1.  Fall Prevention and Mobility One Systems Story Intermountain led CMMI Hospital Engagement Network June 4, 2012 Marlyn Conti, Quality and Patient Safety Consultant, Intermountain Healthcare Central Office Vicki Spuhler, Nurse Manager Respiratory ICU Intermountain Medical Center

2. Disclosure  The presenters of this webinar have no financial conflict to disclose.

3. Objectives At the conclusion of today’s webinar, participants will be able to: 1. List key steps to ‘getting started’ 2. Identify at least 3 strategies for reducing falls 3. List at least 2 outcome and/or process measures to track/trend over time

4. HEN Survey Results

5. HEN Survey Results – Learning Level

6. Getting Started 1 Organizational priority 2 Risk assessment 3 Monitoring systems 4 Champions 5 Care plans 6 Plan-Do-study-Act

7. Getting Started VA Center for Patient Safety

8. Getting Started IHI – Best Practice  The BEST fall prevention programs are multifactorial and interdisciplinary  *AHRQ I-II,USPSTF A: LTC; Ambulatory Care; Source of Policy for JCAHO Fall Program Guidance 2007

9. Getting Started Fall Assessment Tools  Morse  Hendrich II  Schmid  Others

10. Getting Started Fall Assessment Tools cont.  Standard protocol  Tool in computer and paper forms  Hard code frequency of assessment  Monitor compliance Unpublished work of authorship. Copyright © IHC Health Services, Inc. (Intermountain Healthcare). All rights reserved. 2009

11. Getting Started Fall Assessment Tools cont  Hybrid tool  Criteria specific to patient population  Updated and reviewed frequently ScoreGeneral PopulationPost Partum WomenPediatrics 5 History of Falls (within 3 months) 3 Stroke/ impaired mobility (e.g. unstable gait, needs assistance with ambulation, assistive devices, post invasive procedure [e.g., post femoral access]) Impaired mobility (e.g., epidural numbness, unstable gait, needs assistance with ambulation, assistive devices? Impaired mobility (e.g. ustable gait, needs assistance with ambulation, assistive devices, medical equipment, cerebral palsy [CP]) 3 Elimination problems (e.g., diarrhea, constipation, incontinence, urgency, recent removal of indwelling urinary catheter) Elimination problems (e.g., recent removal of indwelling urinary catheter, diarrhea, urgency when ambulating) Elimination problems (e.g., diarrhea, constipation, incontinence, urgency when ambulatory) 3 Sensory deficit (e.g., impaired vision/ hearing/ balance, neuropathy, procedural parasthesia [e.g., post femoral access]) Sensory deficit (e.g., epidural numbness, impaired vision/ hearing, neuropathy) Sensory deficit (e.g., impaired vision/ hearing, neuropathy, communication barrier) 2 Mental status changes (e.g., confusion, drug toxicity or alcohol) Mental status changes (e.g., drug/ alcohol/ confusion) Mental status changes (e.g., confusion, drug toxicity, alcohol, or developmental delay) Unpublished work of authorship. Copyright © IHC Health Services, Inc. (Intermountain Healthcare). All rights reserved. 2012

12. Getting Started Staff Education Signs and posters Chart stickers and door frame magnets E-Learning Bed skills pass off check lists

13. Getting Started Patient/Family Education  Computer prompt to print out patient fact sheet  Posters and door magnets  Enlist patient and family engagement Unpublished work of authorship. Copyright © IHC Health Services, Inc. (Intermountain Healthcare). All rights reserved. 2012

14.  Working Harder Fall Champion Educate Assess Implement Prevent Monitor

15. Working Harder Accountability Diagram Fall Prevention Development Team Region Guidance Facility Champion Team Nursing Safety Physical Therapy Education Pharmacy NOTE: Could be Safety or Quality and Patient Safety Committee

16. Working Harder Teams and Champions  Empower champions  Designate teams/committee  Link to Safe Patient Handling  30% to 51% of falls have injuries  80% - 90% un-witnessed  50%-70% occur during transfer  *Measuring Fall Program Effectiveness. Nursing Quality Network Nursing Quality Network

17. Working Harder Fall Prevention Toolkits Signs and posters Assessment and charting tools Protocols References Education Skill pass off checklists Unpublished work of authorship. Copyright © IHC Health Services, Inc. (Intermountain Healthcare). All rights reserved. 2012

18. Working Harder Monitor Rates Unpublished work of authorship. Copyright © IHC Health Services, Inc. (Intermountain Healthcare). All rights reserved. 2012

