Focus on Falls The importance of vision in preventing falls.
Preventing falls - Fall TIPS
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8 American Nurse Today Volume 13, Number 9 AmericanNurseToday.com ETHAN LARSEN*, age 86, is admitted to the hospital for decompensated heart failure. He lives with his wife in senior housing and has a 3-year history of heart failure, which is treated with captopril and furose- mide. He also has a history of type 2 diabetes, which has been controlled with metformin. On admission, Mr. Larsen’s nurse, Virginia (one of the authors of this article) completes a fall risk assessment. Mr. Larsen tells Virginia that he hasn’t had any re- cent falls, he’s independent at home, and if he has his walker he won’t need help getting to the bathroom in the hospital. Virginia assesses Mr. Larsen’s gait by asking him to walk across the room with his walker. She notes that his gait is unsteady and that he needs to stop several times to catch his breath. Mr. Larsen’s wife tells Virginia that her husband is very weak and has fallen several times at home in the past month, most recently last night. She says that her husband frequently falls at night when get- ting up to go to the bathroom. Based on the admission assess- ment, Virginia determines that Mr. Larsen is at high risk for physiologi- cal falls. In addition to universal fall precautions, which are applied to every patient, Mr. Larsen requires a tailored intervention plan to pre- vent falls related to his medical con- dition while he’s in the hospital. Falls are the most common cause of accidental injury and death in older people. They’re common in hospital settings—about 3% of hos- pitalized patients fall and about 25% of patients who fall sustain an injury, which can range from minor bruises to serious injuries such as fractures and subdural hematomas. Preventing falls in hospitalized patients Engage patients and families in a three-step prevention process to reduce the risk of falls. By Patricia C. Dykes, PhD, RN; Jason Adelman, MD; Lesley Adkison, PhD, RN; Michael Bogaisky, MD; Diane L. Carroll, PhD, RN; Eileen Carter, PhD, RN; Megan Duckworth, BA; Lisa Herlihy, MSN; Ann C. Hurley, DNSc, RN; Srijesa Khasnabish, BA; Susan Kurian, RN; Mary Ellen Lindros, PhD, RN; Kristen F. Marsh, MPA, RN; Thanyanee McNinney, BSN, RN; Virginia Ryan, MSN, RN; Maureen Scanlan, MSN, RN; Linda Spivack, PhD, RN; Alexa Shelley, RN, FNP; Shao Ping Yu, MPH L EARNING OBJECTIVES 1. Identify risk factors for falls in hospi- talized patients. 2. Describe how to screen and assess patients for falls risk. 3. Discuss a three-step process for falls prevention. The authors and planners of this CNE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this ac- tivity. See the last page of the article to learn how to earn CNE credit. Expiration: 9/1/21 CNE 1.58 contact hours
Transcript of Preventing falls - Fall TIPS
8 American Nurse Today Volume 13, Number 9 AmericanNurseToday.com
ETHAN LARSEN*, age 86, is admittedto the hospital for decompensatedheart failure. He lives with his wifein senior housing and has a 3-yearhistory of heart failure, which istreated with captopril and furose -mide. He also has a history of type 2diabetes, which has been controlledwith metformin. On admission, Mr.Larsen’s nurse, Virginia (one of theauthors of this article) completes afall risk assessment. Mr. Larsen tellsVirginia that he hasn’t had any re-cent falls, he’s independent at home,and if he has his walker he won’tneed help getting to the bathroom inthe hospital. Virginia assesses Mr.Larsen’s gait by asking him to walkacross the room with his walker. Shenotes that his gait is unsteady andthat he needs to stop several times tocatch his breath.
Mr. Larsen’s wife tells Virginiathat her husband is very weak andhas fallen several times at home inthe past month, most recently last
night. She says that her husbandfrequently falls at night when get-ting up to go to the bathroom.
