Preventing hospital falls: balancing vigilance, autonomy,

cost and gravity.Ronald I. Shorr, M.D., M.S.

Geriatric Research Education and Clinical Center (GRECC), Malcom Randall VAMC

University of Florida

Today’s talk

• Comments on some new findings and upcoming U.S. studies relevant to falls among community dwelling older adults.

• Falls in hospital• “Under the hood” of two of our groups projects

• Bed alarms

• Effect of “No Pay” regulation on falls and physical restraint use

• Thoughts on future directions for fall prevention research

PCORI/NIA multi-center fall prevention trial

• $30M/5 years

• 80 group practices/6,000 subjects

• Main outcome: Fall Injuries

• Intervention: Risk assessment + nurse “fall care managers” to develop and deliver evidence-based prevention plans tailored to the specific

risks of each individual and to monitor patients’ outcomes in consultation with their primary care providers.

• Control: Risk Assessment + educational materials

Fall Prevention 2016

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Action Plan 1

• Purposeful Hourly Rounding bed huddle presentation (all staff) and PowerPoint presentation

• Leadership purposeful rounding (Kim @8am, Denisha@10am, Katie @12pm and Ro @2 and 4pm) If you will not be present (AL, meeting, etc.)for your rounding hour we will ensure someone is doing the rounding in your place. During leadership rounding we will ask staff (RN and NA) any issues/concerns with patient care, is charting up to date, PRNs cleared, address missing meds, and offer support to assist them.

Evaluation

….Our Purposeful Hourly Rounding Pilot has already shown some positive results! Thank you all so much for your feedback and input. I can’t wait to see the lasting impact this is going to have. If everyone truly does hourly rounding and follows the guidelines discussed below and in the power point using the 4P’s you will DEFINITELY see a reduction in falls and an increase in staff patient interaction that will also reduce the number of call lights….

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Action plan 2

• Bed alarms in-service and check off (all staff)

• Post fall huddles with staff directly involved and present at bed huddle the for all teams to review fall prevention measures.

• Veteran Companion cards for sitters and the NAs

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Fall Rate

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Workload

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Scope of the Problem of Falls in Acute Care

• In US about 1,000,000 falls annually (2% of hospital inpatients fall)

• 11,000 Deaths/year

• Increased LOS

• Bad publicity

• Litigation

Special considerations in US

• Acute care hospitals• Short LOS

• Limited specialized geriatrics services

• Few empty beds

• CMS regulations

• Litigious environment

Falls and injurious falls

Hospital Falls Conceptual “Box Model”

A less refined model

Distraction: Major Fall Risk Factor?

Fall Prevention: Major Fall Risk Factor?

Merging of Interests

Geriatric

Medicine

Pharmacoepidemiology

Quality of Care

Early work

• Fall evaluation “service”

• Case/Control study on restraint use and falls.

Trial of Proximity Alarms

• Funded by NIH (National Institute on Aging)

• Cluster RCT 16 Nursing Units-Single Hospital

• Primary Aim: Determine whether proximity alarms reduce falls by 25%

• Secondary endpoints• Injurious falls

• restraints

Limitations of Previous Research

• Incident reports

• Difficulty controlling for patient as well as unit-specific factors

• Inadequate sample size

• Tracking adherence

• Restriction to older populations

• Definition of “acute-care”

Proximity Alarms

Intervention

• Main point: Let CLINICAL JUDGEMENT prevail—but make alarms “easy to use.”

• Implementation team rounds• Alarms on a cart delivered to nurses

• Administration encouragement and buy-in

• In services on alarm use all shifts and days with frequent refreshers

• 24/7 trouble shoot

• Not a falls intervention service

• Round on control units as well to keep visibility of study high

Implementation Rounds

Fall Evaluators

• Interview with patient and/or witness

• Assessment

• Orthostatic vitals

• 10 orientation items on MMSE

• CAM

• Interview with nurse

• Environmental assessment

• Tubes/lines

• Restraints

• Alarm

Covariates (at unit level)

• Demographic (age, gender, insurance)

• Staffing (RN, NA, LPN)

• Fall risk (from EMR)

• Psychotropic Drug (from BILLING)

Intervention and Control Units

Findings

• Intervention successfully increased the use of bed alarms.

• Compared to control units, we found NO change in:• Falls

• Injurious falls

• Fallers

• Restraint use

Why didn’t alarms prevent falls?

• Alarm issues• False positives (ringing causes patients and staff to turn off)

• False negatives (patient on floor before alarm goes off)

• Staff issues• Alarm fatigue

• False sense of reassurance

Health Care Acquired Complications (HACs)

• On 10/1/08 Medicare stopped allowing hospitals to “upcode” for care related to 8 “preventable conditions”

• Regulation changes have been successful in achieving desired goals (e.g., OBRA-87).

