3rd Annual RCSI Hospital Group Quality & Patient Safety Conference - Falls Prevention Initiative
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V
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F
A
LL
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P
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UC
T
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O
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"In
healthcare
everyone
has
two
jobs:
to
do
your
work
and
to
improve
it."
(Professor
Paul
Batalden,
Senior
Fellow,
Institute
for
Healthcare
Improvement,
2007)
Surgical
2
in
collaboration
with
MDT,
Practice
Development
and
RCSI
specialists
in
falls,
QIP
and
data
management
Cavan
General
Hospital
cristiana.carvalho@hse.ie
3
rd
Annual
RCSI
Hospital Group
Quality
&
Patient
Safety
Conference
24
th
March
2022
Background
Falls
in
acute
hospitals
represent
a
frequent
cause
of
harm
to
patients
and
families
–
fear
of
falling,
increased
length
of
admission,
soft
tissue
injuries,
fractures,
head
injuries,
death
-
cycle
of
falls.
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.
Aims
•
Reduce
the
number
of
falls
from
3
to
2
by
the
end
of
Oct
2022
•
P
r
e
v
e
nt
h
a
r
m
f
ul
f
a
ll
s
a
n
d
ou
t
c
om
e
s
•
Create
a
proactive
rather
than
reactive
approach
towards
falls
prevention
•
Increase
staff
awareness
and
involvement
•
Utilise
MDT
(nursing,
HCAs,
physiotherapy,
occupational
therapy,
pharmacy,
medical
team)
expertise
and
work
with
a
common
goal
Change
initiative
1.
Increase
education
and
training
to
raise
awareness
–
utilise
safety
pause,
staff
meetings
and
one-
on-one
opportunities
2.
Introduction
of
a
new
risk
assessment
tool
–
CANNARD
(to
completed
for
all
patients
within
6hrs
of
admission;
reassessment
weekly,
post
fall
and
if
significant
change
in
condition
occurs)
3.
CANNARD
risk
assessment
triggers
a
number
of
interventions
to
guide
nursing
staff
4.
U
tili
s
e
C
A
NN
A
R
D
s
c
o
r
e
w
h
e
n
r
e
f
e
rr
i
n
g
t
o
M
T
D
What
supports
the
development
of
our
initiative?
"Be
the
change you
want
to
see."
(Mahatma
Gandhi)
Enhanced
Patient safety
&
Quality of care
Value to patients went beyond the aims of this quality improvement
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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Presentation Transcript
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)