Based on the admission assess-ment, Virginia determines that Mr.Larsen is at high risk for physiologi-cal falls. In addition to universalfall precautions, which are appliedto every patient, Mr. Larsen requiresa tailored intervention plan to pre-vent falls related to his medical con-dition while he’s in the hospital.
Falls are the most common causeof accidental injury and death inolder people. They’re common inhospital settings—about 3% of hos-pitalized patients fall and about25% of patients who fall sustain aninjury, which can range from minorbruises to serious injuries such asfractures and subdural hemato mas.
Preventing falls in hospitalized patientsEngage patients and families in a three-step prevention process to reduce the risk of falls.
By Patricia C. Dykes, PhD, RN; Jason Adelman, MD; Lesley Adkison, PhD, RN; Michael Bogaisky, MD; Diane L. Carroll, PhD, RN; Eileen Carter, PhD, RN; Megan Duckworth, BA; Lisa Herlihy, MSN; Ann C. Hurley, DNSc, RN; Srijesa Khasnabish,
BA; Susan Kurian, RN; Mary Ellen Lindros, PhD, RN; Kristen F. Marsh, MPA, RN; Thanyanee McNinney, BSN, RN; VirginiaRyan, MSN, RN; Maureen Scanlan, MSN, RN; Linda Spivack, PhD, RN; Alexa Shelley, RN, FNP; Shao Ping Yu, MPH
LEARNING OBJECTIVES
1. Identify risk factors for falls in hospi-talized patients.
2. Describe how to screen and assesspatients for falls risk.
3. Discuss a three-step process for fallsprevention.
The authors and planners of this CNE activity havedisclosed no relevant financial relationships withany commercial companies pertaining to this ac-tivity. See the last page of the article to learn howto earn CNE credit.
Expiration: 9/1/21
CNE1.58 contact
hours
AmericanNurseToday.com September 2018 American Nurse Today 9
Fall-related injuries lead to prolongedhospital stays for treatment (on av-erage, 6 to 12 additional days in thehospital), surgery, and sometimeseven death. Patients who aren’tphysically injured from a fall maydevelop a fear of falling, leading todecreased mobility and increased fallrisk. The risk for falls increases withage, and fall rates are highest ongeriatric and gero psychiatric units.
Types of fallsThe three falls categories are acci-dental falls, anticipated physiologi-cal falls, and unanticipated physi-ological falls. Accidental falls areprevented through universal fallprecautions that are applied to allpatients: keep pathways clear, wipeup spills, make sure patients haveaccess to their call light, and provideambulatory patients with nonskidfootwear. Anticipated physiologi-cal falls are caused by underlyingmedical problems or symptoms.They’re prevented by engaging thepatient and family in the three-stepfall prevention process. (See 3 stepsto fall prevention.) Unanticipatedphysiological falls are caused byan underlying medical or physio-logical problem that hasn’t beendiagnosed and so isn’t addressedby the fall prevention plan. An ex-ample would be a patient withouta history of a seizure disorder whofalls after she has her first seizurewhile walking down the hall witha nurse. Because the patient didn’thave a history of seizures, onecould argue that this fall couldn’thave been prevented. However,the seizure disorder is now a knownphysiological problem in this pa-tient, whose care plan is updatedto prevent a similar fall. Any addi-tional falls related to a seizure inthis patient would be classified asanticipated physiological falls.
Risk factorsMost patient falls are caused by acombination of factors. The follow-ing fall risk factors for hospitalized
patients are well established:• Previous fall history: Patients who
have fallen recently are more like-ly to fall again and under similarcircumstances unless the factorsthat led to the fall are addressed.
• Gait instability and lower-limbweakness: Gait problems andlower-limb weakness can stemfrom physical illness, decondi-tioning from periods of inactivi-ty, and age-related changes ingait and balance. Lack of accessto walking aids, bedrest, andlimited activity during hospital-ization can exacerbate theseproblems.
• Urinary incontinence, frequency,and/or the need for toileting:Medications and I.V. fluids givenduring an acute hospitalizationcan increase urinary urgency andthe need for frequent toileting.To avoid incontinence, patientsmay get up quickly or ambulatewithout a walking aid/assistance,resulting in a fall.
