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Joe P TomsicBSN, MHPA, MN
RN, ARNP, NEA-BC, PMHNP-BC© Copyright by Joseph Patrick Tomsic, 2012
All Rights Reserved
This document should guide healthcare professionals reviewing their current falls and fall injury prevention program. In no way does this document contain all possible options for developing a falls and fall injury prevention program. Do not use this document as the sole source for developing a falls and fall injury prevention program. Instead, view it as additional information for the development of a fall injury prevention program that matches the complexity of your organization. This presentation is available for use only with permission from the author. The conclusions in this outline are based on available research and represent the opinion of the author. The “Fall Prevention Intervention Workflow Wheel®” , “Fall Prevention Pillars®” and “SBAR Fall Prevention Tool®” are available for use with permission of the author only.
20-years of nursing leadership experience
◦ Board certified nurse executive-advanced and Psychiatric Mental Health Nurse Practitioner
United States Air Force, Major, Nurse Corps
◦ Psychiatric Nurse Practitioner
Education
◦ Master of Nursing, Psychiatric Nurse Practitioner
University of Washington
◦ Master of Health Policy and Administration
Washington State University
◦ Bachelor of Science in Nursing
Seattle Pacific University
Introduction Scope of the Issue Why Do Patients Fall? Sequelae from Falls Psychiatric Nurse Practitioner Role Interventions Fall Prevention Interventions Workflow Wheel Medication Interventions SBAR Risk Identification Scales Example documentation of fall risk Geriatric Considerations Recommendations
Falls rate in hospitals is between 2.2-17.1 per 1000 patient days
The healthcare facility rate is three times higher than the community
Approximately 15,000 people 65 and older die from falls each year
Patient falls result in costs of more than $20 billion a year
Second only to the medication events
The leading cause of nonfatal injuries
Leads to negative outcomes
Prolongs hospitalization
Legal liability
Still searching for an answer….
Individual (intrinsic) factors◦ Comorbidities◦ Behavioral disturbance◦ Agitation◦ Confusion◦ Vision problems◦ Delirium◦ Muscle weakness◦ Urinary incontinence◦ Impaired balance
Environmental (extrinsic) factors◦ Poor workflow design
◦ Inadequate lighting
◦ Trip hazards
◦ Faulty equipment
◦ Poorly defined processes
◦ Nursing unit design flaws
◦ Staff attitude
◦ Lack of education
Five high risk areas1) Medications
Antipsychotics
Benzodiazepines
Sedative/hypnotics
Digoxin medications
2) Orthostatic hypotension3) Poor vision4) Impaired mobility5) Unsafe behavior
Past history of a fall is the single best predictor of future falls
30% to 40% of patients who fall will do so again…
High risk nursing units◦ Psychiatric
◦ Oncology
◦ Orthopedic
◦ Neurology
◦ Geriatric units
Classifications of patient falls◦ Accidental
◦ Anticipated physiological
◦ Unanticipated physiological
Injuries occur in 15% to 50% of fallsRange: Bruises-minor injuries-severe soft tissue wounds-Skeletal fractures-Death
Patient falls account for about 65,000 hip fractures annually
Falls contribute to a 50% higher mortality
Loss of confidence, anxiety and depression, and PTSD
Approximately 1 in 10 falls will result in a serious injury
After adjusting for age◦ Fall fatality rate in can be up to 49% higher
for men
◦ Women are 67% more likely than men to have a nonfatal fall injury
The psychiatric liaison consultant has a growing role in acute care hospitals
The psychiatric nurse practitioner (PNP) is uniquely trained to lead patient fall prevention initiatives.
PNPs are trained to work with patients who are confused, agitated, delirious, demented, non-compliant, and on sedating medications
When almost all the patients are HRF, the focus needs to shift from identification to intervention
Two goals for a successful strategy ◦ Promotion of nurses’ professional knowledge and
skills in implementing a fall prevention program
◦ Cultivation of nurses’ attitudes in treating patients as their own families
Effective interventions are part of a basic universal fall program◦ Assessment of all patients for risk of falling
◦ A culture of safety
◦ Hospital protocol for those at risk of falling
◦ Enhanced communication of risk of injury from a fall
◦ Customized interventions for those at risk of injury from a fall
Hospitals successful at reducing fall rates◦ Developed a culture of safety
◦ Used fall-risk assessments
◦ Deployed multifactorial interventions
◦ Conducted post fall follow-up
◦ Involved quality improvement
◦ Integrated risk screening within the electronic medical record
The causes of falls are multifactorial◦ Intrinsic risk factors
◦ Extrinsic risk factors linked to the environment
Workflow redesign is more pressing than ever◦ Introduction of new technologies
◦ New treatment methodologies
Withdrawal or reduction of psychotropic medications
Delirium avoidance program
Reducing sedative and hypnotic medications
Supplementation with vitamin D and/or of calcium
SBAR is a form of structured communication adapted from aviation and the military
SBAR acronym◦ Situation (S; what is the situation?)◦ Background (B; what is the background
information?)◦ Assessment (A; what is your assessment of the
situation?)◦ Recommendations (R; how do you recommend the
problem be resolved?)
