Making The Number of Falls Fall

1. 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

2. Objectives: 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

3. 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

4. Who falls? • #1 risk factor • Confused • Medicated • Impaired senses • Incontinent/Urgency • Use of adaptive devices • Elderly = History of falls Falls are often multifactorial.

5. Where do they fall? • In the Community: • 35%-40% all 65+ y fall once or more/yr • 25% 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

6. Where do they fall? • In Hospitals: • 0.6-2.9 falls/year per bed • 4-12 falls per 1000 pt bed days

7. Where 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 homes

8. Trend but consider: Some falls may not be preventable without jeopardizing the elder’s dignity &/or compromising function.

9. Trend but consider: 0% fall rate is a problem • Under reporting? • Are residents immobile? Hey! I think he just moved, add one more!

10. Who falls? • #1 risk factor • Confused • Medicated • Impaired senses • Incontinent/Urgency • Use of adaptive devices • Elderly = History of falls Falls are often multifactorial.

11. Multifactorial Falls Medical conditions Medications Impaired vision & hearing FALLS Assistive Devices Environment Psychiatric conditions Social Issues Intrinsic Factors Extrinsic Factors

12. Incident Report: Keep it: • Brief • Easy • Relevant

13. Our form:

14. Fall investigation form:

15. Fall investigation form: 2nd half of page

16. HUDDLE :

17. Huddle in Progress Join the HUDDLE! Help prevent the next fall!

19. Trend but consider: Fall numbers will rise while “frequent fallers” are in the house & fall when they leave.

20. Our fall data: 2010 2011

21. Our fall data: All Falls Falls with injuries 2010 2011

22. Trending all events: Resident-to-Resident Bruise Other Skin Other/Misc Allegation Elopement Employee

23. Trending all events: All falls With or w/o injury

24. Fall Risk Assessment Tools: • Valid? For what population? In what setting? • But if nearly every one is at risk. . . . . is it useful???

25. What’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

26. Falling Stars/Leaves On door jams, foot boards, bracelets, care cards

27. Be realistic • Policies • Forms & Documentation • Interventions

28. What’s been tried? • Staff education • Reprimands for high fall rates • Rewards for low fall rates • Falling Stars & Falling Leaves • Colored bracelets • Colored slippers • Bed & chair alarms • Restraints What else?

29. Lots strategies work • Most do work • To sustain results, best = • QI principles • Trending • Sharing trends with staff • Varied reminders & education In the SHORT TERM

30. “Borrow ideas” from other SNFs For example:

31. Tend to the pain. Prevent the next fall. Mind your ‘P’s! • PAIN • POTTY • POSITION • PERSONAL ITEMS • PLUGS Toilet the patient. Reposition for safety & comfort. Place within reach. Things plugged into pts.

33. Reasons to limit restraint use #1: RESTRAINTS DO NOT REDUCE FALL RATES

34. Reasons to limit restraint use #2: RESTRAINTS MAY INJURE OR KILL PATIENTS

35. Reasons to limit restraint use #3: RESTRAINTS JEOPARDIZE SURVEY RESULTS

36. Reasons to limit restraint use • Increase risk of complications • Skin breakdown • Decrease mobility • Disorient • Frighten • Isolate • Injure • Risk death •  Liability • F-Tags

37. Remember when? • 1980’s • Admission orders: • PRN Tylenol • PRN MOM • PRN Haldol • PRN Vest restraint

38. Miles & Irvine, 1992

39. S Miles,

40. S Miles,

41. S Miles, 1996

42. When falls occurred pre-OBRA: • Nurse assessed for gross injuries • Nurse put bandage on boo-boo • Nurse tied Mrs B to her chair • Nurse tied chair to the handrail

43. When falls occurred post-OBRA: • MDS prompts consideration: • Infection? • Medication? • Glasses/vision? • etc. • Facility QI trending: • Location? • Time? • Equipment? • Personnel

44. Respond to trends: • Staff education • Address “not-my-patient” syndrome • Toileting schedules • Activities

45. Nurses & Nsg Mgt Nursing Assistants Restorative Aides PTs & OTs Resident Resident’s family Maintenance staff Housekeepers Dietitians Dietary aides Staff Development Pharm Consultant Administrator Medical Director EVERY one involved?

46. Facility-wide interventions • All staff involved • Remove clutter • Assess staff competence w/ transfers • Assess staff competence w/ equipment • Assess, address & reassess individuals

47. Individualize interventions • Consider the falls: • Clinically? • From what position? • Where? • When? • Circumstances?

48. Falls from what position? Benefit from PT? Need assistive devices? Develop menu of possible interventions

49. Falls where? • Bedroom? • En route toilet? • Toilet? • Outside? • Activities?

50. Falls when? • During night? • Early AM? • Late afternoon? • Bwt dinner & bed? • After certain activity? • Change of shift?