Introduction to Supplement – Meeting the challenge of falls reduction

Preventing patient falls is at the top of mind for every caregiver in every clinical setting. Multidisciplinary teams across the continuum of care convene each day as falls “champions” to determine the best ways to identify patients at highest risk for falls and to develop falls-prevention strategies.

Despite heightened national attention to this issue, threats to reimbursement, and the best possible intentions, patient fall rates across the United States continue to escalate, putting patients and caregivers at increasing risk. The facts are undeniable: Up to 50% of hospitalized patients are at risk for falls, and almost half of those who fall suffer an injury.

While falls have a tremendous impact on the patient, they also directly affect a healthcare organization’s cost per case and length of stay. The average hospital stay for patients who fall is 12.3 days longer, and injuries from falls lead to a 61% increase in patient-care costs.

Nearly every nurse can recall an incident in which a patient fell, or nearly fell. As patients continue to age and present with increasing vulnerability and comorbidities, their potential for harm increases. Likewise, as the American nurse ages, the risk of caregiver injury escalates, creating scenarios in which harm could be a growing concern. How many times have you hurt your back or shoulder while trying to move a patient or pick her up from the floor after she has fallen?

Patient falls are ubiquitous. We must think of new ways to solve this age-old concern. The stakes have never been higher and the need for holistic falls-prevention programs has never been greater.

This special report describes what we know about patient falls and how to overcome challenges and barriers to creating environments in which patients are safe from falling. Articles were written by thought leaders and experts on patient falls who discuss pertinent evidence and share the programs, care processes, assessment methods, and outcomes associated with their falls-prevention strategies. We share their best practices so that you can use them as a guide as you work to decrease patient falls in your organization.

All articles in this special report reflect the reality that clinical outcomes can improve—and those improvements can be sustained—when the best people, processes, and technology are employed. Not only do the authors share their positive clinical outcomes; they explain how your efforts can contribute to your organization’s bottom line by enhancing throughput and access when patient fall rates decline.

The ability to build a strong business case for quality is an important tool for all nurses today. This special report provides the language and process to help you articulate the difference that quality outcomes mean for patients, caregivers, and the financial health of your organization. Also crucial to your success is the ability to understand the technology available to help keep patients safe from falling, along with the ability to use the science behind the technology to make sound technology decisions. Knowing, for example, when a low bed is too low to keep the patient safe helps you optimize patient safety. Using patient-lift technology also optimizes patient handling and safety for both the patient and caregiver. By using a safety status board to provide visibility to critical protocols and alarms, nurses can monitor patients from afar and keep them safe from falls. You’ll find other examples and approaches in this special report—practical guidelines you can apply where you work.

If patient falls were easy to eliminate, we would have eliminated them by now. As with many clinical challenges, there’s no single easy answer to the challenges posed by patient falls. Analyzing the data, learning from colleagues’ successes, disseminating enhanced outcomes, and stomping out myths and ineffective practices will help you as you work to reduce patient falls on your unit and across your organization.

I wish to thank each of the authors for their contributions to this body of knowledge. I hope you will draw from their rich experience as you try to replicate their strategies and results. All of us at Hill-Rom, including the hundreds of nurses, therapists, and ergonomists on our team, are proud to support this special report on patient falls. We hope you will apply what you learn to your practice so you can continue to make your optimal contribution to patient care.

At Hill-Rom, we are dedicated to enhancing outcomes for patients and their caregivers. We know that as we work together using people, process, and technology, we can achieve better clinical outcomes with fewer patient complications. Thank you for all you do every day and thank you for allowing Hill-Rom to be your partner in patient care.

Introduction written by Melissa A. Fitzpatrick, MSN, RN, FAAN, Vice President and Chief Clinical Officer, Hill-Rom

Selected references

Bates DW, Pruess K, Souney P, Platt R. Serious falls in hospitalized patients: correlates and resource utilization. Am J Med. 1995;99(2):137-143.

Joint Commission. It’s a long way down: reducing the risk of patient falls. www.jointcommissioninternational.org/Web-Based-Education/Its-A-Long-Way-Down-Reducing-The-Risk-of-Patient-Falls/1435/. Accessed January 30, 2011.

Schwendimann R, De Geest S, Millisen K. Evaluation of the Morse Fall Scale in hospitalised patients. Age Aging. 2006;35(3):311-313.

Reducing patient falls: A call to action

By John Jorgensen, MPA, RN

Falls and fall-induced injuries are among the most common and serious health problems facing adults age 65 and older in developed countries. More than one-third of older adults experience falls. In this population, falls are the leading cause of injury-related deaths and the most common cause of injuries and hospital admissions.

