Fall Risk Assessment and Intervention Nursing Practice Changes and Jeff Chart Updates
description
Transcript of Fall Risk Assessment and Intervention Nursing Practice Changes and Jeff Chart Updates
Fall Risk Assessment and InterventionNursing Practice Changes
and Jeff Chart Updates
Tentative Go Live Date September XX, 2012
Falls and Injury from FallsA Nursing Sensitive Indicator
The prevention of falls and injury from falls in patients who are hospitalized are indicators of high quality bedside nursing care given on a particular unit or at a hospital.
Recognizing who is at risk and implementing appropriate interventions aimed at minimizing the risk is part of professional nursing practice at TJUHs, Inc.
Why we needed a New Fall Risk ToolBackground:Morse Falls Risk Tool was not meeting our needs; screens for Fall Risk and did not assess WHY patient is at risk
It did not predict all of our falls
Some of our patients scored not at risk (< 50) experienced a fall
Often incomplete/inaccurate documentation
Jefferson Fall Risk Assessment and Intervention Tool
Goal: To improve patient outcomes (decrease falls and injury from falls) through targeted interventions based on assessment
Jefferson Fall Risk Assessment and Intervention Tool (cont)
What is different?Goes beyond screening – assesses WHY a patient
is at risk for fallNo “points”/numerical values assigned to a risk
factorIf you assess a patient to be at risk to fall due to any
risk factor – then they are at riskSupports clinical judgment and decision making –
re: selecting fall prevention interventions based on the specific risk factor(s)
TimelineSummer
2011FRG SN identified WHY their
patients fell – what put them
at risk?
Summer 2011Fall Task Force created a Fall
Risk Assessment Tool based on a literature review
and the Jefferson specific risk
factors identified by Fall Resource
Group
Fall 2011FRG SN or
designee from pilot units trialed the
assessment criteria and provided
feedback
Winter 2012 Task force identified
specific interventions to
match risk factors based on literature and best practices
Spring 2012 All units on all
campuses trialed new Fall Risk
Assessment and Intervention Tool.
Fall Interdisciplinary Committee provided
feedback.
Summer 2012
Jeff Chart Training and Education
Fall 2012
Go Live!
Fall Risk Assessment Hx of falls prior or during hospitalization Altered mobility/gait disturbancesAltered eliminationAltered balance/risk for dizzinessEquipment Altered mental status &/or behavior riskRisk of injury
Fall Prevention InterventionsSpeci
fic Fall Preventio
n Interventions
General Fall Prevention
Interventions(all pts at risk for Falls
– regardless of why)
General Safety Interventions(all pts – regardless of fall risk)
AssessmentAssess Fall Risk factors through:
Observation of patient
Interview (completion of Nursing Admission Assessment)
Review of the Physician History & Physical
Falls Tab Added to Assessments
Assessment - Complete Fall Risk Assessment in Jeff Chart.
InterventionImplement and document General Safety interventions for ALL patients.
InterventionImplement and document General Fall Prevention Interventions for ALL pts with any risk for falls
Interventions - SpecificSelect appropriate interventions based on patient risk factors and individualized assessment.
Case StudyA 35 year old female is being admitted for wheezing and shortness of breath.
PMH: Hypertension and asthmaAdmission orders include:
InhalersPrednisone 40mg POHydrochlorothiazide 12.5mg PO
What are the Falls Risk Factors for this patient?What Fall Prevention measures would you implement and document for this patient?
Fall Risk AssessmentRisk Assessment Criteria Assessment
Hx of falls prior or during hospitalization
No risk
Altered mobility/gait disturbances
No risk
Altered elimination No risk; has been on HCTZ
Altered balance/risk for dizziness No risk
Equipment
No risk
Altered mental status &/or behavior risk
No risk
Risk of injury No risk
InterventionsGeneral Safety Interventions only
Sensory items within reachCall bell within reachNon-skid footwearNight LightLevel 2 Bed Alarm at nightBed in low position/lockedPt/Family teachingHourly rounding
Case StudyAn 82 year old female was admitted 5 days ago, S/P fall athome.PMH: Hx of falls, has generalized weakness, uses cane to
ambulate, has diabetes with neuropathy in hands and feet, is HOH, and takes Coumadin for chronic atrial fibrillation
Two days ago patient spiked a fever to 101.3F and became confused; found to have a UTI
Current orders include:IV fluids Pain Medications Oxygen at 2 litersAntibiotics PT/OT consult
What are the Falls Risk Factors for this patient?What Fall Prevention measures would you implement and document for this patient?
Fall Risk Assessment Risk Assessment Criteria Assessment – from H & P,
nursing assessment, PT/OT assessment
Hx of falls prior of during hospitalization
Hx of falls
Altered mobility/gait disturbance Generalized weakness; hx of DM with neuropathy
Altered elimination Admitted for UTI
Altered balance/risk for dizziness Uses cane for balance to walk
Equipment
IV pole; Oxygen therapy
Altered mental status &/or behavior risk
Confusion; HOH; Pain medication
Risk of injury Coumadin with therapeutic INR
InterventionsGeneral Safety InterventionsGeneral Fall Prevention InterventionsSpecific Fall Prevention Interventions
Altered mobility Assist with transfers/ambulation
Altered elimination Toilet q1 hour; stay with pt.Bedside commode
Altered balance/risk for dizziness Ambulate with cane at all times
Equipment
Assist with IV pole & Oxygen tubing
Altered mental status &/or behavior risk
Room close to Nurse’s stationSelf-releasing seat belt in chair
Risk of injury Low bed
Key PointsFalls Risk Assessment and Intervention is a
professional nursing role and responsibilityComplete every shift, after a change in condition or
after a fall, and upon transfer to another unit.No “point” values are assigned to risk factorsHaving any risk factor makes the patient at risk for
fallingTailor your interventions to the patient’s
assessmentCommunicate patient’s fall risk and interventions
via handoff, huddles, IPOC, and Teletracking.
Fall Prevention is a Nurse-Sensitive Indicator of Quality
As a professional nurse providing direct care, you are in a position to make a difference in patient outcomes.
Your assessments and thoughtful planning will minimize the risks for patients at risk for falls and injury from falls