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FALLS_PREVENTION_C
FALLS_PREVENTION_C
So, today we have some exciting things to share. Kolton Hewlett is here as well as Jennifer West from IHA and we are here today to share about the falls prevention community of practice, more specifically a post-fall huddle sheet. I know there was some conversation of people wanting that. So that is what we decided to talk about today. So, who do I have on the call? Do I have mostly the champions for the falls prevention or do I have more of the quality directors?
We are the quality personnel 00:00:40 INAUDIBLE.
Okay.
Quality director from Mason City.
Good morning Angela.
Good morning.
This is Juanita, quality manager from Mercy, Des Moines.
Good morning.
Okay, so, so far what I heard is mostly quality managers. I would like you guys to be able to invite your falls prevention champions to these also and then I know that the quality professionals have a lot on their plate and sometimes it is nice to if you want to watch these too, but they can watch them and bring information back. So when we look at the first thing just starting up with our team members, people that can be part of the falls community of practice. We do have our quality staff, we have our providers, pharmacists, we say that I know that we did talk on community practice are we telling our pharmacists when somebody on Coumadin does fall so they are aware of this. That is a good communication area and when we did have some pharmacists’ input on this on HIINnovation; they did say they would like to know when that happens or if they are at a high fall risk. The department managers and directors, the frontline staff, the patient and families, the health coach, social workers, physical, occupational, and speech therapy staff. Once again on the last one the physical, occupational, and speech therapy staff we did have Sarah Pavelka talk about that and she actually suggested that that should be your champion, but physical therapists or the occupational therapists could be your falls champion if anybody is looking for a champion. Just that you guys know going forward I am not seeing the chat box right now, but I will look back. For some reason when I am sharing my screen it is not showing me the chat box. So if you have something to say, I will pause in-between screens and you guys can talk, is that okay? Okay, and then at the end I will look at the chat box.
Some other falls prevention team members when we look at these moving forward this is especially important after discharge from nursing home, the home care hospice doctors asked so this is good. Discharge information and also sharing information moving forward for the patient but they are aware that they have had a fall or found out to be high risk in the hospital. So talking about the post-fall huddle, what we are focusing on is who is on your falls prevention team which we just talked about the post-fall huddle form, how to utilize the new toolkit and how to find the resources on HIINnovation. Starting with the post-fall huddle form. I do not know how many of you guys, but this is a good time for discussion, how many of you guys utilize a post-fall huddle form?
Yes, we do in Des Moines at Mercy.
Okay.
Mason City does.
We have started it here in Illinois but we have not got it implemented yet, but we have got the lead stated.
Okay, wonderful. As we do our community practice today, we are going to utilize this post-fall huddle form. So if you are interested, I will show you how to find this on HIINnovation. Looking at what do you guys as an initial thoughts as it has been off screen here. Is anybody looking at it to see kind of the information that we do have. It is front back. Those of you that do have post-fall huddle forms, is there any part of this that you may copy to utilize with your post-fall huddle form that is not currently on there I know on the back page we do have consideration of all the interventions for the cause of the fall and then also we have an area for education for patients and family that has some great information from the study kit that can be copied and handed straight over to the patient and family that they can utilize not only in the hospital but once they go home. Does anybody have any of those things from their post-fall huddle forms?
Jennifer, this is Angela, Mason City. So, we have some of that information but I do like the layout of this form. Is it possible for you to, did you say you are going to forward that out?
Um, I am can forward this out if you email me and ask me for it, but it is also on HIINnovation under our library which I am going to show you guys at the very end how to find this form.
Okay, great, thanks.
Yup.
So, you will see that we are going to be working on some different types of forms, different types of check list and Iowa Healthcare Collaborative is happy that you guys can utilize any of the information that we put out, whether it is part of it or all of it. So do you guys like this form now that you have had a chance to kind of look at it.
Yeah, I like your form.
Yes, definitely.
You have something that is similar to this?
Yes.
Okay.
The other things and I, I do not know, I do not see on here, one of the other things we do is have the pharmacist review. If they are on any medications that might have caused the fall.