SBAR Fall Prevention Tool was developed J.P. Tomsic. For use with permission only.
Follow your institution’s patient fall policy e.g. notifying the falls provider and reporting patient incidents
SBAR Hand-off
Introduce yourself to the oncoming shift by name, title, and nursing unit.
Prior to change of shift complete an assessment of fall risk. Provide the oncoming care provider with the patient’s risk factors. If using bedside
reporting include the patient and family in fall risk education.
Situation: [patient] is [age] admitted on [date] with a current diagnosis of [diagnosis]. The patient’s is currently [oriented X_], [confused],
[lethargic], [Dizzy], [lightheaded], [unconscious], [seizing], or [other]. The patient is complaining of [_ out of 10 pain]. Patient with [multiple
comorbidities], [behavioral disturbance], [agitation or confusion], [vision problems], [delirium], [muscle weakness], [urinary incontinence],
[impaired balance]. Physically check bed alarm is on and functioning with ongoing shift.
Background: [patient name], [level of activity]. The patient [does] or [does not] have a history of falls. The patient [does] or [does not] have a
history of seizures. The patient [does] or [does not] have a history of orthostatic hypotension. The patient [does] or [does not] has a history of
behavior such as [throwing himself onto the floor] or [other]. The [patient] [does] or [does not] have a history of [dizziness], [lightheaded],
[confused], [agitation], [seizures] or [anything else] that may contributed to the fall risk. The patient’s last Fall Risk Scale score was [number].
Assessment: Patient is not responding to redirection or [state interventions] and has made ___ exits attempts in the past ___ hours. The
patient is at risk due to use of [antipsychotics], [benzodiazepines], [sedative/hypnotics], [digoxin] [orthostatic hypotension], [poor vision],
[impaired mobility], [unsafe behavior]. Patient with behavioral disturbance as evidenced by [agitation], [confusion]. Patient with vision
problems and glasses are [on],[at bedside], [remind family to bring in]. Patient currently be treated for [delirium], [ETOH/Opiate withdrawal].
Ambulation impaired due to [muscle weakness], [impaired balance ]. Provide frequent toileting due to [urinary incontinence], [diarrhea].
Recommendations: Additional orders [Medication change], [1:1 observation], [restraints], [enclosure bed] or [other]. Nursing interventions
[move closer to nursing station], [bed exit alarm], or [other]
SBAR Fall Prevention Tool was developed J.P. Tomsic. For use with permission only.
Follow your institution’s patient fall policy e.g. notifying the falls provider and reporting patient incidents
SBAR After a Fall
Introduce yourself to the provider by name, title, and nursing unit.
Provide lifesaving care if the patient is in acute distress or rapidly deteriorating call a code and get help! Complete an assessment (do not move
if injured) and provide the provider with the patient’s condition.
Situation: [patient] fell on [date] at [time]. [he/ she] is [age] admitted on [date] with a current diagnosis of [diagnosis]. The patient’s is currently
[oriented X_], [confused], [lethargic], [Dizzy], [lightheaded], [unconscious], [seizing], or [other]. The patient is complaining of [_ out of 10 pain],
or appears to be in pain as evidenced by [overt signs of pain such as grimacing, moaning, guarding]. Additional items to report: The patient
currently has [chest pain], [difficulty breathing], [numbness], [suspect a c-spine injury] or [other]. Current vital signs (including pulse oximetry)
are [state].
Background: [patient name], [level of activity]. The patient [does] or [does not] have a history of falls. The patient [does] or [does not] have a
history of seizures. The patient [does] or [does not] have a history of orthostatic hypotension. The patient [does] or [does not] has a history of
behavior such as [throwing himself onto the floor] or [other]. The [patient] [does] or [does not] have a history of [dizziness], [lightheaded],
[confused], [agitation], [seizures] or [anything else] that may contributed to the fall risk. The patient’s last Fall Risk Scale score was [number].
Assessment: Condition is at [baseline] or [has changed]. The patient [does] or [does not] appear to have an injury. The patient appears to have
sustained a [head injury] as indicated by [overt signs such as cuts, abrasion, bump, or swelling on the head], [visual changes] or [headache] from
the fall. The patient appears to have sustained a [possible fracture] AEB [location of deformity or swelling] or difficulty moving, [LLE, RLE, LUE,
RLE etc.] from the fall. The patient appears to have sustained a [neck injury] AEB [numbness] to [extremity]. The patient has a [bruise],
[scratch], [hematoma], [laceration] [superficial wound] on [location]. The injury appears to be [mild], [moderate], [severe].
Recommendations: recommend [provider assessment], [pain medication], [X-ray], [transfer, emergency room] or [other]. The patient is
requesting [pain medication], [anxiety medication], or [other].
