Presented to

3rd Annual Nursing Research and Evidence-Based Practice Symposium

September 10, 2009

By

Fran Vlasses PhD, RN, NEA-BC

Becky Schuetz, RN-BC, BSN

Project Title: Impact of System Factors and Processes of Nursing Care on Patient Falls

2

Members of the Investigative Team

Principal Investigators

–Marita G. Titler PhD., RN, FAAN;

–Loreen Herwaldt, MD;

–Leah Shever PhD, RN

Investigators

–Shelia Barron, PhD;

–Gary Rosenthal, MD

–Marcia Ward, PhD

Site Coordinators and data collectors at each site – big thanks for their work and participation

***Acknowledgement: Robert Wood Johnson Foundation

RN Data Collectors for Medical Record Abstraction

• Becky Schuetz, RN-BC, BSN

• Dan Fraczkowski, RN, BSN

• Rhonda Abdulla, RN, BSN

• Catherine Scheidler, RN

• Tacora Love, RN, BSN, CRN, CMSRN

• Charisee Bedrejo, RN

• Katie Houser, RN, BSN

• Daisy Abraham, RN, BSN

• Cherileen Niemiec, RN

• Byron Lindsay, RN, BSN

• Cherylyn Stark, RN

• Bekka Beil, RN, BSN, CVN

• Leslie Klemp, RN, BSN, CVN

• Maureen Swiderski, RN, CHPN, OCN

• Angela Tosaw, RN, BSN

• Tania Rademacher, RN, CVN

• Clelia Dompe, RN, MSN

Study Purpose

• To investigate linkages among 2 National Quality Forum (NQF) patient outcomes of falls and injury from falls, NQF system-centered measures such as skill mix, nursing care hours per patient day (HPPDs), and professionalism, and processes of care to prevent falls (i.e. interventions to prevent falls).

IMPACT

5

P4P NMs

RN HPPD

Focus onrisk specificfall preventioninterventions

• Administrative Discharge Abstracts (age, severity of illness, primary medical diagnoses)

• Nurse staffing (components to build HPPDs, skillmix, turnover) at the unit level.

• Falls (rate and fall injury rate; severity)

• Chart Abstractions (Daily Fall Risk Assessment and Interventions done Related to Fall Prevention)

Interviews with the CNO, Person in charge of Quality, and Nurse Managers.

Questionnaires completed by staff nurses on each of the study units

Data Sources

Data: Quarter 1 (1/08-3/08) & Quarter 5 (1/09-3/09)

(Quarters 2, 3, 4)

Description of SitesNumber of Hospitals 48

Number of Units 185

Number of States that Hospitals are Located in 18

Hospitals Units

Number Percent Number Percent

Type of Hospital

Community 30 63% 109 59%

Academic/Teaching Hospital 13 27% 65 35%

VAs 4 8% 7 4%

Other 1 2% 4 2%

Hospital Size (Licensed Beds)

       Small (< 100 beds) 5 10% 7 4%

       Medium (101-400 beds) 20 42% 66 36%

       Large (> 401 beds) 23 48% 112 60%

States with Participating Hospitals

• Preliminary Findings

RWJRWJNursing Falls

Study

Preliminary Findings: Fall Rates and Fall Injury RatesVariable Quarter 1

Mean (SD)Quarter 5 Mean (SD)

T- value (p)

Fall Rates 3.78 (2.2) 4.15 (2.3) 1.71 (NS)

Fall Injury Rates

1.14 (1.25) 1.01 (.89) -1.28

(NS)

Data: Quarter 1 (1/08-3/08) & Quarter 5 (1/09-3/09)

RN HPPDs and TurnoverVariable Quarter 1 Mean

(SD)Quarter 5 Mean (SD)

T-value (p)

HPPDs 5.9 (1.7) 6.1 (1.5) 1.71 (NS)

Turnover 1.9 (2.6) .97 (1.2) -4.74 (p<.0001)

