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Falls Prevention in Clinical Environments

Falls Prevention in Clinical Environments

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Published by Janusz Kaleta
Simplicity in Falls prevention by identification of root cause
Simplicity in Falls prevention by identification of root cause

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Published by: Janusz Kaleta on Sep 08, 2012
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05/15/2013

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Falls PreventionMapping
the
incidents
of
falls
as
they
occurthroughout
a
nursing
ltome.facility
can
be
used
to
pinpoint
a specific
pattern
relatedto
location,shift,
time
of
fall,
urrcl/or
particular
day.
By
using
a
falls
mappingtool, a visualrepresentation
on
tlte
emerging,
patterns
for
falls
allows
for
moreexpedient and effective
disseminationof
falls-relutecl
clata,
(fucludingprevention
measures),
to
front-line
staff.Ily
Janusz
Kaleta,
B.Sc.N.(4th
year),
R.P.N.,
C.P.T.A.
'p
rofessionalcare
staffat
Ccdarvale
I
T"rtu."
Lons-Term Care Home
in
dorvntor.vn
To.lnto
have
recognized
the
importance
of
developing
a
fallspreventionprogram
that
works.
Analysis
of
pastinterventions
used
at the Cedarvale
facility
revealed
that,
while
the
response
by
staff to
resident
falls
waspromptand
prof'essional,
and
incident
data
consistently
recorded.
the
interprofessionalcommunication
and
analysis
of
causes
of
falls
was
done
rather
poorly.
Staff,
therefore,
devel-
oped
a
simple colour-codedvisual tool
that
would allow
mapping
of
falls
in
real
time
andthe
recording
of
essentialdetails
including
the
locationof
the
fall,
nursing
shift
(days,evening,
night),
and
specific
action
plans
incorporating
the
Plan-Do-Study-Act
Quality
Improve-
ment
Model.
(See
sidebaron
the
P-D-S-A
model
for
improvement.
See
page
6)
.
Falls analysis
The
inspiration
for
thisinitiative
on
'falls
mapping'camefrom
the
historical
approach
taken
by Dr.
John Snowwhodeciphered
the
origins
of
the
London
choleraoutbreaks
in
the
mid-1800s.
Snow
carefully
analyzed
the
map
of
London
to
sort
out
the
data
of
cholera
cases
into
identifiable
clusters
andlocationsand
then
focusing
on
Page
4
any
emergingpatterns.
As a
result
he
correctly identified
the
major
clusters
of
outbreaks
in
the
city.He
successfully
identified
a
particularwaterpump
on
Broadwick
St.
in
the
Soho
district
which
he
suspected
of
having
water
contaminated
with
fecal
matter.
In
1854, he
convinced
a
localLondon
council
to
disable
the
contaminated
waterpump
by
removing
the
handle.
Within
days,
the
deadlycholera
epi-demicin
that
area
came
to
an
end.Toprovehis
point,
Snowhad mapped
the
London
choleraoutbreak.
He
visually
depictedclusters
of
cholera-
outbreakdata
seen
in
different
parls
of
London.
The
mapping
technique
he
used is
the
basis
of
the
F.A.C';|.
Analy
si
s
Kale ta
To
ol,
whichis
described
below,and
which
is
now
employed
at
CedarvaleTerrace.
Falls
mapping
Mapping
the
incidence
of
falls
throughout
a
nursing
home
facility
can
pinpoint a
specificpatternrelative
to
exact location,
shift,time,
and/or
particular
day.
Thisvisualrepresentation
on
falls
allows
for
expedient
and
eflective disseminationof
data
to
front-
line
staff.Because
nursing
staff
in
LTC
homes
provide
care
24
hours
a
day,
7
daY
a
week.
it
is
possihle
to
track
falls
continuouslyort
a
trtonthly
basis.
Therecortlecldata self-arranges
into
clusters
(cokrur-codedon
tlletool)
and
leads tothe
intelpretalionof emerging
themes.
In
thegraphic
of
the Fall
Analysis
Tirol.one can
see
multiple
falls
oc-
curing
in
the
early
morning
hours
Notemissing
hanclle
ott
thcwalerpump
at
the
Dr.
JohnSIrow
tnetnotial
in
Soho.
Canadian
Nursing
Home
 
