DAY FOUR FALLS AND OTHER HAZARDS OF HOSPITALIZATION

DAY FOUR
FALLS AND OTHER
HAZARDS OF
HOSPITALIZATION
Alicia A. Puppione MS, RN
Sarah H. Kagan PhD, RN
Outline
Best rest and deconditioning
… Hyperactive delirium and physical restraints
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Geriatric Syndromes
From Inouye and colleagues (2007)
Geriatric Syndromes
From Inouye and colleagues (2007)
U.S. Patient Safety and Quality of Care
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National Patient Safety Goals for Hospitals
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Goal 1 – Improve the accuracy of patient identification.
Goal 2 – Improve the effectiveness of communication among caregivers.
Goal 3 – Improve the safety of using medications.
Goal 7 – Reduce the risk of health care–associated infections.
Goal 8 – Accurately and completely reconcile medications across the
continuum of care.
Goal 9 – Reduce the risk of patient harm resulting from falls.
Goal 14 – Prevent health care–associated pressure ulcers (decubitus
ulcers).
Goal 15 – The organization identifies safety risks inherent in its patient
population.
Universal Protocol for Preventing Wrong Site, Wrong Procedure, and
Wrong Person Surgery™
U.S. Patient Safety and Quality of Care
U.S. Pay for Performance and Quality
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Healthcare revolution?
Value
† Performance
† Quality
† Ownership
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What does it mean for nurses?
TCAB
† EBP
† Lots of work…
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Patient Safety and Quality of Care
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Quality of care for older adults
How do we define it?
† How can we measure it?
† What do nurses have to do with it?
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Parsing Out Overt Error in Falls and Falls Injury
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Using fundamentals of “good care”
Rethinking old habits in practice
Readdressing evidence for practice
Best Rest and Deconditioning
Creditor’s Associated Hazards
Creditor’s Proposed Solutions
Best Rest and Deconditioning
Relevant Phenomena
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Geriatric syndromes
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Geriatric principles
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Frailty
Sarcopenia
Frequent falls
Sensory-perceptual aging
Biological age
Functional reserve
Care practices
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Safety assessments
Tethering treatments
Institutional environment
Nursing Management
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Targeting referrals
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Sustaining self-care
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Early ambulation
Functional exercise
Educating for self-care
Educating caregivers
Reducing physical tethers
Personalizing environment
Initiating discharge plans
Falls and Iatrogenic Injury
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People over aged 65 are at increased risk
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Falls
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1/3 falls each year in community
Falls with injury
20-30% of all elder fallers
„ About 18,000 deaths
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Risk factors
Intrinsic
† Extrinsic
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Reporting
Falls/1000 hospital days
† Falls with injury/1000 hospital days
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Falls and Iatrogenic Injury
Relevant Phenomena
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Geriatric syndromes
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Geriatric principles
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Frailty
Sarcopenia
Falls
Fear of falling
Functional reserve
Failure to thrive
Care practices
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Falls assessment
Restrictive precautions
Limited exercise
Nursing Management
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Functional assessment
Therapy referrals
Ambulation
Functional exercise
Coaching for activity
Cognitive assessment
Family involvement
Falls Risk Factor Examples
Intrinsic
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Gait
Strength
Balance
Coordination
Posture
Osteoporosis
Visual acuity
Cognitive impairment
Medications
Extrinsic
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Footwear
Bathroom appliances
Stairs and railings
Floor coverings
Lighting
Maintenance
Clutter
Assistive devices
Falls Assessment Scale
Assessing Physical Risk of Falls
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Get Up and Go Test
Initial Exam
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From a sitting position, stand without using their arms for support.
Walk several paces, turn, and return to the chair.
Sit back in the chair without using their arms for support.
Individuals who have difficulty require further assessment.
Follow Up Exam
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Sit in a chair.
Stand without using their arms for support.
Close their eyes for a few seconds, while standing in place.
Stand with eyes closed, while you push gently on his or her sternum.
Walk a short distance and come to a complete stop.
Turn around and return to the chair.
Sit in the chair without using their arms for support.
Get Up and Go Follow Up
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Is the person steady and balanced when sitting upright?
Is the person able to stand with the arms folded?
When standing, is the person steady in narrow stance?
