIntrinsic Factors Extrinsic FactorsExtrinsic Factors
Social Issues
Incident ReportIncident Report::
Keep it: Keep it:
Brief
Easy Relevant
Our formOur form: : Spaulding Nursing & Rehabilitation Center, North End
EVENT REPORT FORM Use this form for all events other than med events
Date: Time: Location of occurrence: Name: If not a resident: Visitor Outside vendor/clinician Employee (If yes, position & dpt):
Resident condition at assessment (Check all that apply): At baseline Oriented x 3 Orient x 2 Orient x 1 Variable Confused Anxious Reliable historian Resisting assist
If not a resident, phone #: If not a resident, address: Describe the event (what happened, how was it discovered, how pt was first observed ): _________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Describe any known contributing factors: ___________________________________________________________________ _________________________________________________________________________________________________ ___________________________________________________________________________________________________
For all falls, complete FALL INVETSTIGATION WORK SHEET, collect WITNESS STATEMENTS, & call a HUDDLE!
At time of event Resident was: Dry/Continent Incontinent of Urine Feces Catheter in use Leg strap
Other environmental issues noted: . . . .
INDICATE ON BODY LOCATION OF INJURY/INJURIES:
Type of injury: Use # or arrows to locate
Laceration
Hematoma
Abrasion
Burn
Swelling
No apparent injury
Complain / Shows signs of pain (with or without visible injury) Pain Rate 1-10 .
Other – specify: .
NURSE’s NOTE with VS written YES & OrthoVS for all falls YES
Fall investigation formFall investigation form: : Spaulding Nursing & Therapy Center, North End
FALL INVESTIGATION WORKSHEET
Resident Name: Date of fall: Time of fall:
Note: If pt unable to stand, sit, or cooperate with VS assmt, document this in the Nurses’ Note. Lying: BP: AP: Resp: Temp / route:
Sitting: BP: AP: Resp: Temp / route:
VS when found: (temp x 1 only)
Standing: BP: AP: Resp: Temp / route:
Pt’s statement: .. .
PRIOR TO THE FALL:
Where last seen? How long since last seen: Activity prior to fall:
Lighting: Dark Light Floor: Dry Wet
Shoes: Barefoot Regular socks Non-skid socks
Slippers Shoes/sneakers Tied Untied
Continence: Dry Incont of urine Incont of feces
Time since last void/toileting .
Catheter Leg Bag
Mental Status (MS) Prior to Fall:
Oriented X 3 Oriented X 2 Oriented X 1
Forgetful Poor Safety Awareness Impulsive
Lethargic Restless/Agitated MS varies
Other (describe): .
Describe MS after Fall): No change
Change: : .
Alarm: In-place Connected Sounding
If not sounding: . Turned ‘off’ Low/dead battery Type of alarm: .
Call bell: Within reach Call bell functioning: Ringing Hall light on Not working
Equipment in Care Plan:
Cane
Walker
Wheelchair
Seat belt
Brace (type): .
Gait belt
Side rail(s)-how many .
Mechanical lift Other: .
Equip. in use at time of Fall:
Cane
Walker
Wheelchair
Seat belt
Brace (type): .
Gait belt
Side rail(s)-how many .
Mechanical lift Other: .
Fall investigation Fall investigation formform: :
Check all that apply:
Change in med, dose or schedule in past 72 hrs Acute change of condition: .
Fall within the last 30 days Recent change of function: .
This event was witnessed:
No
Yes – Have staff witness(es) complete WITNESS STATEMENT FORM
Yes – If witnessed by another resident or visitor, document their observations on WITNESS STATEMENT FORM Evaluation: This fall is thought to be due to:
Cardiovascular condition
Neuromuscular condition
Orthopedic condition
Vision impairment
Cognitive condition
Environmental condition
Other (describe): ___________________ ___________________________________
Notes & Care Plan: The care plan is updated based on this assessment. Nurse’s note written about this fall. Nurse initials Nurse initials
Signature of person completing this worksheet: Date: _______________________
2nd half of page
HUDDLE HUDDLE ::Spaulding Nursing & Therapy Center, North End
Huddle Worksheet
Patient’s name: . Time of fall: .
Location of fall: . Time Huddle was called: .
Report of what happened: .
Report of intervention: .
Rehab Screen needed: Yes No
Type of service needed: PT OT SLP Members Present at Huddle:
1. 2. 3. 4.
Join the HUDDLE!Help prevent the next fall!
Huddle in ProgressHuddle in Progress
How are we doing?
Let’s do even better in September.
Join the HUDDLE on your unit.
Help us prevent the next fall.
