1. ST FRANCIS HOSPITAL ESCANABA, MI
Fall Prevention and Management

2. BACKGROUD
In 2016, reducing patient falls was made a key focus area by OSF Healthcare and a system-wide fall prevention collaborative was established and tool kit published.

4. Fall Prevention Standard of Care
Assessment: fall risk within 4 hrs of admission, at least 1x/shift, at transfer and with a change in status. Low/Medium/High
Plan of Care: Based on assessment, universal standards PLUS
Reassessment: Shift change, transfer, change in clinical condition, after a fall
Communication: Standardized-caregiver huddles and handoffs, Best Care Dashboard, bedside handoff with patient/family review of fall risk and interventions in place; interdisciplinary rounds

5. Post Fall Standard of Care
Assessment: Physical assessment
Plan of Care: contact provider, patient/family communication, modify risk score as applicable, complete post-fall flow sheet in EPIC and occurrence report if needed (depending if on or off unit)
Reassessment: based on provider orders, change in patient status and clinical judgement, reference Lippincott
Debriefing: within 45” of fall, focus on system not people, identify causal factors and how to prevent in future
Communication: communicate/disseminate results
Assessment
Plan of Care

6. Fall Debriefing Tool

7. Fall Prevention/Management Enhancements May 2018
Additional elements to purposeful hourly rounding:
Clear pathway maintained
Upper side rails up x2
Bed in low position and wheels locked
Chair/bed alarm on based on patient position
Possessions in reach
Safety Sweeps:
Done 3x/day for high fall risk patients-assess for 14 fall bundle components
Immediate correction for gaps in any of the elements above
Focused feedback re: gaps to patient’s RN
Charge RN will complete reassessment 1 hr. to make sure gaps corrected

8. Fall Prevention/Management Enhancements
Fall tracers:
Completed once a month by unit fall champion or identified resource
Check for fall bundle compliance on moderate to high risk patients
Entered into the falls data base
Goal of 90% or better bundle compliance
Patient Leadership Rounding:
New question added “Our priority is to keep you safe. What have we put in place to keep you safe from a fall?”

9. Monitoring Compliance
Adult High Reliability Summary - Rates
High Reliability= Percentage of audits that have 100% compliance for all of the 14 Fall Bundle items
High Reliability Percentage (Fall Risk Score 4 or greater)
Facility/Dept
Total Audits
% Bell Sign
% Risk Poster
% Activity on Care Board
% Hrly Rounding Care Board
% Gait Belt
% Clear Path
%Risk ID Band
% Upper Rails Up
% Bed Low Locked
% Alarms
% Possessions Call Light
% NonSkid Footwear
% Pt Fam Risk Level
% Pt Fam Why
High Reliability
SFH % % 100.0% % % % % % % % % % % % %

12. QUESTIONS?? THANK YOU!!