Fall Prevention in Inpatient and Outpatient Units

1. Fall Prevention in Inpatient and Outpatient Units Essential Hospitals Engagement Network November 19, 2013

2. Our new Name We’ve rebranded! The National Association of Public Hospitals and Health Systems is now America’s Essential Hospitals. Although we’ve changed our name, our mission is the same: to champion hospitals and health systems that provide the highest quality of service to all by achieving the best health outcomes for every patient, especially those in greatest need. The new name underscores our members’ continuing public commitment and the essential nature of our work to care for the most vulnerable and provide vital community services, such as trauma care and disaster response. This is an exciting time for us and our members, as we lean forward into new care models, opportunities and challenges of reform, and quality and safety innovations that often take root in our member systems. Our new website address: www.EssentialHospitals.org

3. Chat feature The chat tool is available to ask questions or comments at anytime during this event.

4. Raise Your Hand To raise your hand – you must be in the “Participants” pane. Your line will be un-muted to ask your question. Once your question has been answered, plus un-raise your hand.

5. Speaker information Vickie Sears, RN, MS Improvement Coach EHEN Carol Boylan, MSS, LCSW Director, Psychiatric Medical Care Unit Hahnemann University Hospital Philadelphia, Pennsylvania Stefania Kaplanes, MSW Injury Prevention Specialist Alameda Health System Highland Hospital Oakland, California John Young, RN, MBA Improvement Coach EHEN

6. Agenda • Falls work in EHEN and Partnership for Patients • Feature falls prevention strategies in inpatient behavioral health and ambulatory elder populations • Q & A • Wrap-up and announcements

7. Partnership for patients

8. EHEN falls Results (as of June, 2013)

9. Risk Factors for Falls in Psychiatric Inpatient Units and Tools to Prevent Falls Carol Boylan, MSS, LCSW Director of the Psychiatric Medical Care Unit Hahnemann University Hospital Broad & Vine Sts.  MS 302 Philadelphia, PA  19102 tel: 215-762-4684 fax: 215-762-3104 pager: 215-762-7243 pin: 41693 carol.boylan@tenethealth.com

10. Hahnemann University Hospital A 496-bed academic medical center in Philadelphia, Pa.  In 2009, Hahnemann earned Magnet® designation. The Leapfrog Group awarded Hahnemann with an “A” Hospital Safety Score in the spring of 2012 and 2013. U.S. News & World Report ranked 5 medical specialties at Hahnemann among the top 50 in the nation and 11 medical specialties as high-performing in the Philadelphia metro area.

11. Psychiatric Medical Care Unit • In 1983 the Psychiatric Medical Care Unit (PMCU) opened a 20 bed acute locked unit to address the special needs of co- occurring psychiatric conditions and medically compromised patients along with care to individuals with co-occurring drug addictions. • We specialized in adult patient programing that bridges healthcare systems to address the holistic needs of the acute mentally ill people in recovery

12. Reasons for Psychiatric Medical Care Units Multiple studies document a higher prevalence of chronic illnesses such as diabetes, respiratory disease, hepatitis B and C, and HIV.5 Depression increases risk of cardiovascular diseases and diabetes.6 Schizophrenia may predispose persons to metabolic syndrome, hypertension, and obesity.7 Fifty percent of patients affected by mental illness are diagnosed with a known medical disorder. Thirty-five percent of these patients have undiagnosed medical conditions and one in five has a medical problem that exacerbates their psychiatric condition(s).8

13. Risk factors for falls • Although previous studies have aimed to identify risk factors for falls, few have focused on falls in psychiatric hospitals where many patients are taking psychotropic medications. • Risk factors for falls frequently associated are sedative medications, urinary urgency, history of falls, diagnoses, mental status and ambulatory aid/gait. • Reducing the risk of patient harm from falls is one of the stated goals of the Joint Commission on Accreditation of Healthcare Organizations. • Falls prevention protocol activated at Hahnemann and a Shared Governance Committee reviews cases weekly for areas to improve and new techniques to roll out.

14. Risk Factors on Psychiatric Units • People admitted to inpatient psychiatric care are at a higher risk for falls due to the nature of care which promotes mobility, independence with self-care activities, community style dining and interaction of patients in a group setting. • Psychopharmacology also impacts the risk for falls due to the sedating side effect of certain medications such as Ativan and Clonazepam. • Co-occurring medical and psychiatric disorders such as management of heart disease and diabetes with depression may impact the person’s awareness of their environment. • People with co-occurring substance and mental health illnesses have an increased risk for falls due to withdraw symptoms. • Impulsivity and active psychosis may also increase risk for falls due to increase in behavioral actions.

15. Preventing falls Upon admission patients are screened for falls by using the Morse Fall Scale risk screen. Nurses complete risk assessments during each 12 hour shift and document any changes. Information is shared at change of shift reports. Patients at risk are educated on fall prevention, given clothes that prevent tripping and fall socks to prevent slipping. Daily interdisciplinary treatment meetings occur twice a day to review at risk patients. Review of medications, behaviors, symptoms, mental status, sleep, nutrition and ambulation are discussed to continuation of safety plan.

16. Preventing falls… • Treatment plans are developed for patients at risk for falls and consideration is given to medication use, dosages and management of behaviors. • Uses of traditional bed alarms are considered only as a last resort due to the increase risk of use to harm self or others. • 1-1 unit companion use is recommended to help reeducate the patient and support the patient with their psychiatric treatment.

