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

Using a Neuroscience Diagnosis as the Patient’s Primary Risk Factor for Falling. Neuroscience Fall Prevention and Safety Performance Improvement Team. Darlene Bailey, PCT Leslie Barna, Manager 2 NE William Benedict, MD Barbara Buturusis, Administrative Director Jose Biller, MD

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

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  1. Using a Neuroscience Diagnosis as the Patient’s Primary Risk Factor for Falling

  2. Neuroscience Fall Prevention and Safety Performance Improvement Team Darlene Bailey, PCT Leslie Barna, Manager 2 NE William Benedict, MD Barbara Buturusis, Administrative Director Jose Biller, MD Mary Healey, Manager 2 S/2 Neuro ICU Meri Hix, PharmD Corrie Husak, RN Bresha Mc Clain, RN Judy Mc Hugh, NQI, Team Leader Lisa Millsap, APN Martina Notovny, PharmD Vikram Prabju, MD Karen Potoki, APN, Risk Management Devra Romick, PT Joanne Scharnak, Nurse Educator, Team Facilitator Theresa Schwenkel, RN Liaison Kate Steinhable, Physical Therapy Educator Azucena Uy, RN

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

  4. Potential Cause of Falls Environment People Documentation Post Fall Analysis (1/06) Age Education Flowsheet Fall Section Incomplete (7-13-05, 8-10-05) Admitting Issues HX of Falls Not in EPIC (7-13-05, 8-10-05) Clutter Bedroom Plan of Care Not Documented (8-10-05) Patient Staff History Of Falls(7-13-05, 8-10-05) Over Estimate Strength & Ability Long Length of Stay IV Poles Chairs Frequent transfers Inappropriate Adm Fast Turn-over Unfamiliar Room Staff Communication Lack of Reg Rounds Not Using Equipment Fall Risk (8-10-05) Gait Belt (7-13-05, 8-10-05) Medications (7-13-05, 8-10-05) Patient Transfers Elimination Medication (7-13-05, 8-10-05) Cannot reach call light Call light too complicated Family assists patient to bathroom Not Answering Call Lights Patients At Risk For Falls Patient Decreased Sensorium Materials Confusion/Altered Mental Status (7-13-05//8-10-05) Medication (7-13-05/8-10-05) Balance Gait Postural Hypotension Call Light Issues Bed Alarm Door Reminder Risk Levels Not on Lost in covers Not available 7/05 Sedation Narcotics Sleepers Gait Belt (8-10-05) Stroke Don’t Realize They Need Assistance Sundowner Weakness Confidential: For Quality Improvement Purpose Only

  5. Solutions Implemented • Multidisciplinary Staff Education • New fall assessment flowsheets • Fall extrinsic and intrinsic factors • Appropriate Bed Alarm Use • Gait belt use and transfer competency • Fall risk associated with neurologic impaired patient • Monthly fall prevention updates

  6. Solutions Implemented • Neuroscience Safety Awareness Week • Falls in the Elderly • Is Polypharmacy Causing Acute Confusion • Touch Therapy • Guided Imagery • Gait Belt Use and Transfer Competency • Massages for staff

  7. Designed a Level 3 Fall Prevention Interventions • All neuroscience patients are at risk for falls • Increased elimination rounds to include mealtime and bedtimes • Observe patient activity ever hour or more • Implemented Bathroom Buddy- staff stays with patient during elimination • Bathroom Buddy- nursing staff stays with patient during elimination • Place patient on a BedCheck Classic bed alarm and chair alarm • Consult pharmacy regarding medications that can cause altered mental status • Repeatedly reinforced limits and safety needs to patient and family • Assign bed that enable patient to exit towards stronger side whenever possible and transfer patient toward stronger side. • Provide comfort rounds- repositioning, back rub with PM care, assisted ambulation before bedtime. • Developed Post Fall Assessment Environment Study

  8. Neuroscience Safety Awareness Week of September 26, 2005 Monday, September 26, 2005 Message of Touch Massage & Guided Imagery by Fran Glowinski, MPS, OSS 2 Neuroscience Unit 11:00 to 13:00 18:00 to 20:00 Tuesday, September 27, 2005 Lunch and Learn -Falls in the Elderly by Dr. Jose Biller Bldg. 105 Maguire, Room 2812. 11:00 12:00 Bed Check Bed Alarm Use Inservice by Bill Saemann, Macon Company 2 Neuroscience Unit 6:00 to 8:00 10:00 to 11:00 18:00 to 20:00 Wednesday, September 28, 2005 Seated Back Massage by Loyola Health and Fitness Club 2 Neuroscience Unit 6:00 to 7:00 16:00 to 17:00 Posey Restraint Use and Other Restraint Alternatives by Fred Demshar, Posey Company 2 Neuroscience Unit 11:00 to 12:00 14:00 to 15:00 Thursday, September 29, 2005 Lunch and Learn –Healing Touch by Ann O’ Malley , RN., C.H.T.P., EMS Bldg. Room 3284 11:00 to 12:00 Bed Check Bed Alarm Use Inservice by Dick Tedesco, Macon Company 2 Neuroscience Unit 6:00 to 8:00 10:00 to 11:00 18:00 to 20:00 Gait Belt Training by Kate Steinhable, PT, MPT. 08:00 to 09:00 Friday, September 30, 2005 Message of Touch & Guided Imagery by Fran Glowinski,MPS, OSS 2 Neuroscience Unit 6:00 to 8:00 Lunch and Learn –Is Polypharmacy Causing Acute Confusion In Your Patient? by Martina Novotny, Pharm. D EMS Bldg. Room 3284 11:00 to 12:00 Nursing Performance Improvement Fall Prevention Initiative 2005

  9. NEXT STEPS • Develop monthly education poster series for Medications Contributing to Mental Status Changes • Design patient and family safety education to neuroscience population • Partner with the Loyola Niehoff School of Nursing to introduce the Neuroscience Level III Fall Prevention Program into student curriculum • Integrate fall risk factors and history of fall into the Electronic Medical Record • Produce and videotape Lunch and Learn Safety Programs • Improve patient care handoff utilizing SBAR Situation, Background, Assessment, and Recommendations

  10. Catching the Safety Culture

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