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September 30, 2016 Preventing Falls: Best Practices and Tools 1
September 30, 2016
Preventing Falls:Best Practices and Tools
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• Michelle Feil, MSN, RN, CPPS
• Senior Patient Safety Analyst
• Pennsylvania Patient Safety Authority
• 610-825-6000 ext. 5453
Speaker
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Objectives
• Describe best practices in falls prevention
• Distinguish between practices that have stronger and weaker levels of evidence to support them
• Identify tools provided in the Pennsylvania Patient Safety Authority’s Falls Toolkit
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“Sometimes I wish for fallingWish for the releaseWish for falling through the airTo give me some reliefBecause falling's not the problemWhen I'm falling I'm in peaceIt's only when I hit the groundIt causes all the grief”
― Florence Welch(lead singer, Florence and the Machine)
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Gravity is a contributing factor in nearly 73 percent of all accidents involving falling objects. -Dave Barry(comedian)
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Grading Levels of Evidence• Level I: Systematic reviews (integrative/meta-
analyses/clinical practice guidelines based on systematic reviews)
• Level II: Single experimental study (randomized controlled trials [RCTs])
• Level III: Quasi-experimental studies• Level IV: Non-experimental studies• Level V: Care report/program
evaluation/narrative literature reviews• Level VI: Opinions of respected authorities/
Consensus panels(Capezuti 2008)
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Key Components
• Organizational support and leadership
• Multidisciplinary falls prevention team
• Risk assessment
• Multifactorial interventions
• Communication
• Reassessment
• Data collection and quality improvement
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Organizational Support and LeadershipLevel of Evidence: V, VI
• Strong organizational support is necessary for the success of any falls reduction program
• Policies and protocols alone will not significantly impact rates of falls and falls with harm
• Organizations must allocate resources to implementing a falls reduction program. Without additional resources, the program may increase falls rates.
(Healey 2007, Lancaster 2007, Cameron 2010, Miake-Lye 2013)
Guidelines: ICSI, NCPS, RNAO
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Multidisciplinary Falls Prevention TeamLevel of Evidence: IV
• Requires support across departments and disciplines
• Consists of clinical and non-clinical staff
• Engages the medical staff(Miake-Lye 2013)
Guidelines: ICSI, RNAO, NCPS
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Falls Prevention Team Members
Guideline: NCPS
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• Clinical Staff
– Falls Clinical Nurse Specialist
– Nurse Managers
– Nursing Assistants & LPNs
– Pharmacist
– Physical & Occupational Therapists
– Physician/Nurse Practitioner
• Non-Clinical Staff– Patient Safety Manager/
Quality Manager Coordinator
– Facility Management Manager
– Supply Processing & Delivery Manager
– Biotechnology Manager
– Transportation Manager
Risk AssessmentLevel of Evidence: II
• Patients should be assessed for their falls risk:
– On admission
– Upon transfer from one unit to another
– With any status change
– Following a fall
– At regular intervals
In other words…
Risk Assessment, Re-Assessment and Post-Fall Assessment
Guidelines: ICSI, HCANJ, HIGN, NCPS, NICE, PSF, RNAO, TCAB
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SensitivityThe ability to predict a true positiveA high score = the patient will fall
SpecificityThe ability to predict a true negativeA low score = the patient will not fall
Risk Assessment Tools
• Risk assessment tools by themselves do not prevent patient falls - they predict them
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Risk Assessment ToolsWhat’s the Evidence?
• Sensitivity and specificity can vary greatly between tools (Perell 2001)
• Risk assessment tools with high sensitivity and specificity assess:– gait instability
– agitated confusion
– urinary incontinence/frequency
– falls history
– prescription of ‘culprit’ drugs (especially sedative/hypnotics)(Oliver 2004)
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Risk Assessment ToolsWhat’s Out There?
