APNA 30th Annual Conference Session 2042: October 20, 2016 Reducing - - PDF document

APNA 30th Annual Conference Session 2042: October 20, 2016 Ives 1

Reducing Falls with Injury on an Inpatient Geriatric Psychiatry Unit through Elevation of Nursing Support Staff: An Interprofessional Approach APNA 30th Annual Conference

Session: 2042.2 Thursday October 20th 2016 3:00pm Jessie Reich, MSN, RN, ANP-BC, CMSRN Professional Practice Consultant Pennsylvania Hospital-Penn Medicine, Philadelphia PA Lynn Ives, MSN, RN-BC Nurse Manager Inpatient Psychiatry Pennsylvania Hospital-Penn Medicine, Philadelphia PA Kathryn Farrell, MSN, RN Professional Practice Consultant Pennsylvania Hospital-Penn Medicine, Philadelphia PA John Brennan, MSN, RN, CNHA Clinical Director Pennsylvania Hospital-Penn Medicine, Philadelphia PA 2

Disclosure

The speakers have no conflicts of interest to disclose

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Learning Objectives

 Identify strategies utilized to implement an internal falls with injury reduction program for nursing support staff  Describe interventions to elevate the practice of nursing support staff  Describe methods to engage interprofessional colleagues in falls with injury reduction

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ABOUT PENN MEDICINE

The University of Pennsylvania Health System was created in 1993 and consists of five hospitals (Hospital of the University

• f

Pennsylvania, Penn Presbyterian Medical Center, Pennsylvania Hospital, Chester County Hospital, Lancaster General Hospital), a faculty practice plan, a primary care provider network, multi-specialty satellite facilities, home care, hospice and a nursing home.

Licensed Beds 2,503 Total Employees 31,235 Admissions 118,445 Outpatient Visits 4,734,948 Physicians 5,314 Nurses 6,793

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 The Nation’s first hospital founded by Benjamin Franklin and Dr. Thomas Bond in 1751 to care for the sick poor and the mentally ill  This was the first hospital that attempted to cure the mentally ill  Dr. Benjamin Rush wrote the first American text on psychiatry titled “Medical Inquiries and Observations upon Diseases of the Mind” in 1812  Dr. Thomas Kirkbride was one of the

• riginal 13 physicians to form what is now

known as the American Psychiatric Association

Pennsylvania Hospital- The Nation’s First

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 989 Registered Nurses

• 761 Full Time
• 147 Part time

 RN Turnover below 6.5%  Relationship Based Care

• Professional Practice Model

 Modified Primary Care Nursing

• Care Delivery Model

Nursing at Pennsylvania Hospital

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Psychiatry at Pennsylvania Hospital

2 inpatient psychiatry units

• 24 bed inpatient psychiatry unit
• 18 bed geriatric, medical, psychiatry unit

– Large population of dementia patients – Traumatic brain injury population

Only geriatric unit in the 5 hospital health system Intervention implemented on the geriatric psychiatry unit due to the unique patient population

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Background

 Geriatric psychiatry patients are at the highest risk of falls and falls with injury

• As evidenced by a high national benchmark

 Patients who are frail and elderly in conjunction with decreased cognition/ mental illness are at increased risk for falls and falls with injury

• Age, confusion, gait instability, medications, previous fall,

multiple diagnoses, psychiatric diagnoses  Prior to intervention, providers at Penn Medicine used the Morse Fall Scale and the Montreal Cognitive Assessment (MoCA) but did not assess patients looking at the two scales together

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Impetus for Change

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Impetus for Change

Multiple different scales used to assess multiple risk factors, but not utilized together Lack of role clarity for nursing support staff (PCTs),

• ccupational therapists (OTs), and Physicians

Inter and intraprofessional communication gaps Undefined process for falls prevention equipment utilization

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Structures in Place

Consistent Reporting Structures

• National

– NDNQI

• Internal

– Falls Debrief Team and Process – Ongoing Falls Reduction Plan – Monthly and Quarterly Falls Analysis – Transparent Data- Unit Based Quality Boards – Transparent Incident Reporting Structure – Morse Fall Scale to Assess Falls Risk – MoCA Scale to Assess Cognition – Existing Team Meetings in Psychiatry

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Intervention

 Interdisciplinary falls reduction team developed

• Physicians, Physical Therapists, Occupational

Therapists, Nursing Quality, Nurse Manager, Clinical Nurses, and PCTs

 Examined unit based data and explored best practice interventions  Developed a bundled approach to reduce falls with injury

• Developed a “falls plus” initiative ( High Morse, Low

MoCA)

• Internally Certified PCTs as Certified Falls

Prevention Advocates (CFPAs)

• Removed structures and barriers which contributed

to breakdowns in communication

• Revised PT and OT assessment structure

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Risk Identification

Morse MoCA

= +

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Revised PT/OT Assessment Process

 All patients assess by unit based OT within 24 hours of admission  Nursing and PCT staff able to provide patients with assistive devices prior to PT/OT evaluation  PT/OT ensure adequate levels of assistive devices available to staff every day on all shifts  Updates whiteboard daily with falls assessment and assistive devices required

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Internally Certified PCTs

 1 hour formal education classes for all unit based PCTs

• Classes included information related to scope of

practice including: – Identification of Lead PCT ○ Responsibilities included gathering information from all PCTs related to falls status – Identification and communication of falls risk to at daily team meeting – PCT assists OT in community meeting to act as a “second set of eyes” in identifying at risk patients

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Unit Based Changes

Falls Plus signage on all identified patient rooms Falls Plus signage on unit based whiteboard Toileting Schedule Established PCTs joined Treatment Team Meeting PCTs initiating internal falls debrief process

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Outcomes

Feb 15 Marc h 15 Aprl 15 May 15 Jun 15 Jul15 Aug 15 Sept 15 Oct 15 Nov 15 Dec 15 Jan 16 Feb 16 Rate per 1,000 Patient Days 4.31 1.96 4.12 3.95 3.77

0.5 1 1.5 2 2.5 3 3.5 4 4.5 5

Rate

Falls with Injury Rate

Intervention

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Take Aways

 Early buy in from all key stakeholders  Interprofessional Approach  Elevation of PCT Autonomy  Culture of Safety  Transparency of Data  Persistence

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Questions