VISN 8 Patient Safety Center of Inquiry: Journey for Change: Innovations to Reducing Fall Incidence and Injury Session

1. VISN 8 Patient Safety Center of Inquiry: Journey for Change:Innovations to Reducing Fall Incidence and InjurySession 2 Thursday, Nov 8, 2012

2. Program Goal To provide VHA healthcare and quality teams with tools and strategies to reduce preventable falls incidence, injury from falls and outline key components of sustaining and spreading successfully.

3. Objectives • Inventory tests of change in fall and injury prevention interventions • Differentiate types of falls as a basis for analysis of program effectiveness • Integrate injury prevention into existing fall prevention programs • Summarize successes ready for adoption and spread

4. Looking Ahead Eight Sessions of Learning and Sharing • Oct 25th: State of Science of Falls and Injury Prevention • Nov 8th: Integrating Falls and Injury Assessment • Nov 29th: Interventions to Reduce Falls and Harm, Part 1 (Equipment and Technology) • Dec 20th : Sustain and Spread Improvements in Reducing Falls and Injury from Falls • Jan 3rd: Injury Risk Assessment and Communication of Risk • Jan 17th: Interventions to Reduce Falls and Harm, Part 2 (Intentional Rounding, Pre-shift Huddle, Post Fall Huddles) • Jan 31st: Use of VANOD, NDNQI and SPOT Databases for Fall Program Evaluation • Feb 7th: Summary of Your Accomplishments

5. Session 2: Integrating Fall AND Injury Risk • Integrate Fall Risk Screening, Assessment and Comprehensive Assessment • Apply Clinical Judgment and Expertise to Patient Care and Vulnerable Patients • Utilize the ABCS Framework to segment vulnerable patients, focusing on both fall and injury risk • Examine new patient learning strategies for care transitions.

6. But first… Let’s hear from you! Report on Session 1 Assignments: Who would like to share???? Your aim statement(s) for fall work including the fall risk assessment tool AND risk for injury tool that you are using or will be utilized. What did you learn from analyzing the gap between current performance and stated aim Who audited last 5 falls with serious injury using Injurious Fall Data Collection Tool What did you learn from your teams when completing your baseline team assessment: Preventing Falls with Injury

7. Differentiate Risk Screeningfrom Assessment • Screening • Disease Detection • Who should undergo diagnostic testing for confirmation- Cut off point to be negative or positive • Assessment - Comprehensive • Data for differential Diagnosis

8. Morse Fall Scale Properties Sensitivity: 78% (a/a+c) (proportion of those who fall and identified at risk by test) Specificity: 83% (d/b+d) (proportion of those who are free of fall and identified not at risk by test) PPV 10.3% (proportion of those with risk who fall) NPV 99.2% (proportion of those with no risk who are free of fall) 100 falls, 4,000 control (due to fall rate X 1,000 pt days of care); 82.9% of cases classified correctly

9. Fall and Injury Risk • Across settings, must have population-based approach to fall prevention • Falls are caused by complex interaction between the individual and the environment • Many effective interventions include multiple components that address a variety of risk factors, such as gait, balance, neurological functions, and medication

10. Most effective, fall prevention interventions should be targeted at both point of care and strategic levels • Best Practice Approach in Hospitals: • Implementation of safer environment of care for the whole patient cohort (flooring, lighting, observation, threats to mobilizing, signposting, personal aids and possessions, furniture, footwear • Identification of specific modifiable fall risk factors • Implementation of interventions targeting those risk factors so as to prevent falls • Interventions to reduce risk of injury to those people who do fall (Oliver, et al., 2010, p. 685)

11. Fall Risk Assessment Template

12. Fall Risk Assessment Template

13. Fall Risk Assessment Template

14. Fall Risk Assessment Template

15. Fall Risk Assessment Template

16. Fall Risk Assessment Template

17. Ambulatory Care AGS, BGS Clinical Practice Guidelines 2010: evention of falls in older adults. • Assessment • Interventions • Evidence Grades • Bibliography • www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2010

18. AGS Guidelines 2010 Assessment Interventions

24. Hospitals (Oliver, et al., 2010) • Patient-specific factors: intrinsic risk factors, the physical environment, and riskiness of a person’s own behavior • Recent fall (fallers);muscle weakness; behavioral disturbance, agitation, or confusion; urinary incontinence or frequency; prescription “culprit” drugs; postural hypotension or syncope. • Risk increases with advanced age, w/ the highest rates seen in the “oldest old”, older than 85 yoa

25. Mental Health Units • Dementia leads to greater risk associated with wandering, restlessness, and dementia-related gait distrubances, and syncope/pre-syncope • Dementia effects 1 in 3 patients older than 65 admitted to general hospitals and delirium has similar prevalence • Those with greatest risk of delirium (and falls) are those with underlying frailty or cognitive impairment

26. Hospital Environments • Unfamiliar environment • Poor lighting • Trip and slip hazards • Suboptimal chair and bed heights • Availability of mobility equipment • Staff availability and attitude

27. Empiric Evidence for Fall and Injury Prevention in Hospitals • Multifactorial (note * no two trials bundle the same interventions) components mostly seen is successful trials • Post fall review, patient education, staff education, footwear advice, toileting • A couple of trials included medication review and prevention and detection of delirium • Patients themselves favored multifactorial approach reviewed by a health professional

28. Multi-Professional Involvement is Essential • No hospitals trials that focused solely on changing nursing practice succeeded in reducing falls or injuries, as is also the case in care home settings

