Joe P TomsicBSN, MHPA, MN

RN, ARNP, NEA-BC, PMHNP-BC© Copyright by Joseph Patrick Tomsic, 2012

All Rights Reserved

This document should guide healthcare professionals reviewing their current falls and fall injury prevention program. In no way does this document contain all possible options for developing a falls and fall injury prevention program. Do not use this document as the sole source for developing a falls and fall injury prevention program. Instead, view it as additional information for the development of a fall injury prevention program that matches the complexity of your organization. This presentation is available for use only with permission from the author. The conclusions in this outline are based on available research and represent the opinion of the author. The “Fall Prevention Intervention Workflow Wheel®” , “Fall Prevention Pillars®” and “SBAR Fall Prevention Tool®” are available for use with permission of the author only.

20-years of nursing leadership experience

◦ Board certified nurse executive-advanced and Psychiatric Mental Health Nurse Practitioner

United States Air Force, Major, Nurse Corps

◦ Psychiatric Nurse Practitioner

Education

◦ Master of Nursing, Psychiatric Nurse Practitioner

University of Washington

◦ Master of Health Policy and Administration

Washington State University

◦ Bachelor of Science in Nursing

Seattle Pacific University

Introduction Scope of the Issue Why Do Patients Fall? Sequelae from Falls Psychiatric Nurse Practitioner Role Interventions Fall Prevention Interventions Workflow Wheel Medication Interventions SBAR Risk Identification Scales Example documentation of fall risk Geriatric Considerations Recommendations

Falls rate in hospitals is between 2.2-17.1 per 1000 patient days

The healthcare facility rate is three times higher than the community

Approximately 15,000 people 65 and older die from falls each year

Patient falls result in costs of more than $20 billion a year

Second only to the medication events

The leading cause of nonfatal injuries

Leads to negative outcomes

Prolongs hospitalization

Legal liability

Still searching for an answer….

Individual (intrinsic) factors◦ Comorbidities◦ Behavioral disturbance◦ Agitation◦ Confusion◦ Vision problems◦ Delirium◦ Muscle weakness◦ Urinary incontinence◦ Impaired balance

Environmental (extrinsic) factors◦ Poor workflow design

◦ Inadequate lighting

◦ Trip hazards

◦ Faulty equipment

◦ Poorly defined processes

◦ Nursing unit design flaws

◦ Staff attitude

◦ Lack of education

Five high risk areas1) Medications

Antipsychotics

Benzodiazepines

Sedative/hypnotics

Digoxin medications

2) Orthostatic hypotension3) Poor vision4) Impaired mobility5) Unsafe behavior

Past history of a fall is the single best predictor of future falls

30% to 40% of patients who fall will do so again…

High risk nursing units◦ Psychiatric

◦ Oncology

◦ Orthopedic

◦ Neurology

◦ Geriatric units

Classifications of patient falls◦ Accidental

◦ Anticipated physiological

◦ Unanticipated physiological

Injuries occur in 15% to 50% of fallsRange: Bruises-minor injuries-severe soft tissue wounds-Skeletal fractures-Death

Patient falls account for about 65,000 hip fractures annually

Falls contribute to a 50% higher mortality

Loss of confidence, anxiety and depression, and PTSD

Approximately 1 in 10 falls will result in a serious injury

After adjusting for age◦ Fall fatality rate in can be up to 49% higher

for men

◦ Women are 67% more likely than men to have a nonfatal fall injury

The psychiatric liaison consultant has a growing role in acute care hospitals

The psychiatric nurse practitioner (PNP) is uniquely trained to lead patient fall prevention initiatives.

PNPs are trained to work with patients who are confused, agitated, delirious, demented, non-compliant, and on sedating medications

When almost all the patients are HRF, the focus needs to shift from identification to intervention

Two goals for a successful strategy ◦ Promotion of nurses’ professional knowledge and

skills in implementing a fall prevention program

◦ Cultivation of nurses’ attitudes in treating patients as their own families

Effective interventions are part of a basic universal fall program◦ Assessment of all patients for risk of falling

◦ A culture of safety

◦ Hospital protocol for those at risk of falling

◦ Enhanced communication of risk of injury from a fall

◦ Customized interventions for those at risk of injury from a fall

Hospitals successful at reducing fall rates◦ Developed a culture of safety

◦ Used fall-risk assessments

◦ Deployed multifactorial interventions

◦ Conducted post fall follow-up

◦ Involved quality improvement

◦ Integrated risk screening within the electronic medical record

The causes of falls are multifactorial◦ Intrinsic risk factors

◦ Extrinsic risk factors linked to the environment

Workflow redesign is more pressing than ever◦ Introduction of new technologies

◦ New treatment methodologies

Withdrawal or reduction of psychotropic medications

Delirium avoidance program

Reducing sedative and hypnotic medications

Supplementation with vitamin D and/or of calcium

SBAR is a form of structured communication adapted from aviation and the military

SBAR acronym◦ Situation (S; what is the situation?)◦ Background (B; what is the background

information?)◦ Assessment (A; what is your assessment of the

situation?)◦ Recommendations (R; how do you recommend the

problem be resolved?)