• Agitation, confusion, or impairedjudgment: Patients who are agi-tated or confused are at risk of
falling out of bed or getting upwithout assistance. However,even patients who are alert andoriented may overestimate theirabilities, not realizing that they’reat risk for falls.
• Medications, especially sedativehypnotics: Hospitalized patientsoften receive medications that maybe new or given in addition to themedications they take at home.Medication side effects may causedizziness, unsteadiness, posturalhypotension, and urinary urgency,increasing fall risk.
Risk factors for fall-relatedinjuryMany studies have identified therisk factors for falls in hospitalizedpatients and many fall predictionscreening tools exist. However, rel-atively few studies have focusedon developing tools to identify pa-tients at risk for fall-related injury.Through its national TransformingCare at the Bedside (TCAB) pro-gram, which ran from 2003 to 2008,the Robert Wood Johnson Founda-tion, in collaboration with the Insti-
3 steps to fall prevention Physiological falls caused by medical problems and symptoms can be prevented whenpatients and their families are engaged in this three-step process.
3 steps to fall prevention
3. Consistent preventative interventions • Universal precautions • Tailored interventions to address patient-specific areas of risk
2. Tailored/personalized care planning
1. Fall risk screening/assessment
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tute for Healthcare Improvement,supported nurses in developing,testing, and implementing changesto improve care on medical-surgicalunits. Through this effort, the ABCSFall Injury Risk screening tool wasdeveloped to help bedside nursesscreen for the following causes offall-related injury: • A = Age or frailty: Patients age
85 and older, especially thosewho are frail, are at increasedrisk for injury if they fall.
• B = Bones: Patients who haveosteoporosis or have had a re-cent fracture are more likely tosustain a fracture if they fall.
• C = anti-Coagulation: Patientswith a bleeding disorder or whoare taking anticoagulants aremore likely to sustain a bleedinginjury if they fall.
• S = Surgery: Patients who haveundergone recent surgery (dur-ing the current episode of care)are more likely to be injured ifthey fall.
Evidence-based fall preventionResearch suggests that patient andfamily engagement in the three-stepfall prevention process is critical.Many hospitalized patients fall be-cause they don’t believe that they’reat risk and they don’t follow theirfall prevention plan. This is espe-cially true for patients who are in-dependent at home and don’t seethemselves as vulnerable to a fallin the hospital. Involving the pa-tient and family in completing thefall risk assessment helps them un-derstand their personal risk factors;including patients in developing a personalized prevention planmakes them more likely to acceptand follow it. In addition, inform-ing patients of their risk for injuryif they fall increases the likelihoodthat they’ll follow their plan.
Step 1: Fall risk screening andassessmentFall risk screening should be doneat every patient admission and with
each status change, which in acute-care settings may require screeningevery day or even every shift. Theoriginal intent of most screeningtools was to predict which patientsare likely to fall due to physiologi-cal problems or symptoms. Howev-er, the tools’ predictive capacity isdifficult to measure because once apatient is screened and fall risk fac-tors are identified, not putting pre-ventive interventions in place isunethical. Once interventions areimplemented, if the patient doesn’tfall, knowing whether the screen-ing tool was inaccurate or not usedcorrectly, or whether the interven-tions were effective isn’t clear. Thesame is true if the patient does fall:Was the screening tool inaccurateor were the interventions ineffectiveor not followed?
Dr. David Oliver, fall preventionexpert and author of the STRATIFYfall risk assessment tool, has sug-gested that rather than using fallscreening tools solely for predic-
tion, they should be used as thebasis for additional assessment andproactive fall prevention planning.Used this way, you can completethe screening on admission andthen develop the initial fall preven-tion plan to address each area ofidentified risk. During the patient’shospitalization, the nursing assess-ment is used to continuously refinethe plan. Because a fall preventionplan should be implemented assoon as possible after patient ad-mission, a comprehensive riskscreening tool that addresses all thecommon actionable risk factors forfalls is needed. (See Screening tools.)
