Volume 4, Issue 2 Topics In Patient Safety May/June 2004

Introducing the Falls Toolkit

In an effort to help facilities address falls and the injuries resulting from those falls, NCPS has developed the Falls Toolkit.The kit is designed to provide comprehensive, practical, evidence-based resources for the prevention of falls and fall-relatedinjuries, as well as provide advice for developing a falls prevention program.

Why a Falls Toolkit?

Falls are a serious issue in both VA and non-VA hospitals. Ofevents occurring in 2003, 23,9821 unique fall events were report-ed to NCPS using the SPOT database (see graphs below). Fallsrepresented 47% of the safety reports and aggregate reviews ofevents occurring in 2003. Of the 23,859 safety reports and aggregated events, 1,914 resulted in a Safety Assessment Code(SAC) actual score of at least 2, meaning that the fall resulted in apermanent lessening of function not related to the natural courseof the patient’s illness.

Inside the Falls Toolkit

The Falls Toolkit is a three-ring binder that includes tabbed sec-tions, videos, flyers, brochures, buttons and a CD-ROM. Thetabbed sections comprise the bulk of the information, rangingfrom advice on forming interdisciplinary falls teams to measuringthe success of a falls prevention program. Additionally, an anno-tated bibliography is included which directs users to journal

articles related to specific areas of interest. The bibliography isindexed by topic and includes a synopsis of the articles, as well asNCPS staff “top picks.”

The CD-ROM contains electronic versions of all the printed mate-rials as well as some additional resources, including a technologyassessment guide, an educational resource guide, andPowerPoint™ presentations.

Distribution Plan

The kit will be distributed to all patient safety managers in thespring of 2004. Each patient safety manager will receive twocopies, one of which is for the falls team at the facility.

Supporting the Falls Toolkit

An interesting and easy-to-use Web site is available to support thekit. One can find and share electronic copies of brochures andposters, download a section of the kit, and find other suggestedWeb resources. The resources on the Web site will be updatedannually to keep up with current research. One can visit the fallstoolkit Web site at: vaww.ncps.med.va.gov/fallstoolkit (Intranet).

Follow-Up

In FY 2005, NCPS will follow up with facilities to find out howthe kit is being used and how useful it has been.

By Erik Stalhandske, MPP, MHSA, program manager, and Amelia Landesman, BA, statistical assistant

Introducing the New Falls Toolkit

Among people 65 years of age and older —

What was the leading cause of death due to injury in 2001?What was the leading cause of injury in 2001?What comprised nearly half of all safety reports and aggregated events that occurred in 2003? What unintentional adverse event leads to depression, anxiety, higher utilization of medical resources, and/or potentially death?

(See back page for answers)

2003 Safety Roports and Aggregated Reviews Submitted to NCPS Using the SPOT Database (N=50,663)

Othe rs5 3 %

(2 6 ,8 0 4 )

Fa ll Re la te d4 7 %

(2 3 ,8 5 9 )

2003 Root Cause Analyses Submitted to NCPS Using the SPOT Database (N=1075)

Fa ll RCAs11%

(12 3 )

Othe r RCAs8 9 %(9 5 2 )

The graphs below represent RCAs, Safety Reports and aggregated events occurring in 2003 (submitted and categorized by 3-12-04)

continued on back page

Descriptions

RCAs involving falls, in which thepatient experienced a fracture, anotherinjury, or death, occur in a variety oflocations and varied situations. Someexamples follow below.

Regularly, they occurred in thepatient’s room or private bathroom. Inone event, a patient was found on thebathroom floor the morning after he fell.The patient told the nursing staff that hewas trying to go to the bathroom whenhe slipped. Another patient believed thathe could try to walk by himself, becausehe had walked in physical therapy earlierthat day. Later that evening, he fell whiletrying to walk to the bathroom

Other patient falls, however, occurredin non-direct care areas of the hospital.In one such event, a patient fell in theambulance bay while exiting from hiscar, fracturing his left hip.