19. Working Harder Monitor Rates cont. Unpublished work of authorship. Copyright © IHC Health Services, Inc. (Intermountain Healthcare). All rights reserved. 2012

20. Working Harder Mobility

21. Ahead of the Curve  Tailor interventions to risk factors  Integrate with ‘rounding’  Assure use of bed, chair and/or toilet alarms  Use computer logic to support decision algorithms

22. Working Harder ICU Risk Factors All four legs of the stool are important for stability, mobility, sedation, delirium, and sleep are important to improve outcomes. Mobility Delirium Sedation Sleep

23. Working Harder ICU Mobility Affinity Diagram SLEEP SEDATIVES MOBILITY DELIRIUM Makes It Worse Makes It Better Courtesy of Terry Clemmer MD

24. Ahead of the Curve ICU Mobility 24 “Improving long-term outcomes after discharge from intensive care unit: Report from a stakeholders’ conference” Critical Care Medicine. 40(2):502-509, February 2012. Post Intensive Care Syndrome (PICS) Family (PICS-F) Mental Health Anxiety/ASD PTSD Depression Complicated Grief Survivor (PICS) Mental Health Anxiety/ASD PTSD Depression Cognitive Impairment Executive Function Memory Attention Visuo-spatial Mental Processing Speed Physical Impairment Pulmonary Neuromuscular Physical Function

25. Working Harder Average Cost/ Patient Day Adjusted for 2010 costs

26. Ahead of the Curve Average ICU LOS 8.5 14.5

27. Ahead of the Curve ICU Discharges 27

28. Ahead of the Curve Monitor Fall Rates Unpublished work of authorship. Copyright © IHC Health Services, Inc. (Intermountain Healthcare). All rights r12erved. 2009

29. Ahead of the Curve Patient Handling Unpublished work of authorship. Copyright © IHC Health Services, Inc. (Intermountain Healthcare). All rights reserved. 2012

30. Ahead of the Curve Drive Improvement System Board goal 2011 and 2012 Mandatory education Connect with safe patient handling Connect bed alarms to nurse call systems (smart beds)

31. Ahead of the Curve Drive Improvement cont. Post-fall tool Care team huddles Additional prevention Gait belts for ambulation

32. Ahead of the Curve Drive Improvement cont Tell your stories! Engage frontline staff and middle management

33. Ahead of the Curve Forcing Functions Computer logic AND Safety Rounds

34. Outcome Measures  Falls per 1000 patient days  Numerator: Count of falls by inpatient unit. All severity levels, assisted or unassisted. Outpatient and visitor falls are excluded.  Denominator: Count of patient days based on midnight room charges for inpatient units. Outpatient units are excluded.  Source - NDNQI

35. Outcome Measures cont  Falls with injury per 1000 patient days  Numerator: Count of falls by inpatient unit. Severity levels greater than “No Harm” also excludes “Emotional Injuries Only”, assisted or unassisted. Outpatient and visitor falls are excluded  Denominator: Count of patient days based on midnight room charges for inpatient units. Outpatient units are excluded  Source: NDNQI

36. Process Measures  Assisted and unassisted falls as a % of falls  Numerator: Count of falls by inpatient unit. All severity levels. Stratified by assisted or unassisted. Outpatient and visitor falls are excluded.  Denominator: Count of falls by inpatient unit. All severity levels. Outpatient and visitor falls are excluded.  Source: NDNQI

37. Optional Process Measures  Fall by risk level  Count of falls by inpatient unit. Stratified by severity level. Includes assisted or unassisted falls. Outpatient and visitor falls are excluded.  Source: Medical Record Review  Fall during transfer per 1000 patient days.  Numerator: Count of falls by hospital that occurred during transfer. All severity levels, assisted or unassisted. Outpatient and visitor falls are excluded.  Denominator: Count of patient days based on midnight room charges for all inpatient units. Outpatient units are excluded.  Source: Medical Record Review

38. Questions?  What tools would you like posted?  Who would be willing to share improvements and/or best practice?

39. Keep the Conversation Going!  Patient Falls and Immobility Affinity Group Call  2 nd Friday of each month  First call – Friday, July 13 th at 11:00 am MST  Info posted on calendar at HENLearner.orgHENLearner.org

40. Acknowledgements Thanks to the hard work and continuing efforts by the Intermountain  Fall Prevention Team  Quality and Patient Safety Staff  Quality data Analyst  Educators, etc.