Fall Risk Assessment and InterventionNursing Practice Changes

and Jeff Chart Updates

Tentative Go Live Date September XX, 2012

Falls and Injury from FallsA Nursing Sensitive Indicator

The prevention of falls and injury from falls in patients who are hospitalized are indicators of high quality bedside nursing care given on a particular unit or at a hospital.

Recognizing who is at risk and implementing appropriate interventions aimed at minimizing the risk is part of professional nursing practice at TJUHs, Inc.

Why we needed a New Fall Risk ToolBackground:Morse Falls Risk Tool was not meeting our needs; screens for Fall Risk and did not assess WHY patient is at risk

It did not predict all of our falls

Some of our patients scored not at risk (< 50) experienced a fall

Often incomplete/inaccurate documentation

Jefferson Fall Risk Assessment and Intervention Tool

Goal: To improve patient outcomes (decrease falls and injury from falls) through targeted interventions based on assessment

Jefferson Fall Risk Assessment and Intervention Tool (cont)

What is different?Goes beyond screening – assesses WHY a patient

is at risk for fallNo “points”/numerical values assigned to a risk

factorIf you assess a patient to be at risk to fall due to any

risk factor – then they are at riskSupports clinical judgment and decision making –

re: selecting fall prevention interventions based on the specific risk factor(s)

TimelineSummer

2011FRG SN identified WHY their

patients fell – what put them

at risk?

Summer 2011Fall Task Force created a Fall

Risk Assessment Tool based on a literature review

and the Jefferson specific risk

factors identified by Fall Resource

Group

Fall 2011FRG SN or

designee from pilot units trialed the

assessment criteria and provided

feedback

Winter 2012 Task force identified

specific interventions to

match risk factors based on literature and best practices

Spring 2012 All units on all

campuses trialed new Fall Risk

Assessment and Intervention Tool.

Fall Interdisciplinary Committee provided

feedback.

Summer 2012

Jeff Chart Training and Education

Fall 2012

Go Live!

Fall Risk Assessment Hx of falls prior or during hospitalization Altered mobility/gait disturbancesAltered eliminationAltered balance/risk for dizzinessEquipment Altered mental status &/or behavior riskRisk of injury

Fall Prevention InterventionsSpeci

fic Fall Preventio

n Interventions

General Fall Prevention

Interventions(all pts at risk for Falls

– regardless of why)

General Safety Interventions(all pts – regardless of fall risk)

AssessmentAssess Fall Risk factors through:

Observation of patient

Interview (completion of Nursing Admission Assessment)

Review of the Physician History & Physical

Falls Tab Added to Assessments

Assessment - Complete Fall Risk Assessment in Jeff Chart.

InterventionImplement and document General Safety interventions for ALL patients.

InterventionImplement and document General Fall Prevention Interventions for ALL pts with any risk for falls

Interventions - SpecificSelect appropriate interventions based on patient risk factors and individualized assessment.

Case StudyA 35 year old female is being admitted for wheezing and shortness of breath.

PMH: Hypertension and asthmaAdmission orders include:

InhalersPrednisone 40mg POHydrochlorothiazide 12.5mg PO

What are the Falls Risk Factors for this patient?What Fall Prevention measures would you implement and document for this patient?

Fall Risk AssessmentRisk Assessment Criteria Assessment

Hx of falls prior or during hospitalization

No risk

Altered mobility/gait disturbances

No risk

Altered elimination No risk; has been on HCTZ

Altered balance/risk for dizziness No risk

Equipment

No risk

Altered mental status &/or behavior risk

No risk

Risk of injury No risk

InterventionsGeneral Safety Interventions only

Sensory items within reachCall bell within reachNon-skid footwearNight LightLevel 2 Bed Alarm at nightBed in low position/lockedPt/Family teachingHourly rounding

Case StudyAn 82 year old female was admitted 5 days ago, S/P fall athome.PMH: Hx of falls, has generalized weakness, uses cane to

ambulate, has diabetes with neuropathy in hands and feet, is HOH, and takes Coumadin for chronic atrial fibrillation

Two days ago patient spiked a fever to 101.3F and became confused; found to have a UTI

Current orders include:IV fluids Pain Medications Oxygen at 2 litersAntibiotics PT/OT consult

What are the Falls Risk Factors for this patient?What Fall Prevention measures would you implement and document for this patient?

Fall Risk Assessment Risk Assessment Criteria Assessment – from H & P,

nursing assessment, PT/OT assessment

Hx of falls prior of during hospitalization

Hx of falls

Altered mobility/gait disturbance Generalized weakness; hx of DM with neuropathy

Altered elimination Admitted for UTI

Altered balance/risk for dizziness Uses cane for balance to walk

Equipment

IV pole; Oxygen therapy

Altered mental status &/or behavior risk

Confusion; HOH; Pain medication

Risk of injury Coumadin with therapeutic INR

InterventionsGeneral Safety InterventionsGeneral Fall Prevention InterventionsSpecific Fall Prevention Interventions

Altered mobility Assist with transfers/ambulation

Altered elimination Toilet q1 hour; stay with pt.Bedside commode

Altered balance/risk for dizziness Ambulate with cane at all times

Equipment

Assist with IV pole & Oxygen tubing

Altered mental status &/or behavior risk

Room close to Nurse’s stationSelf-releasing seat belt in chair

Risk of injury Low bed

Key PointsFalls Risk Assessment and Intervention is a

professional nursing role and responsibilityComplete every shift, after a change in condition or

after a fall, and upon transfer to another unit.No “point” values are assigned to risk factorsHaving any risk factor makes the patient at risk for

fallingTailor your interventions to the patient’s

assessmentCommunicate patient’s fall risk and interventions

via handoff, huddles, IPOC, and Teletracking.

Fall Prevention is a Nurse-Sensitive Indicator of Quality

As a professional nurse providing direct care, you are in a position to make a difference in patient outcomes.

Your assessments and thoughtful planning will minimize the risks for patients at risk for falls and injury from falls