Embed Size (px)
Citation preview
Carrots, sticks and meerkats - changes to
falls prevention and management in SA
hospitals
Preventing falls in the hospital setting seminar - Centre of Research Excellence
in Patient Safety, Dec 2012
Michele Sutherland Safety and Quality Unit, SA Health
SA Health
SA Icons
> Haighs chocolates > Grange Hermitage > Hills Hoists > Coopers beers > Farmers Union Iced Coffee > Pie floaters > Frog cakes > MR58
SA Health
South Australia > Fifth largest population of Australia - 1.7m > 72 % live in Adelaide > 20% born overseas > Local Health Networks – 3 metro, one
country, and women's and children’s. > Metro hospitals 2 large, 4 medium and 1
small, 3 rehab sites > Approx 60 Country hospitals, half beds are
aged care > Second ‘oldest’ state > 30,000 nurses > First falls prevention clinic in 1996
SA Health
What will be covered
> Sticks - How is falls prevention organised in SA? • Governance and Committees • Policies
> Carrots - What resources are available? Protocols and education materials
> Meerkats - Who are the key drivers and who is being towed?
> Learnings - Incident data – what it tells us and how we can use it?
> Musings for the future
SA Health
SA Health
How is falls prevention organised in SA?
1. Governance and Committees > SA Safety and Quality Strategic Group
(exec level) > SA Fall and Fall Injury Prevention and
Management Advisory Group > Each Local Health Network has a Clinical
Governance committee, with a Falls Prevention Group
> Each site has a committee / work group
SA Health
How is falls prevention organised in SA? (Sticks) 1. Policy > SA Health Policy Directive > SA Health Guideline > Accreditation to National Safety and
Quality Health Service Standards (2011)
> Preventing Falls and Harm from falls: Best Practice guidelines for Australian Hospitals, Community Care and Aged Care (ACSQHC, 2009)
SA Health
Policy Directive and Guideline
These describe: > Principles > Standards * (CEO KPIs) > Roles and responsibilities > Identifying consumers at risk > Managing consumers at risk > Managing consumers who have fallen > Incident reporting > Health workers education/training > Safe environment
SA Health
Carrots - What resources are available?
SA Health
Protocols and education materials (Carrots) Safety and Quality Unit’s role is to support health services to bring practice in line with best evidence, and to be able to demonstrate this in order to meet accreditation and policy standards > Toolkit
• Decision-making tools and protocols • Audit tools
> Training materials • E-learning package • Falls Prevention leaders
SA Health
How many people are directly involved in falls prevention?
> In Department there are approximately 2 in the falls team
> Each Local Health Network has approximately 3 people working on falls prevention – staff of falls prevention clinics, assessment and triaging, development of referral pathways, including discharge, emergency
> Hospital Fall Prevention Leaders and Falls nurses
SA Health
Toolkit and other materials • Post fall management protocol • 9 Consumer information leaflets • Risk assessment form • Post fall team review
> Other • Falls Awareness Month materials • Audit tools • Template TOR falls committee • Accreditation resource
SA Health
Fall risk assessment in SA
> Falls screening > MR58 and 58a
• Falls prevention decision-making tool • Falls Intervention deployment system
> MR 58 • 6 questions, plus discharge • Questions match with incident report
and post fall team review protocol > MR58a
• Required for patients with fluctuating risk, and completed each shift
SA Health
Questions > Does the patient have a history of falling? > Is the patient at increased risk of injury or
harm, should a fall occur? > Does the patient have a condition(s) affecting
his/her behaviour, cognitive state, risk-taking, judgement or insight into own physical ability?
> Is the patient taking medication(s) that can affect reaction times, motor function, cause dizziness, postural drops in BP or drowsiness
> Does the patient have a condition(s) or disability that affects his/her ability to transfer and/or mobilise steadily and safely?
> Will the patient still be at risk of falls or injury after discharge?
SA Health
Form includes: > When and how to use the form > The back page of the form has a list
of recommended actions associated with each identified risk factor. This guides staff re evidence based strategies for eliminating or reducing the identified risk factors.
> Guidelines for patient environment set-up. After the assessment has been completed to guide environmental considerations, to match the identified risk factors.