Okay. So would you put that under questions? Did your pharmacist review medications?
Yes.
On this form or where would you put that? The followup plan.
This is part of our review as we are doing our huddle.
Okay. We will take a note about that and then we will add that to, we will change that today to add that. Well, thank you.
Jennifer, this is Angela on Mason City. I have been working through it. The one thing that I thing that we included ours that I feel is probably one of the most important things we do, that I do not see on here is we do the five why process, so for this particular fall asking why, why, why, why, why to try to identify what the root cause is.
That would be a really good thing to add.
I feel like in a way it would fall under your questions, your account of the patient’s fall. I feel like that should be the five why process. Just sort of right off the cuff without really studying it.
Right, and I will add in those little post-fall checklist so we do have the root cause analysis, but we can add the five whys to that.
Okay.
So if you are interested, these slides will be posted on HIINnovation and so you can get these forms that way too. Moving forward, it usually takes about, Luke does it take about a week to put them on HIINnovation after they are transcribed?
Uh, yeah hi this is Luke. It depends on how long it takes vendor we use to transcribe our videos. So, we can get it up as soon as we get our transcription document back.
And so we do have Luke Neitzel here with us now. He is also one of our program specialists and he is in-charge of making sure that all our things are transcribed and then put quickly on to HIINnovation so all of our events are recorded and available to you to use. So, post-fall huddles, why because it is best practice when as soon after the fall as possible and even if the patient is on the ground that is the best time to do that as long as they are not compromised in any way, you know you can make them comfortable but to make sure that everybody is there. To do a post-fall huddle some people want to wait till the family gets there. If the family is not there, it does need to happen right away. So who, the patient and the family and staff of all levels. The main questions, what happened, how it happened, and why it happened, and the outcomes, the care plan change, how to prevent similar outcomes, and educate the patients and families, and I think that when we do look at falls moving forward on patient and family education that is a really good aspect to have on your post-fall huddle form, not only to remind people that that patient family education does need to happen then, but it also needs to continue through discharge and wherever they are discharge location may go.
So now what we are going to do, we are going to go through some scenarios and we are going to use the post-fall huddle sheet, so I am going to give you guys some time to read the first scenario and I do appreciate participation in this as we go through to say number one, what things do you think are relevant, what questions may you ask when Angela talks about the five whys that is really important and then talk about maybe what went wrong, what went right, so go ahead and read the first scenario.
Okay, so just looking at this scenario, what are some things that you think went well during this situation? She did not hurt her head, right? Let’s move on. What do you think things that could have gone differently for this patient?
Fall assessment done.
Correct.
She was disoriented, so we should have had her on a bed alarm.
Okay.
We would have also, if she was disoriented, we should have put her on visual monitoring.
Very good. Do you mind sharing what system you use, Angela, for visual monitoring?
Um, oh my goodness, I am having a TIA. Um,
Do not do that on my call please!
Oh, I will have to think about that for a minute and then tell you. I actually was involved in HIIN Innovation I know, but.
Do you think it was unusual that she could not provide how she fell because she was disoriented? That’s probably harm for her, right? So she was complaining of left leg pain. So if we look at our post-fall huddle form, what are some things you could fill in? Could we fill in the situation?
Yes.
Okay, could we fill out the assessment portion?
Could we do the injury section?
Yeah.
Look at the last question on there and actually the first question, can we do patients account of the falls? She does not know, right? We have to put that like how was the patient at the correct more falls for level. We did not do one, right? There was not a fall assessment, so that would be a spot to look at and a problem obviously. So the followup plan relating to the care plan what things in the followup plan do you think would need to change for this patient?
Bed alarm.
Hmm... hmmm.
Frequent rounding.
Hmm... hmmm.
Environmental problems.
I think we can look at these and kind of come up with a lot of, I mean obviously we are not seeing those happen with the patient, but I think that with the post-fall huddle this brings up a lot of things that you know may be will be addressed because of the huddle if you were not having a huddle. So then when we look at the checklist, again you will see on the next page but the communication of the huddle, the medication review, the root cause analysis, we could go through those five whys and then moving to the second page where would you say that the cause the of the fall was on this one without having a ton of information? There is going to be a few.
