1. Bethesda Hospital Patient Fall Prevention
Welcome to Bethesda Hospital, Patient Fall Prevention Education

2. Welcome! Learning Outcomes Understand the current state
Review the 3-Day Event
discoveries
Understand the future state
Understand expectations for practice
Thank you for taking the time to review this PowerPoint on falls prevention at Bethesda. This PowerPoint should only take you about 17 minutes to review. At the end of the presentation, you will understand the current state of falls at Bethesda, what was discovered during the 3-day event, what the future state looks like, and know what is expected of you in your practice.
If you have questions after the presentation is done, please ask your lead preceptor or falls champion. They have both been trained as super-users and can help you understand the process.

3. Current State of Falls Problem Statement:
The graph on the page shows the falls per 1000 patient days that we have had since September Falls per 1000 patient days can be confusion, so here is a brief explanation of what it means:
Every time we have one patient sleep over on night, it counts as one patient day.
That means that we collect the number of patient falls we have and do math to compare it to how many patient falls we have had in the past 1000 patient days... Or patient nights slept over.
For example, if we have a patient census of 100; it would take us 10 night to get to 1000 patient days. That is 10 days times 100 patients equals 1000.
We use 1000 patient days because we want to be able to compare apples to apples. If we tried to compare each unit based on the number of falls, it wouldn’t be fair because different units have a different number of beds and patients. When we use 1000 patient days, we are making the falls rate comparable.
As you can see in the graph on this slide, the falls rate goes up and down. This means we do not have stability in our process. A stable process will have a flat line, and a process that is making improvements will have a line that is trending down.
Problem Statement:
May 2012 year to date falls rate = 7.02 falls per 1000 patient days
2012 Goal = 4.59 falls per 1000 patient days
2012 includes 1 reportable fall event

4. 3-Day Event June 18th, 19th, and 20th
Included a multidisciplinary team:
Lydia Falade, 2S RN
Heidi Cardinal, 4S Psychology Associate
Eva Acquoi, 5S RN
Katie Reibel, Float Pool NA
Elizabeth Ironside, PT
Kelli Voss, RT
Autumn Zehren, Clinical Director
Amy Kieffer, Director of Rehab Services
Sue Neises, Project Manager
Jill Smith, Quality Consultant
Janet Lotegeluaki, Clinical Nurse Specialist
Our three day event took place in June and we had great representation from all the groups of people that help prevent falls. Thank you to everyone that participated on this team and are helping us understand our current state and where we want to be in the future.

5. 3-Day Event
One of the first things the three day event team completed was a map of our current process. As you can see on the map, there are three boxes on the very left side. These are the three events that trigger a patient to be assessed for his/her falls risk. This happens when a patient is admitted, transfers to a new unit, or after the patient falls. The RN then follows a process with completing Morse and toileting scores, determining the patient’s risk level based on the assessment, figuring out what interventions to implement, getting the right equipment, documenting on the care plan, educating, and passing on information to other care givers.
The team was very pleased to see that there is a process for falls. The team determined that the process as a whole was not the issue and why patients were falling. The team determined that the issue or problem is with processes within the bigger process.

6. 3-Day Event What is the real problem? Lack of Standard Work:
Interventions for High, Medium, and Low falls risk patients
Equipment ordering, set-up, and monitoring process
Visual cues
Hourly Rounding
Staff to Staff communication
Post-Fall Huddle
Confusion with information on admission screen
EHR and Care Plan interventions are not the same
During the three day event the team had a lot of honest discussions to try and figure out why our patients are falling. We came up with many reasons and narrowed them down to three major buckets:
We do not have standard work for many of our processes. This includes what interventions we put in place when a patient is at a certain risk level; how we order equipment, set it up, and make sure it’s working; our use of visual cues so we know who is at risk for falling; how we complete hourly rounding and communicate to each other about falls risk; and how we do post-fall huddles.
We also found out that there is confusion with the admission screen, and
The EHR and Care Plan can cause confusion due to the interventions on each one not being the same with how they are written and in what order.

7. Identifying Solutions
Confusion with information on admission screen
Remember that the admission screen may be several days old.
Your best information on Falls Risk will come from your initial admission and ongoing assessments
EHR and Care Plan interventions are not the same
A review of this will come in the future.
Based on what we discovered for the real problems, the team started to brainstorm solutions. We will review the two real problems from the previous slide first.
First – there was confusion with the admission screen. Not everyone on the team realized that the admission screen and the falls related information on there may be several days old. Please keep this in mind and remember that your best information will come from your assessment upon admission and ongoing.
Second – the team quickly realized that the EHR documentation and Care Plan documentation are set up very differently. Having two different formats makes documenting and planning more difficult. Because the EHR is frozen for updates until later this year, this issue will be addressed in the future. Work is beginning on a care plan revision, and more info will also come out in the future.

