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

NEVER LET A STUMBLE BE THE END OF YOUR JOURNEY: THE ROAD TO DECREASING FALLS ON A GERO-PSYCH UNIT

Ann Evans, MSN, RN Bonnie Underwood, BSN, RN Southern Ohio Medical Center with Horizon Health

Disclosure

The speaker has no conflicts of interest to disclose.

Learning Outcomes

Upon completion of this presentation, participants will be able to:

 understand the impact of the falls epidemic on a gero-psych

unit

 name falls prevention techniques for hospitalized geriatric

psych patients

 recognize best practices in fall prevention

APNA 30th Annual Conference Session 2042: October 20, 2016 Evans 2

Introduction

 Falls continue to be a challenging patient safety issue on an

inpatient geriatric psychiatry unit.

 30-35% of patients who fall will sustain an injury.  Falls are the leading cause of death among the hospitalized

• lder adult.

 Falls with serious injury continue to be in the Top 10 sentinel

events as reported to The Joint Commission.

The Joint Commission, 2015

Summary of Evidence

 Fall rates were consistently above the National Database of

Nursing Quality Indicators (NDNQI) benchmark of 9 or less falls per 1000 patient days.

 The fall rates on this geriatric psych unit was 20.3 in fiscal year

2013, 17.2 in fiscal year 2014, and 14.1 in fiscal year 2015.

 The falls rate continued to be significantly higher than the

NDNQI benchmark at the beginning of fiscal year 2016, with a rate of 14.8.

Trend in Fall Rates

5 10 15 20 25 FY 2013 FY 2014 FY 2015

SBMCU Fall Rate (Before New Interventions)

Fall Rate

APNA 30th Annual Conference Session 2042: October 20, 2016 Evans 3

Falls Analysis

Time Period- July ‘15 to Sept ‘15 N=17 Falls (4 with Injury) #1 Diagnosis- Aggressive Behavior Where did patients fall? 35% Hall 29% Front Nurses Desk 29% Patient Room 6% Dining/Group Room Time of Fall 48% (12pm to 3pm) 23% (Evening shift change) 17% (8pm-11pm) 6% (after breakfast) 6% (at supper) Falls with Injury: 80% (12-2pm) 40% Front of Nurses Desk 40% in Hall 60% were repeat falls

Timeline of New Falls Interventions

November 2015

• Implemented all patients will have their bed/chair alarm set,

regardless of fall risk level

• Implemented bed/chair alarm checks with every 15 minute
• bservation round for all patients
• Begin taking patients to common room between groups/meals

December 2015

• Go Live with the Edmonson Falls Risk Assessment on SBMCU

January 2016

• Change treatment team time to 9:30 am

February 2016

• Assign staff to the common room to monitor patients at all times, and

provide a social activity during this time (increased programming)

Fall Prevention Best Practice

 Use of evidence-based fall risk assessment tool  EDMONSON FALL RISK SCALE—More psych specific  9 Risk areas assessed:  Age  Mental status  Elimination  Medications  Ambulation/balance  Nutrition  Sleep  History of falls  Diagnosis

(Edmonson, D., Robinson, S., Hughes, L. (2011). Development of the Edmonson Psychiatric Fall Risk Assessment

• Tool. Journal of Psychosocial Nursing and Mental Health Services. 49(2): 29-36.)

APNA 30th Annual Conference Session 2042: October 20, 2016 Evans 4

Stumbles in the Night

 There were 5 falls in May, which led to another falls

analysis.

 All May falls occurred during night shift and in the

patient rooms.

 Two falls occurred d/t bed exit alarm not being

• activated. One fall occurred when a high risk falls

patient was left alone on the toilet. Two falls occurred d/t not wearing non-skid socks.

 A detailed falls review was completed with all night

shift staff member involved in each fall, and all staff were re-educated on basic fall interventions.

Results (Falls Rates per 1000 patient days)

Falls Rate 16.13 Falls w/Injury 2.43 Falls Rate 5.38 Falls w/Injury 0.95

Before (July - December) After (January - June)

Fiscal Year 2016 Final Results

 Total Falls = 44  Fall Rate = 10.83  Total Falls w/Injury= 7  Fall w/Injury Rate = 1.72

APNA 30th Annual Conference Session 2042: October 20, 2016 Evans 5

Staff Members’ New Outlook on Fall Prevention

• Staff are proactive in preventing falls.
• Staff show genuine disappointment and take it personally

when a patient falls.

• Unit staff members take ownership in falls rates.
• Staff participate in case studies of falls when one occurs.

Any Questions?

References

• Edmonson, D., Robinson, S., Hughes, L. (2011). Development
• f the Edmonson Psychiatric Fall Risk Assessment Tool. Journal
• f Psychosocial Nursing and Mental Health Services, 49(2), 29-

36.

• The Joint Commission. (2015). Preventing falls and fall-related

injuries in health care facilities. Sentinel Event Alert, (55). Retrieved from http://www.jointcommission.org/assets/1/18/SEA_55.pdf

• The National Database of Nursing Quality Indicators (NDNQI).

Retrieved from https://www.nursingquality.org/data.aspx )