PLS 1302 Fall Prevention LAG MF (1)

Lea Anne Gardner, PhD, RN

Senior Patient Safety Analyst

Pennsylvania Patient Safety Authority

Michelle Feil, MSN, RN



NPSF Professional Learning Series presents:

February 28, 2013

Falls: Risk Assessment, Prevention,

and Measurement

NPSF Professional Learning Series

2

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This webinar activity has been planned and implemented in accordance with the Essential Areas

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joint sponsorship of The Doctors Company and the National Patient Safety Foundation (NPSF).

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4

Disclosure

Faculty Disclosure

Lea Anne Gardner and Michelle Feil have disclosed no relevant, real or

apparent personal or professional financial relationships.

Acknowledgement of Commercial Support

There was no commercial support received for this CME activity.


5

Learning Objectives

Identify evidence-based fall risk assessment tools used in inpatient and outpatient settings.

Describe how pairing fall risk assessment with mobility tests and injury risk assessment may further contribute to decreased falls and falls with injury.

Plan a standardized approach to implementing evidence-based prevention strategies for patients identified at risk to fall, targeted to identified risk factors.

Outline methods for measuring processes and outcomes related to inpatient and outpatient falls.

Lea Anne Gardner, PhD, RN



Michelle Feil, MSN, RN



NPSF Professional Learning Series presents:

February 28, 2013

Falls: Risk Assessment, Prevention,

and Measurement


7

Falls Risk Assessment: A Foundational Element of Falls Prevention Programs

http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2012/Sep;9(3)/P

ages/73.aspx


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Best Practices in

Falls Risk Assessment


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Risk Assessment


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I think that we have to be constantly asking ourselves, 'How do we calculate the risk?' And sometimes we don't

calculate it correctly; we either overstate it or understate

it. Hillary Clinton

Risk Assessment


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Assess patients for their falls risk: On admission

Upon transfer from one unit to another

With any status change

Following a fall

At regular intervals

In other words

Perform Risk Assessment, Re-Assessment and

Postfall Assessment



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Joint Commission

2005 National Patient Safety Goal reduce the risk of patient harm resulting from falls Initial assessment of falls risk

Periodic reassessments

2010 incorporated as a standard with two elements of performance Assess and manage the patients risks for falls

Implement interventions to reduce falls based on the patients assessed risk


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Joint Commission, contd.

0

100

200

300

400

Falls by root cause

Root Cause Information for Falls-related Events Reviewed by The Joint Commission

(Resulting in death or permanent loss of function) 2004 1Q 2012 (N=477)

The majority of events have multiple root causes

Assessment

Leadership

Communication

Human Factors

Physical Environment

Care Planning

Information Management

Continuum of Care

Patient Education


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Risk Assessment Tools Risk assessment tools by themselves do not prevent

patient falls - they predict them

Sensitivity The ability of the tool to identify positive results A high score identifies most of the patients who go on to fall

Specificity The ability of the tool to identify negative results A low score identifies most of the patients who do not go on to fall


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Risk Assessment Tools Whats the Evidence?

Sensitivity and specificity can vary greatly between tools

Risk assessment tools with high sensitivity and specificity assess: Gait instability

Lower extremity weakness

Agitated confusion

Urinary incontinence/frequency

Falls history

Prescription of culprit drugs (especially sedative/hypnotics)


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Morse

Hendrich I & II

STRATIFY

Johns Hopkins

Conley

Innes

Downton

Tinetti

Schmid

Risk Assessment Tools Whats Out There?


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Falls Risk Assessment Tools COMPARISON OF VARIABLES ASSESSED BY FALL RISK ASSESSMENT TOOLS

MORSE HENDRICH II JOHNS HOPKINS

History of falls X X

Gait instability X X X

Lower extremity weakness

Altered mental status X X X

Altered elimination X X

High risk medications X X

Secondary diagnosis X

Ambulatory aid X X

IV/heparin lock X

Dizziness/vertigo X X

Depression X

Male gender X

Advanced age X

Automatic low or high risk triggers X

SENSITIVITY 78 74.9 Not tested

SPECIFICITY 83 73.9 Not tested


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Pediatric Risk Assessment Tools

Pediatric Falls Risk Assessment Tools Schmid Little Schmidy

CHAMPS

General Risk Assessment for Pediatric

Inpatient Falls (GRAF PIF)

Humpty Dumpty

IM SAFE

http://www.ajj.com/services/pblshng/pnj/ce/2011/article35227231.pdf


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Outpatient Risk Assessment Tools

