Transcript Falls 101 - K-HEN

Pioneering
Experienced
Independent
Implementing an EvidenceBased Falls Prevention
Program
Michelle Feil MSN, RN
Senior Patient Safety Analyst
March 5, 2013
Evidence-based
1
1
Objectives
 List components of an evidence-based falls prevention program
 Distinguish between components of a falls prevention program
which have stronger and weaker levels of evidence to support
them
 Identify strategies that are accepted as best practices
 Describe innovative approaches to falls and falls injury
prevention
“Sometimes I wish for falling
Wish for the release
Wish for falling through the air
To give me some relief
Because falling's not the problem
When I'm falling I'm in peace
It's only when I hit the ground
It causes all the grief”
― Florence Welch
(lead singer, Florence and the Machine)
Gravity is a contributing factor
in nearly 73 percent of all
accidents involving falling
objects.
-Dave Barry
(comedian)
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, et al., 2008)
Key Components
 Organizational support and leadership
 Multidisciplinary falls prevention team
 Risk assessment
 Multifactorial interventions
 Communication
 Reassessment
 Data collection & quality improvement
Organizational Support and Leadership
Level 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)
Guidelines: ICSI, NCPS, RNAO
Multidisciplinary Falls Prevention Team
Level of Evidence: IV
 Requires support across departments
and disciplines
 Consists of clinical and non-clinical staff
 Engages the medical staff
Guidelines: ICSI, RNAO, NCPS
The Veteran’s Health Administration, National
Center for Patient Safety Falls Toolkit (2004)
outlines the following Falls Prevention Team
members:
Clinical Staff
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Falls Clinical Nurse Specialist
Nurse Managers
Nursing Assistants & LPNs
Pharmacist
Physical & Occupational Therapists
Physician/Nurse Practitioner
Non-Clinical Staff
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Patient Safety Manager/Quality
Manager Coordinator
Facility Management Manager
Supply Processing & Delivery
Manager
Biotechnology Manager
Transportation Manager
Other Members?
It is recommended to add
people to the team from areas
other than patient care if falls are
occurring in these areas.
(VHA NCPS 2004)
Risk Assessment
 “I think that we have to be
constantly asking ourselves,
'How do we calculate the risk?'
And sometimes we don't
calculate it correctly; we either
overstate it or understate it.” –
Hillary Clinton
Pennsylvania Patient Safety Advisory
 “Falls Risk Assessment: A Foundational
Element of Falls Prevention Programs”
September 6, 2012
 http://patientsafetyauthority.org/ADVISO
RIES/AdvisoryLibrary/2012/Sep;9(3)/Pa
ges/73.aspx
Joint Commission
2005 National Patient Safety Goal “reduce the risk of patient
harm resulting from falls”
 initial
assessment of falls risk
 periodic reassessments
2010 incorporated as a standard with two elements of
performance
 assess and manage
the patient’s risks for falls
 implement interventions to reduce falls based on the patient’s
assessed risk
Joint Commission, cont’d.
Risk Assessment
Assessment
Level of Evidence: II
 Patients should be assessed for their falls risk:
Re On admission
Assessment
 Upon transfer from one unit to another
 With any status change
 Following a fall
Postfall
 At regular intervals
Assessment
Guidelines: ICSI, HCANJ, HIGN, NCPS, NICE, PSF, RNAO, TCAB
Risk Assessment Tools
 Risk assessment tools by themselves do not
prevent patient falls - they predict them
Sensitivity
The ability to predict a true positive
A high score = the patient will fall
Specificity
The ability to predict a true negative
A low score = the patient will not fall
Risk Assessment Tools
What’s the Evidence?
 Sensitivity and specificity can vary greatly between tools
(Perell 2001)
 Risk assessment tools with high sensitivity and specificity
assess:
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gait instability
agitated confusion
urinary incontinence/frequency
falls history
prescription of ‘culprit’ drugs (especially sedative/hypnotics)
(Oliver 2004)
Risk Assessment Tools
What’s Out There?
 Morse
 Hendrich I & II
 STRATIFY
 Johns Hopkins
 Conley
 Innes
 Downton
 Tinetti
 Schmid
Risk Assessment Tools: Comparison of Domains/Variables
Morse
Hendrich II
Johns Hopkins
History of falls
X
X
Gait instability
X
X
X
X
X
X
Altered elimination
X
X
High risk medications
X
X
Lower extremity weakness
Altered mental status
Secondary diagnosis
X
Ambulatory aid
X
IV/heparin lock
X
X
Dizziness/vertigo
X
Depression
X
Male gender
X
X
Advanced age
X
Automatic low or high risk triggers
X
SENSITIVITY
78
74.9
Not tested
SPECIFICITY
83
73.9
Not tested
Pediatric Falls Risk Assessment Tools
 Schmid “Little Schmidy”
 CHAMPS
 General Risk Assessment for Pediatric
Inpatient Falls (GRAF PIF)
 Humpty Dumpty
 I’M SAFE
http://www.ajj.com/services/pblshng/pnj/ce/2011/arti
cle35227231.pdf
Risk Assessment Tools
 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
Mobility Tests
Timed Up and Go (TUG)
 Observe
patient rise from a chair, ambulate three
meters, turn, return to the chair, and sit
 Greater than 14 seconds predicts falls (sensitivity
and specificity greater than 87%)
Mobility Tests
Get Up and Go
 Similar test, longer
in length
Hendrich II includes one element from Get Up and Go:
observing a patient rise from a chair with hands on the thighs
 Rises in single
attempt but must use hands to push up [Odds Ratio
(OR) = 2.16]
 Uses hands, requires multiple attempts (OR = 4.67)
 Unable to rise (OR = 10.06)
Assessing for Risk of Injury
Level of Evidence: II, VI
Use the ABCs to identify patients with the 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
Screening and Risk Assessment
Falls risk assessment is a multi-step process
1.
