1. Falls – Everybody's Business Jane Lees

2. 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

3. Better categorisation

4. SSE falls by DHB

5. Hospital fracture falls - cost
19 ADHB patients 2010/2011 fell and fractured
Average age (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

6. 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)

7. 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

8. 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

9. 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

10. Patients aged 75+ risk assessed

11. 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”

12. Intention rounding

13. 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

14. Patient Information Pamphlet

15. 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

16. 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

17. 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

18. 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 )
Age 55 RR 1.90 (95%CI )
Age 85 RR 1.83 (95%CI )
Bone mineral density only explain part of risk
8% of increased risk in any fracture
22% of increased risk in fractured NOF

19. 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%)

20. Collaboration with Age Related Residential Care to Improve Quality of Care

21. 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

22. 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

23. 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

24. 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

25. Some of the Results

26. Some of the Results

27. 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.

28. 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

29. Resources

30. Resources

31. Resources

32. 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

33. Information Sharing

34. Current / Recent Activities

35. 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

36. 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

37. 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.

38. 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

39. New Website

40. Website New Name! Quality Care For Older People New URL!
New Logo

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

42. 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

43. Cluster Map