• Morse
• Hendrich I & II
• STRATIFY
• Johns Hopkins
• Conley
• Innes
• Downton
• Tinetti
• Schmid
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Risk Assessment ToolsComparison of Domains/Variables
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Depression and Falls
• Patients with depression are twice as likely to fall as those without depression (Perell 2001)
• Observe for any of the following signs:– prolonged feelings of helplessness, hopelessness, or
being overwhelmed– tearfulness– flat affect or lack of interest– loss of interest in life events– melancholic mood– withdrawal– the patient’s statement of depression
(Hendrich 2007)
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Risk Assessment ToolsValidity Testing and Adjunct Screening
• Each hospital should test for internal validity
• A good tool would have limited false negatives
• These tools may be paired with
– a mobility test (Get Up and Go)
– injury risk assessment (ABCs)
Guidelines: ICSI, NCPS, RNAO
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Risk Assessment ToolsPediatric & Outpatient
• Pediatric Falls Risk Assessment Tools– Schmid “Little Schmidy”– CHAMPS– General Risk Assessment for Pediatric
Inpatient Falls (GRAF PIF)– Humpty Dumpty– I’M SAFE
• Outpatient Falls Risk Assessment– History of falls– Get Up and Go– Timed Get Up and Go
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Assessing for Risk of InjuryLevel of Evidence: II, VI
Use the ABCs to identify patients withthe highest risk of falls with injury:(Quigley 2009)
• Age – age > 85
• Bones – osteoporosis, previous fracture, prolonged steroid use, bone metastases
• Coagulation abnormalities – anticoagulants, bleeding disorders, conditions causing coagulopathy)
• Surgery – recent limb amputation, or major abdominal or thoracic surgery
Guidelines: ICSI, TCAB
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• Antiarrhythmics
• Antihypertensives
• Diuretics
• Antihistamines
Medications and Falls Risk
• > 4 medications
• Benzodiazepines
• Anticonvulsants
• Sedative hypnotics
• Antidepressants
• Antipsychotics
• Opiates
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The Challenge
• “Unlike other hospital-acquired conditions that were selected by the CMS, falls are often the result not of medical errors but of diseases, impairments, and appropriate uses of medications and other treatments. Falls and injuries can occur even when hospitals provide the best possible care.”
(Inouye, Brown & Tinetti, 2009)
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The Call for Research
• “Although we have not identified specific prevention guidelines for the conditions . . . we believe these types of injuries and trauma should not occur in the hospital and we look forward to working with CDC and the public in identifying research that has or will occur that will assist hospitals in following the appropriate steps to prevent these conditions from occurring after admission.”
CMS Inpatient Prospective Payment System Final Rule,
Federal Register, August 22, 2007
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So Now What?!
Insanity: doing the same thing over and over again and expecting different results.
- Albert Einstein
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Multifactorial InterventionsLevel of Evidence: I
• Effective falls prevention interventions
– address common reversible falls risk factors in all patients
– target multiple individual risk factors
– are delivered by an interdisciplinary team
(Oliver 2007, Coussemant 2008, Cameron 2010, DiBardino 2012, Miake-Lye 2013)
Guidelines: ICSI, HCANJ, HIGN, NCPS, NICE, PSF, RNAO, TCAB
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Standard Falls Prevention Interventions
• Familiarize the patient to theenvironment
• Place call bell within reach andhave patient demonstrate use
• Position necessary items within patient reach
• Keep hospital bed in low position with brakes locked
• Ensure patient wears non-slip, well-fitting footwear
Guidelines: ICSI, HIGN, NCPS, PSF, RNAO, TCAB
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Standard Falls Prevention Interventions (cont’d)
• Provide night light or supplemental lighting
• Keep floor surfaces clean and dry and clean up spills promptly
• Install handrails in patient bathrooms, room and hallway
• Maintain clutter-free patient care areas
Guidelines: ICSI, HIGN, NCPS, PSF, RNAO, TCAB
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Falls Risk
Interventions for PatientsIdentified at Risk for Falls
• Use visual alerts to communicate falls risk, for example:
– Sign outside door and in room
– Wrist band
– Colored socks/blankets
– Alert in electronic medical record
• Provide cued toileting at least every two hours while awake
• Remain with the patient when assisted to the bathroom or commode
