Join the Falls Prevention Virtual Learning Collaborative Falls Virtual Learning Session # 4 & Closing Congress Team Rapid Fire Presentation Template Cross Cancer Institute, Edmonton, Alberta Amy Kantor, Quality Consultant
Edmonton, Alberta Ambulatory and Inpatient Care 3 inpatient units ~56 beds ~140 RN’s plus NA’s, PT, OT, RT, Pharmacists and MD’s Primary Cancer Care facility, serving all of northern Alberta. Who We Are
Team Members Team MemberRole Nadia KlocInpatient Nurse Manager Carolyn Howe-RiddellInpatient Resources Nurse Carole SzwajkowskiNursing Education Judy PoonRehab Medicine, Physiotherapy Amy KantorQuality Consultant
AIM To lead and coordinate team learning, process and care improvements; to ensure our targeted goals are achieved in falls and injury reduction and that we contribute as active participants in the SHN Falls Prevention VLC. Reduce incidence of falls (fall rate) by 40% from baseline (to 2.4%) by March Reduce injury from falls by 40% from baseline (to 19%) by March Scope: Inpatient units (3 units, 56 beds)
Change Ideas Changes tested during Falls VLC PDSA Cycles: Implementation of an appropriate Assessment Tool Initially used Schmidt tool, now working with Morse tool Inventory of mobilization equipment and aids and storage locations Discovered shortage of transfer belts, purchasing more and moving to a more visible and accessible storage location Evaluate location of majority of falls (~60% occur in the bathroom) Planning to trial bathroom signs encouraging patients to call for assistance Implementation of a Post-Falls Assessment Tool Trialing and revising a tool to help discover specific reasons for falling Implement an apple as a symbol for a patient at risk of falling To be placed outside of patients room, used for recognition and promotional ‘materials’
Measures Implemented Risk Assessment Number of Falls per Month Range: 4-7 Mean: 5 Change in Event Reporting System
Measures Implemented Risk Assessment Number of Falls Causing Injury per Month Range: 0-4 Mean: 2 Change in Event Reporting System
Measures Number of Charts Reviewed per Month Range: Mean: 67
Lessons Learned Lessons Learned/Key Insights Slow and steady wins the race Buy in from staff is essential to success Important to understand the foundation of the concept first The right tool is needed: take the time to find it, don’t be afraid to change it Follow through is required and it needs to be consistent Ongoing compliance monitoring is key to maintaining gains Changes to our event reporting system just prior to implementation may have affected our data We’re still learning!
Champions emerged from Physiotherapy department Data collection became easy with their help SHN Virtual Learning Series taught the team about: Quality improvement methodology (Can be applied to other projects) Data collection, analysis and trending Viewing the issue from a broader perspective: i.e. pharmacology, special considerations for the elderly, etc. Great connections made between departments (Nursing, Education, Physiotherapy, Quality) Great ideas to build on from other teams in the collaborative Quick Wins
Next Steps Key Sustainability Steps/Plan:Target Dates Decide on an assessment tool1 month Implement bathroom signs1 month Finalize post falls assessment tool and decide if it is going to be used Next 2 months Roll out education to the staff (serve apple treats to generate recognition) 1 month Launch the apple symbol1 month
Amy Kantor Judy Poon Contact Information