Nearly half of those who fall suffer moderate to severe injuries that limit their mobility and increase the risk of premature death. Up to 20% of falls cause serious injury, including fractures and subdural hematomas.

Even when a fall doesn’t lead to death, it can necessitate prolonged hospitalization. Many victims spend up to a year in recovery. Some suffer disability and loss of function and are unable to return to their homes; many end up losing their independence. Among older adults who sustain a hip fracture, nearly 50% never regain their previous level of functioning and 30% die within 6 months. With the number of older Americans increasing, the problem of fall-related injuries is likely to rise substantially over the next few decades.

Falls carry staggering economic costs. Annual acute-care costs related to falls are estimated at $1.08 billion; long-term care costs, at $4.9 billion. According to the Centers for Disease Control and Prevention, medical costs related to falls totaled more than $19 billion in 2007–$179 million for fatal falls and $19 billion for nonfatal fall-related injuries. By 2020, the annual direct and indirect cost of fall injuries is expected to reach $54.9 billion.

Given the enormous human and financial consequences of falls, the need for robust falls-reduction programs across the country has never been greater.

Impact of falls on patients

Falls are a major contributor to a patient’s functional decline and increased healthcare use. Even if a fall doesn’t cause a serious injury, it may triple the patient’s likelihood of requiring placement in a skilled nursing facility. A serious fall increases the likelihood of skilled-nursing placement nearly tenfold. A fall can cause lasting pain and suffering and may limit function, imposing additional family and societal care burdens.

Fear of falling

An increasing body of evidence suggests that falls cause psychological problems in many older people—both fallers and nonfallers. Psychological consequences include fear, self-doubt, activity avoidance, and loss of confidence, which may lower the quality of life. Among older adults who have fallen, an estimated 29% to 92% fear they’ll suffer another fall. Among those who haven’t fallen, 12% to 65% fear they will fall. More women than men fear falling.

Fear of falling commonly leads to activity reductions or even avoidance. For some, fear of falling or of a fall-related injury may be as disabling as a fall itself.

Impact of falls on facilities

In today’s evolving pay-for-performance environment, healthcare facilities have a huge financial stake in reducing the number of patient falls. As of 2008, hospitals no longer receive payments for treating injuries caused by in-hospital falls, based on a 2007 final rule by the Centers for Medicare & Medicaid Services (CMS). The rule is a strong incentive for healthcare providers to implement practices that reduce the number of preventable patient falls.

CMS and Joint Commission requirements

CMS requires that a healthcare facility be a safe environment and setting for care. Facilities that don’t meet this requirement can be cited for immediate jeopardy and lose their eligibility to provide services. CMS also requires that the safety of patients at risk be assessed regularly and corrected if found to be deficient. A facility that fails to correct deficiencies is violating conditions of participation and could lose its Medi­care or Medicaid funding. Patients and their families are encouraged to contact the CMS or Joint Commission with a complaint concerning patient care, which may trigger a survey or at least a site visit from the Department of Health. Also, patients and their families may initiate litigation related to a fall.

In 2005, the Joint Commission introduced a national patient safety goal requiring hospitals to reduce the risk of patient harm resulting from falls and to implement a falls-reduction program. In 2010, this requirement was upgraded to a standard. The patient care chapter of Comprehensive Accreditation Manual for Hospitals (CAMH): The Official Handbook lists two requirements:

• Element of Performance (EP) 1: The hospital assesses and manages the patient’s risks for falls.
• EP 2: The hospital implements interventions to reduce falls based on the patient’s assessed risk.

Both requirements carry direct-impact status, meaning they are requirements that, if not met, are likely to create an immediate risk to patient safety or quality of care. Immediate risk occurs because too few processes or preventative measures are in place to protect the patient from harm. If these two elements of performance are unmet at the time of survey, they must be corrected within 45 days. Also, EP 38 in the book’s performance improvement chapter requires that the hospital evaluate the effectiveness of all falls-reduction activities, including assessment, interventions, and education. To meet this standard, data must be collected to show the hospital’s effectiveness in preventing falls and falls with injury. Examples of data collection include outcome indicators for the number and severity of fall-related injuries.

In 2010, the Joint Commission launched the Speak Up™ education campaign, which emphasizes that falls are a serious problem. The campaign offers tips and suggests actions to help people reduce the risk of falling, whether at home or in a healthcare facility. Also, the goal of reducing injuries and deaths from falls was a part of the “Healthy People 2010” program of the U.S. Department of Health and Human Services. Similarly, the Healthy People 2020 campaign has an objective of reducing emergency department visits for fall-related events by focusing on improving functional status through physical therapy and balance screening.