With eyes closed, does the person remain steady?
When nudged, does the person recover without difficulty?
Does with person start walking without hesitancy?
When walking, does each foot clear the floor well?
Is there step symmetry, with the steps equal length and regular ?
Does the person take continuous, regular steps?
Does the person walk straight without a walking aid?
Does the person stand with heels close together?
Is the person able to sit safely and judge distance correctly?
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No Reducing Falls Risk
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Exercise and strength training
Dietary supplementation
Medication modification
Environmental modification
Successful Falls Prevention?
What Works?
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Global programs
Heightened awareness
Family involvement
Early intervention
Strength building
Balance work
Self care initiatives
What Does Not?
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Identification programs
Risk stratification
Patient reminders
Reducing mobility
Frequent Rounds
Move Closer to the Nursing Station
Delirium/Confusion
Involve Family
Pharmacy Review of Medications
Call Light Reinforcement
Diarrhea
Frequent Toileting Rounds
Bedside Commode
PT evaluation for balance/transfer
training
Diuretics
Toileting Rounds Especially Around
Diuretic Times
Bedside Commode/Multiple Urinals
PT evaluation for balance/transfer
training
Call Light Reinforcement
Doesn’t Get It
Move Closer to the Nursing Station
Frequent Rounds
PT evaluation for gait/ balance
training
• Keep beds down and
locked
• Keep personal items within
reach
• Keep call light within reach
• Provide patients with nonskid socks
• Teach them to wear socks
when OOB
• Provide patients with
commodes or urinals
• Provide help with toileting
• Make sure you round on
patients every hour
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Pain
Position
Personal items
Potty
“Is there anything I can do for you
before I go”
• Assess patients’ strength,
gait and balance
– Make referrals to PT/OT as
appropriate
• Teach patients to adhere to
standard safety precautions
Hyperactive Delirium & Physical Restraints
Relevant Phenomena
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Geriatric syndromes
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Frailty
Comorbidity
Polypharmacy
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Geriatric principles
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Nursing Management
Biological age
Functional reserve
Excess disability
Care practices
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Pharmacologic focus
Missed diagnosis
Ageist assumptions
Shift work
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CAM
Medication review
Communicated findings
Targeted referrals
Early mobilization
Restraint reduction
Individualized care
Family coaching
Symptom treatment
Debriefing
Hyperactive Delirium & Physical Restraints
Hyperactive delirium
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Psychomotor agitation
Illusions
Delusions
Hallucinations
Physical restraints
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Attempted behavioral control
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Fail to prevent
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Rarely effective
Falls
Device disruption
Increases
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Falls with injury
Pressure ulcers
UTIs
Skin tears
Death
Physical Restraints
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Definition
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Devices to restrict free movement
Examples
Bedrails
† Sheets
† Vests
† Belts
† Mitts
† Beds
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Physical Restraint Reduction
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Treatment interference
Pain relief
† Device camouflage
† Dummy dressings
† Distracting activities
† Treatment evaluation
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Physical Restraint Reduction
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Falls risk
Physical therapy
† Functional exercise
† Physical training programs
† Low beds
† Fall mats
† Hip protectors
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Physical Restraint Reduction
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Wandering
Needs assessment
† Reminiscence therapy
† Distracting activities
† Personal possessions
† Name sign
† Stop sign
† Functional exercise
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Delirium Treatment
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Etiology resolution
Remove deliriogenic medication
† Substitute non-deliriogenic medication
† Remove sources of infection risk
† Treat infections and symptoms
† Correct electrolyte imbalance
† Correct hypoxia and hypoxemia
† Correct hypercarbia
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Delirium Treatment
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Symptom treatment
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Treat negative and frightening symptoms
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Antipsychotic medication
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Haloperidol 0.125 to 0.5 po/IV every 8 to 12 hours ATC
Options include respiridone, olanzepine
Treat pain and discomfort
† Treat diarrhea and constipation
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Delirium Treatment
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Manage personal and care environment
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Regulate stimulation
Care interactions
„ Family support
„ TV and radio
„ Ambient noise
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Control light and dark
† Remove safety hazards
† Promote mobility
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Debrief experience
Closing for Today
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Questions and comments
Workshop this afternoon
Plan for tomorrow
Thank you