29. Single Interventions in Hospitals • Exercise or Additional PT (RCTs insufficiently powered to detect effect in reducing falls) • Increased observation or assistance – intuitive sense but anectodal • Patient Education – multi-media education with trained health professional follow-up has promise to be beneficial in preventing falls • Specialist Support to Manage Dementia – only 1 trial, no difference • Cal / Vit D: effect determined after discharge • Hip Protectors (no trials in acute care; adherence issues in hospitals) • Flooring to reduce impact: promising • Medication Review and Adjustment: requires specialist pharmacist • Prevention and Management of Delirium

30. Single Interventions without Empiric Evidence • Continence management or promotion • Education and training for staff or relatives • Correction of visual impairment • Recognition or management of dizziness, syncope, pre-syncope, or postural hypotension • Attention to footwear • Environmental modifications (including flooring materials) to prevent falls or injuries

31. Fall Prevention in Nursing HomesWell-established Fall Risk Factors (Becker & Rapp, 2010. Prevention of falls in Nursing Homes) • Muscle Weakness • Balance and gait deficits • Poor vision • Delirium • Cognitive impairment • Functional impairment • Orthostatic hypotension • Urinary Incontinence • Nocturia • Comorbidities: Dementia, depression, stroke, Parkinson Disease • Side effects and interactions of drugs • Reduction in dynamic balance, attention, and dual tasking capacities

32. Interventions • Multifactorial program (unable to tease out effects of single components) • Most successful programs include knowledge improvement, attitudinal change, and staff empowerment • Nursing staff – critical to assessment, implementing change and adherence • Interdisciplinary communication – the second most important component

33. Interventions • Close interaction between caregivers and physician to deliver measures that immediately compensate for functional loses (toileting, assisted transfers, advice to wear hip protectors) • Environment: optimal chair and toilet height, lighting, pathways (walking patterns), shock absorbing floor surfaces in very high risk injury areas (bed and bathroom areas) • Protective Clothing • Training, use and access to assistive devices • Exercise (failed to reduce falls as a single intervention in LTC; must be part of a multifactorial program) • Vision • Incontinence • Medication review • Bone health

34. Fall-related Injuries Osteoporosis/Fractures • Hip • Pelvic fractures • Upper limb • Spine • Skull Subdural Bleeds

35. Clinical Judgment • Evidence-based Practice • Vs • Results of Scientific Inquiry

36. Let’s Focus on Specific Groups How many of you focus on those at Low to Moderate (<45) risk for falls or those at High Risk (45 and higher) for • What does your staff do different for these pts? • How does your organization help you protect these pts? Think differently: What is the score and what is driving the score! Then… only screens – move to assessment • Those who are Known Fallers? • Those At risk for Serious Fall-related Injury? • Those with Known hx of fall-related injury?

37. Known Fallers • Those who enter your care because of a fall (a fall-related admission) • How do you ensure a safe environment before the pt gets in the bed? • How does the protection plan vary from those at risk for falls?

38. Moderate to Serious Injury • Those that limit function, independence, survival • Age • Bones (fractures) • C: Anticoagulation or clotting disorders (hemorrhagic injury) • Surgery (post operative)

39. Framework for Injury Risk Screening Age:  85 years and older Bones:  sample questions to ask: Diagnosis of Osteoporosis:  yes / no   (if yes, when:           ) • If No, Presence of Osteoporosis Risk Factors:  yes/no History of Fracture:  yes/no • Hx of Hip Fracture:  yes/no C: Anticoagulants:  sample questions to ask: Current treatment for anticoagulation:   yes / no • If yes, which meds: History of anticoagulation:  When started:    When stopped S:  Surgery- Post Op/Post Procedure

40. Communication With Patients/Staff about Fall Reduction/Injury Prevention Label or signal patients assessed as known faller or risk / history of mod-serious injury • Use signage/other visual indicators (bracelets, colored socks, special blankets, etc.) Ensure Safe Handoffs • Verbalize and repeat-back risk of fall and risk of harm from fall at change of shift • Verbalize and repeat-back risk of fall and risk of harm from fall between departments Discharge Planning and Follow-up • Ask the 85 yo on follow-up about falls after discharge

41. Patient Education Materials • Healthy Bones – Osteoporosis: pt education brochures / video on the VISN 8 Patient Safety Center/Falls Team website • What to do if you fall and you are on blood thinners – Given to any patient on Anticoagulation • Hip Protectors – Falls Toolkit Media Box – pt and family (and caregiver education), patient education brochures • Other education materials you are using? Integrate into practice: • Teach in All Settings: Home Care -PCC –ER - Hospital - Rehab Units • Add to Standards of Care / Practice • Complete reliability checks (medical record review, staff use, patient learning)

42. 5 Essentials to Protect from FRI You can protect patients from injurious falls

43. Resources: • http://www.visn8.va.gov • /patientsafetycenter/fallsTeam/default.asp

44. Session 3 Interventions to Reduce Falls and Harm, Part 1 (Equipment and Technology) • Faculty: Mary Watson, MSN, RN, GCNS-BC, Falls Clinical Specialist at Little Rock Arkansas VA • Discussion: Interventions to reduce falls and falls harm will be discussed. These include an assessment of the environment (eliminate sharp edges, non-skid safety rails, and ensuring a “safe exit”); use of low beds, bed alarms, floor mats, hip protectors, gait belts; and bathroom safety (raised toilet seats, safety rails)

45. New Tests of Change • New Clinical Practices • New Patient Education Strategies • New Environmental Safety and Technology Innovations

46. Organizational Self Assessment • Complete your self assessments • Part A: Organizational Level • Part B: Unit level • Complete one part

47. Assignments for Session 3 • Review patient education materials for protection from injury • Complete 2-3 patient education sessions and describe experiences with patient/family learning • Complete prior planned small tests of change • Complete self assessment – one part at organizational or unit level • Select one population among ABCS, 1 or 2 patients, and determine if injury reduction strategies in place.

48. Next Session Thursday, Nov 29th , 2012 12N-1PM ET