Quality Improvement Reduction of Falls , Sacred Heart Hospital Carlow

Author: Jenny Dowling CNM1

BACKGROUND HOW WILL WE KNOW THAT CHANGE IS AN IMPROVEMENT ?

A fall has been defined as: ‘ a sudden, unintentional change in 25

100%
120%

98%
position causing an individual to land at a lower level, on an object, Process measures: On going staff education with evaluation of education. 20 89%
100%

80%
the floor, or on the ground, other than as a consequence of sudden
© NHS Improving Quality (2014). Daily communication with safety pause and 15 69%
80%

onset of paralysis, epileptic seizure, or overwhelming external force environmental checklists. Review of clinical incidents 48%
60%

‘(Skelton D., Todd C. 2004). reporting . 10

40%
27%
One in three older people fall every year , it is suggested that falls 5
20%

and related injuries could double over the 25 years. It is estimated Outcome measures: Number of falls, common trends ,data set on Run
and Pareto charts. 0 0%

that the cost of falls in older people is approximately 400 million No Star No alarm No Frase Time 20-8 Time 8-2 Time 14-20 Bed Rail

euro and could increase to 2 billion euro in the next 25 years (HSE Balancing measures: Cost of professional development for all staff.
2008). Increase cost for use of sensor mats, chair/bed alarms Key Learning
The Challenges that are recognized is identifying the potential risk Cost of information leaflet for patients and visitors. •Did Not achieve 25% reduction in the amount of falls post second
of timeframe to undergo PDSA cycles, staff engagement and cost of Cost of resources vs. fractures. PDSA cycle.
resources. The main challenge of this project is to demonstrate that I •Education required for all staff with full participation from all key
the reduction of falls will improve quality of life for older people in the stakeholders.
S.H.H. also reducing cost of treatment of falls for older people in the •The introduction of safety pause had not been achieved which is a
HSE. 6 key aspect in communication between all staff regarding falls
Pre Falls Policy

5
Axis Label prevention.
PROJECT AIM •Clinical Incident forms lack evidence documented of measures put
To reduce falls by 25% in a Rehab Unit primarily for older
4

in place in the prevention of falls.

People by October 2015 . 3

1
.
.
WHAT ARE WE TRYING TO ACOMPLISH? 0
Sustainability & Spread
Oct-13

Dec-13

Feb-14
Jan-14

Apr-14
Nov-13

Mar-14
AIM PRIMARY SECONDARY
DRIVERS DRIVERS
•Next steps are to arrange a meeting with DON and CNMS.
Clinical Incidents Identifying clinical incidents
forms with regards to falls pre
•Inform results of QI.
Patient Safety
National Standards
& post introduction of Falls
policy •Educate regarding use of safety pause ,compliance of clinical
Aim: To
reduce
falls by
National/HSE, Behaviour of staff
Identifying trends/themes from
clinical incident reports incident forms and follow ups.
Local,HIQA
25%in a
Rehab
standards, policy
and guidelines. Does Falls Policy improve
Identifying Education
Programme and the Pre Falls Policy
•Email template of safety pause to all CNMs.
•Attend ward meeting re education of Falls prevention and Falls
Unit for patient safety evaluation
Axis Label
older Staff Awareness
people Documentation, care planning
by
October Evidence based
Practice with
,patient centred 10

9
Policy.
2015 local Falls Policy. MDT Approach
8 •Ensure all staff have attended Falls prevention study day.
Pharmacy ,Medication Review 7

6
•Information leaflet to be made available for all residents/patients ,
Resources
5
families and staff.
•Repeat PDSA in 6 months time.
4

PDSA Cycle 1
.
•Education for all staff .
0
Oct-14
Aug-14

Sep-14
Jul-14
Jun-14
May-

Nov-14
14

•Introduction of Safety Pause-improve communication.

•Falls checklist-FRASE Tool, Falls Bundle, Falls Care plan.
•Falls Identifier-Falling Stars. REFERENCES
•Incident Reporting and follow up.
•Poster-communication. Post Falls Policy
• DOHC(2008)
. Strategy to Prevent Falls and Fractures in Ireland ‘s ageing population .
Axis Label
• Falls Prevention and Management Policy (2013) Sacred Heart Hospital , Carlow.
•Information Leaflet-patients and visitors. 6
• HIQA (2008) National Quality Standards for Residential Care Settings for Older People In
5 Ireland.
4 Median
• HSE(2013) Patient Safety Tool Box Talks, QPS DNE.
• Quality and Safety Walk –rounds –we are responsible …and together we are creating a safer
3
healthcare system Quality and Patient Safety Directorate May 2103.
2 • Royal College of Physicians (2011) The FallSafe Care Bundle.
1
• Skelton D, Todd C. (2004) What are the main risk factors for falls amongst older people and
what are the most effective interventions to prevent these falls ? How should interventions to
0
prevent falls be implemented ? Copenhagen: World Health Organization, Europe ;
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Jul-15
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May-
Mar-15

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http://euro.who.dk/HEN/Synthese/Fallrisk/20041318_1