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10/12/17
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Reducing Falls in the In-patient Setting
Mary Catherine Rawls MS, RN-BC, CNL, FGNLA Clinical Specialist for Medical Specialties
Objectives • Define the magnitude of the problem of patient falls.
• Identify measurements used in process improvement initiatives.
• Describe an in-patient Falls Reduction Program: √ = Established, part of culture √ = In progress √ = Gap, may need to be done
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Falls: An Adverse Event • An unplanned descent to the floor with or without injury
to the patient. • Leading cause of fatal and non-fatal injuries for elders
– Leading cause of hospital admissions – > 800,000 admissions/year – > 27,000 deaths
• ¼ of Americans aged 65+ fall each year – ED treatment: every 11 seconds – Death: every 19 minutes
• 2013 total cost of fall injuries: $34 billion – Possibly $67 billion by 2020
(2017, National Council on Aging)
Quality of Life Issues • Fear of falling increases
• Activities and social engagement limited – Further physical decline – Depression – Social isolation – Feelings of helplessness
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Hospital Issues: A HAC • 3%-20% of patients fall at least once in acute care and
rehab facilities – 30-50% result in some injury
• 6-44% of those injuries may lead to death – Most from standing position (vertical deceleration injury)
• Falls associated with: – Increased LOS
• 6.3 additional days (average stay is 4.8 days) – Increased utilization of health care resources – Poorer health outcomes – Increased costs
• Fall w/o injury- $3500 • > 2 falls- $16,500 • Fall w/injury- $27,000
Hospital Improvement Innovation Network (HIIN)
• Center for Medicare and Medicaid Services (CMS) • Partnership for Patients (PfP)
• The Health Research and Educational Trust (HRET) – An affiliate of the American Hospital Association (AHA)
• Strategies • Change concepts • Actionable items
• HIIN Network change package
– Themes from successful practices across country • Clinical practice sharing • Organization site visits • Subject matter expert contributions
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AHA/HRET HEN Reduction Progress
• 2011-2014 – Reduced falls w/wo injury by 27%
• 1331 harms prevented, $882,453 saved
• 2015-2016 – Reduced falls w/injury by 3%
• 1409 harms prevented • $18,265,000 saved
• By September 27, 2018: – Goal: Reduce the incidence of harm due to falls by 20%
Best Practices I. Interdisciplinary, house-wide approach II. Learning loop III. Identify high-risk, vulnerable populations IV. Assess and implement multifactorial plan V. Prevent delirium and functional decline VI. Provide optimum post-fall care VII. Provide appropriate level of surveillance/observation VIII. Engage patients and families
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I. An Interdisciplinary Team Oversees the Strategic Plan for the
Fall Prevention Program • Organizational Support
– Across all disciplines and departments – Standard interventions implemented – Foster culture to:
• Promote accountability • Safety awareness • Teamwork
• Transparency of falls rates
Change Ideas √ Assess effectiveness of current team, change leadership for fresh ideas √ Reinvent the team- from “Falls Reduction” to
“Safe Mobility” √ Utilize “Unit-Based Geriatric Safety Champions” √ Steering Committee Membership:
Executive Sponsor Patient/Family Representative Clinical Nurses Pharmacy OT Nursing Leaders Dietary Discharge Planner Falls Coordinator Provider PT
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Safety Champions: Geriatric
Measurement:
• Number of positions on interdisciplinary team filled
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Leadership Ensures a Safe Environment
√ Engage all levels of staff and disciplines in monitoring slipping and tripping hazards
√ Get support of management
Change Ideas √ Share Falls event consequences in daily house-wide safety huddles √ Develop an environmental safety checklist
– Designate a time of day for routine rounds – Interdisciplinary
√ Develop a visual cue for low-bed positions – Create a mechanism for regular monitoring of bed position – Identify responsibility and frequency – Arrange patient’s room for safety – Clear pathways, no cords
√ Conduct “clutter rounds” √ Lock all portable furniture for patients
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Bed In High Position Indicator
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Measurement: • Percent of environmental rounds completed
• Number of hazards discovered
• Number of environmental hazards corrected
Use a Patient-Centered Approach
√ Interdisciplinary collaboration re: falls prevention from admission between clinicians √ Incorporate team-based success factors:
