Fall Prevention in Inpatient and Outpatient UnitsEssential Hospitals Engagement NetworkNovember 19, 2013

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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

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CHAT FEATURE

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SPEAKER INFORMATION

Carol Boylan, MSS, LCSWDirector, Psychiatric Medical Care Unit

Hahnemann University Hospital

Philadelphia, Pennsylvania

Stefania Kaplanes, MSWInjury Prevention Specialist

Alameda Health SystemHighland HospitalOakland, California

John Young, RN, MBAImprovement Coach

EHEN

Vickie Sears, RN, MSImprovement Coach

EHEN

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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

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PARTNERSHIP FOR PATIENTS

Partnership for

Patients (PfP)

• CMS-funded• Reduce 9 hospital-acquired conditions by

40%• Reduce readmissions by 20%

Hospital Engagement Networks

(HENs)

• 26 contracted organizations

• 3,700 U.S. hospitals

Essential Hospitals

Engagement Network (EHEN)

• 22 hospitals nationwide

• Only safety-net focused HEN

• Special focus on health equity

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EHEN FALLS RESULTS (AS OF JUNE, 2013)

Measure Baseline events Performance period events

% Change

Falls & Trauma (UHC-Modified

CMS HAC)

11 6 -45.46%

Falls with Injury (JC NSC-5)

19 18 -5.26%

All Falls (JC NSC-4) 155 154 -0.32%

Risk Factors for Falls in Psychiatric Inpatient Units

and Tools to Prevent Falls

Carol Boylan, MSS, LCSWDirector of the Psychiatric Medical Care UnitHahnemann University Hospital Broad & Vine Sts. MS 302Philadelphia, PA 19102tel: 215-762-4684fax: 215-762-3104pager: 215-762-7243 pin: 41693carol.boylan@tenethealth.com

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.

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

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

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.

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.

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.

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.

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.

2012 PMCU Fall Rates

7 FallsNo injuries

THE FALL PREVENTION

CENTER

Stefania Kaplanes, MSW Injury Prevention Specialist

Trauma ServicesAlameda Health System: Highland

HospitalOakland, CA

skaplanes@alamedahealthsystem.org

HIGHLAND HOSPITAL

Projected Senior Population Growth 2005 – 2030

RAND Roybal Center for Health Policy Simulation

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….

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

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

FALL PREVENTION CONTINUITY OF CARE

The Issues: Early

identification of those at risk

Who’s responsible

SOLUTIONSTHE FALL PREVENTION CENTER

Emergency Department Staff

Out-Patient Clinic Staff

Discharge Planners

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

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/AntidepressantBenzodiazepine, Sedative, or Hypnotic

*History of Stroke or Parkinson’s *Recent Acute Illness or Injury*Recent Weight Loss*Fear of Falling

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

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!

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

HIGHLAND’S DIVERSE WORLDAmerican Sign Language (by appointment)AmharicArabicBosnianBurmeseCantoneseCambodianCroatian

DariFarsiHindiKoreanKarenLaotianMandarinMienNepali

PashtuPunjabiRussianSerbianSpanishThaiTigrignaUrduVietnamese

MRS. B & LAS TRES HERMANASMrs. B

88yoF; resides aloneBrought all medsPharmacists asked which ones she takes at night?“Well dear….the ones on my dresser by my bed” Las Tres Hermanas

98yoF95yoF89yoF

Sisters living independently with each other. THANKS FPC!

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

THE FALL PREVENTION CENTER 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 RESULTS……… 100% of our FPC participants have not

returned to Highland Hospital Trauma Center due to a fall.

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.

GOALSTHE FALL PREVENTION CENTER

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

RECOGNITION

Alameda County Board of Supervisor’s Commendation (2010)

United States Congressional Recognition (2010)

THANKS EHEN FOR ALLOWING ME TO

SHARE ALAMEDA HEALTH

SYSTEM: HIGHLAND HOSPITAL

FALL PREVENTION CENTER!

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Q & A

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THANK YOU FOR ATTENDING!

• Patient and Family Engagement Webinar – December 3 @ 2pm ETThe Patient Advisor’s Voice in Patient and Family EngagementSpeakers:

• 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

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• Essential Hospitals Engagement Network website: http://tc.nphhi.org/Collaborate