1. Falls Program Virtual Breakthrough Series 2: (BTS 2) Reducing Preventable Falls and Fall Related Injuries National Center for Patient Safety & VISN 8 Patient Safety Center of Inquiry Wednesdays, starting January 9, 2013 2-3p

3. BTS2 Program Goals: Improve your organization’s infrastructure and capacity to reduce fall-related injures. Enhance environmental safety. Mitigate or eliminate modifiable fall risk factors. Assure reliable handoff communication about patients’ fall and injury risk. Integrate patient (family) as a partner in their fall prevention program. Reduce rate of repeat falls. a Quantify impact of program changes. 3

4. Your Team Goals Each VAMC team will select the goals that you want to work on during this 6 month period. All teams do not need to work on all the goals, but rather are encouraged to select the goals that are congruent with you organization’s fall and injury prevention program needs. 4

5. Looking Ahead Ten Sessions of Learning and Sharing Jan 9 th : Improved Organizational Infrastructure and Capacity for Fall Prevention Programs Jan 23 rd : Ensuring a Safe Environment Feb 6 th : Mitigate or Eliminate Modifiable Fall Risk Factors, Part 1 Feb 20 th : Mitigate or Eliminate Modifiable Fall Risk Factors, Part 2 Mar 6 th : Reduce Moderate to Serious Injuries for Vulnerable Populations Mar 20 th : Clinically Relevant and Reliable Handoff Communication: Let’s Talk about Falls and Fall-related Injuries Apr 3 rd : Patients/Families as Full Partners in Fall Prevention Apr 17 th : Post Fall Management: Reducing Repeat Falls May 1 st : Fall Program Evaluation May 15 th : Sharing Program Successes 5

6. 6 Session Design Welcome and share innovations Work in Hospital Teams Facilitated Learning with Coaches Learn and Share Together Suggested assignments at end of each session Questions and answers Engage each other online

7. Reduce Moderate to Serious Injuries for Vulnerable Populations Session 5

8. Objectives Separate Vulnerable Populations at greatest risk for serious fall-related injury. Illustrate evidence to support separate vulnerable populations. Assimilate results of risk modeling research to predict rare injurious falls as adverse events associated with high mortality and high costs. 8

9. But first… Let’s hear from you! Report on Session 4 Assignments: Who would like to share???? What did you learn when you: Categorized 10-15 patients in your setting of care using the ABCS tool. Examined 5-10 care plans of 5-10 patients with diagnosis of osteoporosis or hip fracture diagnosis for inclusion of injury protection strategies. Examined 5-10 fall patients receiving chronic anticoagulation for inclusion of injury protection strategies 9

10. Integrating Fall-related Injury Risk Assessment into Your Practice Nursing Assessment and Reassessment Policy Fall and Injury Prevention Policies and Guidelines Patient Admission Communication and Handoff

11. 5 Essentials to Protect from FRI You can protect patients from injurious falls Programmatic Shift Change in assessment structures: add risk for FRI and Hx of FRI Change in interventions: Environmental Redesign Assess to protective interventions Organizational Support

12. What to Put in Place Injury Risk Assessment Injury Prevention Interventions Interventions specific to Injury Risk Resources: http://www.visn8.va.gov /patientsafetycenter/fallsTeam/default.asp

13. Fall Prevention and Injury Reduction Matrix (Assumes Universal Falls Prevention Implemented) 13 + RISK FALL/+ RISK INJURY Implement fall reduction interventions Implement injury prevention interventions Assess, intervene and communicate if fall risk or injury risk changes + RISK OF FALL _ LOW - RISK OF INJURY FROM A FALL + --RISK FALL/+RISK OF INJURY Implement injury prevention interventions Assess, intervene and communicate if fall risk changes + RISK FALL/-- RISK INJURY Implement fall reduction interventions Assess, intervene and communicate if injury risk changes --RISK FALL/--RISK INJURY Assess, intervene and communicate if fall risk or injury risk changes

14. 14 Universal Injury Prevention Educate patients / families / staff – Remember 60% of falls happen at home, 30% in the community, and 10% as in-patients – Take opportunity to teach Remove sources of potential laceration – Sharp edges (furniture) Reduce potential trauma impact – Use protective barriers (hip protectors, floor mats) Use multifactorial approach: COMBINE Interventions Hourly patient rounds (comfort, safety, pain) Examine environment (safe exit side)