Step 2: Tailored fall preventioncare planningAfter completing the fall risk screen-ing, collaborate with the patientand family to develop a personal-ized plan to address each identi-fied risk factor. (See Tailored pre-vention.) A common mistake isprescribing interventions based on
The initial fall risk screening forms the basis for additional assessment and careplanning, so use a tool that addresses all of the common predictors and includesonly actionable items that can be implemented in the prevention plan. The fol-lowing fall risk screening scales were developed for use with hospitalized patientsand are in the public domain (no fee charged for use).
Screening tools
Source: Oliver 2004.
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a patient’s level of fall risk (low,medium, or high), rather than tai-loring interventions based on pa-tient-specific risk factors. For exam-ple, patients who are at risk forfalls because of a gait disturbancerequire different interventions thanpatients who have a cognitive im-pairment.
Note that bed and chair alarmsshould be used only for patientswho are confused or who will notreliably call for help. Research indi-cates that alarms are ineffective atpreventing falls in patients whodon’t have a positive mental statusrisk factor and serve only to con-tribute noise to the environment.
Step 3: Consistently carryingout the fall prevention planConsistent implementation of thefall prevention plan requires com-municating the patient’s risk factorsand plan to the healthcare team(including the patient and family).Direct-care team members, such asnurses and patient care assistants,reinforce the plan with the patientand notify you of any change inthe patient’s risk status. You thenreassess the patient and update theplan as needed.
Strategies and tools to integratethe patient’s fall prevention plan intothe workflow at the bedside improvethe likelihood that the plan will be
followed. The Fall TIPS (Tailoring In-terventions for Patient Safety) Toolkitdeveloped by the Fall TIPS Collabo-rative can be used to engage pa-tients and family members in thethree-step fall prevention processand communicate and reinforce thefall prevention plan at the bedside.(See The Fall TIPS Collaborative.)
Mr. Larsen is hospitalized atBrigham and Women’s Hospital inBoston, where the Fall TIPS Toolkitis used to engage patients and fam-ilies in the three-step fall preven-tion process. While Mrs. Larsen isvisiting, Virginia brings the lami-nated Fall TIPS poster to the bed-side. On the left-hand side is theMorse Fall Scale risk assessmenttranslated with icons; on the rightare validated interventions, alsoreinforced with icons. The colorprovides clinical decision supportthat links each area of risk to thecorresponding evidence-based in-terventions. While discussing hisrecent falls with Virginia and hiswife, Mr. Larsen says that his legssometimes get weak when he’swalking to the bathroom at nightand then “give out.” Virginia ex-plains that patients who have a his-tory of falls are much more likelyto fall again unless a preventionplan is developed. They agree thatMr. Larsen should call for help toget out of bed and to use the bath-room. They also agree to keep thebed alarm on to remind Mr. Larsento call before getting up because heoverestimates his abilities and willlikely not call for assistance.
They also discuss that the fu ro -se mide Mr. Larson is taking for hisheart failure will make him urinatefrequently. Mr. Larsen and Virginiaagree that she or someone from theteam will assist him to the bathroomevery hour. Virginia explains to Mr.Larsen that she’s noticed that his walkis unsteady and that he should al-ways use his walker (along with staffassistance) when getting out of bed.
Virginia reinforces Mr. Larsen’s
Tailor your interventions to identified risk factors, not risk level, and workcollaboratively with the patient and family to help ensure understanding of theprevention plan.