17. What has been the best intervention? • Safety Huddles • Review of high risk patients multiple times during the day and night gives the treatment team the opportunity to be proactive rather than reactive. • Staff sharing observations and changes in patient behaviors allow for treatment interventions to be quickly altered to meet the patient’s needs.

18. 2012 PMCU Fall Rates 7 Falls No injuries

19. HIGHLAND HOSPITAL Stefania Kaplanes, MSW Injury Prevention Specialist Trauma Services Alameda Health System: Highland Hospital Oakland, CA skaplanes@alamedahealthsystem.org The Fall Prevention Center

20. Projected Senior Population Growth 2005 – 2030 RAND Roybal Center for Health Policy Simulation

21. Incidence • 30% of community-dwelling people over the age of 65 fall each year • Increases to ~50% for those 80 years and older • Half are repeat fallers • If you’ve fallen once….

22. Falls Cause Morbidity and Mortality • 2.2% of injurious falls death • Cost of fall-related injuries for 65+ • $20.2 billion in 1994 -> 32.4 billion by 2020 (in 1994 dollars) • Injuries are common: • 40% of falls result in minor injuries • 10% result in major injuries • Fracture, soft tissue injury, TBI

23. The LaunchFall Prevention Center (FPC) • Initial Discussions and Research • Senior Injury Prevention Program (SIPP) & Community Partners • Trauma Director • Trauma Team Residents • ED Physicians • Out-Patient Clinics • Out-Patient Physical Therapy

24. fall prevention Continuity of Care • The Issues: • Early identification of those at risk • Who’s responsible

25. SolutionsThe fall prevention center • Emergency Department Staff • Out-Patient Clinic Staff • Discharge Planners

26. fall prevention Continuity of Care • The Issues: • How are those at risk identified • What is done with those at risk • Time lapse in setting follow-up appointments

27. Referral Guidelines • *Abnormal get Up and Go (>13.5 sec) • *60 years old or older (no age turned away) • *Previous Fall/s • *Balance or Gait Problems • *Dizziness • *Vision Problems • *Polypharmacy or High Risk Medications • Psychotropic: • Neuroleptic/Antidepressant • Benzodiazepine, Sedative, or Hypnotic • *History of Stroke or Parkinson’s • *Recent Acute Illness or Injury • *Recent Weight Loss • *Fear of Falling

28. The Fall prevention center • What happens next • Referral made to the FPC • Reminder call made to patient • Importance reinforced • Reminded to bring all medications • Herbs, Vitamins, OTCs

29. The fall prevention center • AT THE FPC • Medication Review by: • Clinical Pharmacist • Screenings by: • Physical Therapy • Occupational Therapy • Fall Prevention Education by: • EMS Educator & Patients* • Geriatrician Consult • as needed • It’s a family affair!

30. MaterialsFall Prevention Center • For Staff • Data • Fall Risk Pocket Cards for MDs • For Patients • Follow-up Letter • Medication Mgmt Form • Fitness Checklist • Fall Prevention Manual • Local Resource Information • Dynaband • Pedometer • Cook Book • Pill Box • Local Walking Groups • Home Safety Resources

31. Highland’s diverse world

32. Mrs. B & lastreshermanas Mrs. B 88yoF; resides alone Brought all meds Pharmacists asked which ones she takes at night? “Well dear….the ones on my dresser by my bed” Las Tres Hermanas 98yoF 95yoF 89yoF Sisters living independently with each other. THANKS FPC!

33. Out-patient Physical Therapy • Special block set aside for quick apt • Clinics • Primary Care MD for Follow-Up • With notes from FPC staff • Community Programs • Physical Activity • Home Modification • Social ReferralsFall Prevention Center

34. Is a Work In Progress and will hopefully in the future include: • Podiatry • Vision • Visit Fall-Risk In-Patients at bedside before discharge • Research and Include additional Resources • Inform/Educate All Staff re: resources • Wii Fit and Balance • Tai Chi • Annual FPAW • Neuro Psych Consults The fall prevention center

35. 100% of our FPC participants have not returned to Highland Hospital Trauma Center due to a fall. THE RESULTS………

36. Fall Prevention Center Mission • The Fall Prevention Center’s mission is to identify older adults who are at risk for a fall and provide them with assessments, screenings, education, resources, and interventions that will decrease their fall risk and thereby reduce the number of preventable falls suffered by older adults in Alameda County.

37. To help ensure that continuity of care for older adults at risk for a fall is provided by: • Early Identification • Quick Appointment at the FPC • Needed Interventions Received in a Timely Manner • Follow up by their primary care physician GoalsThe fall prevention center

38. Recognition • Alameda County Board of Supervisor’s Commendation (2010) • United States Congressional Recognition (2010)

39. THANKS EHEN FOR ALLOWING ME TO SHARE ALAMEDA HEALTH SYSTEM: HIGHLAND HOSPITAL FALL PREVENTION CENTER!

40. Q & A

41. Thank you for attending! • Patient and Family Engagement Webinar – December 3 @ 2pm ET The Patient Advisor’s Voice in Patient and Family Engagement Speakers: • Sharon Cross, LISW, Patient/Family Experience Advisor Program Manager, OSU Wexner Medical Center Patient Experience Department • Cortney Forward, Patient Family Experience Advisor, The Ohio State University Wexner Medical Center • Evaluation: When you close out of WebEx following the webinar a blue evaluation will open in your browser. We greatly appreciate your feedback! • Essential Hospitals Engagement Network website: http://tc.nphhi.org/Collaborate