Transcript Fall Prevention in the Acute Care Setting

Fall Prevention
in the Acute Care Setting
Presented by Lee Jeske MS, GCNS-BC
Aurora St. Luke’s Medical Center, Milwaukee, WI
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Fall prevention in the
acute care setting
- Objectives
• Review process of working with Joint
Commission writers
• Review the important aspects of acute care
fall prevention program
• Discuss current state of fall prevention
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Fall prevention in the
acute care setting
• Contacted by Joint Commission editor
after publishing "Partnering with
Patients and Families in Designing
Visual Cues to Prevent Falls in
Hospitalized Elders," in the Journal of
Nursing Care Quality.
• Case study in Good Practices in
Preventing Patient Falls: A Collection of
Case Studies
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Collaborating with the Joint
Commission
• Issues/Concerns?
- Administrative support
• Process
- Questions for preliminary manuscript
- Interview
- Final review
Preliminary information
requested
1. Provide a description about the types of
falls and the amount of patient/resident
falls that occurred (annual totals) at your
facility.
- Unit based
2. Provide a fall definition
• An unplanned descent to the floor (or
extension of the floor, e.g. trash can or
other equipment)during the course of a
patient’s hospital stay, with or without
injury to the patient.”
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Information requested
cont.
Describe how your organization conducted fall
risk assessment? Which staff members
were involved?
Practice Council
-
Representatives aware of data and issues
•
Developed Safety Care Plan
•
Interventions
•
Staff and Patient Education
•
Low bed
•
Bed and chair alarms
•
Fall calendar
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Fall calendar
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Low bed
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How did you identify
risk for the patient?
Morse Fall Scale
• Developed in mixed group
• Cut off score of 45
- Validated in 6 studies
• Medical,surgical, cardiac, rehab,
long-term care pts.
- Sensitivity: 70%-91%
- Specificity: 29%-83%
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What we know about
falls
• There are three types of falls
- Anticipated physiological falls (fall prone)78%
- Unanticipated physiological falls (stroke,
seizure) -8%
- Accidental (slipping, tripping) –14%
• (Morse, 1997)
What we know about
falls
• Significant risk factors have emerged
consistently in the literature
-
Prior fall history-RR 9.1
Impaired mobility/gait instability
Impaired mental status
Medications (sedative/hypnotics including
benzodiazepines
- Altered elimination
(Agostini et al, 2001, Evans et al, 2001, Oliver
et al., 2004)
What we know about
falls
• High percentage of falls occur when the
pt. is not in the presence of a caregiver
- Most common site is a patient’s bedside,
when alone and unassisted, and are
elimination related
• Hitcho et al., 2004, Oliver et al, 2000
What we know about
falls
Patients who fall:
- Those who can participate in fall
prevention strategies
- Those who cannot or will not
participate in fall prevention
strategies.
What did you implement
and who was involved?
Project involved working with the
patients who will participate in fall
prevention
-
Unit staff wanted to develop a poster to
educate patients/families about fall risk
and consequences
• Black and white
• Paragraphs of information
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Initial poster
Stay put, Stay safe
Our goal is to help you get better and keep you safe.
We want you to call for help when you want to:
Get out of bed,
Move to the chair, or
Go to the bathroom.
This prevents injuries. People are often weaker when they are in the hospital. This weakness can be caused by
the illness, by the tests, or by new medications. We do not want you to fall.
Keeping safe:
Sit at the edge of the bed for a few moments before standing up
Getting up slowly prevents dizziness
Call a staff member for assistance, they will be happy to help you
Sit down immediately if you feel dizzy
Please ask for assistance to get things that are out of reach
Tell the staff if you spilled anything so it can be wiped up
If you are having trouble using your call light, soft call lights are available and may be easier to use.
While walking:
Wear slippers or shoes while walking
Use your walker, cane or wheelchair if needed
Use the railing for support while walking
In the bathroom:
Use the handrails in the bathroom
Use the pull cord in the bathroom if you need help for anything
For family and friends
Help us keep your loved one safe.
