ST FRANCIS HOSPITAL ESCANABA MI Fall Prevention and

ST FRANCIS HOSPITAL ESCANABA, MI Fall Prevention and Management

BACKGROUD • In 2016, reducing patient falls was made a key focus area by OSF Healthcare and a system-wide fall prevention collaborative was established and tool kit published.

Fall Prevention Standard of Care • • Assessment: fall risk within 4 hrs of admission, at least 1 x/shift, at transfer and with a change in status. Low/Medium/High Plan of Care: Based on assessment, universal standards PLUS Reassessment: Shift change, transfer, change in clinical condition, after a fall Communication: Standardized-caregiver huddles and handoffs, Best Care Dashboard, bedside handoff with patient/family review of fall risk and interventions in place; interdisciplinary rounds

Post Fall Standard of Care Assessment Plan of Care • Assessment: Physical assessment • Plan of Care: contact provider, patient/family communication, modify risk score as applicable, complete post-fall flow sheet in EPIC and occurrence report if needed (depending if on or off unit) Reassessment: based on provider orders, change in patient status and clinical judgement, reference Lippincott Debriefing: within 45” of fall, focus on system not people, identify causal factors and how to prevent in future Communication: communicate/disseminate results • • •

Fall Debriefing Tool

Fall Prevention/Management Enhancements May 2018 Additional elements to purposeful hourly rounding: • • • Clear pathway maintained Upper side rails up x 2 Bed in low position and wheels locked Chair/bed alarm on based on patient position Possessions in reach Safety Sweeps: • • Done 3 x/day for high fall risk patients-assess for 14 fall bundle components Immediate correction for gaps in any of the elements above Focused feedback re: gaps to patient’s RN Charge RN will complete reassessment 1 hr. to make sure gaps corrected

Fall Prevention/Management Enhancements Fall tracers: • • Completed once a month by unit fall champion or identified resource Check for fall bundle compliance on moderate to high risk patients Entered into the falls data base Goal of 90% or better bundle compliance Patient Leadership Rounding: • New question added “Our priority is to keep you safe. What have we put in place to keep you safe from a fall? ”

Monitoring Compliance Adult High Reliability Summary - Rates High Reliability= Percentage of audits that have 100% compliance for all of the 14 Fall Bundle items High Reliability Percentage (Fall Risk Score 4 or greater) Facility/Dept SFH Total Audits 20 % Activity % Hrly % Bed % Possession % Non. Skid % Pt Fam % Risk on Care Rounding % Clear %Risk ID % Upper Low High Board Care Board % Gait Belt Path Band Rails Up Locked % Alarms s Call Light Footwear Risk Level Why Reliability % Bell Sign Poster 100. 0% 90. 0% 100. 0% 92. 9%

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