– Interdisciplinary discussion during rounds – Medication review for all at risk during rounds – Nurse rounds for education
• Hospital role • Family’s role at home
√ Interdisciplinary post-fall huddle to discuss action plan
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Change Ideas √ Educate providers
– Meds that can cause falls – Patient self-assessment questionnaires
√ Engage PT and pharmacy in care coordination √ Institute a “NO-Pass” culture √ Leadership, pharmacy and rehab participates in post fall huddles √ CMO or CNO rounds on patients and staff post fall √ Weekly systems fall reviews √ Incorporate TeamSTEPPS concepts of mutual support, shared mental model, other communication techniques
Care Plan
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Measurement: • Percent of patients with a documented interdisciplinary
Plan of Care
II. Create Structure for Hospital-Wide Learning Loops
√ Use “Big Data” √ Get support for systems that promote learning, ongoing evaluation and falls program improvements √ Analyze:
– Falls – Injury rates – Effectiveness of interventions
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Change Ideas √ Use trended data to determine:
– Who is falling, When falls occur, Why falls occur • Share data with leadership, staff, patients and visitors
√ Identify fall characteristics: – Time – Location – Day of week – Age – Race/ethnicity – Sex – Medical condition – Functional abilities
• “Unwitnessed falls are a system failure”
Adult Inpatient Falls High Level Data Specific Event Type
147 Safety Reports
33 From Bed 14 From Chair/Wheelchair
14 From Commode/Toilet 1 From Stretcher 4 While
Transferring 61 Ambulating/
Standing 4 with PT/OT
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Measurement: • Percent of nursing units with current falls data displayed
• Percent of leadership meetings in which falls data is shared
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Conduct Immediate Post-Falls Huddles at the Bedside
√ Facilitate critical thinking about the event √ Immediate review w/patient:
– Root Cause Analysis or Apparent Cause Analysis – Measures to prevent a future fall – Data emerges to identify trends
Change Ideas √ Use a falls resource team/administrator on call to respond to falls for post-huddle √ Conduct the huddle immediately, involve patient √ Use rapid response system for unwitnessed falls √ Track circumstances of falls to identify opportunities for improvement √ Conduct weekly systems falls reviews √ Involve rehab services and pharmacy
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Measurement:
• Percentage of falls that had a post-fall huddle completed with the patient within one hour of the fall
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III. Identify High Risk, Vulnerable Patients and Populations
√ Individualize patient assessment and treatment plans
√ Clinicians use clinical judgement re; factors that put patients at risk
Identify Patients with Fall/History of Falls: Apply Special Interventions
• Fall within past 12 months – Highest predictor for recurrent fall
• 50% do not tell provider • Need a multifactorial assessment by PT:
– Gait – Mobility – Balance – Home Safety assessment
• Referral for strength and balance training (Tai Chi)
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Change Ideas √ Interview family to obtain fall history √ Record “Known Faller” on EMR banner √ Order a PT evaluation for patients admitted with a fall √ Designate specific staff to screen patients for high risk/vulnerable status √ Provide a home environmental safety assessment √ Strength and balance community classes: CDC’s “STEADI Patient Referral Resources” √ Conduct multifactorial assessment, address risk factors
EMR Notification
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Measurements:
• Percent of patients admitted for a fall or with a fall within the past 6 months that received the organization's special interventions
Provide Multifactorial Assessments for High Risk/Vulnerable Populations • See AGS guidelines
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American Geriatric Society Clinical Practice Guideline: Prevention of Falls in Older Persons (AGS Guidelines, 2010): • Screening:
• Gait, balance and mobility assessment
• Medication review • Cognitive assessment • Heart rate and rhythm • Postural hypotension • Feet and footwear • Home environmental hazards
http://www.aafp.org/afp/2010/0701/p81.html#
• Intervention: • Medication Modification • Exercise • Vision Impairment • Management of Postural
Hypotension • Cardiovascular Factors • Vitamin D Supplementation • Management of Foot and
Footwear Problems • Home Modification • Education
Change Ideas √ Evaluate current effectiveness of fall risk assessment tool and work process to create impetus for change
