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Reducing Risk of Falls and Fall-Related Injury in the Hospital Setting
Shanghai Sunshine Rehabilitation Center
October 27, 2017
Dawn M. Venema, PT, PhD [email protected]
Where in the world is Nebraska?
• Population: Approximately 2 million
• Area: Approximately 200,000 km2
• Number of hospitals: Approximately 100;
Approximately 65% are “Critical Access Hospitals”
Research Project:Collaboration and Proactive Teamwork Used to Reduce (CAPTURE) Falls
Purpose: To reduce fall risk and fall-related injury risk by using a multi-team system
The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.
Disclosure
This project is supported by:• Grant number R18HS021429 and
R03HS024630 from the Agency for Healthcare Research and Quality
• Nebraska Department of Health and Human Services, Division of Public Health and the Nebraska Office of Rural Hospital Flexibility Program
• University of Nebraska Medical Center College of Medicine Summer Research Scholarships
Acknowledgement: Research Team
University of Nebraska Medical Center
•Katherine Jones, PT, PhD
•Dawn Venema, PT, PhD
•Victoria Kennel, PhD
•Anne Skinner, RHIA, MS
•Jane Potter, MD
•Linda Sobeski, PharmD
•Robin High, MBA, MA
•Fran Higgins, MA, ADWR
•Mary Wood
•Kristen Topliff, PT, DPT
•Caleb Schantz, PT, DPT
Nebraska Medicine
• Regina Nailon, RN, PhD
University of Nebraska-Omaha Center for Collaboration Science• Roni Reiter-Palmon, PhD
• Joseph Allen, PhD
• John Crow, MA
Methodist Hospital
• Deborah Conley, MSN, APRN-CNS, GCNS-BC, FNGNA
Objectives1. Discuss the motives for reducing falls and fall
injury risk in U.S. hospitals
2. Identify components of a multi-team system that can be used to reduce falls and fall injury risk
3. Explain how the knowledge and skills of physical therapists can be integrated across components of the multiteam system
4. Describe the relationship between fall type (assisted vs. unassisted) and fall injury
Objective 1Discuss the motives for reducing falls and fall injury risk in U.S. hospitals
Financial Motives• The U.S. Centers for Medicare and
Medicaid Services
– U.S. Government Insurance for the Elderly
(Medicare) and the Poor (Medicaid)
• Care for Healthcare Acquired Conditions is not reimbursed
– Examples: Pressure Ulcers, Catheter-
Associated Urinary Tract Infections, Fall-
Related Injury, and others
• Estimated cost of care from fall-related injury is > $7,000 (AHRQ, 2013)
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html
Patient Centered Motives
• Approximately 25% of falls result in physical injury (Bouldin et al, 2013)
• Patients who experience a fall are more likely to require a longer length of stay, and are more likely to be discharged to long term care (Corsinovi et al, 2009; Dunne et al, 2014)
• Patients who fall often develop fear of falling (Deshpande et al, 2008)
Who is responsible for preventing inpatient falls?
Historically, the responsibility has fallen on nursing - National Database of
Nursing Quality Indicators
Fall prevention should be viewed as an organizational responsibility
(Jones et al, 2015)
Evidence indicates that teamsdecrease inpatient fall risk.
Fall risk has been reduced in studies where interprofessionalteam members were actively engaged in fall risk reduction efforts (Gowdy et al, 2003; von Renteln-Kruse et al, 2007)
Cohort pre-post designs
Etiology of falls is multifactorial (Oliver et al, 2004), thus falls require a multifactorial/interprofessional approach for prevention
Systematic review
Themes specific to successful implementation of fall risk reduction programs include multidisciplinary implementation and changing attitudes of nihilism (Miake-Lye et al, 2013)
Systematicreview
Does your fall risk reduction team integrate evidence from multiple disciplines to continually
improve fall risk reduction efforts?