Some falls occurred several timesbefore they were adequately assessed. Inone event, a patient was attempting to sit,missed the dining room chair, and fell tothe floor on his right side. The patienttold the nursing staff that he had alsofallen 15 minutes earlier. Later, the samepatient told the nursing staff that he wastrying to transfer from a geri-chair to thetoilet with the help of another patientwho had turned off the chair alarm. Thepatient was treated in the ER for a headlaceration and underwent a CT scan,which was positive for a right hip fracture.

Other falls occurred even whilepatients were identified and being treatedas a high-fall risk. In one event, a patientwas part of the Falling Star IdentificationProgram. Another patient alerted thenursing staff that a high-fall risk patientwas on the floor in the TV lounge, hav-ing unlatched his Velcro safety belt andhaving attempted to walk unassisted.

Falls Resulting in Patient Injury or Death

By Dea Mannos, MPH, program analyst

Facility Identified Vulnerabilities

While there are many different rea-sons for injuries associated with patientfalls, common causes appear acrossRCAs. Failure to clearly identify thepatient as a fall risk was a vulnerability.The absence or malfunction of specificfall prevention equipment also con-tributed to patient falls. In other events,delays in identification and treatment ofhip fractures increased the patient’s mor-bidity associated with the fall.

The following vulnerabilities andsystems weaknesses were identified:

Appropriate Fall Assessment and PatientRecord Documentation

Lack of identification of the patient asa fall risk

Differing interpretations of the MorseFall Risk Scale questions led to inaccurate scoring and contributed toincomplete fall prevention plans.

Lack of written guidelines detailingpatient needs and handling instructionsduring transport between nursing units orbetween other departments

Equipment Related Issues

The height of an air mattress, its slicksurface, and the lack of raised lowerside-rails contributed to a patient slidingout of bed when turning over, thus result-ing in a fall.

The lack of the use of technology, suchas hip protectors that disperse force dur-ing falls, increases the likelihood thatpatients could suffer from hip fractures.

The lack of an alarm device to warnstaff may have contributed to thispatient’s fall and fractures. During achange of shift report, the patient tookoff his wheelchair safety belt and eitherslid from the wheelchair or attempted totransfer without assistance.

Delays in Fall Treatment

No radiology coverage during week-ends, evenings, and nights for the read-

ing of plain films to rule out fracturesfollowing a patient fall.

The walk-in doctor and nurse were notinformed that the patient had fallen andthat x-rays were ordered.

Actions Taken By Facilities

To address the reliability of fall assessments and improve patient recorddocumentation of fall risk, some facilitiestook the following actions:

Two different units, chosen by thefacility’s Associate Director for PatientCare Services, performed an inter-raterreliability test on the Morse Fall RiskScale for one month.

Units trialing the Hendrich Fall RiskAssessment completed inter-rater relia-bility testing.

A “routing” sheet was designed in onemonth that outlined special needs ofpatients and transportation instructionrequirements.

The following was added to the mentalhealth monthly and quarterly patient sta-tus reviews:

Has the patient fallen since last review?_____no ______yes _______date of fallIf yes, was Fall Risk Protocol initiated?_____yes _____no Why not?

In response to these cases and to addressdevice issues, some facilities took the following actions:

The BioMed Chief, along with SPD,evaluated various methods to supplementbedside rails for patients with overlay airmattresses.

Alarms were purchased and staffreceived in-service training on their usefor patients who are at high-risk for falls.

A system for securing, storing, laun-dering and using hip protectors for high-fall-risk patients was implemented for along term care facility.

To decrease delays in fall treatment,some facilities took the followingactions:

“Severe falls in VA medical centers are the result of many factors, including: incomplete patient fall risk assessments,incomplete medical record documentation, and fall prevention equipment that is disabled or malfunctioning.”

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Coverage was provided on a 24/7 basisfor Radiology to read plain films to ruleout fractures.

The Health Systems template in CPRSwas amended to mandate a provider co-signature on the initial radiology report.

NCPS Comments

Severe falls in VA medical centers arethe result of many factors, including:incomplete patient fall risk assessments,incomplete medical record documenta-tion, and fall prevention equipment that

bridge these gaps in fall preventionstrategies by providing medical centerswith a wealth of information and sup-plies to implement a comprehensive fallprevention program that is visible tocaregivers, administrators, and patients.