√ Develop an assessment tool with linked interventions – Define how initial screening is done – Define who is responsible – Define who is responsible for the initiation of the care plan to
mitigate risk for each patient – Define how the interdisciplinary collaboration will occur
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EMR Flowsheet Extract:
Screen for Risk for Injury Using the ABCS Criteria
• Age, Bones, Coagulation, Surgery – 85 yo or greater, frail – History of orthopaedic conditions – On anticoagulation therapy – Have a bleeding disorder or are post-op
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Change Ideas √ Review high risk patients during shift huddles
√ Use ABCS to identify those patients at highest risk to fall √ Assess for and treat osteoporosis and vitamin D deficiency
√ Flag the EMR of patients on anti-thrombotics to increase awareness of risk
Handoff Huddle
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Measurements:
• Percent of patients with a risk for injury assessment completed within 24 hours of admission
• Percentage of patients on antithrombotics that are flagged as defined by policy
Communicate Risk Across the Care Team and Across Disciplines
• Lack of communication a common failure • Clinical and non-clinical team members who share
information with face-to-face handoffs and huddles share a mental model
• Handoffs between departments • Communicate risk factors related to meds that increase
fall risk: – Sedatives – Hypnotics – Pain meds
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Change Ideas √ Use standardized visual cues for communication
– Red or yellow non-skid socks – Colored wrist bands, lap blankets – Signage inside and outside the patient room
√ Standardize handoff communications – Use “Ticket to Ride” handoff tool – Communicate fall risk-increasing meds in handoff
communications
√ Incorporate alerts into the medical record √ Use in-room whiteboards for staff and family
Ticket To Ride
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Measurements:
• Percent of patients that are identified as having a fall risk that have appropriate visual cues in place per hospital policy.
• Percent of handoffs that include a discussion about patient fall risk as observed or documented.
IV. Implement Multifactorial Interventions to Reduce Risk of Falling
or Injury • Implement Universal Falls Precautions for all patients
– Maintain a safe environment, free of tripping/slipping hazards – Orient patient to surroundings and furniture w/wheels – Keep bed in lowest position when patient in bed – Raise bed for transfers and care – Keep top 2 siderails up for mobility and support – Place call light and frequently needed items within easy reach – Teach family and patient fall safety precautions using teachback – Ensure adequate lighting – Provide proper-fitting, non-skid footwear (not slipper socks) – Address any equipment that tethers the patient
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Change Ideas
√ Engage Falls Team, front-line staff and a patient/family advisor in designing optimal universal falls precautions
√ Integrate precautions into charting, care plans and whiteboards
√ Develop patient teaching materials or orientation checklist to precautions
Whiteboard: Assist Levels
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Measurements:
• Percent of patients observed to have bedside table, call bell, light switch and personal items within reach during leadership rounds
Implement Multifactorial Interventions to Reduce Fall or Risk Injury
• From AGS: • Medication Modification • Individually Tailored Exercise Program • Treat Vision Impairment (including cataracts) • Manage Postural Hypotension • Manage Heart Rate and Rhythm Problems • Supplement Vitamin D • Manage Foot and Footwear Problems • Modify the Home Environment • Provide Education and Information
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Change Ideas • Determine criteria and process for comprehensive
multifactorial assessment √ Use Fall Resource Team or RN Champion √ Integrate assessment and care planning into admission documentation process √ Develop processes for interdisciplinary collaboration for care planning for high risk/vulnerable patients √ Clearly define which discipline completes each dimension
√ Develop a multifactorial fall risk assessment and care planning documentation tool to guide clinicians in decision-making and documentation
– Review National Institute for Health and Care Excellence (NICE) assessment and management tool
Change Ideas √ Engage physicians to collect data to determine risk factors that can be minimized. √ Collaborate w/primary care providers to address fall risks prior to hospitalization using STEADI resources.