Call for assistance to help your family member or friend get up to the chair, go for a walk, or go to the bathroom.
IF YOU DO FALL
Try to stay calm.
Do not get up. Call for help. Wait for a staff member to come.
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What did you implement and who
was involved?
•
Interviewed 20 patients/families with specific
questions about poster being easily seen, read, and
understood.
-
•
Too much information
Can’t see it
Add color
3rd redesign –19 patient/families re-interviewed
- Use simple sign like a stop sign
- Stay put, Stay safe, You are sick, call for help
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What did you implement
and who was involved?
• 4th redesign-26 patients/families
- Stay safe, Stay put. You are sick, call for
help
- 81%-Poster caught attention
• 84% stated that the poster was an effective idea
for fall prevention
• 92% stated the directions were easy to follow
and would help prevent falls
• Still too small
• Enlarged to 15 by 15 inches.
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Final Sign
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IDENTIFICATION OF PATIENTS AT RISK FOR FALLS
IN AN INPATIENT REHABILITATION PROGRAM
Lisa Salamon MSN, GCNS-BC, WOCN
Aurora Health Care Milwaukee, WI
&
Kathleen Bobay PhD, RN, CNAA
Marquette University & Aurora Health Care, Milwaukee, WI
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Background
•More than 75% of the patients admitted
to our inpatient rehabilitation program are
assessed to be at high risk using the
Morse Fall Scale.
•Concern about the use of traditional
means to identify fall risk patients not
effective
• Use of the Morse Fall Scale itself isn’t
sensitive enough to identify patients at
the highest risk for falls
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Definition of Fall
•
Fall: Unplanned descent to the floor (or extension of the floor, e.g.,
trash can or other equipment) during the course of a patient’s
hospital stay with or without injury to the patient, and occurs on
an eligible reporting nursing unit.
•
Assisted Fall: A fall in which any staff member (whether nursing
service employee or not) was with the patient and attempted to
minimize the impact of the fall by easing the patient’s descent to
the floor or in some manner attempting to break the patient’s falls.
“Assisting” the patient back to bed or chair after a fall is not an
assisted fall. A fall that is reported to have been assisted by a
family member or visitor also does not count as an assisted fall.
(ANA-NDNQI, p. 27; JCAHO, p. NSC 3-3)
•Sources: ANA-National Database for Nursing Quality Indicators (NDNQI- 2005),
•National Quality Forum (NQF-2005) endorsed hospital care performance measures and
•Joint Commission on Accreditation of Healthcare Organizations (JCAHO -2005).
Purpose
• To determine if we could find a more
sensitive way of identifying the highest
risk patients for falls
• Specifically we wanted to see if we
could do this without creating
“something else to do”
Current Assessments
• Morse Fall Scale Score
- On admission and then daily
• FIM Scores
- every day & every shift for applicable items
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The Morse Scale
Functional Independence
Measures (FIM)
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•
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•
•
•
•
Eating
Grooming
Bathing
Upper Body Dressing
Lower Body Dressing
Toileting
Bladder: assist level
Bladder: accidents
Bowel : assist level
Bowel : accidents
Bed/chair/wheelchair
transfer
•
•
•
•
•
•
•
•
•
•
Toilet transfer
Tub transfer /Shower transfer
Ambulation : assist level
Wheelchair mobility : assist
level
Stairs
Comprehension
Expression
Social Interaction
Problem solving
Memory
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Functional Independence
Measures (FIM)
• Detail on the FIM breaks it down onto a 1-7 scale
• For example Problem solving
- In order to score a 7
• Pt consistently recognizes problems when present
• Pt makes appropriate decisions regarding problems
• Pt initiates and carries out a sequence of steps to
solve complex problems until the task is completed
• Pt self-corrects if errors are made
- In order to score a 1
• Pt solves routine problems less than 25% of the time
• Pt needs direction nearly all of the time
• Pt may need a restraint for safety
• Pt requires constant 1:1 direction to complete simple
daily activities
Method
• A convenience sample of sixty-seven
patients who experienced a fall from
January 1, 2007 through June 30, 2007
were included in this pilot project.