Visit the NCPS Intranet Web site(vaww.ncps.med.va.gov) or Internet WebSite (www.patientsafety.gov) for addition-al information on the NCPS FallsToolkit.

tributing to the infestation.

Fly larvae found on a patient need tobe removed. The IL contains guidance onhow that procedure should be performed,as well as on vaccinations and on relatedtreatments that may be appropriate.

While the issue of the beneficialeffects of maggots for cleaning a woundmay be medically relevant, this shouldonly be done using laboratory-reared,disinfected fly larvae.

Mitigation should begin by address-ing the source of the flies. Identifyingspecific genus and species of the larva(e)may also be appropriate. Precise identifi-cation is complex, since dead fly larvaemay be difficult to identify, even by anexperienced entomologist. Whether ornot live larvae are submitted for identifi-cation, it is appropriate for several larvaeto be placed in alcohol or formalin andsent to Pathology, as would be done forany other clinical specimen from apatient. An official pathology report willthen be generated for future reference.

In general, a case of myiasis shouldbe a cause for action and re-evaluation ofpractices, not a cause for hysteria orpanic, as adverse patient consequencesare almost always modest. To help pre-vent myiasis or to respond to a case thatoccurs, the IL is an excellent resource forVA personnel.

Myiasis is the condition of infestation ofthe body by fly larvae (maggots).

A case in VA received some notorietyin 2002 and a VHA Information Letter(IL) (http://www.va.gov/publ/direc/health/infolet/10200217.pdf) was subse-quently developed to provide VAMCswith basic information on this little-studied topic.

Myiasis is a relatively rare occurrencein the United States and in U.S. health-care facilities, but it does happen — evenin hospitals without an obvious problemwith cleanliness. The complexity ofhealthcare, an aging population, and theseverity of illness of many patients inhealthcare facilities creates a venue inwhich myiasis can occur. This is espe-cially true in spring and summer whenflies are more widespread.

There are two aspects of myiasis rele-vant to improving patient safety: prevent-ing myiasis and making the appropriateinterventions after myiasis is discovered.

Prevention focuses on the care of at-risk patients, inside and outside thehealthcare facility. This is especially trueof those with chronic skin lesions. Otherpreventative measures center on the envi-ronment of care that can influence thepotential occurrence of myiasis.

Most flies that cause myiasis depositeggs or larvae directly onto the host atpredisposed sites, such as chronicwounds and necrotic or infected tissue.Blood, body fluids, body substances,

excrement, and volatile products ofputrefaction act as olfactory attractantsfor common flies. Recommendationsprovided in the IL include standardizedwound care measures, such as keepingchronic wounds dressed at all times andvisually inspected daily.

With respect to the environment ofcare, the key to prevention of myiasis ina healthcare facility is fairly obvious: tominimize the number of flies that couldcome into contact with patients.

Unfortunately, this turns out to be acomplex issue that involves multipleservices throughout the facility. Both theexternal and internal environment of thefacility must be considered. Specifically,cleanliness and sanitation cannot be con-sidered merely an aesthetic need.

A specific cleaning regimen, includ-ing cleaning intervals and protocols,needs to be in place – and staff membersmust be continually vigilant that all isbeing accomplished as planned. Sampleschedules and protocols can be found inthe Emerging Pathogens guidebookavailable to VA facilities on the Intranet(click to: http://vaww.ceosh.med.va.gov,then to “Guidebooks,” on the left-handside of the screen). The IL also containsan appendix dedicated to “Fly Control inHealth Care Facilities” that providesadditional guidance.

If myiasis is discovered, care for thepatient is the first priority. The secondissue is mitigation of the factors con-

Preventing and Responding to MyiasisBased on VHA Information Letter 2002-017

is disabled or malfunctioning.

NCPS, in conjunction with PatientSafety Center for Inquiry 8 and severalVA medical centers, developed the FallsToolkit to target these multi-dimensionalvulnerabilities.

