Transforming Falls Management Using Data

1. Transforming Falls Management Using Data Jo A. Taylor, RN, MPH July 24, 2013 www.ccmemedicare.org

2. Continuing Nursing Education (CNE) Credit • CCME is accredited as an approved provider of CNE by the North Carolina Nurses Association, an accredited approver of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. • CCME utilizes industry accepted mechanisms to identify and resolve conflicts of interest. The planners, faculty, and speakers for this activity have no unresolved relevant financial relationships with commercial interests that could be perceived as a conflict of interest. • CCME has received no commercial support related to this educational activity.

3. Approved by CCME for 1.0 Contact Hour of CNE Credit To Obtain Credit • Register and attend webinar. • Complete survey evaluation questions before you leave the webinar. • Complete attendance verification through the SurveyMonkey tool by August 1 at 12 noon, the expiration date for awarding contact hours. • CCME will then provide you with an attendance certificate for your records.

4. Learning Objectives • Identify a new QI framework for managing falls in nursing homes • Describe methods for data collection and analysis at both resident and facility levels • Describe critical thinking skills to reduce fall risk

5. New QI Framework for Falls Management

6. Paradigm Shift In a medical model, fall prevention makes the most sense, at any cost. In a person-centered care model, mobility moves out ahead.

7. Paradigm Shift Prevent falls • Immobilize for safety (e.g., restraints, alarms, bedrails, APs) • In rooms on long halls out of sight • Standard interventions • Less frontline input • Emphasis on staff tasks • Limited activity programs • Blame and punitive culture after a fall Reduce risk of injury • Enhance mobility to reduce risk of injury • Individualized care interventions • Neighborhoods • Resident needs • Self care, engagement • Expanded activities • Just culture • QI tools with real time problem solving

8. What You Need to Know • Best practice and clinical guidelines • Systems approach to reduce risk • QI principles for critical thinking • Data collection and analysis methods at resident and facility levels

9. Clinical Guidelines American Geriatrics Society, 2010 AGS/BGS Clinical Practice Guidelines Prevention of Falls in Older Persons http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/prevention_of_falls_summary_of_recommendations

10. Best Practice National Center for Patient Safety 2004 Falls Toolkit • Designing a falls prevention and management program • Effective interventions for high-risk fall patients • Implementing hip protectors for high-risk fall patients • Educating patients, families and staff on falls and injury prevention http://www.patientsafety.va.gov/SafetyTopics/fallstoolkit/index.html

11. Best Practice Agency for Healthcare Research and Quality The Falls Management Program presented in this manual is an interdisciplinary quality improvement initiative. It is designed to assist nursing facilities in providing individualized, person-centered care, and improving their fall care processes and outcomes through educational and quality improvement tools. http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspx/fallspxmanual.html

12. Best Practice Advancing Excellence Promoting mobility reduces the risk of a serious fall related injury. This website includes a wide variety of assessments and interventions that help staff to promote mobility in residents with all levels of function. http://www.nhqualitycampaign.org/star_index.aspx?controls=mobilityexploregoal

13. Falls in Frail, Older Adults are Multi-faceted Resident Risk Factors • Cognition • Medications • Unsafe behaviors • Acute illness • Chronic underlying conditions • Functional status Age Related Changes • Lower extremity weakness • Gait changes • Impaired vision • Slowed response time • Reduced endurance, strength

14. Falls in Frail, Older Adults are Multi-faceted Environmental Risk Factors • Noise • Flooring • Furniture • Personal items • Lighting • Equipment/assistive devices • Clutter

15. Person- centered care Best Practice Multi-factorial interventions based on identified risk factors by interdisciplinary team • High risk medications • Poor vision • Orthostatic hypotension • Impaired mobility • Unsafe behavior • Promotion of mobility • Injury prevention

16. Best Practice Injury Prevention • Mobility enhancement • Exercise specific to resident level of function for balance, endurance, flexibility, and strength • Vitamin D supplements of at least 800 IU/day • Protective gear • Promotion of mobility • Injury prevention

17. Person- centered care Fall Risk Factor + Specific Intervention • Rounding using 4 Ps • Scheduled toileting • Increased supervision, 1:1 assignment • Reduce time in bed, active engagement in self-care • Expanded activities program, Sunshine Room • Consistent assignment • Sleep hygiene • Alarm reduction • Promotion of mobility • Injury prevention