Guidelines: ICSI, HIGN, NCPS, PSF, RNAO, TCAB
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Interventions for PatientsIdentified at Risk for Falls (cont’d)
• Use safe patient handling techniques and assistive devices for all transfers
• Use low beds and floor mats when appropriate
• Use bed and chair alarms if necessary
• Provide frequent or continuous observation if necessary
Guidelines: ICSI, HIGN, NCPS, PSF, RNAO, TCAB
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Hourly RoundingLevel of Evidence: III, IV, V, VI
• The Four P’s– Position– Pain assessment– Personal needs (“potty”)– Placement
• Results– Reduction in falls– Increase in patient satisfaction– Increase in staff satisfaction– Decreased call bell use– Decreased distance walked by nursing staff(Halm 2009)
Guidelines: ICSI, NCPS, TCAB
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AlarmsLevel of Evidence: V, VI
• Alarms are mentioned in several guidelines
• Be sure staff are trained in their proper use according to manufacturer’s instructions
• Ideally the alarm should be triggered in time for staff to respond and prevent a fall
Guidelines: HIGN, ICSI, NCPS, TCAB
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Low BedsLevel of Evidence: V, VI
• 8 to 10 inches off the floor
• Low beds have been included as part of effective multifactorial falls prevention plans
• It is difficult to isolate the impact of low beds
• Research suggests no significant increase or decrease in the rate of injuries or falls from bed
(Lancaster 2007, Anderson 2011)
Guidelines: HIGN, ICSI, NCPS, RNAO, TCAB
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Continuous Observation (AKA “Sitters”)Level of Evidence: V, VI
• Evidence is mixed
• Demonstrating cost justification is an ongoing challenge
• Low rates of falls with injury correlated with three specific sitter program design elements in HEN 1.0 (P < 0.05):– defining criteria for sitter qualifications– providing a training program for sitters– establishing a pool of sitters(Feil & Wallace, 2015)
Guidelines: ICSI, NCPS, TCAB
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Communication
• Visual communication
• Communication with patients and families
• Communication with the healthcare team
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Visual CommunicationLevel of Evidence: V, VI
• Signage
• Patient chart
• Bracelets
• Socks
• Blankets
All healthcare workers must be educated to recognize these visual cues. Caution must be given to “sign fatigue”
Guidelines: HCANJ, HIGN, ICSI, NCPS, RNAO, TCAB
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Communication with Patients and FamiliesLevel of Evidence: V, VI
• Communicate risk factors identified
• Explain hospital falls prevention program
• Engage patient and family as members of the falls prevention team and get their input into the plan
• Provide education using the“Teach Back” method
Guidelines: HCANJ, HIGN, ICSI, NCPS, RNAO, TCAB
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Communication with the Healthcare TeamLevel of Evidence: V, VI
• Housewide, interdisciplinary ongoing education
• Transport checklist (“Ticket to Ride”)
• Handoff Tool (SBAR)
• Patient Safety Huddle
• Post Fall Huddle
Guidelines: HCANJ, HIGN, ICSI, NCPS, RNAO, TCAB
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ReassessmentLevel of Evidence: I, III, VI
• Post Fall Assessment
– Obtain history of the fall from the patient and witnesses
– Note the circumstances (e.g. time, location, activity)
– Review underlying illness and problems
– Review medications
– Assess functional, sensory and psychological status
– Evaluate environmental conditions
– Review risk factors for fallingGuidelines: HCANJ, HIGN, ICSI, NCPS, NICE, PSF, RNAO, TCAB
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Reassessment (cont’d)Level of Evidence: I, III, VI
• Results serve two purposes
– Modify the plan for this individual patient in order to prevent repeat falls
– Collect data to monitor for trends that may focus the attention of the falls prevention team on new strategies to include in the facility’s falls prevention program
Guidelines: HCANJ, HIGN, ICSI, NCPS, NICE, PSF, RNAO, TCAB
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Data Collection and Quality ImprovementLevel of Evidence: VI
• The Veteran’s Health Administration, National Center for Patient Safety Falls Toolkit (2004) outlines the following steps in “Measuring Success”
• Step 1: Define the scope
– Definition of a fall
– Definition of injury levels
(VHA NCPS 2014)
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Data Collection and Quality Improvement (cont’d) Level of Evidence: VI
• Step 2: Decide what to measure and how
– Outcome measures: Is the desired goal being met? (e.g. is falls rate, or falls with injury rate declining?)
