Piloting a Falls Risk Reduction Program in the Trauma & Neurosurgery Intensive Care Unit Barbara Ferguson, RN, BScN St. Michael’s Hospital, Toronto, Ontario, Canada FOCUS
PROCESS CHANGES (CONTINUED)
To create and implement a falls prevention program for the Trauma and Neurosurgery Intensive Care Unit (TNICU) based on current literature on falls in the critical care environment, applicable SIMPLE interventions and the RNAO Best Practice Guideline: Prevention of Falls and Fall Injuries in the Older Adult.
STANDARDIZED FALLS PREVENTION PLAN INTERVENTIONS The following components of the standardized falls prevention plans are to be implemented for every patient:
BACKGROUND Every patient in the critical care department is considered a high risk for falls due to the prevalence of confusion, agitation, mobilization against advice; the significant amount of equipment attached to the patient; deconditioning of the patient; and the use of medications such as sedatives, opioids, or antihypertensives. Although every patient is considered a high risk for falls, no formal falls risk reduction policy was in place.
PURPOSE & OBJECTIVES To trial a falls risk reduction program for the Trauma and Neurosurgery Intensive Care Unit.
Strategies for the Management of Pain, Agitation and Delirium
PAD Algorithm utilized.
Bed Positioning
When patient care is not being provided and the family is not present, the bed should placed in the lowest possible position. Brakes are to always be on.
Elimination Pattern Appropriate ICU bowel routine is to be ordered. Assessment Regular Patient Observation
Appropriate nurse-to-patient ratio based on patient acuity is provided.
Patient and/or Family Education
Patients and/or their families will be informed of the care plan that is implemented to prevent them from falling. They will be encouraged to participate in the falls prevention care plan. The Lexicomp education handouts will be given to all patients and/or their families.
PROCESS CHANGES As every patient is considered a high risk for falls, all patients will have a standardized falls prevention plan. If, based on clinical judgement of the inter-professional team, a patient is identified as needing a more detailed and personalized falls prevention plan, the inter-professional team will collaborate to develop and implement an individualized falls prevention plan. If a fall occurs, a debriefing with the inter-professional team should occur during the same shift as the fall using the Critical Care Falls DEBRIEF Tool, pictured to the right.
Critical Care Falls Debrief Tool: Your Guide for a Post-Fall Review 1. DEBRIEF happens after EVERY fall 2. It takes place on the same shift that the fall occurred 3. A DEBRIEF will be attended by all inter-professional staff members involved in the patients care 4. This tool is intended for use in guiding and structuring post-fall debrief team discussions. General documentation requirements are outlined in section 4.0 of this policy.
Was this the patient’s first fall in the hospital? Description of If no, how many other times has the patient fallen? Events Who found the patient? Or who was witness to the fall? What happened? Brief Review
Interventions in place
Evaluation and Future care
Did the patient have their personal belongings in reach? Did the patient have any mobility or physical weakness of any kind? Did they have any impaired cognitive functioning or decreased insight into their physical limitations? Any other contributing factors? (i.e. medications, elimination, etc.)? Was Pain, Agitation and Delirium assessed in the last hour and has the PAD Algorithm been in use? Was the bed in the lowest possible position with breaks on? Was there an appropriate ICU bowel routine ordered? Has the patient and/or family been educated on their falls risk? Was there an active referral to the interprofessional team members (e.g. PT, OT, Pharmacy, etc.)? Were the surroundings clean, dry, and un-cluttered? Does the patient have an individualized falls prevention care plan? (If not, one should be developed) Was next of kin notified? Was an event tracker completed? How could this fall have been prevented? What changes will we make in the way we care for this patient? What additional falls prevention strategies could be utilized to prevent any further falls (e.g. use of bed alarms, scheduled toileting, call bells)? Has the patient and/or family been re-educated on their fall risk and fall prevention care plan? What changes will we make in the way we deliver care on our unit?