Why nurses must speak up

A culture of safety doesn’t just encourage nurses to work toward change. It requires them to take action when they see something amiss. This culture has no place for those who would say, “Safety isn’t my responsibility. All I need to do is file a report and someone else will take care of it.” Eventually, pressure comes from all directions—peers as well as leaders.

Healthcare organizations can reduce patient falls if their leaders are committed to change and enable staff to openly share safety concerns without fear of retaliation or reprisal. When an organization lacks such a culture, nurses and other staff members are reluctant or unwilling to report events and unsafe conditions that may lead to falls. Some may believe reporting won’t lead to change. A culture change takes a long time. Surveys are available to measure this and gauge its progress.

Essential to health maintenance

Falls prevention is an essential component of maintaining health. Many effective falls-prevention programs exist, both in the community and in healthcare facilities across a wide variety of settings. Implementing such a program can help reduce falls and help older Americans live longer lives of better quality. (See Recommendations for healthcare facilities by clicking the PDF icon above.) To help reduce falls, healthcare facilities may need to purchase safety equipment and upgrade their infrastructures with senior-friendly lighting, signage, color schemes, and other improvements.

According to research, effective falls-intervention programs should take a multifaceted approach that incorporates both behavioral and environmental components. Exercises to improve the patient’s strength and balance are key. The environment both at home and in the hospital may need to be modified. Patient and family education using patient “teach-back” is key to verifying and confirming patient comprehension and compliance with the program. Other elements of an effective falls-intervention program include patient medication reviews and interventions that specifically address patient risk factors. Examples include the use of helmets by patients undergoing chemotherapy who have low platelet, hemo­globin, or hematocrit levels and frequent toileting for patients with elimination problems.

Falls can be prevented. The need to reduce them has never been more important.

Selected references

Centers for Disease Control and Prevention. Falls among older adults: an overview. www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html. Accessed January 31, 2011.

Centers for Disease Control and Prevention. National Center for Injury Prevention & Control. Cost of falls among older adults. September 9, 2008. www.cdc.gov/HomeandRecreationalSafety/Falls/fallcost.html. Accessed January 28, 2011.

Department of Health and Human Services. Centers for Medicare & Medicaid Services. 42 CFR Parts 411, 412, 413, and 489. Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates. Final rule FY 2007 IPPS (71 FR 47881). www.cms.gov/AcuteInpatientPPS/downloads/CMS-1533-FC.pdf. Accessed January 31, 2011.

Institute for Clinical Systems Improvement (ICSI). Health Care Protocol: Prevention of Falls (Acute Care). Bloomington, MN: ICSI; April 2010.
Joint Commission. Speak Up: Reduce your risk of falling [brochure]. http://www.jointcommission.org/assets/1/18/Speakup_falls_brochure.pdf. Accessed January 31, 2011.

John Jorgensen is a medical-surgical clinical practice specialist at Covenant Health in Knoxville, Tennessee.

How to build a successful business case for a falls-reduction program

By Joan Forte, BSN, MBA, NE-BC

Nurses often feel they are out of their league when it comes to convincing the hospital’s business units to support a new program, such as falls reduction. But building a business case follows the nursing process: assess, plan, implement, and evaluate. Critical thinking is
essential throughout the process, and after evaluation, data are used to start the cycle again. This article guides nurses in creating a business case, using a safe patient-handling (SPH) program as an example.

At Stanford Hospital and Clinics in Palo Alto, California, the nursing department created a solid business case for an SPH program, including measures to reduce falls. In October 2008, we received more than $3 million to create the program, then designed and implemented it with the support of the risk management department.

Understand the healthcare environment

The first step in building the business case is to gain a clear understanding of the challenges hospitals face today, such as higher costs and pressure to stay competitive. Acknowledging and addressing these challenges will boost your credibility with administrators.

Obtain relevant data

In an evidence-based culture, data are needed to drive acceptance. The ability to examine the evidence in favor of a particular program is a critical skill. You must be prepared to answer this question: Why is the program you’re proposing so important to this facility?

Both national and on-site data may be available to help you build your case. Examples of data you might want to include are musculoskeletal disorders in healthcare workers. At Stanford, for instance, costs related to employee injuries were documented but not well known. These statistics weren’t in a well-understood format and hadn’t been made available to the nursing department or hospital executives. To present the business case, we used simple bar graphs showing aggregate workers’ compensation costs tied to patient handling. (See Workers’ compensation costs related to patient handling by clicking the PDF icon above.)