FallAnalysis
Tool
@
Kaleta,
Janusz,20l0
Locations
legend
Eachcoloured
dotrepresents
afall
in
thecorrespondinglocation,
day,
timeand
shift.
NursingShifts
07:00-
15:00Study/Actions:
l.
Safe
footwear
2.
Assist
with toileting
3.
Use assistivedevices
4.
Safetychecks
15:00
-
23:00
Study/Actions:
1.
Communicate risk
2.
Assist
withtoileting
3.
PM
hygiene care
4.
Safetychecks
23200
-
07:00
Study/Actions:
1.
Safety
walkabouts
2.
Lowering
beds
3.
Early
toileting
4.
SafetyChecks
 
between
05:00
to
06:00
in
residents'
rooms(red)
and washrooms
(yellow).
With
this
information,
appropriate
falls
preventioninterventions
can
be
implemented by
the
nightshift.
Front-line
staff
also
relate
much
better
to
a
visual
representation
of
the collecteddataratherthanverbally
reported
numbers
alone.
The
visual
representation
ofevery
fall
is
charted
inrelation to
date
of
the
fall,
time
of
the
fall,
the
location[i.e.,room, washroom,
loungearea,
recreation
room,
etc.],
and
the
specific
shift
[day,
evening
or
nightl.Staffnow
have
access
to
a
greater
understanding
of
the
specific
patterns
andprobable
risk
factors
for
the
occurrence
of
falls.For
example,notethe
number offalls
onweekends.
All
the
locations
are
colour-coded
in
order to
provide
ameans
to identifypotential
risk
factors
for
falls
and
to
develop appropriate
interventions.
(See
page8
for
'Team
goals').
Interventions
Basedonthe
locationof
the
identified
risk
factors,
suitableinterventions
can
be
developed
by
the
nursing
teams,
such
as
walkarounds
by
staff, early
toileting
ofresidents, frequent
safety checks,etc.
Providing
a
visual
guidanceto
front-line
staff,
such
as a
colour mark on
the
wall
indicating
the
position
a
particular
bed
should
belowered every evening
wasalso
found
to
be a
simple andeffectivewayto ensureresidents'safety.
The
Falls
Prevention
Team
also
recognized
that,
at
night,
residents
frequently
experience reduced
vision
acuity, slowed
adaptation
to
darkness,
and
reduced
depth
perception
and
colour
contrast
sensitivity.
(See
following
page
on
photo-luminescence).
I
The P-D-S-A
quality
improvement
process
As
a
'model forimprovement,'
the
Plan-Do-Study-Act
is
a
simple
toolfor
making
or
accelerating
change.
The
P-D-S-A
cycle
has been
successfullyemployed
by
hundreds
of
health care organizations
-
including
nursinghomes
- to
improve
manyhealth
careprocessesand ensure thesaftey
of clients.
Although
originally
designed
to
be used
in
thebusinessenvironment,the
P-D-S-A
modelis
a
repetitive
(oi
iterative)
four-step
process
orcycle that
starts
off
small to
test
the potentialeffects on
changes
that
have been made.
This
can
lead
to
larger
and
more
targeted change(s).
With
the
right
health carepersonnelselected
for
the team
(i.e.,
aFalls
PreventionTeam),
and
the
objectiveestablished
(i.e.,
reduction
in
the incidents
of
resident
falls),
the
variety
of
possible
actions
to
reduce the
number
offalls
suffered
by
residentsis thendiscussed
indetail by
teammembers.The team
has
to
initially
determinewhat
it
is
they wantto
accomplish with
the change(s)
it
intends
to
address-the
objective(i.e.,reduction
offalls).
.
Thefirst
step
involves
planning
a
test
or
observation(i.e.,assistive devices such
as
using visual
guides).
This
step also includes
aplan
for
collecting relevant
data
from
various
sources
(i.e.,falls
mapping, staffintervieu,s,incidentreports,
etc.).
.
The
secondstep
is to
try
out ordo a
test
on a small
scale and
see
if
the
change/
innovation
leads
to
an
improvement(i.e.,a reduction in