8. Identifying Solutions
Lack of Standard Work
What is standard work???
A lot of the 3-day event team’s conversation about solutions after that surrounded the topic of standard work. The team knew standard work was lacking because everyone had different ideas on how processes were done. With performance improvement, standard work is crucial. Without a standard on how something is done, how do we even know what the current process is and if improvement is needed. And, like we discussed a couple of slides ago, that is exactly what we are seeing in our graph of falls data. It goes up and down and up and down, which means there is no standard to base improvement on.
So.... The team decided that some standard work were needed, and they started to develop it!

9. Standard Work: Interventions Based on Falls Risk Level
The 3-day event team went through all of the interventions and knew that standard work was needed for patients based on their risk level. These are the bare minimum interventions a patient needs implemented in order to prevent them from falling.
You can see on this slide that they are separated into low, medium, and high. High is yellow because that is our visual cue color for a falls risk patient.
Low risk patients all need to have hourly rounding and their whiteboard updated in their room. The new whiteboards will have fall risk information on them, and you will be able to circle their risk level and some interventions that are in place. This whiteboard will be a good communication tool for people who enter the room that may not have read the care plan and know all the interventions needed.
Moderate risk patients have the low risk interventions in place, and they also have the use of a gait belt with transfers and activities. Patient’s in a hoyer lift will not need a gait belt, but any patient getting up with or without assistance and scoring a moderate risk or higher should have a gait belt on them with transfers and activities If the patient has impaired mental status, then there are a couple more interventions that are now included in the Standard Work. This includes a bed alarm. Some beds have bed alarms built in them and others do not, but we will talk about that on a later slide. Patient’s with impaired mental status also need a chair alarm ordered if they get up to the chair. The patient can use a seat belt if they can self-release. If not, a chair alarm should be used. If you are working with a patient with impaired mental status, restraints may be in use and trump the use chair alarms. For example – if you are using a pelvic. Please take this into consideration when assessing your equipment needs.
High fall risk patients need to have low and moderate standard work put in place. However, there area few differences. A bed and chair alarm needs to be activated when in use and is not related to the patient’s mental status. All high risk patient’s need the bed and chair alarms in place. Also, when these patient’s are up out of bed or out of the chair, they always need to be within arm’s reach of each other. This may feel awkward as care givers, and some patients can get frustrated when want us out to use the bathroom, but we need to stay with them for their safety. A common phrase to tell the patient is this “I know me staying with you when you go to the bathroom is not comfortable, but I am here to protect your safety and you are at risk for falling.” If you need help with what to say, please ask a Falls Champion or Lead Preceptor. There are also three more things that need to be implemented with high fall risk patients. This includes the falls door placard outside the patient room, which may be different in 4W and 2S. HEV should be updated. The RN needs to let the HUC know to do this. And the yellow wristband needs to be on the patient.
Again, if you have questions, please be sure to ask your Lead Preceptor or Falls Champion.

10. Standard Work: Bed Alarms
The next standard work has to do with bed alarms. The Standard Work for High, Moderate, and Low falls risk says that you have to use alarms with some patients in the moderate category and all patients in the high risk category. This can get confusing because we have so many different types of beds.
This slide will help you understand the four different options you have for a bed alarm.
The first option is the Stryker 2 alarm with the alarm set to Zone 2. This bed has an alarm in it and a posey alarm is not required to use it. We use zone 2 because it is the best zone for people that are at risk to fall. Zone one is too sensitive for patients that move, and zone 3 won’t alarm until the patient is already out of bed... And this is when it’s too late!
The second option is the Carroll bed with the alarm set to zone 2. The alarms on this bed are the opposite of the stryker bed, but zone 2 is in the middle and is the same. You are not required to have a posey alarm with this bed either.
The third option is the MC high/low bed with the posey alarm and pad. This bed does not have a built in bed alarm, so you need to use a posey alarm and pad with it.
The fourth option is the HillRom bed. This one also requires the use of a posey alarm and pad.

11. Standard work, like the one on this slide, is available for review in your standard work book on every unit. Please take the time to review the standard work, so you understand what is expected of you and how to complete each task.
Just to make sure we are all understanding this form. I’ll give you a brief review. You will see in the standard work book that all of the documents for standard work use the same format. This is to make it easier to understand. For instance, the description of the task is at the top. This one is called “setting alarm on the Stryker bed standard work”. Next it says the equipment you need. For this task, you only need the bed. Then below that are the important steps. This standard work reviews the need to zero the bed, place the patient, push arm/disarm, select the zone, and make sure the alarm is armed and the light is on. The right side of the page has pictures to help you with each step of the process. If you have questions, the owner of the document is listed at the bottom of the page.

12. Standard Work Setting Alarm on the Stryker Bed
Setting Alarm on Carroll Bed
Posey Alarm Setting with bed and chair pads
Hand-over Communication for RNs and NAs
Ordering, setting-up, safety checks, and returning equipment
Hourly Rounding
Again, please make sure you review the standard work on your unit. You are expected to know this as a patient care provider. Every unit has a book of all the standard work, and the Lead Preceptors and Falls Champions also have their own copy. Again, please take the time to read these documents so you understand what is expected of you. Most of the information is something you have already been taught before and how you may have already been practicing. However, it is good for all of us to have it in writing, so we have something to refer to and educate with. When we are all practicing similarly, we can really find out where our opportunities for improvement are.