These graphs were powerful tools for educating administrators about the hospital’s current state and the ramifications of not supporting the SPH proposal. Also, the literature showed other SPH programs could increase staff and patient satisfaction, boost staff and patient safety, and improve a hospital’s reputation. So be sure to do your homework and document the full range of benefits your proposal could yield.

Be honest about implementation costs

Data related to the full cost of project implementation is important in building a strong business case. While it’s tempting to underestimate costs or omit those that aren’t immediately obvious, doing this will only weaken your case.

The cost of required equipment or technology may be the first expense considered, but it’s rarely the only one. Be sure to consider the cost of any education, labor, systems redesign, or workflow changes your proposal might necessitate. Stanford’s SPH program had three main components that drove the expense of the full program:

• Engineering controls: costs of equipment and maintenance as well as the 2-day equipment fair where staff from all units were able to evaluate the equipment and provide input on equipment and vendor selection. The cost of the fair was minimal.
• Administrative controls: costs of training 175 “super users” and 1,963 patient-care staff members on use of the required SPH equipment and the program principles
• Compliance controls: daily rounding on different shifts by a master’s-prepared nurse to provide support and reinforcement; her salary is part of the program’s ongoing cost.

A full and honest assessment and estimate of costs shows decision makers your proposal is well thought-out and your numbers can be trusted.

Know the basic financial model

Most organizations depend on a simple internal rate of return (IRR) for decision making. IRR is used to measure and compare the profitability of different investments; the higher the IRR, the more desirable the project. IRR is calculated by taking the expected revenue minus annual expenses, then dividing the result by the total initial cost of investment. The finance department usually completes this analysis based on information provided by clinicians.

But the analysis is only as good as the information you provide. Consider possible revenue attained through billing, as well as cost avoidance and savings related to regulations and fines, less litigation resulting from patient falls, and fewer instances of lost reimbursement for care related to preventable falls. Stanford’s program had an IRR of 28% based only on reduction of workers’ compensation costs by 30% during the first year. Additional savings related to “soft” costs were more difficult to quantify.

Although the IRR was crucial in gaining support for Stanford’s SPH program, the knowledge that additional cost savings would accrue drove the proposal’s supporters to quantify “soft” costs and hard-to-project costs. Examples include costs related to:

• reduction in the patient fall incidence
• decrease in pressure ulcer incidence
• increased patient satisfaction
• improved employee satisfaction.

Stanford Risk Consulting, a branch of our risk management department, worked with the Strategic Decisions Group to find a way to deal with the uncertainty of future benefits in these areas and to understand how to increase total value of the program—the sum of many contributing factors, such as reduced cost of caring for injured employees, lower staff turnover, and reduced recruitment costs; all of these increase the value of the proposed program. They used decision analysis (DA), a proven method for understanding uncertainty in
future value. It also helps identify which factors are the most important drivers of program value. Through the use of DA, the expected value of Stanford’s SPH program rose to $5.2 million.

Make the pitch

Once you’ve built your case, you must take it to stakeholders. While administrators may be the decision makers, other departments have an investment in and influence over the proposal. At Stanford, the rehabilitation, transport, housekeeping, infection control, and facilities departments would all be affected by the SPH program. So we educated staff in these departments, knowing we were also educating and influencing the vice presidents to whom they reported.

Other lobbying strategies used at Stanford included:

• • saturating the market and remessaging it, by identifying whom we had to “market” the idea to and making sure to communicate the message to these people more than once and in different ways
  • responding quickly to requests to present the initiative
  • connecting the proposal to other hospital priorities or initiatives
  • being familiar with the data used to calculate the IRR
  • finding stories about individuals who could be helped by the program and using their stories to make the data come alive.

Acknowledging barriers up front also can strengthen your case. All hospitals have to deal with competing priorities. Your organization may have difficulty sustaining initiatives—either because new priorities take precedence or because it’s hard to maintain resources and motivation from year to year. Some organizations work in self-contained “silos,” and departments that need to collaborate on an important project may communicate poorly or even see themselves as competing. This results in poorly implemented programs. Also, timing of the initiative may not be ideal or space constraints may exist. Whatever you think your problems might be, have a reasonable plan to address them up front in your proposal.

Evaluate the program after implementation

Once a program is funded, there’s a tendency to move it into implementation and not report back to stakeholders on whether results were delivered. It’s crucial to evaluate the program and report the results objectively, for two reasons:

• • • Evaluation yields insight into what modifications may be needed to improve the program.
    • Providing information to decision makers acknowledges their support and provides an excellent platform for future efforts. Building a successful track record creates trust in your ideas and ability to design successful strategies that deliver as promised.