– Process measures: Are expected actions being implemented? (e.g. are risk assessments and post-fall assessments being done on every patient, or every patient that falls?)
– Balancing measures: Are other areas being affected adversely? (e.g. is restraint use rising?)
(VHA NCPS 2014)
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• Step 3: Collect baseline data
– Collect baseline data prior toimplementing change
• Step 4: Collection and analysisof data after implementation
– Five or six data points shouldbe collected in order to ensureaccurate information and draw conclusions
(VHA NCPS 2014)
Guidelines: HCANJ, HIGN, ICSI, NCPS, NICE, PSF, RNAO, TCAB
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Data Collection and Quality Improvement (cont’d) Level of Evidence: VI
Conclusion
• Evidence-based “key components” to falls prevention:
– Organizational support and leadership
– Multidisciplinary falls prevention team
– Risk assessment
– Multifactorial interventions
– Communication
– Reassessment
– Data collection & quality improvement
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Pennsylvania Patient Safety AuthorityFalls Toolkit
www.patientsafetyauthority.org
• Place mouse pointer over “Educational Tools”
• Click on “Patient Safety Tools”
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Accessing the Falls Toolkit
• Click on “Falls” in the list of featured patient safety tools
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Falls Toolkit
• Multiple tools are available under the Falls “Prevention Program Tools”
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Falls Toolkit (cont’d)
• The toolkit also contains:
– Educational tools, including webinar recordings
– Articles
– Other companion online information
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Falls Self-Assessment Tool (SAT)
• Adapted from an existing tool developed by ECRI Institute
• Modified based on a review of the literature
• Gap-analysis evaluating 139 individual best-practices in 17 categories (e.g., patient and family education, medication review)
The creation of this tool was in part funded and performed under contract number HHSM-500-2012-00022C, entitled "Hospital Engagement Contractor for Partnership for Patients Initiative."
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Scoring the SAT
• “YES” this element has 100% implementation in the current falls prevention program
• “P/I” (partial implementation) indicates this element has been partially implemented but could be improved
• “NO” this element has not been implemented as part of the current program
The creation of this tool was in part funded and performed under contract number HHSM-500-2012-00022C, entitled "Hospital Engagement Contractor for Partnership for Patients Initiative."
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Falls Prevention Process Measures Audit Tool
• Point prevalence data collection tool
• Used to audit all patients in selected areas
The creation of this tool was in part funded and performed under contract number HHSM-500-2012-00022C, entitled "Hospital Engagement Contractor for Partnership for Patients Initiative."
Audit Components
• Documentation Review
– Risk assessment
– Patient and family education
– Hourly rounds
• Visual Observation
– Call bell
– Risk identifiers
– Appropriate footwear
– Special equipment
– Alarms
– Sitter
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The creation of this tool was in part funded and performed under contract number HHSM-500-2012-00022C, entitled "Hospital Engagement Contractor for Partnership for Patients Initiative."
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Quarterly Audits
• Periodic evaluation of compliance with fall prevention program interventions
• Can be used more frequently
(Charts display mock data)
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Postfall Investigation (PFI) Tool
• Design based on:
– Evidence-based falls prevention guidelines and toolkits (e.g., AHRQ, VHA)
– Existing PFI tools shared by HAP PA-HEN collaboration members
The creation of this tool was in part funded and performed under contract number HHSM-500-2012-00022C, entitled "Hospital Engagement Contractor for Partnership for Patients Initiative."
PFI Tool Components
• Patient information
• Timeline and assessments
• Fall details
• Medications
• Fall prevention interventions
• Environmental status
• Attachments
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The creation of this tool was in part funded and performed under contract number HHSM-500-2012-00022C, entitled "Hospital Engagement Contractor for Partnership for Patients Initiative."
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Data Aggregation Workbook
• Excel workbook pre-formatted with pivot charts and tables
• Aids in identifying common risk factors and potential root causes to prevent future falls
The creation of this tool was in part funded and performed under contract number HHSM-500-2012-00022C, entitled "Hospital Engagement Contractor for Partnership for Patients Initiative."