SBAR Fall Prevention Tool was developed J.P. Tomsic. For use with permission only.

Follow your institution’s patient fall policy e.g. notifying the falls provider and reporting patient incidents

SBAR Hand-off

Introduce yourself to the oncoming shift by name, title, and nursing unit.

Prior to change of shift complete an assessment of fall risk. Provide the oncoming care provider with the patient’s risk factors. If using bedside

reporting include the patient and family in fall risk education.

Situation: [patient] is [age] admitted on [date] with a current diagnosis of [diagnosis]. The patient’s is currently [oriented X_], [confused],

[lethargic], [Dizzy], [lightheaded], [unconscious], [seizing], or [other]. The patient is complaining of [_ out of 10 pain]. Patient with [multiple

comorbidities], [behavioral disturbance], [agitation or confusion], [vision problems], [delirium], [muscle weakness], [urinary incontinence],

[impaired balance]. Physically check bed alarm is on and functioning with ongoing shift.

Background: [patient name], [level of activity]. The patient [does] or [does not] have a history of falls. The patient [does] or [does not] have a

history of seizures. The patient [does] or [does not] have a history of orthostatic hypotension. The patient [does] or [does not] has a history of

behavior such as [throwing himself onto the floor] or [other]. The [patient] [does] or [does not] have a history of [dizziness], [lightheaded],

[confused], [agitation], [seizures] or [anything else] that may contributed to the fall risk. The patient’s last Fall Risk Scale score was [number].

Assessment: Patient is not responding to redirection or [state interventions] and has made ___ exits attempts in the past ___ hours. The

patient is at risk due to use of [antipsychotics], [benzodiazepines], [sedative/hypnotics], [digoxin] [orthostatic hypotension], [poor vision],

[impaired mobility], [unsafe behavior]. Patient with behavioral disturbance as evidenced by [agitation], [confusion]. Patient with vision

problems and glasses are [on],[at bedside], [remind family to bring in]. Patient currently be treated for [delirium], [ETOH/Opiate withdrawal].

Ambulation impaired due to [muscle weakness], [impaired balance ]. Provide frequent toileting due to [urinary incontinence], [diarrhea].

Recommendations: Additional orders [Medication change], [1:1 observation], [restraints], [enclosure bed] or [other]. Nursing interventions

[move closer to nursing station], [bed exit alarm], or [other]

SBAR Fall Prevention Tool was developed J.P. Tomsic. For use with permission only.

Follow your institution’s patient fall policy e.g. notifying the falls provider and reporting patient incidents

SBAR After a Fall

Introduce yourself to the provider by name, title, and nursing unit.

Provide lifesaving care if the patient is in acute distress or rapidly deteriorating call a code and get help! Complete an assessment (do not move

if injured) and provide the provider with the patient’s condition.

Situation: [patient] fell on [date] at [time]. [he/ she] is [age] admitted on [date] with a current diagnosis of [diagnosis]. The patient’s is currently

[oriented X_], [confused], [lethargic], [Dizzy], [lightheaded], [unconscious], [seizing], or [other]. The patient is complaining of [_ out of 10 pain],

or appears to be in pain as evidenced by [overt signs of pain such as grimacing, moaning, guarding]. Additional items to report: The patient

currently has [chest pain], [difficulty breathing], [numbness], [suspect a c-spine injury] or [other]. Current vital signs (including pulse oximetry)

are [state].

Background: [patient name], [level of activity]. The patient [does] or [does not] have a history of falls. The patient [does] or [does not] have a

history of seizures. The patient [does] or [does not] have a history of orthostatic hypotension. The patient [does] or [does not] has a history of

behavior such as [throwing himself onto the floor] or [other]. The [patient] [does] or [does not] have a history of [dizziness], [lightheaded],

[confused], [agitation], [seizures] or [anything else] that may contributed to the fall risk. The patient’s last Fall Risk Scale score was [number].

Assessment: Condition is at [baseline] or [has changed]. The patient [does] or [does not] appear to have an injury. The patient appears to have

sustained a [head injury] as indicated by [overt signs such as cuts, abrasion, bump, or swelling on the head], [visual changes] or [headache] from

the fall. The patient appears to have sustained a [possible fracture] AEB [location of deformity or swelling] or difficulty moving, [LLE, RLE, LUE,

RLE etc.] from the fall. The patient appears to have sustained a [neck injury] AEB [numbness] to [extremity]. The patient has a [bruise],

[scratch], [hematoma], [laceration] [superficial wound] on [location]. The injury appears to be [mild], [moderate], [severe].

Recommendations: recommend [provider assessment], [pain medication], [X-ray], [transfer, emergency room] or [other]. The patient is

requesting [pain medication], [anxiety medication], or [other].