15. Vulnerable Populations: Moderate to Serious Injury Those that limit function, independence, survival Age (85 yoa)Bones (fractures) antiCoagulation (bleeds/hemorrh agic injury) Surgery (post operative)

16.  Aging Population  2009: 12.9% of US population 65 yo and >  By 2030: will be 19 % of population (AoA)  3-5 Falls per 1000 Bed Days of Care -Avg Rate  Older adults are hospitalized for fall-related injuries 5 times more often than they are for other cause injuries  0.6-0.7 Falls with Injury per 1000 Bed Days of Care: Avg Rate  In 2000, 78% of fall deaths were due to TBI  Injuries to internal organs were responsible for 28% of fall deaths  Fractures were both most common and costly  Hip Fractures are most common fall-related fracture http://www.cdc.gov/HomeandRecreationalSafety/Falls/fallcost.html In hospital setting, 3% to 20% of inpatients fall at least once during their hospital stay, translates to 4 to 12 falls per 1,000 Bed Days of Care – (Clyburn and Heyedemann (2011). Evidence for Vulnerable Populations 16

17. Consequences of Falls 30%-51% of falls in hospitals and rehab result in some injury 1%-3% of fall result in fracture Proximal femoral fractures caused by falls that occur in hospital setting found to result in poorer health outcomes than those that occur in the community Soft tissue injury or minor fractures among frail elders and those with poor functional reserve lead to significant functional impairment, pain and distress – Oliver, et al., (2010, Nov). Preventing falls and fall-related injuries in hospitals. Clinics in Geriatric Medicine: 645-692.

18. Falls in Hospital 10% of fatal falls for the elderly occur in hospitals The majority of hospital falls occur in patient rooms and bathrooms – Pearson, K.B., Coburn, A.F. (2011, Dec.) Evidence- based fall prevention in critical access hospitals. Policy brief #24. Flex Monitoring Team. www.flexmonitoring.org www.flexmonitoring.org

19. Age: > 85 years old Education: Teach Back Strategies Assistive Devices within reach Hip Protectors Floor Mats Height Adjustable Beds (low when resting only, raise up bed for transfer) Safe Exit Side Medication Review 19

20. Bones Hip Protectors Low Beds Floor Mats Evaluation of Osteoporosis 20

21. Bleeds Evaluate Use of Anticoagulation: Risk for DVT/Embolic Stroke or Fall-related Hemorrhage Patient Education TBI and Anticoagulation: Helmets Wheelchair Users: Anti-tippers 21

22. Surgical Patients Pre-op Education: – Call, Don’t Fall – Call Lights Post-op Education Pain Medication: – Offer elimination prior to pain medication Increase Frequency of Rounds 22

23. Risk Modeling for Serious Injury in Long Term Care November 16, 2010 Funded by VA Rehabilitation Research and Development

24. Study Team  PI: Gail Powell-Cope  Co-PI: Robert Campbell  Co-Investigators: Elizabeth Bass, Inez Joseph, Tatjana Bulat  Project Manager: Bridget Hahm  Site Coordinators: Tracy Thatcher (Bay Pines) Jan Odell (Baldomero Lopez State Veterans‘ Nursing Home) Ron Shorr (NFSG)  Partner: Outcomes Engineering, John Westphal

25. Our Goal  The goal of this study is to apply ST- PRA methods to proactively identify and prioritize risks for injurious falls in residents of Florida VA Community Living Centers  [Apply what we learned to foster change in VA Community Living Centers to decrease injury risk]

26. Why Socio-technical Probabilistic Analysis (ST-PRA)?  Prospective analytic strategy Does not depend on incremental, case-by- case analyses Uses cumulative knowledge of operations experts [group think]  Can lead to rapid assessment and improvement

27. Overview of ST-PRA Pick an Outcome for Analysis Identify All Possible Failure Modes Leading to the Outcome Assemble Fault Trees to Visually Represent Combinations of Failures and Degree of Risks Mitigate Highest Risk Failure Combinations Injurious Fall Resident transfers from wheelchair to bed without assistance Faulty wheelchairs increase the risk Implement preventive maintenance process for wheelchairs