History of falls

Get Up and Go

Timed Get Up and Go


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Risk Assessment Tools

Each hospital should test for internal validity

A good tool would have limited false negatives

These tools may be paired with A mobility test (Get Up and Go)

Injury risk assessment (ABCs)


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Mobility Tests

Timed Up and Go (TUG) Observe patient rise from a chair,

ambulate three meters, turn, return

to the chair, and sit

Greater than 14 seconds predicts falls (sensitivity and specificity

greater than 87%)


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Mobility Tests

Get Up and Go Similar test, longer in length

Hendrich II includes one element from Get Up and Go: observing a patient rise from a chair with

hands on the thighs Rises in single attempt but must use hands to push up

[Odds Ratio (OR) for falling = 2.16]

Uses hands, requires multiple attempts (OR = 4.67)

Unable to rise (OR = 10.06)


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Assessing Risk of Injury

Use the ABCs to identify patients with the highest risk of falls with injury:

Age age 85 or older

Bones osteoporosis, previous fracture, prolonged steroid use, bone metastases

Coagulation abnormalities anticoagulants, bleeding disorders, conditions causing coagulopathy

Surgery recent limb amputation, or major abdominal or thoracic surgery


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Screening and Risk Assessment

Falls risk assessment is a multi-step process 1. Screening using a risk assessment tool

2. In-depth multifactorial risk assessment

Risk assessment does not end with

administration of the screening tool

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Individual Falls Risk Factors FALLS RISK FACTORS WITH CORRESPONDING MEAN RELATIVE RISK

RISK FACTOR MEAN RELATIVE RISK RATIO (RANGE)

Muscle weakness 4.4 (1.5-10.3)

History of falls 3.0 (1.7-7.0)

Gait deficit 2.9 (1.3-5.6)

Balance deficit 2.9 (1.6-5.4)

Use of assistive device 2.6 (1.2-4.6)

Visual deficit 2.5 (1.6-3.5)

Arthritis 2.4 (1.9-2.9)

Impaired activities of daily living 2.3 (1.5-3.1)

Depression 2.2 (1.7-2.5)

Cognitive impairment 1.8 (1.0-2.3)

Age over 80 1.7 (1.1-2.5)

Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clinics in Geriatric Medicine 2002;18:141-158.


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Profile of a Hospitalized Patient

at Risk for Falls

Cognitive impairment (including depression)

History of previous falls

Impaired mobility

Special toileting needs

Other contributors Advanced age

Medications


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Cognitive Impairment

Delirium Hypoactive

Hyperactive

Dementia

Slower cognitive processing

Depression


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Depression and Falls

Twice as likely to fall as those without depression

Observe for any of the following signs: Prolonged feelings of helplessness, hopelessness, or

being overwhelmed

Tearfulness

Flat affect or lack of interest

Loss of interest in life events

Melancholic mood

Withdrawal

The patients statement of depression


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History of Falls

Prior falls predict future falls

History of falling within previous 12-month period can triple the risk

of future falls

Different studies have used different cut-off points


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Impaired Mobility

Muscle weakness

Decreased gait speed

Decreased stride length

Use of assistive devices

Arthritis

Impairment in activities of daily living

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Special Toileting Needs

Incontinence

Urinary frequency

Diarrhea

Toileting - related falls increase the risk of fall-related injuries by an

odds ratio of 2.4


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Advanced Age

1 in 3 adults over age 65 fall each year

Falls are the leading cause of injury death in adults over 65

Adults 75 and older are four times as likely to suffer an injurious fall than

adults ages 65 to 74

http://www.cdc.gov/homeandrecreationalsafety/fal

ls/adultfalls.html


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Medications and Falls Risk

4 or more medications

Benzodiazepines

Anticonvulsants

Sedative hypnotics

Antidepressants

Antipsychotics

Opiates

Antiarrhythmics

Antihypertensives

Diuretics

Antihistamines


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Reassessment

Suggested intervals for reassessment of falls risk: Upon transfer from one unit to another

With any status change

Following a fall

At regular intervals

With change in caregiver


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Postfall Risk Assessment

Obtain history of falls from the patient and witnesses

Note the circumstances (e.g. time, location, activity)

Review underlying illness and problems

Review medications

Assess functional, sensory and psychological status

Evaluate environmental conditions

Review risk factors for falling


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Postfall Risk Assessment, cont'd

Results serve two purposes Modify the plan to prevent repeat falls

Begin postfall investigation process, from which lessons learned can be applied to all patients


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Evidence-based Falls

Prevention Strategies


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Key Components of Falls

Prevention Organizational support and leadership

Multidisciplinary falls prevention team

Risk assessment

Multifactorial interventions

Communication

Reassessment

Data collection & quality improvement

(VHA NCPS 2004)


