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Lessons Learned from the VHA and Recommendations for Fall Related Injury Prevention

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Lessons Learned from the VHA and Recommendations for Fall Related Injury Prevention Lessons Learned from the VHA and Recommendations for Fall Related Injury Prevention Christina Soncrant M.P.H. VA National Center for Patient Safety Christina Soncrant, M.P.H. Christina Soncrant, MPH, has worked for the VA National Center for Patient Safety for 8 years. She is currently a Health Science Specialist at the NCPS Field Office in Vermont. She joined the VA in 2011 after graduating from Dartmouth College with her masters degree in public health with a focus in healthcare improvement, implementation science, and health science research. Over the last 8 years her focus has been on fall and fall related injury prevention, fall data collection and evaluation, and coaching and leading breakthrough series nationwide on the topics of implementation science, falls prevention, pressure injury prevention, CAUTI and sepsis. In addition she does extensive work with other program offices such as the VISN 8 falls PSCI, the VA National surgery office, and the National Anesthesia Office. Her work involves evaluation of patient safety efforts such as Ensuring Correct Surgery, development of surgical and anesthesiology adverse event lessons learned for the field and research on adverse event prevention and improvement on various topics areas as well as research on implementation science and improvement projects such as the lessons learned and virtual breakthrough series. Learning Objectives: 1. Discuss the background of the current problem on preventing falls and fall related injuries. 2. Share the success stories from collaboration between the National Center for Patient Safety and State Veterans Homes in preventing fall and fall related injuries. 3. Describe the results and lessons learned from a year of reported root cause analyses on serious falls in the VHA. 4. Peer to peer sharing on the successes and barriers to fall prevention interventions on the front line. 5. Provide an overview of the concepts of Diffusion of Innovation and Leading Change. How do we make change happen on the front line? 4 Epidemiology: around the world Over 80% of falls occur in those over the age of 65, with the age adjusted death rate from falls over 65 years increasing from 47.0 per 100,000 in 2007 to 61.6 per 100,000 in 2016 (Healey et al. 2012, CDC M&M 2018). Nearly 25% of falls required MD or hospitalization (Healey et al, 2012) More than three-fourths of all falls occur in rooms or bathrooms of residents Sit-to-stand or stand-to-sit transfers were associated w/ higher percentage of falls (42%) than walking (35%) (McGibbon et al, 2019) Long Term Care 5 Falls prevention in Nursing Homes. C. Becker & K. Rapp. 2010, Nov. Clinics in Geriatric Medicine. Falls in LTC result in more serious complications: 10-25% resulting in fractures or lacerations; most serious – hip fractures Hip fractures- associated with a host of negative outcomes- increased mortality (mortality 36% within 6 months, worst prognosis in those over 90 years of age). Those that survive, most have decreased mobility and ability to function independently. Other injuries (fx pelvis, UE, Spine or skull) result in considerable suffering Reducing the risk of falling can positively affect residents’ quality of life to a considerable extent Mean Fall rate 1.7 falls per person-year (range 0.6-3.6), considerably higher than community-based fall rate (mean 0.65; range, 0.3-1.6) In a facility with 100 beds, a fall can be expected about every other day. Falls are one of the top ten sentinel events reported to Joint 6 Commission and the number one Root Cause Analysis event type reported to the National Center for Patient Safety The Challenge of Falls Goal is to promote mobility and independence without injury Risk factors: All are high risk (unless immobile or in coma) We work with a population that often meets several of the well established risk factors: muscular weakness, balance and gait deficits, poor vision, delirium, cognitive and functional impairment, orthostatic hypotension, urinary urge incontinence, and nocturia. Comorbidities (dementia, depression, stroke, PD) may lead to attention deficits, executive dysfunction, or visual field loss – result in higher propensity to fall. Side effects and interactions of drugs Not all falls are preventable Anticipated physiological; due to fall risk factors Accidental; due to environmental causes Unanticipated physiological; physical events unable to predict Decision Tree for Types of Falls Wednesday June 13, 2018 Fall Post Fall Huddle Determine What was different Immediate this time? Cause Immediate Causes E.g., Spill on floor E.g., Postural hypotension E.g., Heart Attack Trip over tubing Weak or impaired gait Seizure Broken Loss of balance Drop Attack equipment or Confusion furniture Centrally acting medication Unknown Sudden condition that Known Intrinsic/ Environmental cannot be Extrinsic Risk Factors predicted before the first occurrence NCPS falls Types of Falls toolkit: Anticipated Unanticipated