Successful fall prevention programsmust not merely implement a new policyor device, but address fall risks at all lev-els of patient care, including: admission,medical record management, and patientmonitoring. The Falls Toolkit attempts to

By Noel Eldridge, MS, NCPS executive officer

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1VA NCPS RCA database. Events categorized as of Mar. 1, 20042Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS) [Online]. (2002). National Center for InjuryPrevention and Control, Centers for Disease Control and Prevention (producer). Available from: URL: http://www.cdc.gov/ncipc/wisqars/. [2004 Mar 19].3VA NCPS RCA database. Events reported as of Mar. 12, 20044Centers for Disease Control and Prevention Web site. National Center for Injury Prevention and Control. Available from URL: http://www.cdc.gov/ncipc/factsheets/nursing.htm [2004 Mar 30].

Introducing the New Falls Toolkit (continued from front page)

TIPS is published bimonthly by the VANational Center for Patient Safety. As the official patient safety newsletter of the Department of Veterans Affairs, it is meant to bea source of patient safety information for all VAemployees. Opinions of contributors are not necessarily those of the VA. Suggestions and articles are always welcome.

VA National Center for Patient SafetyP.O. Box 486Ann Arbor, MI 48106-0486

Phone: . . . . . . . . .(734) 930-5890Fax: . . . . . . . . . . .(734) 930-5877E-mail: . . . . . . . . .ncpstips@med.va.govWeb sites: . . . . . .Internet - www.patientsafety.gov

Intranet - vaww.ncps.med.va.gov

NCPS Director . . . . . . . . . . . . . . . . . . .James P. Bagian, MD, PEEditor . . . . . . . . . . . . . . . . . . . . . . . . . .Joe Murphy, APRAsst. Editor, Layout & Design . . . . . .Jean Alzubaydi, MA

Thanks to all contributors and those NCPS program managersand analysts who offered their time and effort to review andcomment on these TIPS articles prior to publication.

Hip Protector Quality Improvement Project:Success Factors for Implementing Hip ProtectorsNCPS supported the Hip Protector Quality Improvement Project at 13facilities. Below are some of the general factors that were found toincrease the success rate of their programs:

#1 Staff Ownership/Involvement in the ProgramEducation/orientationObtaining staff inputSupportive managementDeveloping unit championsReporting results of the interventions

#2 Program LogisticsAssigning responsibility to one person or one teamPlanning the process from beginning to endIncluding stakeholders in development (purchasing, SPD,

facility management, nurse managers, LPNs/NAs, etc.)

#3 CommunicationCommunicate through a variety of methods, post signs where

people need the informationIdentification of high-risk patientsTalking with staff and answering their questions

#4 Patient/Family InvolvementFamily support and reinforcementCommunicating with the family, during visits and treatment

team meetings, and through lettersObtaining patient input leads to patient involvement

#5 Other FactorsActive patient safety programUsing small cycles of changePatient/family education

Inside the Falls ToolkitThe tabbed sections:

BackgroundFalls TeamFalls PolicyInterventionsMeasuring SuccessResources

Educational & Awareness Raising Materials:

Posters on falls prevention and hip protectorsaimed at patients and staff

Flyers on performing the “Timed Up & Go Test”Brochures for patients on hip protectors and on

evaluating a home for fall risksThree videos for patients and staffButtons for identifying fall resources/advocates on units/shiftsTechnology Assessment GuideEducational Resource Guide

ASK MEABOUTFALLS

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Buttons that will be available with the Toolkit

Answers to the questions on page 1:Among people 65 years of age and older:Q: What was the leading cause of death due to injury in 2001?

A: Unintentional falls were the leading cause of death: 11,623 (29.6%)2

Q: What was the leading cause of injury in 2001?

A: Unintentional falls: 1,642,135 (61.6%)2. People aged 65 years and older were the only age group where motor vehicle accidents werenot the leading cause of injury2.Q: What comprised nearly half of all safety reports and aggregated events reported to NCPS that occurred in 2003?

A: Falls represented 23,859 or 47%3 of all the safety reports and aggregated events.Q: What unintentional adverse event leads to depression, anxiety, higher utilization of medical resources and/or death?

A: FALLS4