SA Health
MR58a Where a risk factor is present. It is a shift by shift summary of: > aids / assistance required for bed,
chair, toilet, mobility > continence strategies > dizziness and strategies > medication > behaviour > pain > feet / footwear
SA Health
Training
> Falls Prevention Leader training > Teaching packages for all elements
of the toolkit > Fall incident reporting guide > SA Falls Forum > E-learning package
SA Health
Falls Prevention Leader training
Over 300 FPL – at least one in each site > Training
• Self-directed learning (knowledge) • 2 day workshop (skills) • Follow-up support – monthly newsletters,
annual updates, networks
> Role • Falls committees • Information / communication • Feedback / consultation
> Train the leader / train the trainer model
SA Health
Who is leading and who is being towed?
> Change Champions > Falls Prevention Leaders > Others, including S&Q managers
and clinical educators > April in SA is Falls Awareness
Month – a fun way to be a champion
SA Health
SA Health
SA Health
Meerkats
> Why meerkats?
SA Health
SA Health
Purpose of incident reporting - improve patient safety
> Analysis of single incidents – propose solutions for that patient
> Analysis of many similar incidents –
propose solutions that are applicable to groups of similar patients, similar services (Look for patterns)
SA Health
SA Health
Results of analysis of 7214 falls (2011/12)
1. the outcome of fall 2. the circumstances and activities
associated with the fall 3. the characteristics of those who
have fallen 4. the interventions that were in place 5. the communication with patients
and their families around falls.
SA Health
1. Outcome of the fall Actual SAC 2011 - 12
SAC1 47
SAC 2 166
SAC 3 4090
SAC 4 2666
Uncoded 245
TOTAL 7214
> 2376 (32.9%) were notified as resulting in harm
SA Health
2. The circumstances and activities associated with the fall
74.4% falls were described as unwitnessed
SA Health
The circumstances and activities associated with the fall What was mechanism of fall? 5597 responses
Other/Unknown 4369 (78.1%)
Slipped (usually wet, slippery floor)
738 (13.2%)
Tripped over an object 333 (5.9%)
Faint, LOC, cardiac collapse 143
Epilepsy 14
SA Health
The circumstances and activities associated with the fall
What was the place of the fall? 5978 responses
Bed 2174 (36.4%) Ward 1528 (25.6%) Bathroom 1052 (14.6%) Corridor 401 Dining room 355 Grounds 250 Treatment cubicle 75 Allied health treatment area 71 Carpark 38 Waiting room 34
SA Health
The circumstances and activities associated with the fall Height of fall?
6092 responses
Fall from standing position 3164 (51.9%)
Low fall <0.5 1665 (27.3%)
Unknown 743 (12.2%)
Medium fall 0.5 – 1.0 metre (e.g. off bed)
401 (6.6%)
High Fall > 1.0 metre (e.g. over high bed rail)
107 (1.8%)
SA Health
Height vs SAC
> High falls • 6.0% are SAC 1 or 2
> Medium height • 2.9% are SAC 1 or 2
> Low falls • 1.6% are SAC 1 or 2
SA Health
What was the activity at the time of the incident?
5539 responses
Walking 1573 (28.4%) Attempting to sit/stand 859 (15.5%) Getting in/out of bed 754 (13.6%) Toileting, or attempting to toilet 728 (13.1%)
Standing 479 (8.6%) Bending/leaning/reaching over 343
Sitting 302 Rolling on bed 194 Getting in/out of wheelchair 108
Climbing over/around bedrails 101
Showering 83 Running 15
SA Health
3. The characteristics of those who have fallen Age Band (years) 1415 responses 2-20 4 20-29 6 30-39 16 40-49 29 50-59 67 (4.7%) 60-69 146 (10.3%) 70-79 292 (20.6%) 80-89 600 (42.4%) 90-99 230 (16.3%) 100+ 8
SA Health
The characteristics of those who have fallen
Falls History? 5008 responses
None 1193 (23.8%)
>1 fall in previous 6 months 2347 (46.9%)
Had fall/s or near miss/es during current admission
2198 (43.9%)
Admitted as a result of a fall 740 (14.8%)
SA Health
The characteristics of those who have fallen Risk factors for injury? 4755 responses
None 1181 (24.8%) Fragile skin 2701 (56.8%) Low body mass index 1035 (21.8%) Diagnosis of osteoporosis
768 (16.2%)
Anticoagulant therapy/bleeding disorder
760 (16.0%)
Indwelling devices 426 (9.0%)
SA Health
