Rapid Fire Team Presentation Template Nancy Fletcher, Suzanne Vanderlip and Kelly Stajer

Falls Facilitated Learning Series Markham Stouffville Hospital Markham, Ontario Number of Patients/Clients: 200

Falls Facilitated Learning Series AIM “To learn and integrate strategies of sustainability into our organization’s falls improvement plans to ensure we increase the likelihood of sustaining practice change for prevention of falls and injury reduction while holding the gains over time. We will be active participants in data submission to SHN Falls Intervention and network with other enrolled teams in the National Falls Facilitated Learning Series (FFLS)”

Falls Facilitated Learning Series Nancy FletcherTeam sponsor, Prof.Practice Suzanne VanderlipTeam lead, Prof.Practice Toni BrittonData support Karen HickmanProfessional Practice Med Doreen KanekoProfessional Practice Surg Kelly StajerProfessional Practice Peds Roger PerezProfessional Practice ED MaryLou JamesQuality and Risk

Falls Facilitated Learning Series Change Ideas tested to date Changes Implemented within Organization Working/Not WorkingFacilitators/Barriers identified New falls policy June 2011Interprofessional & included clinical and non clinical staff, MDs & volunteers Ongoing education to continue to sustain practice and maintain awareness Falls Champions (IDHCT) -New risk assessment tool -New post falls monitoring tool with classification of falls into Type I & Type II (unwitnessed, bleeding risk & witnessed & no bleeding risk) -ID cards made for clinical & non clinical staff 100% compliance with completion of falls risk within 24h of admission Post falls monitoring tapered off after 4 – 8h monitoring Time frame for post falls monitoring =37h for Type I (not completed) Falls champions developed a tick sheet tool that helped prompt when the next monitoring was due Leaf identifiers -client door, aids, chart, communication boards Consistency with all locations except for spine of chart Challenges with identifying risk client when not on unit eg. DI

Falls Facilitated Learning Series Type I Fall Unwitnessed, witnessed with head injury, bleeding risk Q15mins x4 Q1h x4 Q4h x8 Then as ordered Type II Fall Witnessed without head injury, no bleeding risk Q30mins x4 Q1h x4 Then as ordered

Falls Facilitated Learning Series Change Ideas tested to date Changes Implemented within Organization Working/Not WorkingFacilitators/Barriers identified Revised audit tool and 10 charts audited each month in all areas Currently professional practice completing audits need to extend this to the falls champions Challenges with accessing falls champions & tool is a visual audit of identifiers & electronic audit N eurological E nvironment A ctivity T oilet

Falls Facilitated Learning Series Change Ideas tested to date Changes Implemented within Organization Working/Not WorkingFacilitators/Barriers identified Adoption of a specific tool for obstetrical patients intra/post partum Similar challenges as mentioned previously with other adult population Similar as other adult population Adoption of a Pediatric tool “Humpty Dumpty” Similar challenges as with adult population Similar to adult N eurological E nvironment A ctivity T oilet

Falls Facilitated Learning Series

Falls Facilitated Learning Series Lessons Learned on Sustaining Falls Improvement Work during Action Period Include all members of the team Ensure senior team involved Include clinical and non clinical staff Include MDs and volunteers Engage front line champions Regular auditing with feedback Share stories & learn from each other

Falls Facilitated Learning Series Ongoing education on falls prevention Continue to use the NEAT acronym but incorporate into daily work Include patient/family in prevention strategies Work on ways to communicate falls risks Challenges to Sustaining Falls Improvement

Falls Facilitated Learning Series Remember to “Focus on Falls”

Falls Facilitated Learning Series Name: Suzanne Vanderlip Phone Number: Contact Information