Utilizing a Neuroscience Diagnosis as the Patient s Primary Risk Factor for Falling

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Utilizing a Neuroscience Diagnosis as the Patient's Primary Risk Factor for Falling

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Neuroscience Fall Prevention and Safety Performance Improvement Team Darlene Bailey, PCT Leslie Barna, Manager 2 NE William Benedict, MD Barbara Buturusis, Administrative Director Jose Biller, MD Mary Healey, Manager 2 S/2 Neuro ICU Meri Hix, PharmD Corrie Husak, RN Bresha Mc Clain, RN Judy Mc Hugh, NQI, Team Leader Lisa Millsap, APN Martina Notovny, PharmD Vikram Prabju, MD Karen Potoki, APN, Risk Management Devra Romick, PT Joanne Scharnak, Nurse Educator, Team Facilitator Theresa Schwenkel, RN Liaison Kate Steinhable, Physical Therapy Educator Azucena Uy, RN

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Opportunity Statement Reduce inpatient falls on the 2 NE Neuroscience Unit and increment staff learning identified with patient wellbeing

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Potential Cause of Falls Environment People Documentation Post Fall Analysis (1/06) Age Education Flowsheet Fall Section Incomplete (7-13-05, 8-10-05) Admitting Issues HX of Falls Not in EPIC (7-13-05, 8-10-05) Clutter Bedroom Plan of Care Not Documented ( 8-10-05) Patient Staff History Of Falls (7-13-05, 8-10-05) Over Estimate Strength & Ability Long Length of Stay IV Poles Chairs Frequent exchanges Inappropriate Adm Fast Turn-over Unfamiliar Room Staff Communication Lack of Reg Rounds Not Using Equipment Fall Risk (8-10-05) Gait Belt (7-13-05, 8-10-05) Medications (7-13-05, 8-10-05) Patient Transfers Elimination Medication (7-13-05, 8-10-05) Cannot achieve call light Call light excessively confounded Family helps persistent, making it impossible to lavatory Not Answering Call Lights Patients At Risk For Falls Patient Decreased Sensorium Materials Confusion/Altered Mental Status (7-13-05//8-10-05) Medication (7-13-05/8-10-05) Balance Gait Postural Hypotension Call Light Issues Bed Alarm Door Reminder Risk Levels Not on Lost in spreads Not accessible 7/05 Sedation Narcotics Sleepers Gait Belt (8-10-05) Stroke Don't Realize They Need Assistance Sundowner Weakness Confidential: For Quality Improvement Purpose Only

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Solutions Implemented Multidisciplinary Staff Education New fall appraisal flowsheets Fall extraneous and inherent elements Appropriate Bed Alarm Use Gait belt utilize and exchange competency Fall chance connected with neurologic weakened patient Monthly fall avoidance overhauls

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Solutions Implemented Neuroscience Safety Awareness Week Falls in the Elderly Is Polypharmacy Causing Acute Confusion Touch Therapy Guided Imagery Gait Belt Use and Transfer Competency Massages for staff

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Designed a Level 3 Fall Prevention Interventions All neuroscience patients are at hazard for falls Increased disposal rounds to incorporate mealtime and sleep times Observe tolerant action ever hour or more Implemented Bathroom Buddy-staff remains with patient amid end Bathroom Buddy-nursing staff remains with patient amid end Place quiet on a BedCheck Classic bed alert and seat caution Consult drug store in regards to prescriptions that can bring about modified mental status Repeatedly fortified points of confinement and security needs to patient and family Assign bed that empower patient to exit towards more grounded side at whatever point conceivable and exchange understanding toward more grounded side. Give comfort rounds-repositioning, back rub with PM mind, helped ambulation before sleep time. Created Post Fall Assessment Environment Study

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Neuroscience Safety Awareness Week of September 26, 2005 Monday, September 26, 2005 Message of Touch Massage & Guided Imagery by Fran Glowinski, MPS, OSS 2 Neuroscience Unit 11:00 to 13:00 18:00 to 20:00 Tuesday, September 27, 2005 Lunch and Learn - Falls in the Elderly by Dr. Jose Biller Bldg. 105 Maguire, Room 2812. 11:00 12:00 Bed Check Bed Alarm Use Inservice by Bill Saemann, Macon Company 2 Neuroscience Unit 6:00 to 8:00 10:00 to 11:00 18:00 to 20:00 Wednesday, September 28, 2005 Seated Back Massage by Loyola Health and Fitness Club 2 Neuroscience Unit 6:00 to 7:00 16:00 to 17:00 Posey Restraint Use and Other Restraint Alternatives by Fred Demshar, Posey Company 2 Neuroscience Unit 11:00 to 12:00 14:00 to 15:00 Thursday, September 29, 2005 Lunch and Learn –Healing Touch by Ann O' Malley , RN., C.H.T.P., EMS Bldg. Room 3284 11:00 to 12:00 Bed Check Bed Alarm Use Inservice by Dick Tedesco, Macon Company 2 Neuroscience Unit 6:00 to 8:00 10:00 to 11:00 18:00 to 20:00 Gait Belt Training by Kate Steinhable, PT, MPT. 08:00 to 09:00 Friday, September 30, 2005 Message of Touch & Guided Imagery by Fran Glowinski, MPS, OSS 2 Neuroscience Unit 6:00 to 8:00 Lunch and Learn –Is Polypharmacy Causing Acute Confusion In Your Patient? by Martina Novotny, Pharm. D EMS Bldg. Room 3284 11:00 to 12:00 Nursing Performance Improvement Fall Prevention Initiative 2005

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NEXT STEPS Develop month to month training publication arrangement for Medications Contributing to Mental Status Changes Design patient and family wellbeing instruction to neuroscience populace Partner with the Loyola Niehoff School of Nursing to present the Neuroscience Level III Fall Prevention Program into understudy educational modules Integrate fall hazard components and history of fall into the Electronic Medical Record Produce and tape Lunch and Learn Safety Programs Improve tolerant care handoff using SBAR Situation, Background, Assessment, and Recommendations

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Catching the Safety Culture