Frequency of Fall Prevention Interventions: MRA

Intervention Patient days Patients

PT session 13% 23%

Ambulation 38% 61%

Toileting 17% 22%

Delirium Scr. 7% 10%

Pharm referral 1% 2%

Chg. Meds- Dr. 0.6% 1%

Cues/signs 25% 32%

Pt. instructed 33% 44%

Patient days = 29,706; Patients = 7,699

Frequency of Fall Prevention Interventions: MRA

Intervention Patient days Patients

Sitter < 24 hrs 1% 4%

Sitter = 24 hrs./day 1% 3%

Bed rails adj. 60% 66%

Bed rails adj.: lower down

47% 51%

Bed alarm 8% 11.%

Physical restraints 0.8% 1%

Low bed (6”) 19% 23%

Patient days = 29,706; Patients = 7,699

Selected Findings: NM Interviews Category Frequency Percent

Primary Resp QI data: NM

117 80.1%

Fall Prevention Team: Yes

81 55%

NM Compensated: NO 123 84.8%

Annual Staff Competencies for FP: Yes

86 58.9%

Focused F/U - > 1 fall: Yes

54 37%

N=146

Selected Findings: NM InterviewsCategory Frequency Percent

Referral for > 1 fallers: Yes

15 10.3%

Satisfaction with fall rates in unit: Ext & Very

38 26.2%

Recall patient injury: Yes

94 65.3%

Injury type: Death, Major, Moderate

54 60.7%

Use of Physical Restraints

Some=23

Not at all = 17

15.9%

11.7%

Findings

Variable Coefficient p value

Fall rates PES Comp = 1.487292 p=.02

Fall Injury rates RN HPPD = .113985 p=.047

H1 & 2: Fall rates and fall injury rates explained by skill mix, HPPD, voluntary turnover, PES-NWI, when controlling for age, SI, and PMD

(cross sectional analysis for Q 1; HLM)

Implications• Variety of fall prevention interventions used • Most nurse managers (86%) believed their fall prevention standard (p/p)

was based on evidence but when asked to identify the evidence, many were unable to

• P4P – target nurse manager• Need focused follow-up for patients that have fallen once or more• Risk factor assessment provide a score but it is the specific risk factor for

patients that guide risk specific interventions – work on risk specific fall prevention interventions individualized to the patient.

Research Plan

• Still analyzing data

• Results presented today are preliminary

• Thank you for participating

Unanticipated Ways Research Improves Practice

Chart Abstraction Tool

Fall Risk Assessment Done?

Yes

No

Score:

______

Pt at risk for falling?

Yes

No

Mobility

Attended Physical Therapy (PT) session

Gait training by PT

Exercises (e.g. ROM, strength training) by PT

Scheduled ambulation with supervision

Scheduled ambulation without supervision

Assistive device readily available for use by patient

Tool Continued…

Elimination

Toileting regimen (e.g. toileting rounds every 2 hours)

Physician orders to reduce dose and/or discontinue diuretics

Physician orders to reduce dose and/or discontinue laxatives

Pharmacological

**Medication orders were modified by the physician for the specific purpose of minimizing fall risk

Education

Cues or signs are placed to identify patient as being at risk for falling

Patient instructed to call for assistance when getting out of bed or chair

Patient/family provided with written educational materials on fall prevention

Tool continued…

Bed/Restraints Physical restraints applied Bed alarm activated Low bed (6 inches from ground) Mats on floor next to bed Hip protectors applied Bedrails adjusted All up Lower down One side down

Referral/Follow-up INR obtained Referral to Gerontological Nurse

Practitioner (GNP) Comprehensive assessment by

GNP performed Referral to interdisciplinary fall

prevention team Comprehensive post-fall

assessment completed Pharmacy referral PT referral made Other ____________

Impact on Documentation:In Their Own Words

• “The Falls Study taught me to be more consistent in charting the musculoskeletal, fall risk and functional mobility assessments…to be concise in charting items used to decrease fall risk, such as assistive devices by the bedside.“ -Tania Rademacher

• “The Falls Study helped me to recognize gaps in nursing documentation …. I was able to improve my documentation as a nurse by incorporating multiple fall prevention techniques into my charting….my documentation more accurately reflects measures taken to improve patient care and prevent falls.“ -Katie Houser

Documentation (Continued)

• “The Titler Falls Study helped highlight areas of fall prevention needing improvement. Recognizing these areas helped me to improve my nursing practice by incorporating multiple disciplines and practices into fall prevention for my patients……I have been able to sooner recognize signs of high fall risk patients, and therefore been able to facilitate the implementation of appropriate means to keep my patients safe from falls.” –Katie Houser

• “Abstracting data ….. encouraged me to change my charting habits. Doing chart audits really opens your eyes to the good and the bad. I have definitely started to be more meticulous with my charting…Participating as a data abstractor was a learning experience .. and has resulted in positive changes in my daily charting as a nurse.” –Bekka Beil

Growing Culture of Inquiry

• Nurses valued the Medical Record Abstraction process: More nurses joined for the 2nd set of data collection

• Enthusiasm on the nursing units

• “Opened doors”

Increased Interest in Research (Outcomes)

• Chapman Scholars

• Data Collectors for other studies

• Attending graduate school

• Enrolled or have taken the Nursing Research & Evidence-Based Practice: A Nurse’s Guide course

• Participated in the Nursing Research Lunch & Learns

Questions?