A fall-risk assessment is required to meet the Joint Commission standards
Commonly used fall-risk assessments◦ Morse Fall Scale (MultiCare Health System)
◦ Hendrich Falls Risk Model II
◦ Edmonson Psychiatric Fall Risk Assessment Tool (Memorial Hospital in Illinois)
◦ The Conley Scale
◦ Tinetti Balance Assessment Tool (Western State Hospital)
◦ The Johns Hopkins Fall Risk Assessment Tool (UW Medical Center)
Risk Factors Edmonson
The Johns Hopkins
Fall Risk Assessment
Tool
The Conley Scale Morse Falls Scale TinettiHendrich II Fall Risk
Model
Psychiatric
Assessment
Risk Assessment
Questions?No
Yes
(Low Risk if complete
paralysis immobilized,
High risk if history of >
one fall within 6
months or fall during
hospitization)
No
Yes
(IV or IV Access is 25
points)
No No Past Medical History
Age? Yes Yes No No No NoIdentifying
Information
Mental Status or
Cognition?Yes
Yes
(cognition)
Yes
(Orientation,
Agitation, Impaired
Judgement)
Yes
(oriented abulation
ability and limitations)
No
Yes
(confusion,
disorientation,
impulsivity,
depression)
Mental Status
Examination
Altered Elimination? Yes Yes
Yes
(Bathroom in a hurry,
wet or soil self on way
to bathroom, up at
night to use BR)
No No Yes Past Medical History
Medications? Yes Yes No No No
Yes
(antiepileptics,
Benzodiazepines)
Past Medical and
Psychiatric History
Diagnosis? Yes No No Yes No No Multiaxial Diagnosis
Ambulation and
Balance?Yes
Yes
(mobility)
Yes
(difficulty getting out
of bed or chair, Using
supports, weak)
Yes
(Gait)
Yes
(various maneuvers
that takes 8-10
minutes to complete
and requires training)
Yes
(get and go test)
Mental Status
Examination
Screening for
abnormal movement
and gait
Nutrition? Yes No No No No NoScreening for
depression
Sleep Disturbance? Yes No No No No No
Screening for various
psychiatric diagnosis
depression and
bipolar
History of Falls? Yes YesYes
(last 3-months)Yes No No Past Medical History
Psychiatric professionals can accomplish a fall risk assessment with every intake simply by increasing their awareness of the items included in a falls risk assessment
Example questions◦ “Have you had any falls in the past 6-months or
during the hospitalization?”◦ “Are you having any issues going to the bathroom
such as urgency or getting up at night?”
The most common cause of accidental death amount older adults
5th leading cause of older adult death◦ Seniors older than 80 years are most likely
to be injured
Older adults with mental illness are at increased risk for both falls and subsequent fractures
Patients do not generally regain pre-injury levels of physical functioning
Seniors with mild Alzheimer's may not adapt mobility behavior to match cognitive and physical impairments
Frontal lobe dysfunction◦ Disinhibition of behavior
◦ Poor judgment
◦ Movement disorders
Develop a delirium avoidance program as a key intervention
Use a risk screening tool but consider also rank ordering patients by fall risk◦ Consider a parallel process to rank order
patients by degree of falls risk in addition to the hospital-wide falls risk assessment scale
Involve the psychiatric liaison team◦ Add fall risk screening to psychiatric
intakes
◦ Add fear of falling to the multiaxial assessment
◦ Review medications for all HRF patients
◦ Develop a process to review all patient falls within 24-hours
Develop chart audit processes
Develop realistic training including role playing and hands-on training
Track the cost of falls and use this information to calculate the return on investment for new equipment, staff education or items such as electronic incident reporting
Apply Lean principles to any fall prevention program
Incorporate fall prevention interventions into the nurse’s workflow
Implement bedside change of shift handoff communication
◦Use standardized communication
Place patients in the High Risk for Falls (HRF) subgroup on bed alarms or document the reason why a bed alarm is not appropriate◦ Develop a standard algorithm for bed-exit
monitoring◦ Monitor time from bed-exit alarm to staff
response
Add bed-exit attempts to the RN to RN and charge nurse report
Place patients at the “highest” HRF next to nursing station
Also consider non-HRF patient rooms e.g. rooms too far from nursing station to quickly respond
Review patient fall data to determine each unit’s “Fall Safe Zones”◦ Chart audit results often substantiate safer rooms
◦ Conduct a “Safety Reshuffle” q shift
Track close calls e.g. HRF patient self ambulates to bathroom
Develop visual tools◦ Strategically located
List “Priority High Risk to Fall“ patients
Risk for current shift
Patient on alarms
Alarm standards
Patients with communication issues
More
Develop process to make “Fall Safe Patient Assignments”◦ Ensure that nursing assignments are
acuity neutral so nurses have time to frequently check patients.
◦ Develop process for nursing staff input on falls risk acuity, falls risk and bed alarm data to build an overall risk profile for patients each shift
Develop fall risk hand-off communication process◦ Awareness of patients with bed alarms◦ Nurses share falls risk for the oncoming shift◦ Standardized interventions for patients at the
highest risk for falling
Have the charge nurse read the names of each “Priority High Risk to Fall”, High Risk to Falls with bed alarm as part of a 2-minute overview
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