Falls – Everybody's Business Jane Lees

Auckland DHB Approach Steering Group formed including ARRC representation Regional work with FDNH and HOP CN standardized definition of fall with harm Understanding the Problem Numbers Cost in $$ Cost to our customers Developing Solutions innovation

Better categorisation

SSE falls by DHB

Hospital fracture falls - cost 19 ADHB patients 2010/2011 fell and fractured Average age 83 (range 55-92) ALOS (whole episode) 40 days ALOS post-fall 27 days Average costs Whole episode $34,981 Post-fall $22,618 Total costs Whole episode $666,641 Post-fall $429,749 Notably 5 patients died

Average cost of Fall Events Average cost of control events Cases vs controls Average cost of Fall Events $34,981 Average cost of control events $8,937 Cost difference $26,044 (95%CI $16,790 - $35,298, P<0.0001)

What our Customers say Barbara's story It was her day to go home, something so simple as using the bathroom resulted in a fall Keeping the bathroom clear of clutter would have prevented this

What our data says Almost all falls associated with toileting: Either with assistance or independently No transparent involvement of MDT in: Analysis of event Recommendations for prevention of future events Secondary prevention actions unclear Risk of injury would have identified 83% of SSE falls Age (>75), Bone disease, anti-Coagulation

What are we doing New risk assessment tool & planning tool implemented Based on Morse Falls Scale validated in US Used in Counties Manukau DHB Tested and updated at ADHB Second iteration now testing Adult campus-wide policy in development Risk assessment with 6 hours of admission Audit – monthly safety audit

Patients aged 75+ risk assessed

What we are doing Intentional rounding, sometimes known internationally as hourly rounding, is a process where nurses spend time with their patients regularly (usually every hour) focussing on 4 aspects of care, toileting requirements, positioning, pain management and possessions always ending their interaction with the sentence “is there anything else I can do for you, I have time”

Intention rounding

Reporting – breaking down the barriers Many fields on RMPro form not used when completing fall report SOLUTION Quick submission form for RMPro for inpatient fall Includes fields where information required Prompts for ACC45 or 2152 included

Patient Information Pamphlet

Management Operation System (MOS) A Management Operating System (MOS) promotes greater visibility, transparency and shared ownership for organisational priorities. visibility of the team’s issues, priorities and actions. Wards with a MOS have a daily start up meeting using ‘Cause, Concern and Countermeasures’. falls that occurred in the pervious 24 hours are discussed with a clear plan articulated re prevention of further falls

What we are doing Patient status boards. Uncluttered bed space, with some wards reserving one side of the patient’s bed for visitors and the other for nurses and their equipment - linked to our RTC activity Developing a better understanding of why nurses leave the patient bedside and how this can be managed so the nurse can spend more time with the patient – top 8 most used items in a patient room now available

What next Continue to collect and understand our data Model Ward Identification of patients who are at risk of harm from a fall integrated into assessment

Fractures beget fractures Since July 2009,1675 admissions for fracture Age 55-75: 115 #NOF, 448 other # Age 75+: 586 #NOF, 526 other # Prior fracture at any site almost doubles risk of future fracture Any age (>50 y) RR 1.86 (95%CI 1.75-1.98) Age 55 RR 1.90 (95%CI 1.73-2.09) Age 85 RR 1.83 (95%CI 1.65-2.04) Bone mineral density only explain part of risk 8% of increased risk in any fracture 22% of increased risk in fractured NOF

Secondary prevention opportunity Case find patients with any fracture to assess for opportunities to: Prevent future fragility fractures Suitability for bisphosphonates 45% reduction future vertebral # 53% reduction in future #hip Prevent future falls Exercise program (decrease falls by ~35%) Suitability for vitamin D (decrease falls by 43%) Home hazard assessment (decrease falls by 34%) Medication review by GP and family (decrease falls by 39%)

