Experienced

1. Pioneering Experienced Independent Implementing an Evidence-Based Falls Prevention Program Michelle Feil MSN, RN Senior Patient Safety Analyst March 5, 2013 Evidence-based 1 1

2. Objectives • List components of an evidence-based falls prevention program • Distinguish between components of a falls prevention program which have stronger and weaker levels of evidence to support them • Identify strategies that are accepted as best practices • Describe innovative approaches to falls and falls injury prevention

3. “Sometimes I wish for fallingWish for the releaseWish for falling through the airTo give me some reliefBecause falling's not the problemWhen I'm falling I'm in peaceIt's only when I hit the groundIt causes all the grief” ― Florence Welch (lead singer, Florence and the Machine)

4. Gravity is a contributing factor in nearly 73 percent of all accidents involving falling objects. -Dave Barry (comedian)

5. 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)

6. Key Components • Organizational support and leadership • Multidisciplinary falls prevention team • Risk assessment • Multifactorial interventions • Communication • Reassessment • Data collection & quality improvement

7. Organizational Support and LeadershipLevel 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

8. Multidisciplinary Falls Prevention TeamLevel of Evidence: IV • Requires support across departments and disciplines • Consists of clinical and non-clinical staff • Engages the medical staff Guidelines: ICSI, RNAO, NCPS

9. The Veteran’s Health Administration, National Center for Patient Safety Falls Toolkit (2004) outlines the following Falls Prevention Team members: • Clinical Staff • Falls Clinical Nurse Specialist • Nurse Managers • Nursing Assistants & LPNs • Pharmacist • Physical & Occupational Therapists • Physician/Nurse Practitioner • Non-Clinical Staff • Patient Safety Manager/Quality Manager Coordinator • Facility Management Manager • Supply Processing & Delivery Manager • Biotechnology Manager • Transportation Manager

10. Other Members? • It is recommended to add people to the team from areas other than patient care if falls are occurring in these areas. (VHA NCPS 2004)

11. Risk Assessment • “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

12. Pennsylvania Patient Safety Advisory • “Falls Risk Assessment: A Foundational Element of Falls Prevention Programs” September 6, 2012 • http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2012/Sep;9(3)/Pages/73.aspx

13. 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 patient’s risks for falls • implement interventions to reduce falls based on the patient’s assessed risk

14. Joint Commission, cont’d.

15. Risk AssessmentLevel of Evidence: II • Patients should be assessed for their falls risk: • On admission • Upon transfer from one unit to another • With any status change • Following a fall • At regular intervals Guidelines: ICSI, HCANJ, HIGN, NCPS, NICE, PSF, RNAO, TCAB

16. Risk Assessment Tools • Risk assessment tools by themselves do not prevent patient falls - they predict them

17. Risk Assessment ToolsWhat’s the Evidence? • Sensitivity and specificity can vary greatly between tools (Perell 2001) • Risk assessment tools with high sensitivity and specificity assess: • gait instability • agitated confusion • urinary incontinence/frequency • falls history • prescription of ‘culprit’ drugs (especially sedative/hypnotics) (Oliver 2004)

18. Risk Assessment ToolsWhat’s Out There? • Morse • Hendrich I & II • STRATIFY • Johns Hopkins • Conley • Innes • Downton • Tinetti • Schmid

19. Risk Assessment Tools: Comparison of Domains/Variables

20. Pediatric Falls Risk Assessment Tools • Schmid “Little Schmidy” • CHAMPS • General Risk Assessment for Pediatric Inpatient Falls (GRAF PIF) • Humpty Dumpty • I’M SAFE http://www.ajj.com/services/pblshng/pnj/ce/2011/article35227231.pdf

21. 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) Guidelines: ICSI, NCPS, RNAO

22. 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%)

23. 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) = 2.16] • Uses hands, requires multiple attempts (OR = 4.67) • Unable to rise (OR = 10.06)

24. Assessing for Risk of InjuryLevel of Evidence: II, VI Use the ABCs to identify patients withthe highest risk of falls with injury (Quigley 2009): • Age – age > 85 • 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 Guidelines: ICSI, TCAB