Rosenthal M. N Engl J Med 2007;357:1573-1575

“Never Events”

• Retained object in surgery

• Air embolism

• Blood transfusion incompatibility

• CAUTI

• Pressure Ulcers

• CLABSI

• Mediastinitis after CABG

• Fall with injury

How to prevent falls?

“… we believe these types of injuries and

trauma should not occur in the hospital, and

we look forward to …identifying research…

that will assist hospitals in following the

appropriate steps to prevent these conditions

from occurring after admission…”

Non Payment inpatient claims ICD-9 Codes

• comorbid condition (CC) or major comorbid condition (MCC)

• fractures (ICD-9-CM code range 800 through 829)

• dislocations (ICD-9-CM code range 830 through 839)

• intracranial injury (ICD-9-CM code range 850 through 854)

• crushing injury (ICD-9-CM code range 925 through 929)

• other and unspecified effects of external causes (ICD-9-CM code range 991 through 994).

Did the intervention “work?”

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Before After

Bad Thing

Did the intervention “work?”

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Before After

Bad Thing

Did the intervention “work?”

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Bad Thing

Difference-In-Difference

• Difference in slopes (interaction between treatment*time)

• Challenges• Where do you draw the line between segments?

• How far back (or forward) do you measure?

• Seasonality or other perturbations

• Other things happening?

• Ascertainment bias

• National registry ~2,000 hospitals

• Voluntary participation

• Collect data on outcomes• Falls

• Restraint prevalence

• Staffing

• Staff surveys

Four HACs

• Short term (DID) effects (study ended at end of 2010)

• Units in 1,381 hospitals participating in NDNQI

DID Crude DID Adjusted

(Hospital/Unit)

CLABSI 0.89 (0.83-0.95) 0.88 (0.82-0.94)

CAUTI 0.90 (0.85-0.95) 0.90 (0.85-0.95)

Pressure Ulcers 0.98 (0.96-1.01) 1.00 (0.98-1.03)

Falls 1.00 (0.99-1.00) 1.00 (0.99-1.00)

Strengths/Limitations

• NDNQI- nurse reported outcomes which didn’t change reporting criteria after the intervention.

• Large diverse sample consisting of several thousand nursing units

• NDNQI hospitals tend to be larger and urban (perhaps more resources than all US hospitals).

• Volunteer bias (hospitals may select to participate because these are problem indicators).

Conclusions

• The HAC “no pay rule” resulted in declines in 2 of 4 HACs studied.

• CLABSI and CAUTI improved

• Falls and Pressure Ulcers no effect

• Why?• CLABSI/CAUTI have been well studied and approaches to prevention have

been described.

• The prevention of falls and pressure ulcers is not well defined.

• May take longer to realize the effects of the “no pay” rule on HACs where strategies for prevention are not well defined.

The effect of CMS “non-payment” on falls and physical restraint use in hospitals

• 9-year study (ended Q4 2015).

• 2862 adult medical, medical-surgical and surgical units in adult U.S. hospitals participating in NDNQI,

• Three endpoints: falls, injurious falls and physical restraint use.

• Three time segments (short, intermediate, long term)

Falls and injurious falls

Restraints

Falls

Difference in Difference (95% CI)

Unadjusted Adjusted

1 year post-CMS -2.09 (-3.27 to -0.90) -2.13 (-3.32 to -0.94)

4 years post-CMS -2.15 (-3.19 to -1.11) -2.17 (-3.21 to -1.14)

7 years post-CMS -2.20 (-3.42 to -0.99) -2.22 (-3.43 to -1.01)

Injurious falls

Difference in Difference (95% CI)

Unadjusted Adjusted

1 year post-CMS -0.49 (-2.71 to 1.73) -0.33 (-2.55 to 1.88)

4 years post-CMS -1.87 (-3.77 to 0.04) -1.83 (-3.74 to 0.08)

7 years post-CMS -3.22 (-5.50 to -0.95) -3.30 (-5.57 to -1.02)

Restraints

Difference in Difference (95% CI)

Unadjusted Adjusted

1 year post-CMS -3.90 (-11.29 to 3.49) -4.32 (-11.63 to 2.99)

4 years post-CMS 2.63 (-4.11 to 9.38) 2.42 (-4.27 to 9.11)

7 years post-CMS 3.30 (0.54 to 6.05) 3.31 (0.56 to 6.05)

Conclusions

• Falls and injurious falls have been gradually decreasing in the long term and the timing CMS regulation has been associated with modest accelerations in these declines.

• Physical restraint use had been declining prior to the CMS but have leveled off beginning year 4 after the implementation of no pay.

• Overall assessment, may have accelerated the improvements which were already occurring.

• Unanswered whether the floor in restraint use is related to financial incentives for fall prevention

• Unmeasured effects on mobility, use of sitters, alarms, rails or other fall prevention programs.

Promising future directions

• Understand drivers of variation• Patient level care

• Unit culture

• Hospital culture

• Role of built environment• 40% environment related

• Trend towards privacy (at expense of vigilance)