CONCLUSION
METHOD
Plan Do Study
Act
•Development of Falls Risk Reduction Program with the Critical Care Educators Falls Working Group •Staff Engagement for feedback in developing new policy
•Pre-Education Audits: Observational audits performed on 50 bedsides, looking for the presence or absence of the Standardized and Individualized Falls Prevention Plan interventions •Implementation of policy using: •Education sessions and interactive discussions in small groups at patient bedside with quick reference guide (fig.1) •Educational poster in staff conference room summarizing new policy •Email follow-up
•Post-Education Audits: Observational audits performed on 50 bedsides, looking for the presence or absence of the Standardized and Individualized Falls Prevention Plan interventions •Feedback provided by staff led to a change in process and location of the DEBRIEF tool •Identified gap in knowledge for how to use bed alarms and provided education on the different bed alarms available
•Communication: KARDEX to be modified to include a designated area to write Individualized Falls Prevention Plan •Documentation: ICU Flowsheet has been modified to allow for documentation of Standardized Falls Prevention Plan and assessment for Individualized plan however it is still pending various committee approval for roll-out
Fig.1: Quick Reference Guide (back)
Take a deep breath and follow these steps for post fall management If a patient falls, the following steps will be taken:
Inter-professional Team Member Involvement
An active referral to inter-professional team members (e.g., PT, OT, Pharmacy, Speech Language Pathology) as appropriate based on patient care needs.
Minimize Clutter
A physical environment (including patient bedsides and the path to the bathroom) that is free of extraneous clutter.
INDIVIDUALIZED FALLS PREVENTION PLAN INTERVENTIONS Examples of individualized falls prevention strategies may include, but are not limited to the following: Bed Alarms Call Bells Mobility Plan
Toileting Schedule
Utilize bed alarms when available. Utilize call bells when available and patient can participate. Once it is appropriate to mobilize a patient, ensure a mobility plan has been established, signage displayed by PT and followed by all staff. Scheduled toileting once patient has Foley catheter discontinued.
• The pre-education audits helped to quantify the fact that the TNICU had multiple falls prevention interventions already in place even though there was not a formal falls prevention program. • The creation and implementation of a falls prevention program in the TNICU introduced the use of best practices for staff to guide their efforts in preventing falls. • Post-education audits showed an increase in use of falls prevention interventions. Most notably, there was an increase beds being in the lowest possible position; however, there is still room for improvement to attain the ultimate goal of all patients with beds in the lowest possible position. • Staff were able to identify patients who needed an individualized care plan and develop personalized strategies for preventing falls. • A gap in knowledge for the use of bed alarms was identified, and after education was provided, every patient with an individualized care plan had their bed alarm turned on.
Complete a full patient assessment, including assessing for injury, and safely assist patient up from the floor. Notify the MRP and appropriate consulting services, charge nurse, and Liz (CLM) or delegate. Notify the patient’s next of kin of the fall. This is to be completed on the same shift that the fall occurred. Complete an incident report in the St. Michael’s Hospital Event Tracking System, giving as much detailed information as is known. Using the Critical Care Falls debrief tool as a guide, initiate a debrief session with inter-professional team members. There is no documentation requirement associated with the post-fall debrief00\
POST FALL DOCUMENTATION: The post-fall assessment Notification of MRP, relevant consulting services, charge nurse, and Liz (CLM) Notification of Next of Kin Post-fall interventions Occurrence of a debrief Plan to prevent future falls
FINDINGS: OBSERVATION AUDITS Pre-Education Audits: • Although no formal falls prevention program was in place, staff in the TNICU had informally implemented the majority of the proposed standardized falls prevention strategies. • There was no standardized way of communicating falls prevention strategies for patients. • The largest gap in practice was that none of the patient beds were in the lowest possible position. Post-Education Audits: • Three patients were identified to require an individualized falls prevention plan and every one of these patients had a bed alarm turned on and falls prevention strategies written in the Kardex. • One of these identified patients was able to use a call bell and it was within reach. • There was a 34% increase in bed being in lowest possible position when not in use or family not present.
RECOMMENDATIONS/NEXT STEPS • An education refresher on communication and on change in documentation when the new KARDEX and flowsheet are available • Falls Prevention Plan added to the ICU-ICU TOA checklist • Education added to the TNICU orientation • Documentation auditing added to the dashboard
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ACKNOWLEDGEMENTS The author would like to thank Colleen McNamee, Denise Ouellette, Vasuki Paramalingam, Elizabeth Butorac, the Critical Care Educators Falls Prevention Working Group and the members of the BPG Communities of Practice.