An Epidemiological review of inpatient falls and the implications for nursing practice

1. An Epidemiological review of inpatient falls and the implications for nursing practice Sara Wanner, RN, BSN

2. Introduction • Definition of “Fall” (from the Joint Commission’s Implementation Guide for the National Quality Forum Endorsed Nursing—Sensitive Care Performance Measures) : an “unplanned descent to the floor with or without injury to the patient • Patient falls in hospitals are common and may lead to negative outcomes such as: • Injuries • Prolonged hospitalization • Legal liability • Because of the considerable burden falls have on patients, nurses, and hospitals, preventing falls from happening should be a priority in healthcare organizations. • In the national patient safety goals for 2007, the Joint Commission emphasized the need to reduce the risk of patient injuries from falls. • Fall rates are perceived as the indicator that could be most improved through nurse-led safety strategies or interventions • The risk cannot be completely eliminated, but can be significantly reduced with successful implementation of a fall prevention program

3. Background • Patient falls occur approximately 1.9 to 3% of all acute care hospitalizations, with anywhere from 2-15% of inpatients experiencing at least one fall • An estimated 30% of inpatient falls result in serious injury • Falls are a leading cause of death in people 65 years of age or older • With the number of older Americans increasing, the problem of fall-related injuries is likely to rise substantially over the next few decades • Injuries are costly due to: • Additional treatments • Longer lengths of stay • Estimated that these patients sustain upwards of 60% higher total charges than other hospitalized patients • Estimated cost to an acute care facility to treat the 30% of falls that result in serious injury is expected to reach $54.9 billion in 2020.

4. Risk factors- never a single cause for falls! (Tzeng & Yin, 2008)

5. An effective falls prevention program consists of: • Risk Assessment • Morse Fall Scale • Targeting common falls risk factors • Modifying the environment • Conducting post-fall assessments • Education • Safety huddles

6. Epidemiology of hospital inpatient falls in the U.S. • 19.1% occurred during ambulation • 10.9% when getting out of bed • 9.3% when standing up • 4.4% while using the bedside commode or toilet • 79.5% occurred in patient rooms • 11% in patients’ bathrooms • 9.5% in hallways or by the nurses stations (Tzeng & Yin, 2008)

7. Consequences of patient falls • Physical impact on patient: • Discomfort • Injury • Among older adults who sustain a hip fracture, nearly 50% never regain their previous level of functioning and 30% die within 6 months • Decreased mobility • Increased morbidity • Death • Psychological/Emotional impact on patient: • Decrease in self-confidence • Fear of future falling • The physical and emotional impact can greatly affect the patient’s quality of life • Economic impact on health care system: • Increased stay • Possible surgery/additional treatment • Threats to reimbursement • As of 2008, hospitals no longer receive payments for treating injuries caused by in-hospital falls (“Special supplement,” 2011)

8. Moving from “Why patients are falling” to “Preventing patients from falling”Implications for the apn • Education • Staff • Patients • Patient’s family members • Possible home assessments • Identification of Risk • Member of hospital renovation projects or in designs of new hospitals • Be a member of the fall-response team • Timely analysis of individual fall incidents • Goals: • To gather data surrounding the circumstance of every fall to analyze for trends • Once similarities are noted, education or practice changes can be implemented • To teach staff, patients, and families about future falls prevention • Develop an action plan to prevent future falls in similar circumstances • Be a motivator for change!! (Bognar, 2012)

9. Primary root causes of falls • Inadequate staff communication • Incomplete orientation and training • Incomplete patient assessment and reassessment • Environmental issues • Incomplete care planning • Unavailable or delayed care provision • Inadequate organizational culture of safety

10. references • Bognar, L. (2012). The fall-response team: An innovative approach. American Nurse Today, 7(4), 1-3. Retrieved from http://www.americannursetoday.com/Popups/ArticlePrint.aspx?id=10858 • Hill, A., Hill, K., Brauer, S., Oliver, D., Hoffmann, T., Beer, C., McPhail, S. & Haines, T. (2009). Evaluation of the effect of patient education on rates of falls in older hospital patients: Description of a randomised controlled trial, 9(14), 1-9. Retrieved from http://www.readcube.com/articles/10.1186/1471-2318-9-14 • Pearson, K. & Coburn, A. (2011). Evidence-based falls prevention in critical access hospitals (Policy brief 24). Retrieved from http://flexmonitoring.org/documents/PolicyBrief24_Falls-Prevention.pdf • Special supplement to american nurse today- best practices for falls reduction: A practical guide (2011). American Nurse Today, 6(2), 1-79. Retrieved from http://www.americannursetoday.com/article.aspx?id=7634&fid=7364 • Tzeng, H., & Yin, C. (2008). Nurses' solutions to prevent inpatient falls in hospital patient rooms. Nursing Economics, 26(3), 179-187. Retrieved from http://www.medscape.com/viewarticle/576954_4

11. Falls prevention program should include: • Multidisciplinary teams • Pharmacy • Medical • Nursing • Physical therapy • Quality officers

12. assessment • Patients should be assessed for their fall risk: • On admission • On any transfer from one unit to another • Following any change of status • Following a fall

13. AssessmentMORSE FALL RISK ASSESSMENT One of the most widely used fall risk assessments available *It is a reliable and valid measure of fall risk.

14. interventions • Bed and chair alarms • Move patients closer to nursing stations • Purposeful hourly rounding • Communication among staff, patients, and their families • Culture Change • When an organization lacks a safety culture, nurses and other staff are reluctant or unwilling to report events and unsafe conditions • Sitters • Toileting regimens • Medication review • Hourly rounding • To anticipate and address patient needs

15. Magnet model

16. Magnet model • “With emphasis on applying an evidence-based practice model through point-of-service solutions, innovations, and collaboration, the approach departs from the traditional top-down method for quality-improvement initiatives. Empowering and involving staff from the onset, disseminating data, involving staff in work groups, and educating colleagues help ensure that staff ‘own’ the program and incorporate its values into their practice” “Special supplement,” 2011)

17. Health belief model applied to the application of the education intervention (Hill et al., 2011)

18. Challenges to implementation • Other pressing quality initiative programs • Insufficient staff and resources • Not actively involving a pharmacist • Lack of alignment between a reporting mechanism for tracking falls and programs of education and training • Often not recognized as high priority

19. For the future • More reliable instruments are needed that will predict falls and recurrent falls for the nurses to predict and intervene more effectively • There is still insufficient evidence to clearly identify which interventions may reduce the incidence of falls