3rd Annual RCSI Hospital Group Quality & Patient Safety Conference - Falls Prevention Initiative
Falls in hospitals are a significant concern, leading to various harms for patients. This initiative aims to reduce falls through the implementation of a new risk assessment tool and proactive prevention measures involving multidisciplinary team collaboration. Analysis and improvement strategies have shown promising results in reducing falls and improving patient safety.
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3rdAnnualRCSIHospital GroupQuality & PatientSafetyConference24thMarch 2022 QUALITY IMPROVEMENT INITIATIVE FALLS PREVENTION AND REDUCTION Surgical 2 in collaborationwithMDT, Practice Developmentand RCSI specialists in falls,QIP and datamanagement Cavan General Hospital cristiana.carvalho@hse.ie "In healthcare everyone has two jobs: to doyour work and to improve it." (ProfessorPaulBatalden,Senior Fellow,InstituteforHealthcare Improvement,2007)
Background Falls in acute hospitals represent a frequent cause of harm to patients and families fear of falling, increasedlength ofadmission, soft tissueinjuries,fractures, headinjuries,death-cycleof falls. Why anewriskassessmenttool? Mod. Stratifytool Riskfactors CANNARD RA tool X historyof falls X X The average number of falls in Surgical 2 was 3 per month ( Jan-Sept 2021) with 2 SRE in 2020 and 1 SRE until June 2021. This QI was implemented in Oct 2021 and is planned to run until Oct 22. gender X age X X sensorydeficit X X X Aims X X medical history X X X X X Reducethe numberof fallsfrom3 to 2by the end ofOct2022 Preventharmfulfallsand outcomes medication X X X mobility X X X X Createa proactiverather than reactive approachtowardsfallsprevention X gait X X X X Increasestaffawarenessandinvolvement Utilise MDT (nursing, HCAs, physiotherapy, occupational therapy, pharmacy, medical team) expertise and workwitha commongoal Y/N ANSWERS ATRISK/NOTAT RISK CATEGORIES TRAFFIC LIGHT SYSTEM MeasurementPlan Changeinitiative 1 Number of falls andSRE s per month 1. Increase education and training to raise awareness utilise safety pause, staff meetings and one- on-oneopportunities 2 Is the CANNARD score usedin PT and OT referrals 2. Introduction of a new risk assessment tool CANNARD (to completed for all patients within 6hrs of admission;reassessmentweekly,postfallandif significant changein condition occurs) 3 Is CANNARD completed within 6 hours of admission 4 Is riskof falls reassessed 3. CANNARDriskassessmenttriggersanumber ofinterventions to guide nursingstaff 5 Collatethe CANNARD scoreforall patients 4. Utilise CANNARD scorewhenreferringtoMTD
Retrospective incident formanalysis(trend:bedside falls; eliminationneeds) Analysisofriskassessmenttool notcomprehensive forcohortofpatients IntroductionofQIand CANNARD to staff -brainstorming 84%CANNARDcompletion 64%fallsriskreassessment 20DAYS NOFALLS Deep analysisof falls/near missstarted 41%CANNARDcompletion 19%falls risk reassessment 44%increasein risk offalls CANNARDSvsStratify tool 29DAYS NOFALLS PDSA 2.0 Oct 2021 PDSA 3.0 Nov 2021 PDSA 4.0 Dec 2021 PDSA 1.0 Sep 2021 PDSA 5.0 Jan/Feb 2021 Plan Act Do Study 75%CANNARDcompletion 57%fallsriskreassessment 16DAYSNOFALLS MTD collaborationwith PT,OT, pharmacyandmedical team FormalintroductionofCANNARDtool Ongoingeducationandtraining(safetypause,one-on- one talks)
Value to patients went beyond the aims of this quality improvement Teamwork Practice Preventiveapproach,increasedinitiative, "it is myjob" T eam building, welcomingchanges Enhanced Patient safety & Quality of care Reduction of falls No SER since initiative started Nursingmetrics- 86%to 94% Reductionof falls,no SRE,no injuriessinceOct21 Reduction on pressuredamage What supportsthedevelopmentofour initiative? What comes next? "do not give up", "we are proud", "we can make the difference", "can do" attitude We will continue to implement and measure the outcomes of our QI Deep analysis of falls on the ward trends? Use of resources Person- centred Leadership Falls board on ward Communication Profile? New prevention strategies? Trial QI on a different ward. Empower link nurses on the ward to point Appreciation, positive reinforcement Shared information and expertise Leading by example Monthy updates Patient safety Audits Job satisfaction Active listening further areas for development and start planning next QI. "Be the change you wantto see."(MahatmaGandhi)