• The mean age of patients was 66.34
(range 39-89, SD = 14.08).
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FIM Measures Chosen
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•
•
•
•
•
•
•
•
•
•
Eating
Grooming
Bathing
Upper Body Dressing
Lower Body Dressing
Toileting
Bladder: assist level
Bladder: accidents
Bowel : assist level
Bowel : accidents
Bed/chair/wheelchair
transfer
•
•
•
•
•
•
•
•
•
•
Toilet transfer
Tub transfer / Shower transfer
Ambulation : assist level
Wheelchair mobility : assist
level
Stairs
Comprehension
Expression
Social Interaction
Problem solving
Memory
Findings
• Significant correlations were found
when Morse Fall Scale scores were
compared against FIM (Functional
Improvement Measures) scores.
- problem solving (r = .898, p < .000)
• score 6 or less
- expression (r = .883, p < .000)
• score 5 or less
- memory (r = .772, p < .000)
• score 4 or less
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Interventions
• On line learning module
- Focus on FIMs to guide patient specific intervention
• Case studies with photo shots of rooms
• Patient Intervention laminated poster for rooms
• Pocket Cards
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Next Steps
• Follow up data collection
- 1 day per week for 5 weeks
- Done at random
- In the process of evaluating this data
• Expected Practice Changes
- Nurses individualizing careplans and
Overviews based on FIM scores
- Has this hightened awareness of patient
deficits impacted fall rates
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Overview Screen / Careplan
Therapy
Tips
Nursing
Communication
Conclusion
• It is believed that by using the Morse
score in combination with a FIM score
below the identified cut point, high risk
patients can be better identified so
appropriate interventions individualized
to their deficits can be put in place. Step
two of this project is to refocus the
nurse’s attention on these findings.
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References
• Agostini, J., Baker, D., & Bogardus, S. J. (2001) Prevention of falls in
hospitalized and institutionalized older people. In K. G. Shojania, B.W.
Duncan, K.M. McDonald, & R.M Wachter (Eds.) Making healthcare
safer: A critical analysis of patient safety practices. Evidence
report/technology assessment no. 43, AHRQ publication no. 01-E058.
(pp.281-299). Rockville, MD: Agency for healthcare Research and
Quality.
• Coussement, J., De Paepe, L., Schwendimann, R., Denhaerynck, K.,
Dejaeger, E., & Milisen, K., (2008). Interventions for preventing falls in
acute- and chronic-care hospitals: a systematic review and metaanalysis. Journal of the American Geriatric Society, 56(1), 29-36
• Evans, D., Hodgkinson, B., Lambert, L., & Wood, J., (2001). Falls risk
factors in the hospital setting: A systematic review. International
Journal of Nursing Studies, 39(7), 735-743.
References
• Hitcho, E. B., Krauss, M. J., Birge, S., Claiborne Dunagan, W., Fischer, Il,
Johnson, S., et al (2004). Characteristics and circumstances of falls in a hospital
setting: A prospective analysis. Journal of General Internal Medicine 19(7), 732739.
• Hook, M.L. (2008). Risk for falls in adults in acute care: A synthesis. Unpublished
manuscript, Aurora, Cerner, UW-Wisconsin (ACW) Knowledge-Based Nursing
Initiative, University of Wisconsin – Milwaukee, College of Nursing.
• Lee, JE, Stokic DS (2008) Risk factors for falls during inpatient rehabilitation. Am
J Physical Medicine & Rehabilitation 87: 341-353.
• Morse, J. M. (1997). Preventing patient falls. Thousand Oaks, CA: Sage
Publications, Inc.
• Oliver, D., Daly, F., Martin, F.C., & McMurdo, M. E. (2004) Risk factors and risk
assessment tools for falls in hospital in-patients: A systematic review. Age and
Ageing, 33(2) 1679-1689.