*Negative binomial model
p=.046*
p=.01*
(Jones et. al, 2015)
6.2
1.9
4.6
1.0
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
All Falls Injurious Falls
Eve
nt
Rat
e/1
00
0 p
atie
nt
day
s
Sometimes/rarely/never (n=32) Always/Frequently (n=27)
(Jones et al, 2015)
p=.046*
p=.01*
*Negative binomial model
Objective 2Identify components of a multi-team system that can be used to reduce falls and fall injury risk
Patient/
Family
Core Team
Coordinating Team
Hospital Administration
ContingencyTeam
Multi-team System (MTS)
Two or more component teams work together toward a goal
Mathieu, Marks, & Zaccaro, 2001
http://teamstepps.ahrq.gov
Patient/
Family
Core Team
Coordinating Team
Hospital Administration
ContingencyTeam
Fall Risk Reduction MTSCore Team
• Provide direct patient care
• Diagnose and treat
• Conduct fall risk assessment
• Implement interventions that address fall risk factors
• Conduct medication review
• Evaluate mobility and functionPatient/
Family
Core Team
Coordinating Team
Hospital Administration
ContingencyTeam
Core Team
Physicians
Nurses Pharmacists
PT/OT
Fall Risk Reduction MTSCoordinating Team- Develop and implement hospital-wide policies and procedures for fall risk reduction
- Educate core team and hold them accountable for following policies and procedures
- Span status and knowledge
boundaries across
disciplines (Edmondson, 2012)
St. Francis Memorial Hospital Fall Risk Reduction Coordinating Team
Patient/
Family
Core Team
Coordinating Team
Hospital Administration
ContingencyTeam
Coordinating
TeamNurse
NursingAssistant
Pharmacist
PT/OTQuality
Improvement
Coordinator
Physician
Administrative Leader
Fall Risk Reduction MTS
Contingency Team
• Post-Fall Huddle:– Meet immediately after a fall to
determine what happened, why it happened, what will be done differently going forward
• Goals: 1. Decrease risk of future falls for an individual patient
2. Apply what is learned throughout hospital
3. Build trust and share knowledge
Patient/
Family
Core Team
CoordinatingTeam
Hospital Administration
ContingencyTeam
Objective 3Explain how the knowledge and skills of physical therapists can be integrated across components of the multi-team system
Patient/
Family
Core Team
Coordinating Team
Hospital Administration
ContingencyTeam
Common Fall Risk Factors
History of Falls
Muscle Weakness
Gait Deficits
Balance Deficits
Use of Assistive Device
Impaired ADL status
Arthritis
Visual Deficit
Depression
Cognitive Impairment
Age > 80
Polypharmacy
(American Geriatrics Society, 2001; Tinetti et al, 1986)
Falls occur when the center of mass is outside the base of support
Biomechanical Basis for Falls
How do we maintain our center of mass within our base of support?
Sensory Input
Motor Output
PTs Can Share Knowledge and Skills Throughout the MTS
PT Contribution to Decrease
Fall Risk
Biomechanical Basis of
Movement
Impact of Pathophysiology
on Movement
Impact of Physical
Impairments on Movement Interaction of
Environment and Ability to
Move
Psychometric Properties of Measurement
PT Role on Core Team
• Assess patients and provide interventions to address impairments
• Recommend and instruct in use of assistive devices
• Educate patient and family about safe mobility & environmental modifications
• Provide discharge recommendations for ongoing services
Photo Credit:work.chron..com
Photo Credit:www.clinicaladvisor.com
PT Role on Coordinating Team
Collaborate with others to:
• Develop fall risk policies and procedures
• Develop or select patient/family education materials
• Select fall risk screening tools with strong predictive validity
True Fall StatusSc
ree
nin
g Te
st
Res
ult
Faller Non-Faller
+ for FallRisk
True + False +
- for Fall Risk
False - True -
PT Role on Coordinating Team
Collaborate with others to:
• Develop strategies to document and communicate mobility and transfer status
• Design environmental modifications to rooms and public areas
• Provide staff training for safe transfers and mobility
PT Role on Contingency Team
Mobility Status
Medical Status
Environment
Cognition
Meds
Provide our unique and complementary perspective of a fall event and future prevention strategies during post-fall huddles
Objective 4Describe the relationship between fall type (assisted vs. unassisted) and fall injury
Predictors of Fall-Related Injury – Krauss et al, 2007
Based on 3,962 falls from 8 Midwestern U.S. Hospitals from 2001-2003
Predictor Odds Ratio
Unassisted Fall 1.83
Being in the Bathroom 1.46
Increased Age 1.01
“Even if fall rates remain the same, increasing
the proportion of falls that are assisted by a staff
member could help decrease injury rates.”
Predictors of Fall-Related Injury – Staggs et al, 2014
Based on 154,324 falls reported to the NDNQI in 2011
Predictor Odds Ratio
Unassisted Fall 1.59
Male Gender 1.12
Assessed for Risk 1.22
Medical Unit (vs. Surgical) 1.08
Nonteaching Hospital 1.17
Small Hospital (<300 beds) 1.08
Results from CAPTURE FallsUnassisted falls are significantly more
likely to result in injury
p = 0.021
Chi-Square
Test
Predictors of Fall-Related Injury – CAPTURE Falls
Based on 353 falls from 17 Small Rural Hospitals in 2012-2014
Predictor Odds Ratio
Unassisted Fall* 1.48
Assisted Fall without a gait belt* 3.65
Being in the Bathroom 2.48
Increased Age 2.55
*As compared to an assisted fall with a gait belt
Purpose of Gait Belts
• Control the patient’s center of mass during mobility
• Control descent if a fall occurs
• Reduce need to grab the patient's upper extremities or waistband
Gait Belt ApplicationRecommendation: Keep a gait belt in a specific place in each patient room to
make it easy to find and use.