Thank you for all your hard work & care! Posted. 9/7/10
FALLS May ‘10 19 falls 15 residents June ‘10 24 falls 15 residents –
1 resident fell 5 times! July ‘10 25 falls 13 residents –
1 resident fell 5 times!
August ‘10 11 falls 8 residents
Mr SS fell twice. Mr EM fell three times.
We did a terrific job in preventing falls
in August!
Trend but Trend but considerconsider::
Fall numbers will rise while
“frequent fallers” are in the house
& fall when they leave.
Our fall dataOur fall data::
0
5
10
15
20
25
30
2010 2011
0
5
10
15
20
25
30
Falls with injuries
All Falls
Our fall dataOur fall data::
2010 2011
Trending all Trending all eventsevents:: FALL / RELATED INJURIES EVENT BY TYPE See log* Rpt DPH
Date
Unit Time Resident Fall
No Yes If yes,injury type Rsdt-
Rsdt
Bruis
e
Othe
r Skin
Othe
r
Alleg
ation
Elop
emen
t
Emplo
yee
Notes & Other Events
Med event if yes, date
1-May 2 Anne See Med Event log 1
2-May 4 7:35a Bernard 1 1leaned forward from WC and fell to floor; laceration on eyebrow sent to ER; wound sutured 3-May
2-May 3 10:10a Carolyn 1 Bruise found on posterior hand; phlebotomy draw yesterday
4-May 4 11:30a Dora 1 1 Fall from toiled during BM
4-May 4 2:00p Edward 1 Skin tear noted on LLE; rsdt says bumped on leg rest of WC
5-May Frost, Frank 1 See Employee Event Log5-May 2 5:15p Geraldine 1 1 Spilled hot soup in lap; denies pain; area pinkened immediately post event
5-May 3 12noon Howard 1 1 abrasion In main DR; tried to help peer to her seat; witnessed fall to knees
6-May 3 3:15p Imogen 1 1Roommate summoned staff; rsdt found on floor beside bed; rsdt report tried to go back to bed w/o help
6-May 4 2:00p Joyce 1 missing hearing aide
7-May 4 6:20p Kate 1 1 found on floor outside of room; said going to work; no injury; restless
7-May 4 7:10p Kate 1 1 c/o hip pain
seated in corridor for observation; witnessed evt: pt rose from chair & fell to left rsdt c/o hip pain; ROM at baseline; Xray neg; resumed baseline activ/amb
8-May 3 2:30a Louise 1 1 See Med Event log 1
TOTALS 7 4 3 0 1 2 2 0 0 1 2
STAFF:
Resident-to-Resident
Bruise
Other Skin
Other/Misc
Allegation
Elopement
Employee
Trending all eventsTrending all events:: FALL / RELATED INJURIES EVENT BY TYPE See log* Rpt DPH
Date
Unit Time Resident Fall
No Yes If yes,injury type Rsdt-
Rsdt
Bruis
e
Othe
r Skin
Othe
r
Alleg
ation
Elop
emen
t
Emplo
yee
Notes & Other Events
Med event if yes, date
1-May 2 Anne See Med Event log 1
2-May 4 7:35a Bernard 1 1leaned forward from WC and fell to floor; laceration on eyebrow sent to ER; wound sutured 3-May
2-May 3 10:10a Carolyn 1 Bruise found on posterior hand; phlebotomy draw yesterday
4-May 4 11:30a Dora 1 1 Fall from toiled during BM
4-May 4 2:00p Edward 1 Skin tear noted on LLE; rsdt says bumped on leg rest of WC
5-May Frost, Frank 1 See Employee Event Log5-May 2 5:15p Geraldine 1 1 Spilled hot soup in lap; denies pain; area pinkened immediately post event
5-May 3 12noon Howard 1 1 abrasion In main DR; tried to help peer to her seat; witnessed fall to knees
6-May 3 3:15p Imogen 1 1Roommate summoned staff; rsdt found on floor beside bed; rsdt report tried to go back to bed w/o help
6-May 4 2:00p Joyce 1 missing hearing aide
7-May 4 6:20p Kate 1 1 found on floor outside of room; said going to work; no injury; restless
7-May 4 7:10p Kate 1 1 c/o hip pain
seated in corridor for observation; witnessed evt: pt rose from chair & fell to left rsdt c/o hip pain; ROM at baseline; Xray neg; resumed baseline activ/amb
8-May 3 2:30a Louise 1 1 See Med Event log 1
TOTALS 7 4 3 0 1 2 2 0 0 1 2
STAFF:
All fallsAll falls With or w/o injury
Fall Risk Assessment Fall Risk Assessment ToolsTools::
Valid? For what population? In what setting?