29. Findings: Priority Scenarios  At initial training on STPRA methods, staff identified priorities to model that represented the highest risk scenarios Wheelchair / bed transfers Wheelchair / toilet transfers Propelling from bed to bathroom Falls in hallways [ended up not modeling]

30. Model Descriptions  Top Level Event was explained by Functional Failure [Fall] combined with Risk of Harm  Models built separately for residents with Impaired mobility (gait/balance) Functional (ADLs) and Sensory impairment Medication risks Cognitive impairment Hypotension/dizziness

31. Resident incurs serious harm from fall (risk of injurious fall per unassisted movement) Transfer from bed to wheelchair Propelling wheelchair from bedside to bathroom Transfer from wheelchair to toilet Transfer from toilet to wheel- chair Transfer from wheelchair to bed.018.021.002.003 Propelling wheelchair from bath- room to bedside.017 Overall risk model predicted 28 serious injurious falls across three facilities during one-year (compared to 21 actual serious injurious falls)

32. Greatest Path of Risk Residents with impaired mobility and osteoporosis or bleeding risk, Who engaged in unassisted wheelchair transfers between bed and toilet (either because they did not call for help, or staff did not respond to an alarm in a timely manner), When the wheelchair locks were not engaged (e.g. broken or not applied), and When protective measures were not in place (e.g. bedside floor mats, hip protectors).

33. Summary  Greatest risk of falls occurred when residents with impaired mobility transfer unassisted to and from wheelchairs  Greatest risk of injurious falls was most affected by combination of residents with osteoporosis and lack of protective factors (mats, hip protectors)  Staff behaviors, environmental factors, and systems factors contributed to risk of serious injurious falls

34. Sensitivity Analysis Showed that…  A 26% reduction in injurious falls could be achieved by: Reducing the number of unassisted transfers through a modest improvement in response time to alarms, Installing automatic break locks on 90% of wheelchairs, Making the wheelchair maintenance process highly reliable, and A 10% decrease in improper transfer techniques 34

35. Practice Recommendations  Attend to most vulnerable residents Functional and mobility impairments Frailty (osteoporosis, bleeding risks)  Attend to both falls prevention and injury prevention

36. Fall Reduction Implement interventions to decrease fall risk: Staff Behaviors: Help staff to respond to alarms in a more timely manner  E.g. working in pairs, improving communication, decreasing false positives Equipment: Decrease failure of wheel locks on wheelchairs  Improve maintenance process?  Install automatic breaking systems? Resident Behavior: Improve resident transfer techniques? 36

37. Future Research  Develop models specific to locked dementia units  Translate models into decision support tools that could be used by clinic staff to rapidly evaluate effects of competing interventions to reduce risk 37

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39. 39 Integrate Injury Risk into Assessment Add to: Fall program policy Patient admission assessment policy and tools Handoff reports Patient problem list, i.e. Hx of hip fracture

40. 40 Communication With Patients/Staff About Fall Reduction/Injury Prevention Label or signal patients assessed at risk of fall or 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

41. 41 Communication With Patients/Staff about Fall Reduction/Injury Prevention Verify Understanding Use teach-back strategies to verify what patients and families understand and customize education about harm risk accordingly Learn from Failures and Transfer Learning Use unit-based post-fall team huddles to learn what happened and how to prevent injuries from future falls Discuss post-fall huddle findings at house-wide nurse manager meetings

42. 42 Visual Cues Re-evaluate use of visual cues – Patients – Staff Reinvent usage to identify vulnerable patients at risk for injury

43. Assignments for Session 5 Select 5 patients from one vulnerable population (patients with hip fracture, patients anticoagulated, patients who are wheelchair-mobile) and examine their plan of care for injury reduction interventions. Design and pilot test the use of a monitor to observe (verify) that protective interventions are implemented on 2 patients with the condition selected. 43

44. Next Session Session 6 – 3/20/13, 2-3 PM Eastern Clinically Relevant and Reliable Handoff Communication: Let's Talk about Falls and Fall-related Injuries 44