2. Two South Falls 2010 Analysis of Patient Profile January 1 – October 8, 2010 Annie Cordova, RN

3. ObjectivesObjectives Analyze Trended Patient Falls Data Identify Falls Risk Patient Profile Analyze National Database of Nursing Quality Indicator (NDNQI) Falls Score Mean Comparison to Two South Falls Score Mean Review Extreme Falls Risk Pilot (2009) Discuss Next Steps

4. Day of Week

5. Time of Day

6. ShiftShift

7. Room Number

8. SectionSection

9. GenderGender

10. Average Age

11. Average Age by Gender

12. Patient Aggregate

13. LocationLocation

14. Level of Injury

15. Genitourinary Status

16. Falls/1000 Patient Days

17. Two South Falls Risk Patient Profile 2010 26% Saturday 58% 7a-7p Shift 53% 8am-3pm 63% Bayside (283-287) 58% Male 72 Average Age

18. Two South Falls Risk Patient Profile 2010 Patient Aggregate Increased Risk Medical NeuroSurgical 79% Fall Location Bedside/Bathroom 32% Genitourinary Not Within Defined Limits

19. Extreme Falls Risk Implementation Plan January 2009 Patient Profile: –Team Leader to screen admissions for increased falls risk –Unexpected admits –Especially Trauma –Hip Fractures –Other Fractures –MVAs –Falls Prior to Admission

20. High Fall Risk Implementation Plan Pilot: 3-1-09 – 9-1-09 Patients who are at high risk for fall will be identified by the Team Leader and communicated to the primary nurse within a 2 hour period. Criteria include patients with traumatic injuries (hip and femur fractures, mva, recent falls) and anyone requiring a tab alarm. “Star” Sticker will be placed on TL patient card and individual assignment sheets. High risk patients will be identified on the Master assignment sheet and all copies (HUC, Conference Room, Assignment sheet book) of assignment sheet via pink highlighter. This will provide us with a record of patients at high fall risk and allow for staff awareness and HUC awareness. Falls toolkit located in 2 South equipment room includes: Tab Alarm Gait Belt 3 signs (modified fall risk sign on door, above bed and greaseboard at FOB) Marker Safety information brochures for patient and family IMPLEMENTATION Tab alarm on patient and turned on Place modified fall risk sign on door and above patient’s bed Give patient and family safety information brochure as appropriate Potty checks q 2 hrs, visual checks q 30 min using greaseboard at FOB. Utilize the team for rounding. Not doing the checks is not an option but delegation is. Document checks in Cerner at the end of shift in nursing notes.

21. Extreme Falls Risk Pilot Tools 2009

23. Next Steps Falls Risk Patient Profile Review Falls Team Implementation Literature Review Falls Reduction Implementation Plan File IRB Nursing Research Implement/Evaluate Outcomes/Revise Sustainability of Reduction

24. SummarySummary Two South has identified patient falls to be above the NDNQI Comparison Mean in 2010 Analysis of data reflects patients at high risk for falls Review of 2009 implementation plan to reduce risk for patient falls Describe Next Steps…..