But if every one is at risk. . . . .nearly
is it useful???
What’s been triedWhat’s been tried??
Staff education
Reprimands for high fall rates
Rewards for low fall rates
Falling Stars & Falling Leaves
Colored bracelets or socks
Bed & chair alarms
Restraints
Falling Stars/LeavesFalling Stars/Leaves
On door jams, foot boards, bracelets, care cards
Be realistic
Policies
Forms & Documentation
Interventions
What’s been tried? Staff education
Reprimands for high fall ratesRewards for low fall ratesFalling Stars & Falling Leaves Colored braceletsColored slippers Bed & chair alarms Restraints
What else?
Lots strategies workMost do work
To sustain results, best ==
QI principlesTrending Sharing trends with staffVaried reminders & education
In the SHORT TERMIn the SHORT TERM
“Borrow ideas” from other SNFs
For example:
Prevent the next fall.
Mind your ‘P’s! PAIN
POTTY
POSITION
PERSONAL ITEMS
PLUGS
Tend to the pain.
Toilet the patient.
Reposition for safety
& comfort. Place within
reach. Things plugged into
pts.
Reasons to limit restraint use
#1:#1: RESTRAINTS DO NOT REDUCE FALL RATES
#2:#2: RESTRAINTS MAY INJURE
OR KILL PATIENTS
Reasons to limit restraint use
Reasons to limit restraint use
#3:#3: RESTRAINTS JEOPARDIZE
SURVEY RESULTS
Reasons to limit restraint use Increase risk of complications
Skin breakdownDecrease mobilityDisorientFrighten
Isolate Injure Risk death Liability F-Tags
Remember when?
1980’sAdmission orders:
PRN Tylenol PRN MOM PRN Haldol PRN Vest restraint
Miles & Irvine, 1992
S Miles,
S Miles,
S Miles, 1996
When falls occurred pre-OBRA:
Nurse assessed for gross injuriesNurse put bandage on boo-booNurse tied Mrs B to her chairNurse tied chair to the handrail
When falls occurred post-OBRA:
MDS prompts consideration:MDS prompts consideration:
Infection?
Medication?
Glasses/vision?
etc.
Facility QI trending:Facility QI trending:
Location?
Time?
Equipment?
Personnel
Respond to trends:
Staff education
Address “not-my-patient” syndrome
Toileting schedules
Activities
EVERY one involved?
Nurses & Nsg MgtNursing AssistantsRestorative AidesPTs & OTsResident Resident’s family
Maintenance staffHousekeepersDietitiansDietary aidesStaff DevelopmentPharm ConsultantAdministrator Medical Director
Facility-wide interventions
All staff involved
Remove clutter
Assess staff competence w/ transfers
Assess staff competence w/ equipment
Assess, address & reassess individuals
Individualize interventions
Consider the falls:Clinically?From what position? Where? When? Circumstances?
Falls from what position?
Falls fromBEDBED
↓↓
Falls fromCHAIRCHAIR
↓↓
Falls fromSTANDINGSTANDING
↓↓
Benefit from PT?Need assistive devices?
Develop menu of possible interventions
Falls where?
Bedroom?
En route toilet?
Toilet?
Outside?
Activities?
Falls when?
During night? Early AM? Late afternoon? Bwt dinner & bed? After certain activity?
Change of shift?
Summary: For individual:
AssessEducate Address ReassessRe-address
For population:Assess/trendEducate Address Continue to monitorRe-address
Summary:
“Falling itself is not a diagnosis but a symptom of multiple underlying diseases,
the effects of certain medications …, and /or environmental hazards or obstacles
that interfere with safe mobility”(Tideiksarr, 1993)
Summary:
Therefore, individual assessments must be frequent and interdisicplinary.
And each rsdt’s care plan must also be frequently reviewed and interdisicplinary.
Summary:
And…And… Trending must be continuous, thoughtful,
& interdisciplinary. Facility-wide interventions must be thoughtful,
interdisciplinary, & continuously reviewed, reinforced, and changed as trending indicates.
Summary of Summary of strategiesstrategies::
Include ‘front line’ staff in developing care plans
Include ‘front line’ staff in changing practice
Trend falls
Share fall trends with staff
Periodic and varied in-services
Fliers (in staff-access areas)
Be creative
Share/adopt strategies from other facilities
DiscussionDiscussion. . .. . . To reach Mara:
Mara Aronson, Director of Nursing Spaulding Nursing & Therapy Center, North End 70 Fulton Street Boston, MA 02109 (617) 726-9702 [email protected]