Quality Improvement: Falls

1. Quality Improvement: Falls “United we stand, divided they fall” Analeissa Gutierrez, Heddy Cortijo, Jennifer Mariano, Mary Camille Salvador, Marvin Berueda, and Samuel John

2. Clinical Practice Problem: Patient Falls • An unplanned descent to the floor (trash can, door, or other equipment), WITH or WITHOUT injury to the patient • Most prevalent in-hospital adverse event (Huey-Ming, 2015.) • Leads to injury, prolonged hospital stay, increased expenses (among others) • GENERALLY PREVENTABLE!!!!!!

3. Facts about Falls Per Quigley (2013)..Cost to Hospital 3-20% of patients will experience @ least one fall Cost the hospital $3500/fall 30-51% of these falls will result in some sort of injury Cost the hospital $16,000 if two or more falls occur Costs to treat patient’s post fall equal to up to $1.08 billion per year 6-44% of these falls will result in a serious injury such as subdural hematoma, fracture, bleeding, or even death Cost the hospital $27,000 Per CDC (2016)..Cost to patient 2.5 million people are seen for falls 700, 000 patients are hospitalized for falls As of 2008, Medicare no longer reimburse hospitals for costs due to injury from a fall Fall risk increase with age Hip fracture 95% of the time are caused by falls Extended length of stay up to 12.3 days longer

4. National/State Indicators 3 different indicators: • Structural: supply, skill, and education of staff • Process: methods of assessments and interventions, job satisfaction • Outcome: nursing sensitive, depend on the quantity or quality of nursing care The National Database of Nursing Quality Indicators (NDNQI) was established by the ANA to collect information related to impacts on the quality of nursing care. NDNQI uses process and outcome for patient falls and patient falls with injury (injury level). No real indicators related to patient falls yet.

5. Institute for Healthcare Improvement (IHI) Quality Improvement Model The PDSA cycle guides the test of change to determine if the change is an improvement. Plan: Develop an action plan based on the 3 questions. Do: Take actions to test the plan. Study: Make refinements to the plan as needed. Act: Implement the changes in the real work setting.

6. Quality Improvement Tools Cause and Effect Diagrams - To brainstorm the main causes of falls, and the sub-causes leading to falls. Check Sheets - To collect data on the quality problem and identify the most important source of the problem. Pareto Charts - To plot defects, or causes of defects, graphically.

7. Examples of QI tools: Graphing data in a run chart is a good way to visually examine trends in the fall rate. The fishbone diagram that helps visually display the many potential causes or effects of a problem. The Morse Fall Risk Assessment Tool is a quick and simple method of assessing a patient’s likelihood of falling.

8. Examples of Causes and Solutions 1. Noncompliant. Patients do not call for nurse assistance 2. The bed-exit alarm is not set 3. The patient is on high-risk medications, new meds 4. The patient assessment was inadequate 5. There was a delayed response to the nurse call bell 6. Decreased mobility 7. Devices (faulty, or not using) 8. Insufficient lighting, vision impairment 9. Clutter http://www.healthworkscollective.com/chgbeds/55851/5-major-causes-patient-falls Solutions: • Patient • Environment • Staff

9. 3 EBP articles: Hempel, S., Newberry, S., Wang, Z., Booth, M., Shanman, R., Johnsen, B., ... & Ganz, D. A. (2013). Hospital fall prevention: a systematic review of implementation, components, adherence, and effectiveness. Journal of the American Geriatrics Society, 61(4), 483-494. Quigley, P., White, S., (May 31, 2013). Hospital-Based Fall Program Measurement and Improvement in High Reliability Organizations OJIN: The Online Journal of Issues in Nursing Vol. 18, No. 2, Manuscript 5. Center for Disease Control and Prevention, (2016). Important facts about falls. Center for Disease Control and Prevention. Retrieved from http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html Based on the analysis of the root cause, make recommendation to eliminate or reduce the risk of the problem reoccurring. Use at least 3 evidence-based resources to support your recommendation.