Navigating the Workbook
• Right click the forward arrow in the lower left-hand corner of the Excel window to see a list of all available worksheets
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The creation of this tool was in part funded and performed under contract number HHSM-500-2012-00022C, entitled "Hospital Engagement Contractor for Partnership for Patients Initiative."
Fall Records Data Entry
• Enter information about a fall across a single row
• Most questions have a drop-down menu of answer selections
• Click on the green box in the upper left-hand corner when complete
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The creation of this tool was in part funded and performed under contract number HHSM-500-2012-00022C, entitled "Hospital Engagement Contractor for Partnership for Patients Initiative."
Sample Pivot Charts
• Pivot charts are generated from falls records data
• All charts can be filtered by:– Injury level
– Cognitive impairment
– Age group
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The creation of this tool was in part funded and performed under contract number HHSM-500-2012-00022C, entitled "Hospital Engagement Contractor for Partnership for Patients Initiative."
Sample Pivot Charts (cont’d)
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The creation of this tool was in part funded and performed under contract number HHSM-500-2012-00022C, entitled "Hospital Engagement Contractor for Partnership for Patients Initiative."
Other Tools Available
• Falls Risk Checklist– Tool to help determine whether the facility’s falls risk
assessment tool screens for certain risk factors associated with greater risk of falls and falls with injury
– http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/falls/Pages/checklist.aspx
• Falls With Harm Savings Calculator– Tool to calculate cost savings associated with reductions in
falls with serious injury
– http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2012/Jun;9(2)/Pages/calculator.aspx
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Other Tools Available (cont’d)
• Falls Event Type Decision Tree
– Guide to help staff systematically evaluate the circumstances after a patient falls and assign an event type in the Pennsylvania Patient Safety Reporting System
– http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/falls/Pages/algorithm.aspx
• Radiology Falls Risk Assessment Tool
– Sample falls risk assessment tool for use in radiology
– http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/falls/Pages/assessment.aspx
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Start by doing what’s necessary; then do what’s possible; and suddenly you are doing the impossible.
-Saint Francis of Assisi
How do you eat an elephant?One bite at a time.-Origin Unknown
Falls Prevention Guidelines• Agency for Healthcare Research and Quality (AHRQ)
– Agency for Healthcare Research and Quality. Preventing Falls in Hospitals [online]. 2013 Jan .[cited 2016 Jul 13]. http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html
• Hartford Institute for Geriatric Nursing (HIGN)
– Gray-Miceli D, Quigley PA. Fall prevention: assessment, diagnoses, and intervention strategies. In: Boltz M, Capezuti E, Fulmer T, Zwicker D, editor(s). Evidence-based geriatric nursing protocols for best practice. 4th ed. New York (NY): Springer Publishing Company; 2012. p. 268-97.[cited 2016 Jul 13]. http://www.guideline.gov/content.aspx?id=43933
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Falls Prevention Guidelines (cont’d)
• Health Care Association of New Jersey (HCANJ)– Health Care Association of New Jersey. Fall management
guidelines [online]. 2012 [cited 2016 Jul 13]. http://www.hcanj.org/files/2013/09/hcanjbp_fallmgmt13_050113_2.pdf
• Institute for Clinical Systems Improvement (ICSI)– Institute for Clinical Systems Improvement . Health care
protocol: prevention of falls (acute care) [online]. 2012 Apr [cited 2016 Jul 13]. https://www.icsi.org/_asset/dcn15z/Falls-Interactive0412.pdf
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Falls Prevention Guidelines (cont’d)• National Center for Patient Safety (NCPS)
– National Center for Patient Safety. Falls toolkit [online]. 2014 Jun [cited 2016 Jul 13]. http://www.patientsafety.va.gov/professionals/onthejob/falls.asp
• National Institute for Clinical Excellence (NICE)
– National Institute for Clinical Excellence. Falls in older people: assessing risk and prevention [online]. 2013 Jun [cited 2016 Jul 13].
http://www.nice.org.uk/guidance/cg161
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Falls Prevention Guidelines (cont’d)
• Patient Safety First (PSF)– Patient Safety First. The ‘how-to guide’ for reducing harm
from falls [online]. 2009 Sep.
