pat quigley, phd, mph, arnp, crrn, faan, faanp · patricia quigley, phd, mph, arnp, crrn, faan,...
TRANSCRIPT
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Pat Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP
Fall SME; Nurse Consultant
Martha Ackman BSN, MA, CPHQ, CPPS, CPHRM
Clinical Improvement Advisor, HQI
July 25, 2016
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Poll #1
Who is in the room?
• Frontline RNs
• CNAs
• PT/RTs
• Management
• Senior leadership
• Other
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Patient Falls Coaching Webinar Series Objectives
• Extend application of fall and fall-injury prevention interventions to specific populations
• Restate critical program elements to reduce repeat falls and preventable falls
• Compose strategies to reduce barriers and enhance facilitators to short-term and long-term program implementation
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Webinar Series
• Coaching Session #4 – Mobility Issues, Walkers in Rooms – Postural Hypotension
• Coaching Session #3 – Proactive Toileting - Bathroom vs. Bedside Commodes; Toileting
prior to Pain Medication
• Coaching Session #2 – Protection from Injury – Unit Based Champions
• Coaching Session #1 – Post Fall Management – Patient Engagement
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Poll #2
Does your mobility assessment include:
1. Gait evaluation?
2. Transfer evaluation?
3. Lying to Sitting status?
4. Ability to lift legs on and off bed?
5. Sensory Neuropathy?
6. Proprioception?
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Poll #3
Do you assess older adults/patients or those with hypertension for:
1. Postural Hypotension on admission?
2. Postural Hypotension after change in HTN medications?
3. Routinely for patients admitted on mental health units?
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Faculty
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Patricia Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP,
Nurse Consultant, Retired Associate Director, VISN 8 Patient
Safety Center of Inquiry, is both a Clinical Nurse Specialist and
a Nurse Practitioner in Rehabilitation. As Associate Chief of
Nursing for Research, she was a funded researcher with the
Research Center of Excellence: Maximizing Rehabilitation
Outcomes, jointly funding by HSR&D and RR&D. Her
contributions to patient safety, nursing and rehabilitation are
evident at a national level – with emphasis on clinical practice
innovations designed to promote elders’ independence and
safety. She is nationally known for her program of research in
patient safety, particularly in fall prevention. The falls program
research agenda continues to drive research efforts across
health services and rehabilitation researchers.
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Webinar 4
Mobility Issues, Walkers in Rooms
Postural Hypotension
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Normal Aging
Balance-function of vision, balance and
sensory systems
Increased postural instability due to
changes in your inner ear (increased
sway)
Awareness of body position and
feedback decreases and interferes with
proper foot placement
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Normal Aging con’t
Posture changes with wider base
Shorter steps, decreased velocity, decreased steppage height and decreased arm swing
Vision changes with increased sensitivity to glare and adapting environmental lightning
Risk Factors are many and complex –
◦ Intrinsic Risk Factors
◦ Extrinsic Risk Factors
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Risk Factors-Intrinsic
Cognitive impairment (delirium, dementia,
depression)
Previous falls, fear of falling
Cardiac arrhythmias, transient ischemic
attacks, stroke
Parkinson’s disease
Acute and subacute medical illness
Orthostatic hypotension, dehydration,
hypoglycemia
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Intrinsic Factors – con’t.
Musculoskeletal conditions, problems with gait and mobility, ADL impairment
Incontinence (bowel or bladder)
Vision (both contrast sensitivity and acuity) or auditory impairment
Sensory impairments (proprioception), vestibular dysfunction
Foot problems, ankle dorsiflexion
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Extrinsic Risk Factors
Polypharmacy vs. polymedicine- more
then 4 medications
“No risk factor for falls is as potentially preventable or reversible as medication
use” (Leipzig RM et al. JAGS, 47:30-39, 1999.)
benzodiazepines, diuretics, psychotropics
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Extrinsic Risk Factors – con’t.
Use of restraints
Environmental factors-dim lighting, glare,
inappropriate footwear, uneven flooring,
loose rugs, wet, slippery floor, old and
unstable furniture, etc.