https://www.pa Accidental Fall Physiological Fall Physiological Fall tientsafety.va.g Unpreventable Falls ov/professiona Determine ls/onthejob/fal Preventability ls.asp Think, Pair and Share Are falls and fall prevention an issue? What are your facilities top concerns and priorities right now? Is fall prevention a priority at your facility currently? Results from a Virtual Breakthrough Series to Prevent Fall and Fall-Related Injuries "Caring for America's Heroes" Collaboration between State Veteran Homes (SVH) and the Veterans Health Administration (VHA), National Center for Patient Safety (NCPS), and the VA Office of Geriatrics and Extended Care Operations Background 2 completed breakthrough series on falls with State Veterans Homes and an ongoing relationship between VHA NCPS and State Veteran Homes. - 2015 - 2016/2017 2 Papers, one published NCPS falls toolkit: https://www.patientsafety.va.gov/professionals/onthejob/falls.asp AHRQ falls toolkit: https://www.ahrq.gov/sites/default/files/publications/files/fallpxto olkit.pdf Interventions Most common interventions: 1. Post fall huddles- you cant fix it if you don’t know the cause of the problem 2. Other interventions (e.g., improved documentation, improved communication, delirium/cognitive assessment, etc. 3. Program evaluation (e.g., review post-fall huddle data, regular meetings review fall cases, etc.) 4. Staff education 5. Intentional rounding Outcomes Unparalleled commitment and dedication Individual teams made significant gains in attaining their aims- both process and outcome Reduction in falls with non major injury in both breakthrough series and major injuries in the first. Peer to peer learning and sharing Despite the barriers you made CHANGE HAPPEN. 2015 State Veteran Homes VBTS- Outcomes Number of Falls per 100 Census Days by Month 9 25 F a 8 24.5 A l g l 7 24 g r I 6 23.5 e n g Fall Injury Rate j 5 23 a u t Fall with Major Injury Rate r 4 22.5 e Fall with Non-Major Injury Rate y d Aggregated Fall Rate 3 22 marks statistically R R significant changes (p<0.01) a 2 21.5 a t t e 1 21 e s 0 20.5 September October November December 16 Lessons Learned from Root Cause Analyses in the VHA: A 1- Year Review of Falls with Injury and Recommendations Soncrant C, Neily J, Bulat T, Mills P. Recommendations for fall related injury prevention: a 1-year review of fall related root cause analyses in the Veterans Health Administration. J Nurs Car Qual. (in press) Methodology We completed a Retrospective analysis of RCA reports between August 1, 2016 and August 1, 2017. Study included all VA facilities. Over 1243 health care facilities nationwide, including 172 VAMC and 1062 outpatient sites. We looked at the types of falls, preventability, patient outcome (injury level), injury type (fracture, laceration, etc.), root cause of the event, and lessons learned. Results- Patient Characteristics 90% of falls classified as preventable Majority of the falls (83%) resulted in a major injury The most common injury types were hip fracture (43%), other fracture (25%), and head injuries (16%). Most falls (75%) were unwitnessed. [Oliver et al. (80% - 90%)] Reported Root Causes/Contributing Factors of Events oEquipment and environmental hazards (21%) oCommunication issues such as handoffs or post fall huddles (14%) oPatient supervision (10%) 21 Accident Theory- All new admissions are considered a fall risk until proven otherwise Reason. , Human Error: models and management, 2000 22 Best Practice Approaches Fall prevention requires multiple interventions that are multifactorial, crossing several disciplines to be effective in mitigating or eliminating patient-specific, modifiable, fall risk factors It takes truly an interdisciplinary team effort to reduce the risk of falls and related injuries Most effective, fall prevention interventions should be 23 targeted at both point of care and strategic levels. Best Practice Approach: Implementation of safer environment of care – protect and pad the environment ID those at risk for injury Implementation of interventions targeting those at risk for falls Interventions to reduce risk of injury to those who do fall Identifying High Risk, Vulnerable Populations Screen for history of falls, or falls as reason for admit Consider elders high risk Screen for risk of injury using a tool such as the A, B, C, S A = Age (equal to or greater than 85) or frailty B = Bones (fracture risk or history) C = AntiCoagulation (bleeding disorder) S = Recent surgery (during current episode of care) Health Research & Educational Trust (June 2018). Falls with Injury Change Package: 2018 Update. http://www.hret-hiin.org/Resources/falls/18/falls-with-injury-change- package.pdf (see page 31) The ABCS Tool Tool offers insight into what interventions should be put in place to protect the patient from injury in the event of a fall. Examples: patients at risk for hip fracture due to poor bone health might be offered hip protectors. Assume your at risk patient WILL FALL. How do we prevent falls with injury while encouraging mobility and independence? Hip Fractures and Hip Protectors Our study showed that 43% of all injuries were hip fractures.
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