• Registered Nurses’ Association of Ontario (RNAO)– Registered Nurses’ Association of Ontario. Prevention of
falls and fall injuries in the older adult [online]. 2011 [cited 2016 Jul 13]. http://rnao.ca/sites/rnao-ca/files/Prevention_of_Falls_and_Fall_Injuries_in_the_Older_Adult.pdf
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Falls Prevention Guidelines (cont’d)
• Transforming Care at the Bedside (TCAB)
– Institute for Healthcare Improvement. Transforming Care at the Bedside How-to guide: reducing patient injuries from falls [online]. 2008 [cited 2016 Jul 13]. http://www.ihi.org/knowledge/Pages/Tools/TCABHowToGuideReducingPatientInjuriesfromFalls.aspx
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Reference Articles
• Ang NKE, Mordiffi SZ, Wong HB, Det al. Evaluation of three fall-risk assessment tools in an acute care setting. Journal of Advanced Nursing 2007;60(4),427–435
• Anderson O, Boshier P, Hanna G. Interventions designed to prevent healthcare bed-related injuries in patients. Cochrane Database of Systematic Reviews 2011;11:1-30.
• Cameron ID, Murray GR, Gillespie LD, et al. Interventions for preventing falls in older adults in nursing care facilities and hospitals. Cochrane Database of Systematic Reviews 2010;1:1-117.
• Capezuti, E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds). (2008) Evidence Based Geriatric Nursing Protocols for Best Practice, (3rd ed). New York: Springer Publishing Company.
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Reference Articles (cont’d)• Child Health Corporation of America Nursing Falls Study Task Force.
Pediatric falls: state of the science. Pediatric Nursing 2009 Jul-Aug;35(4):227-231.
• Coussement J, De Paepe L, Schwendimann R, et al. Interventions for preventing falls in acute- and chronic-care hospitals: a systematic review and meta-analysis. J Am Geriatr Soc 2008;56:29-36.
• DiBardino D, Cohen ER, Didwania A. Meta-analysis: multidisciplinary fall prevention strategies in the acute care inpatient population. J Hosp Med 2012; 7:497-503.
• Feil M, Wallace S. The use of patient sitters to reduce falls: Best practices. Pa Patient Saf Advis [online] 2014 Mar;11(1):8-14 [cited 2016 Jul 13]. http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2014/Mar;11(1)/Pages/08.aspx
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Reference Articles (cont’d)
• Halm M. Hourly rounds: what does the evidence indicate? American Journal of Critical Care 2009 Nov;18(6):581-584.
• Healey F, Scobie S. Slips trips and falls in hospitals. London (UK): National Patient Safety Agency; 2007.
• Hendrich A. Predicting patient falls: Using the Hendrich II Fall Risk Model in clinical practice. American Journal of Nursing 2007 Nov;107(11):50-58.
• Inouye SK, Brown CJ, Tinetti ME. Medicare nonpayment, hospital falls, and unintended consequences. NEJM 2009 Jun;360(23):2390-2393.
• Lancaster AD, Ayers A, Belbot B, et al. Preventing falls and eliminating injury at Ascension Health. Jt Comm J Qual Patient Saf 2007 Jul;33(7):367-375.
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Reference Articles (cont’d)
• Miake-Lye IM, Hempel S, Ganz DA, et al. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Ann Intern Med 2013 Mar 5;158(5 Pt 2):390-6.
• Oliver D, Daly F, Martin FC, et al. Risk factors and risk assessment tools for falls in hospital in-patients: a systematic review. Age Ageing 2004 Mar;33(2):122-30.
• Oliver D, Connelly JB, Victor CR, et al. Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses. BMJ 2007;334:82.
• Perell KL, Nelson A, Goldman RL, et al. Fall risk assessment measures: an analytic review. J Gerontol A Biol Sci Med Sci 2001 Dec;56(12):M761-6.
• Quigley P, Hahm B, Collazo S, et al. Reducing serious injury from falls in two veterans’ hospital medical-surgical units. J Nurs Care Qual 2009 Jan-Mar;24(1):33–41
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