resident
falls).
.
The
third
step
involves
setting
aside
time to
study
or
analyze
the results
of
thetest,(i.e.,a
test
to determine the
eficacy
of strategicallyplacedvisualguidesto
reduce
falls
as
determined,for
example,from
the mapping
procedure).
.
The
fourth
step is the
refinement, or
action
stage;
that
is, theteamtakesrvhat
has
beenlearned
from
the test and refines
orimproveson
it.After
testingthe
change
on
a
small
scale,
including duplicating
the test andlearning
from
each test, and
refining
the change
or
changes
introduced, the team
now
hasthe
option to implement
the changes to
other
parts
of
the
facility.
.
For
more infbrmation
on
P-D-S-A,
see:
<www.innovations.ahrq.gov/content.aspx?id=2398>.
l
Page
6
CanadianNursing
Home
Bibliography
.
OHQC
-
Ontario
Health
Quality
Council,Rcsidents-Firsl
',
AdvaneiugQuality.
in
Ontario
I-ong-Ternr
eare
l{-mes.
SoadMap
to
lalls
Preyentiln
=
May,2010.
See:
<http://www.
res
identsfi
rst.caldoc
u
me
nts/qi
roadmap
s/rf-
preventingfalls-d6-may
I
1
pdf>.
.
RNAO
-
Registered
Nurses'
Association
ofOntario,
Pr-eventiln.
o*f
.Ialls
-and
Fall
IqDqes
i-n
Lhe
Older
Adult.
RNAO,
:5,
Available
at:
<www.mao.org/Page.
asp?PagelD=$24&ContentlD=810>.
Retrievedon
May
15,2011.
.
RNAO,Falls
Preventiol:
_Buil=djn€:the
Esutdatlons
lor
PauEntja
ly'-Self-Learnin€
Paqkagc.
R-NAQ
Nursing
Best
hactrce G.uidcline
Prograq"2007.
See:
<www.rnao.org/Page.asp?P
agelD=924
&ContentlD=
I
707>.
.
Ontario
Injury
Prevention Resource
Centre,
Falls
Across
the
Lifespan;
Evidence-based
Practrec-S-v.ntbEsts
Docurnent-Ilqvembel.
2008.
<www.oninjuryresources.caldownloads/misc/
FallsReview-D8.pdf>.
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Lynons,R.,
John,
A.
et
a1.,
Modification of
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home
environment
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injuries;
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o
I
laboration,
2006.
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CNA
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CanadianNurses Association. Back-
srounder:
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IniuruPrevention-ane!-Nursing:
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I-$uas,2005.
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Wasner. L..
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Safetv in Lons-Term
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PatientSafety
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2008.
See
:
<www.patientsafetyinstitute.cal
English/research/commissionedResearch/
SafetyinLongTermCareSettings/Documents/
Re
po
rt
s
/LTC
7o
20
p
ap er
Vo
20
-
Vo
20
S
af ety
Eo
20inTo2lIll
CVa20
S
ettin
gs%o2}
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Vo20200
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Zimmerman,
R.,Ip,
I.,
et
al.,
An
evaluation
of
patientsafety
leadership
-
walkarounds;
HealthcareQuarterly;Volume
11; Special
Issue;
P
16-20;2008.
About
the
author
Janusz
Kaleta, B.Sc.N.
(4th
year),
R.P.N.,
C.P.T.A.,
is a
staff
educator
at
Cedarvale
Terrace
Long
Term CareHome
in
Toronto.
Author
contact:
<jkaleta@cedarvaleterrace.ca>.
The
author
acknowledges
the input
of
the
multi-disciplinaryteam
at
CedarvaleTer-race, as
well
as residentsand
families,
front-line
nursingstaff,
the
medical
team,
rehabilitation/physiotherapy,administration,
housekeepingand
dietary
departments.

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