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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