18. Person- centered care Environment and Equipment • Personalization, spaces for privacy and socialization • Noise, activity, stimulation level • High contrast • FMP Living Space Inspection • Paths • Stable furniture • Easy access • Lighting • Floor • Equipment • Foot care and footwear • Promotion of mobility • Injury prevention

19. Paradigm Shift Reactive • Focus on standard interventions • Staff oriented schedules • Signage • Alarms Proactive • Focus on cause • Anticipate needs • Individualized responses • Resident-centered schedules • Mobility

20. What You Need to Know • Best practice and clinical guidelines • Systems approach to reduce risk • QI principles for critical thinking • Data collection and analysis methods at resident and facility levels

21. Real time problem solving in a culture of safety Systems Approach • Culture, organizational commitment, teamwork • Staff education and training Best practice and clinical guidelines • Resident/family involvement • Environment and equipment

22. Real time problem solving in a culture of safety Culture of Patient Safety • Creating atmosphere for reporting errors without punishment • Making it easier for personnel to admit they made a mistake • Focusing on the system, not individual • Accountability but no blame or shame for falls • “Just Culture”

23. What About Your Activity Culture? A full, robust activities program increases supervision and safety as well as promoting socialization and enhanced function. Where is your culture in terms of activities and mobility? • A safe culture includes multiple activities throughout the day and evening and on the weekends including activities for residents with dementia. • Are there residents in their rooms, alone, bored and uncomfortable in poorly fitting wheelchairs? • Are there residents grouped up waiting for meals without any activity or supervision? • How mobile are your residents? • Promotion of mobility

24. Real time problem solving in a culture of safety Empowered Teams: Communication Across Shifts • How do CNAs communicate changes in fall risk from shift to shift? • Behaviors • Dizziness • Weakness • Fatigue • Vision • Urgency, frequency Do staff members walk on the unit cold?

25. Real time problem solving in a culture of safety Investigate Circumstances FMP 8 Step Fall Response Post Fall Huddle on Unit

26. Staff Education and Training • In-service content • Handouts • Pre- and post-tests • Case examples • Program examples www.joataylor.com/resources • Presentation by Sue Ann Guildermann • Tools and materials www.ccmemedicare.org Register My CCME Access code: ACEProgram

27. Resident/Family • Involvement from day one • Education about your policies and procedures • 0% restraint use • Reducing alarm use • Mobility over immobility • Participation in care • Awareness of falls management practices • Promotion of mobility • Injury prevention

28. Resources for Families Ways Families Can Help Reduce Fall Risk and Reducing Falls: A Safety Checklist for the Home. FMP Manual. http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspx/fallspxmanual.html The False Assurance of Resident Alarms and Fall Management Program by Empira. www.ccmemedicare.gov Login to MyCCME. Access code: ACEProgram. Clinical topics: falls. A Family’s Guide to Bed Safety. www.ofmq.com/Websites/ofmq/Images/NEWBedSafetyBrochure.pdf

29. Administrative Commitment • Protective devices (e.g., helmets, wrist protectors, hip protectors) • Signage, high contrast • Range of activity supplies, music • High/Low beds, mats (for specific needs), bolsters, pillows • Individualized wheelchair seating • Specialized chairs • Merrywalkers, walkers, canes, reachers • Staff time for weekly meetings and supervision • Expanded activities program • Active therapy role • Promotion of Mobility • Injury prevention

30. What You Need to Know about Falls • Best practice and clinical guidelines • Systems approach to reduce risk • QI principles for critical thinking • Data collection and analysis methods at resident and facility levels

31. Critical Thinking • Basis of good nursing process and quality improvement • Vital to falls management, restraint elimination, and alarm reduction because of complexity associated with reasons for use

32. Absence of Critical Thinking Common signs: • Routine list of possible interventions • High alarm use • Restraint use • Antipsychotic medications • Lack of resident and family input • Lack of resident choice • Low involvement of frontline staff • Poor resident outcomes

33. QI Tools for Critical Thinking • Root cause analysis, 5 Whys, brainstorming • PDSA cycles of change • Standardized assessment and investigation tools • AGS/BGS clinical practice guidelines • Falls toolkit on VA site • FMP on AHRQ site

34. What You Need to Know • Best practice and clinical guidelines • Systems approach to reduce risk • QI principles for critical thinking • Data collection and analysis methods at resident and facility levels

35. Data Based Decisions Collect the right data Enter the right variables and analyze Implement and monitor Make the right conclusions to make better decisions

36. Reporting Process • Everyone know the definition? • Everyone reporting all falls? • Even found on floor without injury? • Lowered to floor? • In a culture of safety all falls, near misses, and concerns are reported. • 30-40% of those who fall, will fall again. • Prior fall is most powerful predictor of future risk.