Significant predictors of falls Tailored interventions
Previous fall history • Document circumstances of previous fall • Implement tailored interventions to prevent a similar fall
Gait instability/ • Nonskid footwearlower-limb weakness • Assistive devices • Physical therapy • Assistance getting out of bed and with ambulation • Avoid bedrest
Urinary incontinence, • Hourly roundingfrequency, and/or the • Toileting scheduleneed for toileting • Incontinence briefs
Agitation, confusion, • Frequent rounding/surveillance planor impaired judgment • Activity schedule • Continuous virtual monitoring • Bed/chair alarms • Floor mats to reduce trauma from bed-related falls • Assess for alcohol or drug withdrawal and place on appropriate protocol • Rule out delirium
Medications, especially • Consult pharmacist about medicationssedative hypnotics • Assess for/treat orthostatic hypotension (adequate fluid intake, slow position changes, compression stockings) • Assess for medication side effects (sedation, dizziness, lightheadedness, unsteadiness) and develop management plan • Avoid hypnotics
Tailored prevention
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personal fall risk factors and the pre-vention plan and explains that be-cause of Mr. Larsen’s age he’s athigh risk for injury if he does fall.She then hangs the Fall TIPS Toolkitlaminated poster on the wall next tohis bed and explains that the posterwill remind Mr. Larsen, his family,and all hospital staff about his fallrisk factors and his personal fall pre-vention plan to help ensure that hedoesn’t fall while he’s in the hospital.
Nurses’ role in fall preventionMost nurses routinely complete thefall risk assessment and develop afall prevention plan for all patients,but engaging patients and familiesin the three-step process representsa practice change for many nurses.Supporting nurses in this practicechange requires education aboutthe evidence behind patient en-gagement, ongoing monitoring to
evaluate the practice change, peer-to-peer feedback and coaching, andleadership backing.
*Patient names are fictitious.
Patricia C. Dykes is a senior nurse scientist and pro-gram director for research at Brigham and Women’sHospital Center for Patient Safety Research andPractice and an associate professor at Harvard Med-ical School in Boston. Jason Adelman is the chief pa-tient safety office, associate chief quality officer, anddirector of patient safety research at New York–Pres-byterian Hospital/Columbia University Medical Cen-ter in New York. Lesley Adkison is the nursing prac-tice innovation leader at Newton–Wellesley Hospitalin Newton, Massachusetts. Michael Bogaisky is ahospitalist, clinical educator, and assistant professorat Montefiore Medical Center in Bronx, New York. Di-ane L. Carroll is nurse specialist in the Yvonne L.Munn Center for Nursing Research at MassachusettsGeneral Hospital in Boston. Eileen Carter is a nurseresearcher at New York–Presbyterian Hospital andassistant professor of nursing at Columbia UniversityMedical Center in New York. Megan Duckworth is aresearch assistant at Brigham and Women’s Hospital.
Lisa Herlihy is a senior nurse scientist at Brigham andWomen’s Hospital. Ann C. Hurley is a nurse scientist atBrigham and Women’s Hospital. Srijesa Khasnabish isa research assistant Brigham and Women’s Hospital.Susan Kurian is assistant director of nursing qualityat Montefiore Medical Center. Mary Ellen Lindros isthe director of professional practice and nursingquality officer at Montefiore Medical Center and TheUniversity Hospital for the Albert Einstein College ofMedicine. Kristen F. Marsh is a patient care director atNew York–Presbyterian Medical Center. ThanyaneeMcNinney is a senior staff nurse at New York–Presby-terian Medical Center on the Bone Marrow and StemCell Transplant Unit. Virginia Ryan is a clinical nurseat Brigham and Women’s Faulkner Hospital in Boston.Maureen Scanlan is vice president of nursing and pa-tient care services for Montefiore Health System.Linda Spivack is assistant vice president/clinical di-rector of nursing at Montefiore Medical Center. AlexaShelley is a clinical project coordinator at New YorkPresbyterian Medical Center. Shao Ping Yu is qualityand patient safety project manager at New York–Presbyterian Hospital.
Visit americannursetoday.com/?p=50110 for alist of references.