2.
Screening using a risk assessment tool
In-depth multifactorial risk assessment
Risk assessment does not end with administration of the
screening tool
Individual Falls Risk Factors
TABLE OF FALLS RISK FACTORS WITH CORRESPONDING MEAN RELATIVE RISK
RISK FACTOR
MEAN RELATIVE RISK RATIO (RANGE)
Muscle weakness
4.4 (1.5-10.3)
History of falls
3.0 (1.7-7.0)
Gait deficit
2.9 (1.3-5.6)
Balance deficit
2.9 (1.6-5.4)
Use of assistive device
2.6 (1.2-4.6)
Visual deficit
2.5 (1.6-3.5)
Arthritis
2.4 (1.9-2.9)
Impaired activities of daily living
2.3 (1.5-3.1)
Depression
2.2 (1.7-2.5)
Cognitive impairment
1.8 (1.0-2.3)
Age over 80
1.7 (1.1-2.5)
Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope.
Clinics in Geriatric Medicine 2002;18:141-158.
Profile of the Hospitalized Patient
at Risk to Fall
 Cognitive impairment (including depression)
 History of previous falls
 Impaired mobility
 Special toileting needs
 Other contributors
Advanced age
 Medications

Cognitive Impairment
 Delirium
Hypoactive
 Hyperactive
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 Dementia
 Slower cognitive processing
 Depression
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:
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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)
History of Falls
Prior falls predict future falls
History of falling within previous 12-month
period can triple the risk of future falls
Different studies have used different cutoff points
Impaired Mobility
Muscle weakness
Decreased gait speed
Decreased stride length
Use of assistive devices
Arthritis
Impairment in activities of daily living
Special Toileting Needs
Incontinence
Urinary frequency
Diarrhea
Toileting - related falls increase the risk of
fall-related injuries by an odds ratio of 2.4
Advanced Age
1 in 3 adults over age 65 fall each year
Falls are the leading cause of injury
death in adults over 65
Adults 75 and older are four times as
likely to suffer an injurious fall than
adults ages 65 to 74
http://www.cdc.gov/homeandrecreationalsafety/falls/
adultfalls.html
Medications and Falls Risk
4 or more medications
Benzodiazepines
Anticonvulsants
Sedative hypnotics
Antidepressants
Antipsychotics
Opiates
Antiarrhythmics
Antihypertensives
Diuretics
Antihistamines
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)
A New Challenge
 “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
So Now What?!
Insanity: doing the same thing over and
over again and expecting different results.
- Albert Einstein
Multifactorial Interventions
Level of Evidence: I
Effective falls prevention interventions
 address
common reversible falls risk factors in all patients (Oliver
2004)
 target multiple individual risk factors
 are delivered by an interdisciplinary team (Cameron 2010)
Guidelines: ICSI, HCANJ, HIGN, NCPS, NICE, PSF, RNAO, TCAB
Standard Falls Prevention Interventions
 Familiarize the patient to the
environment
 Place call bell within reach and
have 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
Standard Falls Prevention Interventions
 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
Interventions for Patients
Identified at Risk for Fall
 Use of visual alerts to communicate falls risk, for example:
Sign outside door and in room
 Wrist band
 Colored socks/blankets
 Alert in electronic medical record
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Falls
Risk
 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
Interventions for Patients
Identified at Risk for Fall
 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
Hourly Rounding
Level of Evidence: III, IV, V, VI
 The Four P’s
Position
 Pain assessment
 Personal needs (“potty”)
 Placement
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 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
Alarms
Level 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
Low Beds
Level of Evidence: V, VI
 Low beds have been included as part of effective multifactorial
falls prevention plans (Lancaster et al., 2007)
 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. (Anderson et al., 2011)
Guidelines: HIGN, ICSI, NCPS, RNAO, TCAB
Continuous Observation (AKA “Sitters”)
Level of Evidence: V, VI
Provide training to designated staff
Create clear guidelines for use of
continuous observation
Monitor outcomes (e.g. falls with injury)
and balancing measures (e.g., restraint
use) to support cost justification (Harding
2010)
Guidelines: ICSI, NCPS, TCAB
Communication
 Visual communication
 Communication to patients and families
 Communication to the healthcare team
Visual Communication
Level 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
Communication to Patients and Families
Level 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
Communication to the Healthcare Team
Level of Evidence: V, VI
 Housewide, interdisciplinary ongoing education
 Transport checklist (“Ticket to Ride”)
 Handoff Tool (SBAR)
 Patient Safety Huddle
 Postfall Huddle
Guidelines: HCANJ, HIGN, ICSI, NCPS, RNAO, TCAB
Reassessment
Level of Evidence: I, III, VI
 Postfall Assessment
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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 falling
Guidelines: HCANJ, HIGN, ICSI, NCPS, NICE, PSF, RNAO, TCAB
Reassessment
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
Data Collection and Quality Improvement
Level 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 NCPS2004)
Data Collection and Quality Improvement
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 postfall 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 NCPS2004)
Data Collection and Quality Improvement
Level of Evidence: VI
Step 3: Collect baseline data
 Collect
baseline data prior to implementing change
Step 4: Collection and analysis
of data after implementation
 Five or six data points
should be collected in order to
ensure accurate information and draw conclusions
(VHA NCPS2004)
Guidelines: HCANJ, HIGN, ICSI, NCPS, NICE, PSF, RNAO, TCAB
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
How do you eat an elephant?