37. Facility - Macro Level • Generate monthly reports on: • # of falls • # of fallers • # of serious injuries, fractures • # of recurrent fallers Trend over time for patterns • No national benchmark for falls in nursing homes • 1 in 2 residents or 50% of all NH residents fall annually • 1 in 3 community dwelling older adults fall annually

38. Graphs Run Chart # of Falls in 12 Month Period Months (2013)

39. Fall Incidence Rate Number of falls X 1000 = fall rate Number of resident days (Number of resident days = average daily census multiplied by # of days in month) Time period is usually one month. Fall rate is adjusted for resident census and compared across units and facilities.

40. Example Unit B had an average daily census of 32 residents for the month of July (31 days) = 992 resident days. There were 15 falls on that unit for that month. 15 divided by 992 multiplied by 1000 = 15% fall rate Unit A has an average daily census of 23 residents for the month of July (31 days) = 713 resident days. There were 5 falls in that unit for that month. 5 divided by 713 multiplied by 1000 = 7% fall rate

41. Fall Injury Severity Number of injuries X 100 = fall injury rate Number of falls Example Minor injury rate = 5 minor injuries divided by 80 falls per 100 falls = 6.25% Major injury rate = 3 major injuries divided by 80 falls per 100 falls = 3.75%

42. Recurrent Falls • 30-40% of residents who fall will fall 2 or more times. Residents with 2 or more falls X 100 = % of residents > 2 falls Total residents who fell Example 25 residents fell 2 or more times in July. Total number of residents who fell in July was 36. 25 divided by 36 multiplied by 100 = 69 Sixty-nine percent of those who fell in July fell 2 or more times.

43. Drill Down the Data Variables will help you get at the root cause. Staffing patterns • Time • Location and unit • Shift • Day of week • Mealtimes • Change in shift

44. Drill Down the Data Resident Variables • Personal agenda • Evidence of incontinence • Toileting routine • Direction • Location • Meds • Pain • Footwear • Vision • Acute conditions such as BS, VS, Pulse Ox, low blood pressure

45. Drill Down the Data Equipment and Environment • Wheelchair placement, brakes • Bed placement, wheel locks, height, side rails • Pathways • Lighting • Assistive devices • Flooring • Call bell, personal items • Alarm

46. Making Data Useful • We had a spike in falls last month. It must be a late flu season. It’s that time of year. VS • We had a 25% increase in falls in Jan-Feb. Sixty percent of the residents that fell did so while they had the flu or in the following 30 days. • Falls in last 6 months compared to same period in prior 3 years • Rate of flu illness • Prophylaxis treatment • Other acute illnesses • Resident variables • Staffing variables

47. Making Data Useful • We have a lot of falls on our dementia unit. Must be because of so much confusions and unsafe behaviors. VS • 50% of all falls in our building occur on the dementia unit. 70% of those falls occur between 5-9 p.m. Staff input tells us they are busy, noisy, and chaotic at that time. • Time of day • Shift • Day of week • Location • Staffing • Rounding • Noise level, confusions • Resident needs

48. Examples of Facility Level Analysis • Large % of new admissions falling – hourly rounding with 4 Ps • Large % of residents falling during unsafe toileting – Voiding diaries, increase and match toileting to specific needs • Large % of falls on third shift – management presence with emphasis on accountability for rounding, sleep hygiene, individual patterns and needs • Large % of residents falling while alone in room during day shift – examination of activities program and culture of participation, increased activities, mobility

49. Real time problem solving in a culture of safety Resident – Micro Level • Empowered Teams: Post Fall Huddle • On unit • Immediately after fall • Frontline staff involvement • Deep root cause analysis and critical thinking • Specific strategy development

50. Real time problem solving in a culture of safety Real Time Problem Solving • Date, day of week • Time, shift • Location • Position, direction • Cause • Activity, personal agenda • Admission date • Bed height, wheels • W/C brakes • Footwear • Aid • Restraint • Side rails • Mental status • BS, HR, BP, temp • Injury • Meds • Last toileted • Variation from baseline