Evercare Quality Improvement Awards Falls Reduction Program Susan E. Harris, CRA, ADC, LNHA Assistant Executive Director Daughters of Israel West Orange, New Jersey

Faculty Disclosures: Ms. Harris has disclosed that she has no relevant financial relationship(s).

Learning Objectives By the end of the session, participants will be able to: Objective 1 Understand the importance of multi-pronged interventions Objective 2 Understand the relationship between falls patterning and the decrease of falls Objective 3 Understand how program model can be replicated Objective 4 Understand how the falls reduction model can be utilized to affect change in other areas

Facility Demographics Daughters of Israel West Orange, New Jersey Total # of Beds = 303 6 separate nursing units Inclusive of Alzheimer’s and End Stage Units Type of Ownership = Non-Profit

QI Project Falls Reduction Program Description of Problem- Falls were significantly higher than others in country, region, state Additional compounding problems Falls Quality Indicator at 91st Percentile Fall Rate = 13.34; Industry standard = *4.16 Based on historical performance trends Objective – Develop a Performance Improvement team to reduce resident falls by 10% annually *Per study published by L. Rubenstein, et al, in materials distributed by CMS at a QI training seminar, Baltimore, MD, May 2000 We had 1119 falls in May 1999. According to the fall rate that we used we should have had no more than 450 falls annually. Compounding problems: 2nd oldest population in our state Dementia population of 63% Statistically this meant that we could expect to have a higher than average number of falls Standardized Fall rate formula: total number of monthly falls divided by the total number of patient days times 1000

Project Timeline Project began – May 1999 Planning & Implementation Falls committee met twice weekly, then weekly Reported to CQI weekly Currently audits reported at CQI Planning & Implementation Core of program developed over 4 years Various components added after that time When did project end? The reduction of falls is an ongoing process Monitoring, evaluation and CQI reporting continues today

QI Planning & Implementation Leadership Falls Sub-committee of members included staff close to the problem Team Work Team analyzed falls and determined what could be done to reduce them Data collection tools developed Communication Project introduced through care plan team meetings; in-service education Results communicated to staff through Team meetings In-service education Posted QI studies

Falls Sub-Committee DON Charge nurse Floor nurse Nursing assistants In-service coordinator MDS coordinator Activities staff Alzheimer’s Unit Director Physical therapist Social worker Dietician Medical Director Administrator Quality Assurance Director

Falls Reduction Program Issues Encountered Tried falling leaf program briefly but too much was involved Tried developing a definition of what is a fall which didn’t make any difference in what we were looking to accomplish

Tools Used to Affect Change Computerized falls tracking system to identify Unit Time of fall Ambulatory status Use of side rails Use of restraining device Any injury incurred Staff involved Shift Expanded to look at other relationships with falls This early tool helped us to understand where, how and why our residents were falling Other relationships with falls Psychosocial Environmental – cluttered room, overly shiny floors Patterning – when did the fall happen? Had it happened this way before? Medication usage – when was a psychotropic medication dispensed in relation to the time of the fall or same for diuretic

Tools Used to Affect Change Data on the patterning of falls Developed a weighted falls risk assessment – at specific score CP required Policies and Procedures for Falls Reduction Program Changed incident report to better collect needed data Back page included list of investigation points to cover Today divided into 3 columns to improve data collections and understanding Falls Care Plan Book – interventions listed by reason for fall Created Falls Tracking System Staff Education Falls Investigators QI audits of falls care plans and changes made to them per fall Incentive programs for units with the lowest number of falls monthly Tracking system is reported monthly to CQI – covers by resident, by unit and fall rate by unit and the overall house fall rate

Facility Expenses The cost to us to reduce falls is minimal $1500 covered educational seminars, travel to seminars Planning and implementation for all staff involved approximately 654 hours per year

Resident Outcomes Prior to Program Falls QI 91st to 95th percentile Fall Rate = 13.34 Average of 1119 falls annually Today – 2008 Falls QI 37th percentile Fall Rate = 4.16 Average of 398 falls annually Fall Rate of 4.16 is at the benchmark and meeting our goal Use a very basic rule: we should do everything reasonable to prevent a fall, do everything reasonable to prevent future falls and have the documentation do support this

Regulatory Outcomes No deficiencies for falls Surveyors not looking as hard in this area Falls QI is low Compliance with regulatory codes has increased

Improved Quality of Service Outcomes In the first 4 years of this program dropped our fall rate by 59.2% Staff follow-up for care plans and intervention changes went from 0% accuracy to 95% accuracy Exceeded 10% goal Restraint use has not increased Fall related fractures has decreased Met national benchmark

Enhanced Staff Performance Outcomes Improvement on: Investigation of falls Understanding patterning/causal factors Trained to pay attention to observable facts surrounding a fall Immediate response to care plan for updates Understanding when to change or add interventions Understand importance of immediate intervention Care Plans no longer state “will not fall” , “Will not have any injury” Retain personhood Activities are crucial Good communication with families in regard to a fall

Improved Organization, Management Structure and Systems Outcomes Entire process changed centralized at CQI to decentralized on units Fall Management is a priority for everyone Chair and bed alarms are overused or misused – changes in intervention use Weekend supervisor now begins investigation at the time the fall occurred All shifts trained on falls prevention Nursing assistants held accountable for falls interventions All CP and CNA CP updated at every fall Interventions in place earlier at admission, readmission, unit or room change Response at one fall or to high risk assessment score No longer document care plan remains same – change what isn’t working Starts prior to admission Tracking system used for falls carried over to skin tears and bruises Investigation process now used to investigate abuse allegations Prior to program the resident may have fallen multiple times before any interventions were applied

Financial Outcomes Average hospital charge for fall related injury $11,800.70 (Nurse Practitioner, March 2002) Decreased rate of emergency admissions to hospital Most recent Evercare rate = 77 admissions per 1000 member years; one of lowest in country QI New Fractures declined from 67th percentile in 2002 to 38th percentile in 2007 Results in less need for post fracture care

Closing Thoughts Replication of Model – inexpensive to set up; easy to implement; mostly requires staff buy in and understanding that it is a priority for all Lessons Learned – It is not any one intervention that made a difference but instead the use of a multi-pronged attack of the problem and using multiple interventions at one time. Insights – Not all falls can be prevented must also look at what can be done to minimize severity of injury Questions? Multiple interventions instead of just trying one approach at a time chair alarm, non-skid floor strips, a specific activity intervention and a toileting plan might all be applied at the same time More Insights - As we have come through this project we have learned that the best way to serve our population is to minimize “staff fall failures”. To accomplish this staff must: be properly educated on falls Have the proper tools to do their jobs Understand the importance of educating and communicating with families in regard to falls Have the skills to report a fall to the family Trained to devise and implement appropriate follow up and care plan change Complete a thorough fall investigation Document accurately and timely Make reduction of falls a priority for all staff We created an interdisciplinary approach in which all levels of staff were invested. No one intervention, one idea, or one discipline made the difference by itself.