– Provider Fall Risk checklist – Preventing Falls in Older Patients: Provider Pocket guide – Integrating Fall Prevention into practice
√ Provide early activation of interventions for discharge planning purposes
– Home environmental safety assessment – Exercise ambulation plan to prevent further functional decline – Referral for community strength and balance training
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From National Council on Aging
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Measurements: • Outpatient focus: • Percent of patients 65 years and older with walking or
balance problems with a fall in the past 12 months who report discussing falls or problems with balance or walking with the practitioner AND report a fall reduction intervention was received
V. Prevent Delirium and Functional Decline in Vulnerable Populations
• Deconditioning occurs by day 2 in elderly – Leading to increased risk for falls and immobility: Orthostatic
hypotension, decreased muscle strength, increased bone loss, decreased bone density
Mobility Interventions: Assist with transfers
Wear shoes/non-skid footwear Use pt.’s assistive device, gait belts
PT and OT consults for evaluation/Rx Regular assistance w/toileting
Instruct pt. to rise slowly Provide supportive chairs w/armrests
Early and regular assisted ambulation of pts Daytime/nighttime lighting
Repeated education of safety measures Elevated toilet seats
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Change Ideas √ Incorporate assessment of gait, balance, lower extremity muscle strength and functional abilities into initial assessments √ Use automatic triggers in the EMR to notify rehab services of the need for a PT/OT evaluation √ PT/OT staff attend daily rounds with charge nurses to discuss patients that need evaluation and intervention √ Review mobility on interdisciplinary rounds with PT/OT √ PT/OT recommend mobility schedule. Write on board √ Make gait belts available √ Provide appropriate footwear
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Measurements:
• Percent of patients ambulating as prescribed.
• Percent of patients with mobility program defined on whiteboard.
Avoid Meds that Affect the Central Nervous System: Follow Beers Criteria • Changes in metabolism, slowed metabolism, decreased
renal clearance, hepatic impairment • Drug interactions,: additive/synergistic • 4 or more meds increase fall risk
Avoid the following: Anti-epileptics Benzodiazepines Anticholinergics Opioid receptor agonist
analgesics Tricyclic antidepressants “Z” hypnotics Antipsychotics Avoid drug-drug interactions
of 3+ CNS impacting hypnotics
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Change Ideas √ Include a review of pt. medications in the fall and injury risk assessment √ Flag vulnerable patients for a review of their meds by a pharmacist √ Use the Beers criteria to determine inappropriate meds √ Ask pharmacy to recommend alternatives to meds that increase falls risk
– Place an alert in the system for care providers √ Review standing order sets for inclusion of high-risk meds such as Ambien- remove from order sets √ Educate nurses and patients about med side effects √ Create alerts in the MAR when a fall-risk increasing drug is given
Published 9/19/17 http://www.medscape.com/viewarticle/885881?src=WNL_infoc_170928_MSCPEDIT_TEMP2&uac=221425FX&impID=1443726&faf=1
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Measurements:
• Percent of vulnerable patients receiving medication review by a pharmacist
• Percent of falls with medications attributed to the cause of the fall.
VI. Provide Optimal Post-Fall Care to Minimize Injury
√ Assess for injury prior to mobilizing the patient after an unwitnessed fall
√ Evaluate for head injury, fracture and spinal injury before moving
– Staff may want to minimize patient embarrassment and get patient up immediately
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Change Ideas √ Use a Rapid Response Team to respond to falls:
– Suspected head injury – Unwitnessed falls a – Fall where the patient is on anti-thrombotics
√ Establish protocols for VS and neuro checks for patients on anti-thrombotics and with suspected head injury √ Communicate patient’s injury risk factors to all team members: age, bones, recent surgery, anti-thrombotics √ Escalate unwitnessed falls to an administrator on call, supervisor or leadership point person to assure care and diagnostics are delivered
Measurements:
• The percentage of patients who fell who had documented physical assessment prior to mobilization.
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Provide Specialized Post-Fall Care for Patients on Anti-thrombotics
√ Change Ideas: Establish protocols for post-fall VS and neuro checks for all patients on anti-thrombotics
√ Communicate that the patient is on anti-thrombotics to the RRT and provider to determine treatment plan and/or diagnostics needed
Measurements:
• The percentage falls with patients on anti-thrombotics who had their antithrombotic status included in the post-fall care plan.
