1 / 16

Experience to date Nov. 1, 2008 - Feb. 1, 2009

South West Nova District Health Authority (SWNDHA) Safer Health Care Now! Falls Prevention Project Roseway Hospital. Experience to date Nov. 1, 2008 - Feb. 1, 2009. South West Nova District Health Authority is one of nine district health authorities serving Nova Scotia.

lars
Download Presentation

Experience to date Nov. 1, 2008 - Feb. 1, 2009

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. South West Nova District Health Authority(SWNDHA)Safer Health Care Now! Falls Prevention Project Roseway Hospital Experience to date Nov. 1, 2008 - Feb. 1, 2009

  2. South West Nova District Health Authority is one of nine district health authorities serving Nova Scotia. SWNDHA is situated on the southern most tip of Nova Scotia. It covers a geographical area of ~7000 square kilometers. It provides health care services to ~61,000 residents of Shelburne, Yarmouth and Digby Counties.

  3. Background PROJECT LOCATION Roseway Hospital (RH) Shelburne, Nova Scotia 26 bed unit 14 designated Alternative Level of Care (ALC) beds 3

  4. ImprovementTeam Members • Margo Lowe, Clinical Resource Nurse, • Kim Ott, Rehabilitation Services • Sheila Hartley Gallion, Environmental Services • Angela Stanley, Nursing Team Leader • Darlene Huskins, Nurse Manager • Dr. Riley, Physician • Tamra Farrow, Falls Prevention Coordinator • Team Sponsor: Department of Health Promotion and Protection, Department of Health and South West District/Cathy Blades VP, clinical.

  5. Aim • Purpose of Project: Implement a comprehensive Falls Prevention/ Management program for ALC population at RH that includes: policy and processes, health care provider education, and safe environments. • Goal: By May 2009, the goals of the Falls Prevention/Management Program are to: reduce the number of falls and the severity of the falls within RH ALC population by 10%. • Scope and Boundaries: • All patients admitted to the 14 bed ALC unit at RH Nov/08- May. • Include all types of falls that occur, according to the Safer Health Care Now! Definition. • Exclude the falls incidents that occur outside the pilot location.

  6. Aim (con’t) • Improvement Objectives: • Reduce fall rates by 10% compared to baseline data. • Reduce severity of injury by 10% compared to baseline data. • 100% of the individuals included in pilot will have a falls risk assessment completed within 24 hours of admission. • Work toward 100% of the individuals at risk for falls to have a documented plan of care to address identified risk factors. • Restraint practice (physical and medical) will follow SWNDHA Least Restraint policy.

  7. Results # of falls- RH 07/08 Community Client 1 Employee 7 In Patient/Resident 66 Out Patient 1 Visitor/Family 2 Grand Total 77

  8. Changes tested • Knowledge of employees Falls risk factors • Action for employee education and awareness building • Data collection tool for SHN project stats, created for use with ALC patients - is it user friendly? • Formation/effectiveness of multidisciplinary Falls Prevention team weekly rounds • Action to address environmental hazards

  9. PDSA – Employee Knowledge - Plan What change are we testing? Employee knowledge on fall risk factors. What is our prediction and theory? 50% response rate.; 60% the respondents will score 80+% on quiz Details of the plan Who: Project Improvement team and all hospital staff What: Quiz created by RNAO titled Falls Prevention: Building the Foundation for Patient Safety. Where: RH - all units When: December 1-24, 2008 How: The team delivered quiz - memo attached re project; a ballot was attached as incentive to complete and return - three prizes were available. Data collection: 1. # quiz distributed 2. # returned/completed quiz

  10. PDSA – Employee Knowledge - Do Returned Quiz • By department: # returned; knowledge level, average # correct answers Every department participated and had correct and incorrect answers. Only one returned quiz had a perfect score. • Which questions were correctly answered; highest percentage All respondents correctly answered that a risk assessment should be performed on all admissions • Which questions were incorrectly answered; highest percentage #1 – death in the elderly, # 2 – acute care setting, #9 Restraint use, # 5 – laxative use (shown in highest-lowest %)

  11. PDSA – Employee Knowledge - Study Do the results agree with the predictions? Yes and No • Predicted a 50% return of quiz sheets - had a 51% return; predicted 60% of staff would score 80+% - only 42% met the prediction. What new questions or issues arose? • Quiz not given to the physicians or front desk staff. • Question on call bells not included because a new call system is being installed What are our updated theories? • The knowledge level is not as high predicted therefore more employee education and awareness is necessary - there are specific areas identified from the quiz. Under what conditions could the results be different? • Stronger employee understanding regarding the elderly and fall risk factors. Summarize new knowledge. • There are gaps in employee knowledge regarding fall risk factors, particularly the Least Restraint policy and the role of laxative use as it impacts on fall risk.

  12. PDSA – Employee Knowledge - Act What action are we going to take as a result of this cycle (Adopt, Adapt or Abandon)? • Continue to raise fall risk level of awareness • Create a newsletter • Logo design contest Are we ready to implement? • YES!!! What other processes or systems might be affected by this change? • Care for the ALCU patient has improved • RH is now looking at other fall risk initiatives • Safety Culture at RH will improve. • This is a small District – the other sites will hear our success and will want to implement change as well.

  13. Universal Falls PrecautionsAll patients are at risk for falls.Everyone has a role in falls prevention. • Safe environment • Bed rails down unless assessed otherwise • Pathways clear of clutter • Bed and chairs in locked position • Adequate and appropriate lighting • Assist with mobility • Mobility assist documented • Safe and regular toileting • Assistive devices within patient reach • Fall risk reduction • Call bell in patient's reach • Bed lowered to patients knee height • Personal items reachable • Proper footwear available and in use • Engage patient and family • Discuss risk factors with patient and family • Communicate mutual plan Keeping SAFEfrom falls

  14. OtherResources • T&F quiz from RNAO • Newsletter created specifically for project • Branding Poster and Logo contest • Handout “Don’t Fall for Christmas” adapted from Community Links Preventing Falls Together Coalition • Developing: Falls Prevention education package for patients, education handout for family and caregivers, shoe guidelines, general awareness pamphlet, best practice recommendations for strategic direction, orientation package for new staff

  15. LessonsLearned Fall Prevention strategies although identified in Accreditation Canada’s ROPs and accepted by SWNDHA have not been totally embraced. This is primarily due to lack of education and understanding of the complexities of Fall Prevention. There is a need for an ongoing comprehensive Falls Prevention Strategy throughout the District. This is beginning to be developed and actioned.

  16. NextSteps • Intervention Programs • Patient/Family Strategies • Exercise • Medication Review • Nutrition, Vitamins and Supplements • Rehabilitation Assessment • Environmental Considerations • Continence Management • Behavioural Strategies • Post Fall Management • Education Requirements

More Related