Collaboration with Age Related Residential Care to Improve Quality of Care

Why did we Need to do This Ministry Target to Reduce Falls with Harm by 20% Regional Target to Reduce Falls with Harm and PI’s by 20% Patient Impacts: Loss of confidence / lower quality of life Fracture Falls lead to increased mortality Financial Impacts Costs of $6.8m to ADHB for Direct Care 20 beds permanently occupied in Hospital

Engagement The Numbers: 55 of 68 Facilities have attended meetings 34 of 68 Facilities have submitted data 20+ people (15+ Facilities) attending training sessions Attendance of FDNH Learning Sessions

Date Collection What we decided: Agreed what to collect Didn’t want to just meet MOH requirements but also provide meaningful data Agreed definitions Agreed how to submit Started collecting the Data

Data Collection Initial State: Many facilities didn’t understand their own data Most facilities had no idea of how they were doing (good or bad) compared to others Many facilities couldn’t tell if they were improving their processes or if it was just natural variation

Some of the Results

Some of the Results

Data Collection going forward? Data Entry will be moved to the new website. Encourage more facilities submitting data Increase facilities knowledge of data and how to use it effectively Improved Reporting functionality which will provide each facility with a greater understanding of what is occurring.

Resource Development Initial scoping work determined that there was a large variety of different tools used and different ways of applying these tools Many facilities did not have the resources to dedicate to improving / developing tools Advantages of leveraging off a single resource (ADHB) Started developing Templates Start sharing resources eg. Brochures Access to ADHB policies on request

Resources

Resources

Resources

Information Sharing Advantages Gained: Constant positive feedback about meeting and getting to engage with other facilities Understanding of potential Pressure Injuries being developed during the patient transfer process Better relationships and passing on of residents to each other Started sharing interventions / information Bupa Little Sisters etc

Information Sharing

Current / Recent Activities

Yellow Envelope Regional Project Led and Co-ordinated by FDNH (NDSA) First six months cost carried by FDNH Ongoing costs carried by Northern DHBs To be reviewed in six months time Add / remove anything

Yellow Envelope Initial Feedback Adoption has been fantastic with many facilities ready to use them on go live date Positive feedback from Hospital Emergency Departments Positive feedback from Facilities Usage higher than expected May be due to non weight bearing patient exchanges No reported issues but if there are, contact us

Dementia Care Pathway Requirement for all DHBs to develop a Dementia Care Pathway Aligns with National Dementia Care Pathway Framework and the Regional Dementia Services Guide ADHB Dementia Care Governance Group established Representatives: NGOs, primary care, secondary services, ARRC, consumers Subject matter experts identified – 4 workshops scheduled for May 2013 ARRC representation Pathway to cross the health continuum from community to aged residential care Incorporate components of work already underway e.g carer training; in patient screening of 75+ years for cognitive decline; memory clinic.

InterRAI Announcement in Oct 2012 interRAI LTCF to become mandatory by July 2015 District Annual Plan requirement: 100% of ARRC facilities are using or training their nurses to use the interRAI LTCF by 30 June 2014 Currently 17 facilities engaged in training Regional approach Establishment of a regional interRAI Governence Group that is meeting monthly with the National Project Team Establishment of ADHB and WDHB ARRC Providers interRAI Forum to discuss issues, share information, identify solutions feedback to regional Governance Group and National Project Team Paper to ADHB and WDHB Boards

New Website

Website New Name! Quality Care For Older People New URL! www.qualitycare4olderpeople.org.nz New Logo

Website Coming soon… Increased Reporting Capabilities Online forums Training Calendars Patient Case Studies? Would these be useful?

Moving Forward The cluster model approach was a new idea and the first time it had been tried. It has been a great success but that doesn’t mean we can’t do better! Changes to Clusters Meetings We will be merging cluster groups 11 clusters down to 7 We will broaden the focus wider than Falls and Pressure Injuries Focus on any activity that increases resident care Making more relevant Add a “feedback” session to each meeting

Cluster Map