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Grading Levels of Evidence Level I: Systematic reviews (integrative/meta-

analyses/clinical practice guidelines based on systematic

reviews)

Level II: Single experimental study (randomized controlled trials [RCTs])

Level III: Quasi-experimental studies

Level IV: Non-experimental studies

Level V: Care report/program evaluation/narrative literature reviews

Level VI: Opinions of respected authorities/ Consensus panels

(Capezuti, et al., 2008)


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Organizational Support and Leadership Level of Evidence: V, VI

Strong organizational support is necessary for the success of any falls reduction program

Policies and protocols alone will not significantly impact rates of falls and falls with harm

Organizations must allocate resources to implementing a falls reduction program

Without additional resources, the program may increase falls rates

(Healey 2007, Lancaster 2007, Cameron 2010)

Guidelines: ICSI, NCPS, RNAO


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Multidisciplinary Falls Prevention Team Level of Evidence: IV

Requires support across departments and disciplines

Consists of clinical and non-clinical staff

Engages the medical staff

Guidelines: ICSI, RNAO, NCPS


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Multifactorial Interventions Level of Evidence: I

Effective falls prevention interventions Address common reversible falls risk factors in all

patients (Oliver 2004)

Target multiple individual risk factors

Are delivered by an interdisciplinary team (Cameron 2010)

Guidelines: ICSI, HCANJ, HIGN, NCPS, NICE, PSF, RNAO, TCAB


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Standard Falls Prevention

Interventions

Familiarize the patient to the environment

Place call bell within reach and have patient demonstrate use

Position necessary items within patient reach

Keep hospital bed in low position with brakes locked

Ensure patient wears non-slip, well-fitting footwear

Guidelines: ICSI, HIGN, NCPS, PSF, RNAO, TCAB


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Provide night light or supplemental lighting

Keep floor surfaces clean and dry

Clean up spills promptly

Install handrails in patient bathrooms, room and hallway

Maintain clutter-free patient care areas


Standard Falls Prevention

Interventions


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Interventions for Patients at Risk for Fall

Use visual alerts to communicate falls risk Sign outside door and in room

Wrist band

Colored socks/blankets

Alert in electronic medical record

Provide cued toileting at least every two hours while awake

Remain with the patient when assisted to the bathroom or commode


Fall Risk


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Use safe patient handling techniques and assistive devices for all transfers

Use low beds and floor mats when appropriate

Use bed and chair alarms, if necessary

Provide frequent or continuous observation, if necessary


Interventions for Patients at Risk for Fall


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Hourly Rounding Level of Evidence: III, IV, V, VI

The Four Ps Position

Pain assessment

Personal needs (potty)

Placement

Results Reduction in falls

Increase in patient satisfaction

Increase in staff satisfaction

Decreased call bell use

Decreased distance walked by nursing staff (Halm 2009)

Guidelines: ICSI, NCPS, TCAB


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Alarms Level of Evidence: V, VI

Alarms are mentioned in several guidelines

Be sure staff are trained in their proper use according to manufacturers instructions

Ideally the alarm should be triggered in time for staff to respond and prevent a

fall

Guidelines: HIGN, ICSI, NCPS, TCAB


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Low Beds Level of Evidence: V, VI

Low beds have been included as part of effective multifactorial falls prevention plans (Lancaster et al., 2007)

It is difficult to isolate the impact of low beds

Research suggests no significant increase or decrease in the rate of injuries or falls from bed (Anderson et al., 2011)

Guidelines: HIGN, ICSI, NCPS, RNAO, TCAB


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Continuous Observation (AKA Sitters) Level of Evidence: V, VI

Provide training to designated staff

Create clear guidelines for use of continuous observation

Monitor outcomes (e.g. falls with injury) and balancing measures (e.g.,

restraint use) to support cost

justification (Harding 2010)

Guidelines: ICSI, NCPS, TCAB


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Communication

Visual communication

Communication to patients and families

Communication to the healthcare team


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Visual Communication Level of Evidence: V, VI

Signage

Patient chart

Bracelets

Socks

Blankets All healthcare workers must be educated to recognize these visual

cues. Caution must be given to sign fatigue

Guidelines: HCANJ, HIGN, ICSI, NCPS, RNAO, TCAB


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Communication to Patients and Families Level of Evidence: V, VI

Communicate risk factors identified

Explain hospital falls prevention program

Engage patient and family as members of the falls prevention team and get their input into the

plan

Provide education using the Teach Back method



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Communication to the Healthcare Team Level of Evidence: V, VI