Imperative that health care providers
routinely assess risk factors and inquire
about falls
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Connecting SPH to Falls:
At the Point of Care
Patient Handling
◦ Bed Mobility
◦ Transfers
◦ Toileting
◦ Gait
ADL Tasks ◦ Toileting Transfers
Clothing Management
Reaching to clean and wipe
◦ Dressing ◦ Grooming ◦ Bathing
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SPMM: Patient Handling Injury
Barriers to prevent
injury
Float Nurse pulled to Med/Surgical
Care area Mobility Assessment of Patient not completed according to Policy
FRD not returned from Laundry and placed in patient room
Staff in a hurry and did not reinforce the use of the Mobility Assessment or the use of the FRD when repositioning
Injury
Employee sustained a Lumbar injury
requiring LWD and Medical intervention
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Fall Event: Fall Risks
Fall Risk Factors
Universal Fall Precautions
Fall Risk Assessment of Patient not completed according to Policy
Postural Hypotention: Pt NOT Symptomatic
Impaired Gait and Balance and Walker not within Reach
Fall &
Injury
Employee sustained a Lumbar
injury requiring LWD and
Medical intervention
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Manage and Reduce Risk
Patient: Screening and Assessment
Environment: Infrastructure and
Capacity
Interaction between Both: Consider
Cognitive and Mobility Function
Role of Autonomy
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Normal Aging
Balance-function of visual, vestibular and proprioceptive sensory systems
Increased postural instability due to vestibular dysfunction (increased sway)
Proprioceptive feedback decreases and interferes with proper foot placement
Decline of central integration of visual, vestibular and proprioceptive senses
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Normal Aging con’t
Gait: flexed posture and wider base-
men;narrower base and tendency to
waddle when walking-females
Shorter steps, decreased velocity,
decreased step height and decreased arm
swing
Vision: Greater sensitivity of aging eye to
glare, slower adaptation to changes in
environmental lightning
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Normal Aging cont.
Decline in depth perception (step edges, curbs)
Baroreflex activity-progressive decline-blunted heart rate response to postural change resulting in transient hypotension
Musculoskeletal- relative decrease in muscle mass-muscle strength (proximal muscles), rapid deconditioning
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Risk Factors
Intrinsic
Extrinsic
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Risk Factors-Intrinsic Cognitive impairment (delirium, dementia,
depression)
Previous falls, fear of falling
Cardiac arrhythmias, transient ischemic attacks, stroke
Gait and balance deficits
General weakness / debility
Parkinson’s disease
Acute and subacute medical illness
Orthostatic hypotension, dehydration, hypoglycemia
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Intrinsic Risk Factors, con’t.
Musculoskeletal conditions, problems with gait and mobility, ADL impairment
Incontinence (bowel or bladder)
Vision (both contrast sensitivity and acuity) or auditory impairment
Sensory impairments (proprioception), vestibular dysfunction
Foot problems, ankle dorsiflexion
Peripheral neuropathy
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Extrinsic Risk Factors
Polypharmacy vs. polymedicine- more then 4 medications
Benzodiazepines, psychotropics, antihypertensive medications
Environmental Risk Factors
“No risk factor for falls is as potentially preventable or reversible as medication use” (Leipzig RM et al. JAGS, 47:30-39, 1999.)
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Postural Hypotenson
Known Fall Risk Factor
◦ decrease in systolic BP >20mmHg; or diastolic 10 mmHg: supine, Immediate standing or
within 1 min standing, then 3 min after
standing
◦ assess compensatory elevation of pulse and
◦ if patient is symptomatic
Medications which may cause postural
hypotension include: Antihypertensives,
Diuretics, Nitrates, Antypsychotics,
Tricyclic antidepressants, L-dopa
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Extrinsic Risk Factors, con’t.
Use of restraints
Environmental factors-dim lighting, glare, inappropriate footwear, uneven flooring, loose rugs, wet, slippery floor, old and unstable furniture, etc.
Imperative that health care providers routinely assess risk factors and inquire about falls
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Environmental Considerations
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Let’s Share!
Your experiences with Mobility
Assessment and Modification
Plans to enhance mobility assessment?
Experiences with assessing postural
hypotension?
◦ Revised Toileting Protocols
◦ Post Fall Huddles?
◦ Patient Engagement and Teach Back?
◦ Population-based approach to injury reduction?
◦ Peer Leaders?
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Thank you for sharing!
Together we accomplish more!
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Closing Remarks
• What are your questions?
• What are you going to do by next Tuesday?
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Fall Coaching Webinar Series 12:00 – 1: 00 PM
• 5/26/16 Session 1: Post Fall Huddle, Involving the Patient; Patient Engagement
• 6/13/16 Session 2: Protection from Injury: Injury Reduction Environmental Assessment, Floor Mats, Hip Protectors, Helmets; Implementing Population-based approach to Injury Reduction (A, B, C, and S); Unit-based Champions: Resources for Peer Leaders
• 7/5/16 Session 3: Proactive Toileting - Bathroom vs. Bedside Commodes; Toileting prior to Pain Medication
• 7/25/16 Session 4: Mobility Issues, Walkers in Rooms; Postural Hypotension
• 8/15/16 Session 5: Accelerate Improvement- Share your Experience; Closure to the Webinar Series
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Thank You!
For further questions:
• Martha Ackman [email protected]
• Pat Quigley [email protected]
• Shweta Krishnan [email protected]
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mailto:[email protected]:[email protected]:[email protected]