10. High Reliability Organization: Safe Reliable performance Characterized by… • Sensitivity to operations: awareness of surrounding and what’s going on within the hospital • Reluctance to simplify: be as detailed as possible, don’t oversimplify • Preoccupation with failure: use what has happened previously to plan for the future • Deference to expertise: involve all staff, and be open to others thoughts and ideas • Resilience: be knowledgeable and able to react if falls occur

11. What the patient can do: Nursing Educate • CALL for assistance • Increase strength and balance through exercise • Keep up with preventative care (ex. Vision and hearing) • Know your medications and possible side • effects • Take health advice seriously • Maintain safe environment • No rugs, cords, etc. • Railings, bars to hold on to • Lighting • Keep environment free of objects • Proper footwear • Proper maintenance of household (ex. broken stairs)

12. What can we do about it? • Fall risk assessment (Morse Fall Scale) • Purposeful hourly rounding (NA’s & RN’s) • “No pass zone!” (Answer ALL call lights) • Place call lights within reach • “High Risk for Falls” door signs, and wrist bands • Bed-exit alarm • Non-skid footwear • Moving high-risk patients closer to nurses’ station • Medication review (side effects) • Update documentation/charting

13. Data to collect to evaluate effectiveness of the recommendation To evaluate effectiveness, we will calculatefall rate & fall-related injuries (data). *Fall-prevention practices may also be evaluated. Step 1: Count # of fallsover given period (e.g. 1-mo, 3-mo, etc.) # of fall-related injuries (i.e. fractures, sprains, head trauma, etc.) **Definition of “injury” important to identify; facilities may vary # of occupied bed days, i.e. census, on unit over given period (e.g. Mar 1 = 20 beds, Mar 2 = 23 beds...Mar 30 = 9 beds → calculate 30-day total) Step 2: Calculate # of falls occupied bed days 1000 fall rate (e.g. 4 falls / 590 OBDs is 0.00677966, multiply by 1000 = 6.78% fall rate) Step 3: Visualize Graph findings (e.g. run chart) Step 4: Evaluate Look at trends (increasing, decreasing, etc.) *Based on findings, make recommendations (e.g. disseminate info, study data, run root cause analyses, suggestions for improvement, etc.)

14. References 5. How do you measure fall rates and fall prevention practices?. (2013). Agency for Healthcare Research and Quality, Rockville, MD. Retrieved from http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk5.html Hempel, S., Newberry, S., Wang, Z., Booth, M., Shanman, R., Johnsen, B., ... & Ganz, D. A. (2013). Hospital fall prevention: a systematic review of implementation, components, adherence, and effectiveness. Journal of the American Geriatrics Society, 61(4), 483-494. Hinshaw, P. (2011). The National Database of Nursing Quality Indicators (NDNQI): linking nurse staffing with patient outcomes. Arizona Nurse, 64(2), 6-6 1p. Huey-Ming, T. (2015). Patient Engagement in Hospital Fall Prevention. Nursing Economics, 33(6), 326-334. Lara-Medrana, R., Alcazar-Quinones, C., Galarza-Delgado, D. A., & Baena-Trejo, L. (2014) Impact of a fall prevention program in the internal medicine wards of a tertiary care university hospital. Medicina Universitaria, 16(65), 156-160. Mantalvo, I. (2015). The National Database of Nursing Quality Indicators (NDNQI). The Online Journal of Issues in Nursing. Preventing Falls in Hospitals. (n.d.). Retrieved from http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk5.html Tools and Strategies For Quality Improvement and Patient Quality. (n.d.). Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK2682/ What are nursing sensitive indicators anyway? American Sentinel, (2011). Retrieved from http://www.americansentinel.edu/blog/2011/11/02/what-are-nursing-sensitive-quality-indicators-anyway/