Housewide, interdisciplinary ongoing education

Transport checklist (Ticket to Ride)

Handoff Tool (SBAR)

Patient Safety Huddle

Post Fall Huddle



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Falls Measurement


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Falls Risk Assessment Findings

Identified gaps in the Authoritys adverse event reports Risk assessments

Identification of patients at risk for falls

Prevention strategies in place

Development of falls dashboard and process measure report


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Pennsylvania Risk Assessment Compliance

2011 Patient Safety Reporting System Data

Falls Questions

Re

spo

nse

s

Risk Assessment Identified at Risk for Fall

Fall Prevention Strategies in Place

Yes 64.4% 59.7% 65.2%

No 5.2% 18.1% 15.0%

Unknown 4.3% 6.6% 4.8%

No Response 26.1% 15.6% 15.0%

Total 100% 100% 100%


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Falls Dashboard


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Risk Assessment Compliance

Unknown and no response on adverse event reports identified gaps

Possibly a documentation issue


Yes No Unknown No Response Total

Falls Risk Assessment Completed 16 0 4 9 29

Patient Identified at Risk of Fall 13 0 0 16 29

Falls Precaution(s) in Place 16 5 0 8 29

Prior History of Falls in the past 12

months

6 5 1 17 29


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Falls Details Report

Identify patterns between falls event types and patient characteristics

Inform falls prevention strategy choices

Identify patterns between falls event types and patient characteristics

Inform falls prevention strategy choices


61

Falls Prevention Strategy Report

Identify patterns in falls event types and implemented prevention strategies

Standardized falls event type categories

Identify patterns in falls event types and implemented prevention strategies

Standardized falls event type categories


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Process Measure Report


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Risk and Strategy Process

Measure

Drill down reporting capabilities Identify specific patient events

Learn details about circumstances

Identify patterns and investigate

Make changes based on new information


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Point Prevalence Audit Tool Facility:

Falls Prevention Process Measures Audit Tool Date:

Unit: Census:

DOCUMENTATION VISUAL OBSERVATION

Room #

Patient ID W

as r

isk

asse

ssm

ent

com

ple

ted

?

Ente

r ri

sk s

core

Was

pat

ien

t id

enti

fied

at

risk

to

fal

l?

Was

fal

ls p

reve

nti

on

pla

n

do

cum

ente

d?

Was

pat

ien

t an

d f

amily

ed

uca

tio

n d

ocu

men

ted

?

Is t

her

e d

ocu

men

tati

on

of

ho

url

y ro

un

ds?

Is c

all b

ell w

ith

in r

each

?

Do

es p

atie

nt

hav

e ri

sk

iden

tifi

ers?

Do

es p

atie

nt

hav

e ap

pro

pri

ate

foo

twea

r?

Is s

pec

ial e

qu

ipm

ent

in u

se?

Are

ala

rms

in u

se?

Is s

itte

r in

pla

ce?

Y N Y N Y N Y N Y N Y N

sign outside room sign inside room wrist band colored blanket colored socks other ________

non-skid socks/slippers rubber soled shoes other ________

low bed 2 side rails up floor mat hip protectors other ________

bed alarm chair alarm other ________

Y N


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Point Prevalence Audit Report

Graphs have been created to

display

individual

facility results,

and

comparison to

group averages


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Sometimes I wish for falling Wish for the release Wish for falling through the air To give me some relief Because falling's not the problem When I'm falling I'm in peace It's only when I hit the ground It causes all the grief Florence Welch (lead singer, Florence and the Machine)


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Thank you for your attention.


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Falls Prevention Guidelines

Hartford Institute for Geriatric Nursing (HIGN) Gray-Micelli D. Preventing falls in acute care. In: Capezuti E,

Zwicker D, Mezey M, Fulmer T, editor(s). Evidence-based

geriatric nursing protocols for best practice. 3rd ed. New York

(NY): Springer Publishing Company; 2008. p. 161-98. [cited

2012 May 15]. Available from Internet:

http://guideline.gov/content.aspx?id=12265

Health Care Association of New Jersey (HCANJ) Health Care Association of New Jersey. Fall management

guidelines [online]. 2007 Mar [cited 2012 May 15]. Available

from Internet: http://www.hcanj.org/docs/hcanjbp_fallmgmt6.pdf


69


Institute for Clinical Systems Improvement (ICSI) Institute for Clinical Systems Improvement . Health care protocol:

prevention of falls (acute care) [online]. 2012 Apr [cited 2012 May

15]. Available from Internet:

http://www.icsi.org/falls__acute_care___prevention_of__protocol_

/falls__acute_care___prevention_of__protocol__24255.html

National Center for Patient Safety (NCPS) National Center for Patient Safety. Falls toolkit [online]. 2004 Jul