A fall-risk assessment is required to meet the Joint Commission standards

Commonly used fall-risk assessments◦ Morse Fall Scale (MultiCare Health System)

◦ Hendrich Falls Risk Model II

◦ Edmonson Psychiatric Fall Risk Assessment Tool (Memorial Hospital in Illinois)

◦ The Conley Scale

◦ Tinetti Balance Assessment Tool (Western State Hospital)

◦ The Johns Hopkins Fall Risk Assessment Tool (UW Medical Center)

Risk Factors Edmonson

The Johns Hopkins

Fall Risk Assessment

Tool

The Conley Scale Morse Falls Scale TinettiHendrich II Fall Risk

Model

Psychiatric

Assessment

Risk Assessment

Questions?No

Yes

(Low Risk if complete

paralysis immobilized,

High risk if history of >

one fall within 6

months or fall during

hospitization)

No

Yes

(IV or IV Access is 25

points)

No No Past Medical History

Age? Yes Yes No No No NoIdentifying

Information

Mental Status or

Cognition?Yes

Yes

(cognition)

Yes

(Orientation,

Agitation, Impaired

Judgement)

Yes

(oriented abulation

ability and limitations)

No

Yes

(confusion,

disorientation,

impulsivity,

depression)

Mental Status

Examination

Altered Elimination? Yes Yes

Yes

(Bathroom in a hurry,

wet or soil self on way

to bathroom, up at

night to use BR)

No No Yes Past Medical History

Medications? Yes Yes No No No

Yes

(antiepileptics,

Benzodiazepines)

Past Medical and

Psychiatric History

Diagnosis? Yes No No Yes No No Multiaxial Diagnosis

Ambulation and

Balance?Yes

Yes

(mobility)

Yes

(difficulty getting out

of bed or chair, Using

supports, weak)

Yes

(Gait)

Yes

(various maneuvers

that takes 8-10

minutes to complete

and requires training)

Yes

(get and go test)

Mental Status

Examination

Screening for

abnormal movement

and gait

Nutrition? Yes No No No No NoScreening for

depression

Sleep Disturbance? Yes No No No No No

Screening for various

psychiatric diagnosis

depression and

bipolar

History of Falls? Yes YesYes

(last 3-months)Yes No No Past Medical History

Psychiatric professionals can accomplish a fall risk assessment with every intake simply by increasing their awareness of the items included in a falls risk assessment

Example questions◦ “Have you had any falls in the past 6-months or

during the hospitalization?”◦ “Are you having any issues going to the bathroom

such as urgency or getting up at night?”

The most common cause of accidental death amount older adults

5th leading cause of older adult death◦ Seniors older than 80 years are most likely

to be injured

Older adults with mental illness are at increased risk for both falls and subsequent fractures

Patients do not generally regain pre-injury levels of physical functioning

Seniors with mild Alzheimer's may not adapt mobility behavior to match cognitive and physical impairments

Frontal lobe dysfunction◦ Disinhibition of behavior

◦ Poor judgment

◦ Movement disorders

Develop a delirium avoidance program as a key intervention

Use a risk screening tool but consider also rank ordering patients by fall risk◦ Consider a parallel process to rank order

patients by degree of falls risk in addition to the hospital-wide falls risk assessment scale

Involve the psychiatric liaison team◦ Add fall risk screening to psychiatric

intakes

◦ Add fear of falling to the multiaxial assessment

◦ Review medications for all HRF patients

◦ Develop a process to review all patient falls within 24-hours

Develop chart audit processes

Develop realistic training including role playing and hands-on training

Track the cost of falls and use this information to calculate the return on investment for new equipment, staff education or items such as electronic incident reporting

Apply Lean principles to any fall prevention program

Incorporate fall prevention interventions into the nurse’s workflow

Implement bedside change of shift handoff communication

◦Use standardized communication

Place patients in the High Risk for Falls (HRF) subgroup on bed alarms or document the reason why a bed alarm is not appropriate◦ Develop a standard algorithm for bed-exit

monitoring◦ Monitor time from bed-exit alarm to staff

response

Add bed-exit attempts to the RN to RN and charge nurse report

Place patients at the “highest” HRF next to nursing station

Also consider non-HRF patient rooms e.g. rooms too far from nursing station to quickly respond

Review patient fall data to determine each unit’s “Fall Safe Zones”◦ Chart audit results often substantiate safer rooms

◦ Conduct a “Safety Reshuffle” q shift

Track close calls e.g. HRF patient self ambulates to bathroom

Develop visual tools◦ Strategically located

List “Priority High Risk to Fall“ patients

Risk for current shift

Patient on alarms

Alarm standards

Patients with communication issues

More

Develop process to make “Fall Safe Patient Assignments”◦ Ensure that nursing assignments are

acuity neutral so nurses have time to frequently check patients.

◦ Develop process for nursing staff input on falls risk acuity, falls risk and bed alarm data to build an overall risk profile for patients each shift

Develop fall risk hand-off communication process◦ Awareness of patients with bed alarms◦ Nurses share falls risk for the oncoming shift◦ Standardized interventions for patients at the

highest risk for falling

Have the charge nurse read the names of each “Priority High Risk to Fall”, High Risk to Falls with bed alarm as part of a 2-minute overview

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