The characteristics of those who have fallen Risk factor for Falls – Mobility/Transfer? 5493 responses None 245 (4.5%)
Poor balance, unsteady 3613 (65.8%)
Requires walking aid or similar e.g. crutches, walking frame 3567 (64.9%)
Requires standby assistance 2319 (42.2%)
Requires assistance to mobilise 2314 (42.1%)
Weakness, generalised muscular weakness 2155 (39.2%)
Urge incontinence, occasional incontinence 1778 (32.4%)
Neurological condition e.g. Parkinson’s, spinal cord injury 709 (13.0%) Poor vision, such that if affects mobility 622
Non or partial weight-bearing 552
Dizziness, light-headedness, faintness, dehydration 530
Significant pain when walking, transferring 447
Severe foot problems – pain, deformity, or marked swelling 433
Impaired lower limb peripheral sensation 365
SA Health
The characteristics of those who have fallen Risk factor for Falls – Medications ? 4864 responses
None 650 (13.4%)
Poly-pharmacy – more than five prescribed medications
3737 (76.8%)
Psychoactive medications – antidepressants or benzodiazepines
1441 (29.6%)
Diuretics 694 (14.3%)
Sedation within 12/24 of assessment 478 (9.8%)
Substantial change to medication regime
190
General Anaesthetic (within 24/24) 20
SA Health
The characteristics of those who have fallen
Risk factors for Falls – Behaviour/mental state ?
6027 responses
None 699 (11.6%) Dementia/Cognitive impairment 2040 (33.8%) Difficulty communicating or following instructions
1319 (21.9%)
Delirium, Anxiety, Agitation 1262 (20.9%) Neurological condition 737 (12.2%) Marked depression 648 (10.8%) Intellectual disability affecting judgement of physical ability
191
Impaired consciousness 132 Dehydration 87 Under the influence of alcohol or illicit drugs
23
SA Health
4. Interventions that were in place
Was there a current fall risk assessment?
5900 responses
Yes 5233 (88.7%)
No 668 (11.3%)
There was a current care plan in place
Yes 695 (11.8%)
SA Health
Most common interventions in place What were the interventions in place at the time?
5907 responses (81.9%)
None 313 (5.3%)
Call bell/personal items within reach
2517 (42.6%)
Mobility/ADL aides 1534 (26.0%)
Bed rails 858 (14.5%)
Supervision of mobility transfers 820 (13.9%)
Current Care Plan 695 (11.8%)
Alarm system 629 (10.6%)
SA Health
Interventions in place less than 10% of the time Footwear 551 Toileting routine 501 Hip protectors 424 Information provided to pt/carer re safe mobility/risks 336 Discussed care plan with Patient/Carer 284 Crash mat 258 Bed/chair height determined by PT/OT 245 Special bed 196 Bed mobility aides 169 Visual aides 169 Mattress 86 Restraint with plan to monitor safety 41 Helmet 47 Delirium reduction 16 Limb protectors 36
SA Health
Interventions in place - referrals made Referral to Physiotherapist 394
(6.7%) Referral to Occupational Therapist 135
Referral to Dietitian 48
Referral to Doctor/Specialist 64
Referral to Pharmacist 27
Referral to Speech Pathologist 34
Referral to Podiatrist 22
SA Health
Questions about incident reporting and data
How good are notifications to SLS, ie how good is the data? > How complete are reports? > How accurate are reports?
SA Health
Question % of reports where question completed
Actual SAC 100% Harm 100% What was the place of the fall? 82.9% Height of fall? 84.4% What was mechanism of fall? 77.6% What was the activity at the time of the incident? 76.8% Age Band (years) 19.6% Falls History? 69.4% Risk factors for injury? 65.9% Risk factor for Falls – Mobility/Transfer? 76% Risk factor for Falls – Medications ? 67.4% Risk factors for Falls – Behaviour/mental state ? 83.5% Was there a current fall risk assessment? 82% What were the interventions in place at the time? 81.9%
Open Disclosure / communication with patients and families /
79% of notifiers reports 73% of managers reports
SA Health
Thoughts for the future
Essential ingredients > Education / training is critical – the myths
are still out there > ‘Built-in’ is the way to go > Make data easy to get, clinically relevant > Decision-making guidance is the way to
go – give directions but leave room for clinical judgement
> Accountability / sticks are important > Change champions are important and
should be cloned
SA Health