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VII. Provide the Appropriate Level of Surveillance/Observation
• Implement Intentional Rounds on Patients – Hourly rounding with toileting assistance – More than 45% of falls are related to toileting – Improves patient satisfaction and safety – Hospital personnel experience less job fatigue and burnout – Fewer call bells throughout the shift
Change Ideas √ Engage front-line staff in designing rounding workflows √ Combine rounds with other patient tasks:
– Turning – Pain Assessment – VS
√ Educate the patient about rounds- “5 Ps” – Pain, position, personal belongings, pathway and potty
√ Involve all staff in patient’s care in rounds expectations
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Bathroom Signage
Measurements:
• Percent of patient rooms with documented periodic rounds as per hospital policy
• Percent of patients who report that toileting is offered each time staff rounds on them.
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Keep Vulnerable Patients at Arms Length When Toileting
• Change Ideas: √ Provide patient and family education using teach-back √ Listen to patient and staff concerns regarding privacy.
• Modify assignments as needed • Male vs. Female care-givers
√ Use signage, scripting and messaging to support safety on the toilet
• “Safety Trumps Privacy”
Bathroom Signage
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Measurements:
• Percentage of patients to be at arms-length observed to receive that level of supervision in toileting
Increase Intensity and Frequency of Observation
• Sitters have little impact on falls rate
• Increased surveillance and supervision by nursing has more consistent positive effect on falls rates.
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Change Ideas √ Encourage family members to stay with patients whenever possible √ Place high-risk patients in rooms closer to the nurse’s station:
– More visible, direct line of sight √ Round more frequently than every 1-2 hours
– Escalate to every 15 minutes – Identify patients needing more frequent monitoring in pre-shift huddles
√ Develop an individualized toileting schedule √ Use video surveillance √ Utilize 1-to-1 companions or sitters for high risk times of day
Measurements:
• Percentage of close-monitoring patients that have documented observations
• Percentage of nursing staff who report in leadership rounds they have the tools and resources to adequately monitor the safety of high-risk patients.
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VIII. Engage Patients and Families in Design and Implementation of Fall Injury Prevention Activities
√ Use Patient and Family Advisors for program design • Change ideas:
√ Invite 2-3 patient/family advisors to join the falls improvement team √ Ask a patient who experienced a fall to share their experience with staff as part of new hire orientation √ Ask advisors to preview educational materials or documents provided to patients as tools: readability, understanding, etc. √ Include patient/family advisors in environmental design for fall safety √ Involve in small tests of change, seek input
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Measurements:
• Percentage of falls education materials or handouts that have been reviewed by a patient/family advisor.
Engage Patient and Caregivers in Fall Safety at the Bedside
• Change Ideas: – √ Determine who the learners are
• Get patient permission • Address family members
– √ Provide structured fall safety education that includes: • Info about fall risks:
– Meds – Tripping hazards – Orthostatic hypotension (esp. in AM) – Footwear – Rolling equipment, furniture – IV and other tubing/catheter hazards
– √ Include the fall prevention program on the whiteboard
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Change Ideas, cont’d. √ Initiate a “Patient Agreement/Contract” for those reluctant to call- patient and staff responsibilities √ Provide “Fall Safety Tips” to each patient upon admission √ At handoff- Include fall prevention status with pt/family
– Use teach-back method • Reason for patient risk • Necessary precautions • Methods to keep patient safe
– If no understanding, provide additional teaching and another teach-back request
Falls Education Signage
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Measurements:
• Percent of patient whiteboards with fall prevention program outlined as observed during leadership rounds
• Percent of bedside hand-offs that include the patient and family in fall prevention
Annotated Bibliography • Dupree, E., Fritz-Campiz, A. & Musbeno, D. (2014). A New Approach to Preventing
Falls With Injuries. Journal of Nursing Care Quality 29(2), 99-102. – Results of 18-month projects with 7 hospitals and The Joint Commission Center for Transforming Healthcare
piloting falls reduction strategies.
• Health Research & Educational Trust (2017, February). Falls with Injury Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at www.hret-hiin.org
– A change package summarizing themes from successful practices of high-performing health organizations across the country.
• National Council on Aging. (2016). Falls Prevention Fact Sheet. Accessed at www.ncoa.org/wp-content/uploads/
– Facts about fall challenges and the NCOA’s role.
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Questions?
Thank You!
Mary.Catherine.Rawls@Hitchcock.org 603-650-6067
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