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1. Clinical Academic Project Presentation VIVIAN BALDOVINO
KENELENE MALLARES
MARILOU ROSARIO
KHAM THAI
2. Introduction Problem
Increasing fall or injury rate on a medical telemetry patient care unit with high fall risk patients (elderly patients).
Falls create high medical expense.
Target population
All patients admitted to 9T
3. SLEH – Monthly Unit Fall & Injury Trend Report
4. SLEH – Monthly Unit Fall & Injury Trend Report
5. SLEH – Monthly Unit Fall & Injury Trend Report
6. Introduction Purpose of proposed CAP
Creates high patient satisfaction
Decrease in medical expense
Improve quality of care
Improve quality of life
7. Needs Assessment Medical telemetry 34 bed (adult)
Fall tracking awareness
Sharing information with staff
Resources- staffing matrix according to patient acuity
8. Needs Assessment Individuals involved
Nurse Manager/Asst. NM
MS Education Specialist
Staff nurses
Patient care assistants
Unit secretary
Patient’s family and significant other
9. Review of Literature Patient falls were significantly reduced only during the one-hour experimental rounding (Meade, Bursell, & Ketelsen, 2006).
Early identification and full assessment of individuals at particular risk (Campbell, 2006).
10. Project Model Purpose and Goals
To reduce fall and injury rates (per 1000 patient days) < 2 over a period of four months
Methodology
PDSA tool
11. PDSA Tool
Plan
Institute hourly rounds protocol on 9T
Communicate protocol to staff, patients, and families/significant other
Track number of patient falls
12. PDSA Tool DO
Develop hourly rounding protocol
Even hours- RNs
Odd hours- PCAs
Develop communication mechanism
Provide training to nursing staff
Plan kick-off date
Conduct 120 day pilot data review
13. PDSA Tool
STUDY
Evaluate monthly fall and injury rate.
Analyze and compare to previous results
Call light numbers
Patient and family satisfaction
Staff satisfaction
14. PDSA Tool ACT
ASSESSMENT
ASSESSMENT
ASSESSMENT
Review of HENDRICH’s fall risk assessment
Institute “HUDDLE” per SLEH protocol
15. Projected Cost Analysis
FTE
8 hour project preparation
Ongoing analysis- 4 hr monthly
16. Evaluation
Evaluate fall and injury rates after 120 days pilot by comparing results prior to pilot.
Significant improvement- implement to 15T and 24T
If not- start over for another 120 days.
17. Evaluation Effectiveness
Staff commitment
Management support
SLEH commitment
Adequate staffing- staffing matrix
18. Conclusion
PDSA
HENDRICH’s fall risk assessment tool
HUDDLE at shift change
19. Conclusion Strengths
Staff commitment
Management commitment
Weaknesses
Staffing issues
Time management
20. References Campbell, J. (2006) How do we apply the results of falls prevention trials in the real world? Internal Medicine Journal, 36 (Suppl. 5) A163-A188
Meade, C., Bursell, A.L., & Ketelsen, M. (2006) Effects of nursing rounds: On patients’ call light use, satisfaction, and safety. American Journal of Nursing, Vol. 106 (9), p. 58-70