13. One of the standard works that the team knew was needed included hourly rounding. We will go over this standard work in the powerpoint due to the importance of this evidence based practice.
The team talked about hourly rounding, and it appeared there was not a standard for how to do it and what to say to patients and families when we were doing it. With everyone doing hourly rounding differently, this led the patients and families to believe that we weren’t doing it. Hourly Rounding can be tricky because it is the patient and family’s perception of care. We don’t want everything to be scripted, but we do want consistency in our practice so patients and families understand that we are rounding.
The standard work for hourly rounding includes six steps:
Upon admission, the RN educates the patient and family on hourly rounding. They tell the patient and family about the hourly rounding log and that it means we will address pain, potty, positioning, and placement of items every hour on the day and evening shift, and every two hours on the night shift. We tell them this is evidence based practice to improve patient safety and the patient experience.
When we round as care givers, we complete our activities in the room. This will include addressing pain, potty, positioning, and placement of items. How we do this will depend on the patient we are with and how we practice as a care giver. Addressing these four areas may not be the only things we do in the room, but we always make sure we cover these topics. This is steps 2 through 5 in the hourly rounding standard work.
The last step in the standard work is what is most important for all of us to understand as care givers. The last step states that the nurse or nursing assistant fills out the hourly rounding log . It also states that we speak out loud to the patient and/or family when we are filling it out. This is the step that we all need to be consistent in. When we all fill out the log, and say what we are doing out loud, this builds trust between the care giver and patient and family. They hear and see that we are all practicing the same way. When they hear this, they understand what we are doing and they do not need to interpret our actions. This consistency in practice is what will help us decrease call lights, falls, pressure ulcers, and improve the experience for both our patients and us!

14. Current State
Part of our process needs to be knowing if we are doing well or if there are opportunities for improvement. The graph on this slide shows us that there are opportunities compared to the standard work we developed for low, moderate, and high risk interventions.
The 3-day event team created the standard work for fall risk level interventions, but then was wondering how well we are doing now. The audit was completed on June 19th. The team went out and audited all of the patients in the hospital. The falls risk level was reviewed, and then the team checked to see if the standard interventions that the team created were in place. As you can see by the red bar on the slide, all of the patients had only 45% of the minimum interventions in place. The blue bars show the individual units, and the results varied, but this shows that standard interventions were not developed and were not put in place.

15. Current State
On this slide, you can see that the team took it a step further and just looked at the bed alarms needed. If you remember from a previous slide, moderate fall risk patients that are cognitively impaired now require alarms, and all high fall risk patients require alarms. The audit was completed and across the entire hospital, only 28% of alarms needed were in use. This means that 72% of our patients that needed an alarm for fall prevention did not have one in place. The 3-day event team saw this as a major ah-ha moment and knew that we were not preventing as many falls as we probably could if alarms were in place.

16. Auditing for the Future State
Two Audits – Completed Weekly
Percent compliance for fall interventions in place per standard work
Percent compliance for chair/bed alarms in use per standard work
95% compliance needed to show process improvement
Falls rates will continue to be monitored
The 3-day event team wanted to be sure that the work they completed was going to stick. Auditing was discussed and needed in order to make improvements and give people feedback. The same two measures on the previous slides will continue to be used to monitor our progress. Audits will be completed weekly on the percent compliance on standard interventions in place for high, moderate, and low risk patients. Audits will also be completed on just the alarm section.
The 3-day event team is looking for 95% compliance or greater on these standard interventions. As a hospital, we will continue to monitor the falls rate; but we know that monitoring the falls rate will not help us make improvements. The real thing that will help us make improvements is monitoring the interventions in place. If those are getting better, then we hope to see improvements with the falls rate.

17. Expectations Understand the PowerPoint presentation
Read and understand the Standard Work
Understand the minimum interventions for high, moderate, and low risk patients
Understand what will be audited
Keep up to date on progress and let champions know if you have ideas
This slide presentation includes a lot of information. To make it a little bit more simple, we will go over your expectations:
First, you should understand the information presented in this powerpoint. If you don’t, please ask your Lead Preceptor or Falls Champion to clarify information.
Second, you need to read and understand the standard work that is available on your unit. Again, ask questions if you have them.
Third, clearly understand the minimum interventions needed for low, moderate, and high risk patients. These interventions are not optional. These are the bare minimum and all patients should have them in place based on their risk level. Additional interventions can be put in place, but these are the bare minimum.
Fourth, know what will be audited and
Fifth, keep up to date on the audits. Understand how we are doing and let your champions know if you have ideas. The falls committee will review ideas and data monthly.

18. Thank you, again, for taking the time to review this information
Thank you, again, for taking the time to review this information! We look forward to improvements in patient safety!!!