I mean as I go though the fist one, it looks like almost all of them until substance abuse would be possible for a cause of the fall because she does not know. Just going down to the elimination and toileting issues I think a lot of times when the patients are admitted I am not sure your facility if you guys make that part of the known facts but when do they go to the bathroom or do they have a full pitcher of water at their bedside at all times. Does anybody take the pitchers of water out of patient rooms after supper or does anybody use pitches of water anymore?
We use pitchers of water and we do not take them out of the room.
Okay. So, we did have someone talk and this is under recorded ones, but Sue Helderman spoke and she talked about when you think about people falling at night which they do a lot of times if you take their water pitchers away or decrease the amount of water that they are drinking after supper, there is less of a chance to have to go the bathroom, so you especially have to take it out of the room, but you could empty it. So that is some good practice to get into to make sure that the patient, you know, if they are at home, they are doing their own thing, maybe they are not concentrating on the water, but visualize yourself in your hospital bed and you are looking at the TV, but you are also looking at that water pitcher that may be more of a chance for you to drink water more frequently especially in the evenings.
Any comments.
You know, Jennifer West, that is an interesting idea I guess. That has never come up in any of our discussions, but the majority of our falls are on the night shift between 7:00 p. to 7:00 a. with patientsenroute to the bathroom, so it probably does have some, we just have not entertained it yet.
Thank you. I thought when I listened to Sue Ann Guildermann and if you can ever listen to any of her webinars, anything that she does, she is fabulous. If your hospitals are looking for speakers to come in and talk about falls, she does. If you go back and look at her webinar, you will see that she does talk a lot about their circadian rhythm and the light and basically how the body functions if you give the body drinks it is going to have to eliminate it somehow and so she does talk about a lot of things that are really commonsense that you know we just don’t think about so.
Okay, lets move on to our next scenario. I will give you some time to read scenario number two. Okay, what went well in this one?
Jennifer, this is Jodie Atkinson from Clinton, can you hear me?
Yes.
Well, thank you. I have been having problems with this mic and I have just been wanting to chat and chat and I cannot, so I called in now.
Wonderful.
I think the four rail is up that could be positive and a negative depending on your policy at the hospital. If they climb over those rails, they are falling farther to the floor, otherwise some people view it as kind of a distraction and/or a blockade as long as they can get out in-between the rails safely if not considered a restraint. Our beds do have 18 inches between the rails, so it is not considered a restraint here, but some other ones many not.
Okay____.
The side rails, I have just a question. How many of you when you get out of your bed at home get out on the right side and how many get out on the left side? Think about that and then I think of may I am not quite as present but I am almost there and I think if you gave me Benadryl, Restoril, and Dilaudid and I normally get out of the right side of my bed if the railing was up I might climb over, I might take it to one of my dogs by my pillow at that point with all those medications, because I do not take any medicine, so. May be you were able to hear that.
The medications are definitely a risk. Yeah, they are definitely a risk.
So any other thoughts about this? So obviously she was looking for her husband, she was a little confused, right?
Hmm... hmmm.
So lets look at our huddle sheets. Can we fill out the first portion?
Yes.
Yeah.
How about the second?
I would think we could call it an anticipated physiological fall because of all of her medications that we were on we should have been expecting these side effects from the medication even though she is a younger person.
Hmm... hmmm. I agree with that because it does not matter even if it was a 20-year-old to be quite honest.
It could happen to any of us, yep.
And then the injury obviously we would have to, they did not talk about that. What on the follow-up plan do you think could help this woman?
Definitely a bed alarm. She is high-risk so a bed alarm. We know when she is on the move.
Yep.
We think she might when she is out of bed maybe with all those meds she might.
Maybe look at alternatives to the high-risk medications that they gave her, use, I do not know warm blankets, warm milk, something other than medication to help her sleep at night, maybe distraction for her pain.