One bite at a time.
-Origin Unknown
Start by doing what’s necessary; then
do what’s possible; and suddenly you
are doing the impossible.
-Saint Francis of Assisi
Fall Prevention Guidelines
Agency for Healthcare
Research and Quality (AHRQ)

Agency for Healthcare Research and
Quality. Preventing Falls in Hospitals:
A Toolkit for Improving Quality of Care
[online]. 2013 Jan [cited 2013 Feb 25].
Available from Internet:
http://www.ahrq.gov/research/ltc/fallpx
toolkit/index.html
Falls Prevention Guidelines
 Hartford Institute for Geriatric Nursing (HIGN)
 Gray-Micelli D. Preventing falls in acute care. In: Capezuti E,
Zwicker D, Mezey M, Fulmer T, editor(s). Evidence-based geriatric
nursing protocols for best practice. 3rd ed. New York (NY): Springer
Publishing Company; 2008. p. 161-98. [cited 2012 May 15].
Available from Internet: http://guideline.gov/content.aspx?id=12265
 Health Care Association of New Jersey (HCANJ)
 Health Care Association of New Jersey. Fall management
guidelines [online]. 2007 Mar [cited 2012 May 15]. Available from
Internet: http://www.hcanj.org/docs/hcanjbp_fallmgmt6.pdf
Falls Prevention Guidelines
 Institute for Clinical Systems Improvement (ICSI)
 Institute for Clinical Systems Improvement . Health care protocol:
prevention of falls (acute care) [online]. 2012 Apr [cited 2012 May 15].
Available from Internet:
http://www.icsi.org/falls__acute_care___prevention_of__protocol_/falls_
_acute_care___prevention_of__protocol__24255.html
 National Center for Patient Safety (NCPS)
 National Center for Patient Safety. Falls toolkit [online]. 2004 Jul [cited
2012 May 15]. Available from Internet:
http://www.patientsafety.gov/SafetyTopics/fallstoolkit/index.html
Falls Prevention Guidelines
 National Institute for Clinical Excellence (NICE)
 National Institute for Clinical Excellence. Clinical practice guideline for
the assessment and prevention of falls in older people [online]. 2004
Nov [cited 2012 May 15]. Avaialble from Internet:
http://www.nice.org.uk/nicemedia/pdf/CG021fullguideline.pdf
 Patient Safety First (PSF)
 Patient Safety First. The ‘how-to guide’ for reducing harm from falls
[online]. 2009 Sep [cited 2012 May 15]. Available from Internet:
http://www.patientsafetyfirst.nhs.uk/ashx/Asset.ashx?path=/Interventi
on-support/FALLSHowTo%20Guide%20v4.pdf
Falls Prevention Guidelines
 Registered Nurses’ Association of Ontario (RNAO)
 Registered Nurses’ Association of Ontario. Prevention of falls and fall
injuries in the older adult [online]. 2011 [cited 2012 May 15]. Available
from Internet: http://rnao.ca/sites/rnaoca/files/Prevention_of_Falls_and_Fall_Injuries_in_the_Older_Adult.pdf
 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
2012 May 15]. Available from Internet:
http://www.ihi.org/knowledge/Pages/Tools/TCABHowToGuideReducing
PatientInjuriesfromFalls.aspx
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.
 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.
Reference Articles
 Halm M. Hourly rounds: what does the evidence indicate? American Journal of
Critical Care 2009 Nov;18(6):581-584.
 Harding AD. Observation assistants: sitter effectiveness and industry measures.
Nursing Economics 2010 Sep-Oct;28(5):330-336.
 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.
Reference Articles
 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):367375.
 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.
 Perell KL, Nelson A, Goldman RL, et al. Fall risk assessment measures: an
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 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 JanMar;24(1):33–41
Questions?
Contact Information
Michelle Feil, MSN, RN
Patient Safety Analyst
[email protected]
610-825-6000 ext. 5453
THANK YOU