Annapolis Valley Health

Falls Virtual Learning Session # 4 &
Closing Congress Team Rapid Fire
Presentation Template
Name of Organization: Annapolis Valley Health
Name of Speaker:
Join the Falls Prevention Virtual Learning Collaborative
Who We Are
Location of Facility: Annapolis Valley
Number and type of Patients/Residents/Clients:
• 21 medical beds with a mixture of acute patients, and longer
term care patients. Our patients are generally geriatric, frail and
have complex medical conditions and co-morbidities.
Team Members
Team Member
Donna Arsenault
Nurse Manager
Julie Sutherland-Jotcham
Clinical Resource RN - geriatrics
Jodi Goudey
Occupational Therapy
Kathie Swindell
Manager ICU, Medicine
Stephanie Harvey
Manager Surgical Program
Tom MacNeil
Seniors LINCS AVH (community)
Sean Smith
Data Analyst
Jane Thompson
Assistant Manager Ambulatory Care
Jenn Best
ER Manager
Karen Ilsley
Cheryl Boyer
•Reduce incidence of falls (fall rate) by 40% from baseline by March 2011
•Reduce injury from falls by 40% from baseline by March 2011
•Monitor falls rate per 1000 pt days on the pilot unit
Change Ideas
List Changes you have tested during Falls VLC PDSA Cycles:
Updating mobility logos to reflect patients ability to ambulate/transfer
Trialed set of safety interventions/care plan (x2) limited and then an
expanded interventions list
Education blitz (raising awareness) – correct categorization of falls into the
AEMS system to ensure more accurate data collection for analysis (ToW)
Audits and posting results for sharing and learning, and compliance
1. % of patients with assessments completed on admission went from 86.2% at baseline
(October 2010) to 100% in January 2011; using the Morse Fall Scale.
2. % of patients at risk with care plans documented was 5% at baseline, and has steadily
increased to 33.3%. Strategies have been targeted to try to increase this objective.
3. % of falls causing injury for the 4 month period of October 2010 to January 2011
Goal – 40% reduction
Total # of falls with injury
Total number of falls
X 100 =
16 X 100 = 43% reduction
4. Monitored fall rate per 1000 pt days ( goal will be a reduction of 40% annually)
• data for January – Dec 2010
• 7069 patient days with 55 falls = 10%
• Will continue to monitor
Lessons Learned
List any “key” advice or insights you would like to share with other teams?
Lessons Learned/Key Insights
Documentation continues to be an issue
Compliance with completing the MFS is excellent, and there is
evidence of care planning to meet identified risk level (but not
the consistent documentation)
Our patients are frail and elderly and have continued to fall but
our incidents of injuries has decreased
Next Steps
What are some things you will do to sustain the work on reducing
falls and injury from falls and by what date?
Key Sustainability Steps/Plan:
Target Dates
Monitoring and education –
sharing results
Sharing information and
successes across the district
Implementation of a pt safety
care plan across inpt units
Fall 2011
Contact Information
Name: Donna Arsenault
Julie Sutherland-Jotcham
Phone Number:
902-825-6160 Ext 312
902-825-6160 Ext 229