25. Screening and Risk Assessment • Falls risk assessment is a multi-step process • Screening using a risk assessment tool • In-depth multifactorial risk assessment Risk assessment does not end with administration of the screening tool

26. Individual Falls Risk Factors

27. Profile of the Hospitalized Patientat Risk to Fall • Cognitive impairment (including depression) • History of previous falls • Impaired mobility • Special toileting needs • Other contributors • Advanced age • Medications

28. Cognitive Impairment • Delirium • Hypoactive • Hyperactive • Dementia • Slower cognitive processing • Depression

29. Depression and Falls • Patients with depression are twice as likely to fall as those without depression (Perell 2001) • 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 patient’s statement of depression (Hendrich 2007)

30. 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

31. Impaired Mobility • Muscle weakness • Decreased gait speed • Decreased stride length • Use of assistive devices • Arthritis • Impairment in activities of daily living

32. Special Toileting Needs • Incontinence • Urinary frequency • Diarrhea • Toileting - related falls increase the risk of fall-related injuries by an odds ratio of 2.4

33. 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/falls/adultfalls.html

34. Medications and Falls Risk • 4 or more medications • Benzodiazepines • Anticonvulsants • Sedative hypnotics • Antidepressants • Antipsychotics • Opiates • Antiarrhythmics • Antihypertensives • Diuretics • Antihistamines

35. The Challenge • “Unlike other hospital-acquired conditions that were selected by the CMS, falls are often the result not of medical errors but of diseases, impairments, and appropriate uses of medications and other treatments. Falls and injuries can occur even when hospitals provide the best possible care.” (Inouye, Brown & Tinetti, 2009)

36. A New Challenge • “although we have not identified specific prevention guidelines for the conditions . . . we believe these types of injuries and trauma should not occur in the hospital and we look forward to working with CDC and the public in identifying research that has or will occur that will assist hospitals in following the appropriate steps to prevent these conditions from occurring after admission.” CMS Inpatient Prospective Payment System Final Rule, Federal Register, August 22, 2007

37. So Now What?! Insanity: doing the same thing over and over again and expecting different results. - Albert Einstein

38. Multifactorial InterventionsLevel 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

39. 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

40. Standard Falls Prevention Interventions • Provide night light or supplemental lighting • Keep floor surfaces clean and dry and clean up spills promptly • Install handrails in patient bathrooms, room and hallway • Maintain clutter-free patient care areas Guidelines: ICSI, HIGN, NCPS, PSF, RNAO, TCAB

41. Interventions for PatientsIdentified at Risk for Fall • Use of visual alerts to communicate falls risk, for example: • 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 Guidelines: ICSI, HIGN, NCPS, PSF, RNAO, TCAB

42. Interventions for PatientsIdentified at Risk for Fall • 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 Guidelines: ICSI, HIGN, NCPS, PSF, RNAO, TCAB

43. Hourly RoundingLevel of Evidence: III, IV, V, VI • The Four P’s • 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

44. AlarmsLevel of Evidence: V, VI • Alarms are mentioned in several guidelines • Be sure staff are trained in their proper use according to manufacturer’s instructions • Ideally the alarm should be triggered in time for staff to respond and prevent a fall Guidelines: HIGN, ICSI, NCPS, TCAB

45. Low BedsLevel 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

46. 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

47. Communication • Visual communication • Communication to patients and families • Communication to the healthcare team

48. Visual CommunicationLevel 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

49. Communication to Patients and FamiliesLevel 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 Guidelines: HCANJ, HIGN, ICSI, NCPS, RNAO, TCAB

50. Communication to the Healthcare TeamLevel of Evidence: V, VI • Housewide, interdisciplinary ongoing education • Transport checklist (“Ticket to Ride”) • Handoff Tool (SBAR) • Patient Safety Huddle • Postfall Huddle Guidelines: HCANJ, HIGN, ICSI, NCPS, RNAO, TCAB