[cited 2012 May 15]. Available from Internet:

http://www.patientsafety.gov/SafetyTopics/fallstoolkit/index.html


70

National Institute for Clinical Excellence (NICE) National Institute for Clinical Excellence. Clinical practice

guideline for the assessment and prevention of falls in older

people [online]. 2004 Nov [cited 2012 May 15]. Avaialble from

Internet:

http://www.nice.org.uk/nicemedia/pdf/CG021fullguideline.pdf

Patient Safety First (PSF) Patient Safety First. The how-to guide for reducing harm from

falls [online]. 2009 Sep [cited 2012 May 15]. Available from

Internet:

http://www.patientsafetyfirst.nhs.uk/ashx/Asset.ashx?path=/Inte

rvention-support/FALLSHowo%20Guide%20v4.pdf



71


Registered Nurses Association of Ontario (RNAO) Registered Nurses Association of Ontario. Prevention of falls and

fall injuries in the older adult [online]. 2011 [cited 2012 May 15]. Available from Internet: http://rnao.ca/sites/rnao-ca/files/Prevention_of_Falls_and_Fall_Injuries_in_the_Older_Adult.pdf

Transforming Care at the Bedside (TCAB) Institute for Healthcare Improvement. Transforming Care at the

Bedside How-to guide: reducing patient injuries from falls [online]. 2008 [cited 2012 May 15]. Available from Internet: http://www.ihi.org/knowledge/Pages/Tools/TCABHowToGuideReducingPatientInjuriesfromFalls.aspx


72

Agency for Healthcare Research and Quality (AHRQ) Agency for Healthcare Research and

Quality. Preventing Falls in Hospitals: A

Toolkit for Improving Quality of Care

[online]. 2013 Jan [cited 2013 Feb 25].

Available from Internet:

http://www.ahrq.gov/research/ltc/fallpxt

oolkit/index.html



73

Reference Articles

Ang NKE, Mordiffi SZ, Wong HB, Det al. Evaluation of three fall-risk assessment tools in an acute care setting. Journal of Advanced Nursing 2007;60(4),427435

Anderson O, Boshier P, Hanna G. Interventions designed to prevent healthcare bed-related injuries in patients. Cochrane Database of Systematic Reviews

2011;11:1-30.

Cameron ID, Murray GR, Gillespie LD, et al. Interventions for preventing falls in older adults in nursing care facilities and hospitals. Cochrane Database of

Systematic Reviews 2010;1:1-117.

Capezuti, E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds). (2008) Evidence Based Geriatric Nursing Protocols for Best Practice, (3rd ed). New York: Springer

Publishing Company.

Child Health Corporation of America Nursing Falls Study Task Force. Pediatric falls: state of the science. Pediatric Nursing 2009 Jul-Aug;35(4):227-231.

Halm M. Hourly rounds: what does the evidence indicate? American Journal of Critical Care 2009 Nov;18(6):581-584.


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Reference Articles Harding AD. Observation assistants: sitter effectiveness and industry measures.

Nursing Economics 2010 Sep-Oct;28(5):330-336.

Healey F, Scobie S. Slips trips and falls in hospitals. London (UK): National Patient Safety Agency; 2007.

Hendrich A. Predicting patient falls: Using the Hendrich II Fall Risk Model in clinical practice. American Journal of Nursing 2007 Nov;107(11):50-58.

Inouye SK, Brown CJ, Tinetti ME. Medicare nonpayment, hospital falls, and unintended consequences. NEJM 2009 Jun;360(23):2390-2393.

Lancaster AD, Ayers A, Belbot B, et al. Preventing falls and eliminating injury at Ascension Health. Jt Comm J Qual Patient Saf 2007 Jul;33(7):367-375.

Oliver D, Daly F, Martin FC, et al. Risk factors and risk assessment tools for falls in hospital in-patients: a systematic review. Age Ageing 2004 Mar;33(2):122-30.

Perell KL, Nelson A, Goldman RL, et al. Fall risk assessment measures: an analytic review. J Gerontol A Biol Sci Med Sci 2001 Dec;56(12):M761-6.

Quigley P, Hahm B, Collazo S, et al. Reducing serious injury from falls in two veterans hospital medical-surgical units. J Nurs Care Qual 2009 Jan-Mar;24(1):3341


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PLS 1302 Fall Prevention LAG MF (1)

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