Assisted Falls Should Not Be Viewed as a Failure
Assisted falls are less
likely to result in injury.
Staff has accurately identified
that a patient
needs help.
Staff was in the “right
place at the right time.”
A goal of preventing all falls may discourage appropriate mobilization of patients.
Staggs et al, 2014; Staggs et al, 2015
Summary
Motives for Fall and Fall Injury Risk
Reduction
Components of the Multi-team
System
Where does PT fit into the Multi-team System?
Relationship Between
Assistance and Injury
For More Information….
https://www.unmc.edu/patient-safety/capturefalls/index.html
ReferencesAHRQ. TeamSTEPPS 2.0.
http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/index.html. Accessed July 27, 2017.
Agency for Healthcare Research and Quality. Interim update on 2013 annual hospital-acquired condition rate and estimates of cost savings and deaths averted from 2010 to 2013. http://www.ahrq.gov/professionals/quality-patient-safety/pfp/interimhacrate2013.pdf. Accessed October 25, 2017.
Bouldin EL, Andresen EM, Dunton NE, et al. Falls among adult patients hospitalized in the united states: Prevalence and trends. J Patient Saf. 2013;9(1):13-17.
CAPTURE Falls. Available at: http://www.unmc.edu/patient-safety/capturefalls/. Accessed October 25, 2017.
Centers for Medicare and Medicaid Services. Hospital Acquired Conditions. Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html. Accessed October 24, 2017.
Corsinovi L, Bo M, Ricauda Aimonino N, et al. Predictors of falls and hospitalization outcomes in elderly patients admitted to an acute geriatric unit. Arch Gerontol Geriatr. 2009;49(1):142-145.
ReferencesDeshpande N, Metter EJ, Lauretani F, Bandinelli S, Guralnik J, Ferrucci
L. Activity restriction induced by fear of falling and objective and subjective measures of physical function: A prospective cohort study. J Am Geriatr Soc. 2008;56(4):615-620.
Dunne TJ, Gaboury I, Ashe MC. Falls in hospital increase length of stay regardless of degree of harm. J Eval Clin Pract. 2014;20(4):396-400.
Edmondson AC. Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy. San Francisco: John Wiley & Sons; 2012.
Gowdy M, Godfrey S. Using tools to assess and prevent inpatient falls. JtComm J Qual Saf. 2003;29(7):363-368.
Grundstrom A, Guse C, Layde P. Risk factors for falls and fall-related injuries in adults 85 years of age and older. Arch Gerontol Geriatr. 2012;54(3):421-428.
Guideline for the prevention of falls in older persons. American geriatrics society, British geriatrics society, and American academy of orthopaedic surgeons panel on falls prevention. J Am Geriatr Soc. 2001;49(5):664-672.
ReferencesJones KJ, Venema DM, Nailon R, Skinner AM, High R, Kennel V. Shifting
the paradigm: An assessment of the quality of fall risk reduction in Nebraska hospitals. J Rural Health. 2015;31:135-145.
Krauss MJ, Nguyen SL, Dunagan WC, Birge S, Costantinou E, Johnson S, Caleca B, Fraser VJ. Circumstances of patient falls and injuries in 9 hospitals in a midwestern healthcare system. Infect Control HospEpidemiol. 2007 May;28(5):544-50.
Mathieu, J. E., Marks, M. A., & Zaccaro, S. J. (2001). Multiteam systems. In N. Anderson, D. Ones, H. K. Sinangil, & C. Viswesvaran (Eds.), International handbook of work and organizational psychology (pp. 289–313). London, UK: Sage.
Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158:390-396.
Oliver D, Daly F, Martin FC, McMurdo ME. Risk factors and risk assessment tools for falls in hospital in-patients: A systematic review. Age Ageing. 2004;33:122-130
ReferencesStaggs VS, Mion LD, Shorr RI. Assisted and unassisted falls: different
events, different outcomes, different implications for quality of hospital care. Jt Comm Jrnl. 2014;40: 358-364
Staggs VS, Davidson J, Dunton N, Crosser B. Challenges in defining and categorizing falls on diverse unit types: lessons from expansion of the NDNQI Falls Indicator. J Nurs Care Qual. 2015 Apr-Jun;30(2):106-12.
Tinetti M, Williams T, Mayewski R. Fall risk index for elderly patients based on number of chronic disabilities. Am J Med. 1986;80(3):429-434.
von Renteln-Kruse W, Krause T. Incidence of in-hospital falls in geriatric patients before and after the introduction of an interdisciplinary team-based fall-prevention intervention. J Am Geriatr Soc. 2007;55(12):2068-2074.