The Fall TIPS CollaborativeBrigham and Women’s Hospital in Boston and Montefiore Medical Center and New York–Presbyterian in New York have formed a Fall TIPS Col-laborative to spread the Fall TIPS Toolkit and ensure that all patients have access to evidence-based fall prevention care. The toolkit includes thislaminated poster that can be used to engage patients at the bedside. For more information, go to the Fall TIPS Website (FallTIPS.org) or emailthe Fall TIPS team at [email protected].
Encourage your nursing leadership to join the Fall TIPS Collaborative to receive the toolkit, training, and implementation materials. There’s no costto join the collaborative, but participating hospitals are asked to submit monthly deidentified data related to patient engagement in the three-step fall prevention process, patient falls, and fall-related injuries. For more information, email the Fall TIPS team at [email protected].
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Please mark the correct answer online.
1. The percentage of hospitalizedpatients who sustain an injury when theyfall is about
a. 3%.b. 15%.c. 25%.d. 33%.
2. Fall-related injuries lead to longerhospital stays for treatment. The averagenumber of additional days is
a. 1 to 3.b. 4 to 8.c. 6 to 12.d. 13 to 15.
3. An example of an unanticipatedphysiological fall is
a. a 46-year-old woman who falls whenshe reaches too far for the TV remote.
b. a 53-year-old man with a diagnosis ofsevere bradycardia who falls.
c. a 64-year-old woman who slips on apatch of spilled water on the floor.
d. a 78-year-old man who is diagnosedwith hypotension after he falls.
4. An example of an accidental fall is a. a 68-year-old woman with urinary
urgency who falls on her way to thebathroom.
b. a 37-year-old woman wearing smooth-soled footwear who slips on a floorand falls.
c. a 77-year-old man with chronicdementia who falls while in thehospital.
d. a 56-year-old man who is diagnosedwith epilepsy after he has a seizureand falls.
5. Gait instability can result from all ofthe following except
a. use of a walking aid.b. physical illness. c. deconditioning from periods of
inactivity.d. age-related changes in balance.
6. Which statement about risk factors forfalls in hospitalized patients is correct?
a. Patients who receive I.V. fluids are lesslikely to ambulate without assistance.
b. Patients who are alert and orientedmay underestimate their mobilityabilities.
c. Patients who have fallen recently areless likely to fall again.
d. Patients who have fallen recently aremore likely to fall again.
7. In the ABCS Fall Injury Risk Screeningtool, the C stands for
a. comprehension.b. confusion.c. cancer.d. anti-coagulation.
8. Which of the following screening toolsdoes not assess medication?
a. Smith Fall Scaleb. Morse Fall Scalec. STRATIFY Fall Risk Assessment Toold. Schmid Fall Risk Assessment Tool
9. Your 74-year-old patient has ad-vanced Alzheimer’s disease. An interven-tion that is targeted toward him is
a. bedrest.b. floor mats.c. incontinence briefs. d. toileting schedule.
10. Which patient is a candidate for bedand chair alarms?
a. A man suffering from confusionpostoperatively
b. A woman with moderate Parkinson’sdisease
c. A teenager just started on fluoxetinefor anxiety
d. An 80-year-old man with urinaryincontinence
11. Which statement about the steps ofthe falls prevention process is correct?
a. Patient and family participation in thethree-step process will improvesuccess.
b. Patient and family participation in thethree-step process is optional.
c. The two-step process consists of fallrisk screening and assessment andtailored fall prevention care.
d. The two-step process consists oftailored fall prevention care planningand consistently carrying out the fallprevention plan.
POST-TEST • Preventing falls in hospitalized patients Earn contact hour credit online at americannursetoday.com/article-type/continuing-education/
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ANA Center for Continuing Education and Professional Devel-opment’s accredited provider status refers only to CNE activitiesand does not imply that there is real or implied endorsement ofany product, service, or company referred to in this activity norof any company subsidizing costs related to the activity. Theauthor and planners of this CNE activity have disclosed no rele-vant financial relationships with any commercial companiespertaining to this CNE. See the banner at the top of this pageto learn how to earn CNE credit.
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