At the end of the first year (2010), Stanford’s SPH program showed impressive results. It reduced workers’ com­pensation costs by 40% (a savings of $333,392) through decreases in the number of nurse injuries and reduced severity of those injuries.

As for “soft” costs, there have been no patient claims or litigation related to falls from program implementation in September 2009 to December 2010. Also, Press Ganey scores on the question “help getting up to the bathroom” have risen consistently. What’s more, our annual Gallup employee satisfaction survey found a 6.3% increase in satisfaction in response to the statement, “I have the equipment I need to do my job.”

At Stanford, we created a solid business case for a clinical program by showing safe patient handling is right for the caregiver, the patient, and the business of health care. Nurses in every role are powerful patient advocates. Our advocacy must extend past the bedside to the boardroom. Learning how to build a strong business case for an SPH program and knowing how to garner support are fundamental to your role in delivering safe patient care.

Joan Forte is the director of patient care services at Stanford Hospital and Clinics in Palo Alto, California.

Components of a comprehensive fall-risk assessment

By Carole Kulik, MSN, RN, ACNP, CRNP-BC

Up to 50% of hospital patients are at risk for falls, and those who fall commonly have longer hospital stays. Even more alarming, during the first month after discharge, injuries related to falls account for about 15% of all readmissions.

As the number of patient risk factors increases, so does the likelihood of falling. Therefore, identifying patients at risk for falling can significantly improve a hospital’s fall rate. Yet fall-risk assessment alone isn’t enough; it’s just one piece in an overall falls-reduction plan. Following through with strategies to reduce patient risk based on assessment findings is crucial for healthcare facilities as a whole and for individual healthcare professionals.

For an effective falls-reduction program, healthcare providers must use appropriate assessment tools consistently, improve communication and education related to falls, and institute a plan of care. The plan must be individualized to each patient and include interventions that address specific factors identified in the risk assessment. Including the patient’s family and the interdisciplinary team is crucial. The plan should call for regular patient assessment and reevaluation, mobility monitoring, exercise alternating with rest, safe toileting practices, maintaining a safe environment, medication evaluation, educating the patient and family about falls, and communicating adequately with other care providers.

Risk categories

The patient’s fall risk should be assessed on admission, when­ever a change in physical or mental status occurs, on transfer, and before discharge. Tools are available to aid risk-factor assessment. (See Risk-assessment tools by clicking the PDF icon above.)

Risk factors for falls break down into two categories:

• • • Intrinsic factors are patient-related and encompass such physiologic conditions as vision disturbances, dizziness, incontinence, muscle weakness, mental impairment, gait and balance disorders, polypharmacy, and older age.
    • Extrinsic factors are environmentally related and include room clutter, loose electrical cords, and spills.

Assessment components

A patient’s fall risk can be decreased through a comprehensive medical assessment, medication review and management, environmental safety assessment and modification, and exercise and safety programs.

Staff must follow through with actions that address the identified risks.

Medical assessment

Medical assessment should include simple tests of vision, hearing, mobility, peripheral sensation, muscle force, reaction time, gait, and balance. Many acute and chronic medical conditions increase the risk of falls. Stay alert for a history of agitation, delirium, orthostatic hypotension, impaired mobility or vision, dizziness, physical weakness, and a recent history of falls.

Medication review and management

Assess and reassess the patient’s medications, as needed. Medications most likely to increase the risk of falls include benzodiazepines, antipsychotics, diuretics (partly because they cause frequent urination), antidepressants (particularly tricyclics), neuroleptics, opioids, insulin, and oral hypoglycemics. Cardiac drugs and antihypertensives also increase the fall risk because they can cause an orthostatic blood pressure drop.

Environmental assessment

To help ensure patient safety and a safe care environment, conduct a 360-degree overview of the patient’s room each time you enter and leave. Give the patient a chance to speak up to express a need or make a request.

Conduct the environmental assessment in light of history findings and the patient’s personal preferences. For example, ask how frequently the patient voids; this knowledge can help staff ensure an unobstructed path to the bathroom and plan for timed interventions. Keep the room temperature comfortable so the patient
isn’t tempted to get out of bed to make adjustments.

Follow these additional guidelines to help make the environment safe:

• • • Eliminate environmental hazards, such as clutter, inappropriate lighting, and flooring problems (such as dampness or uneven surfaces).
    • Keep the bed in a low position with wheels locked and side rails down (or per facility policy). When side rails are up, falls may be more likely, as some patients try to climb over them to get out of bed. Keep the bed at the right height to minimize the risk of falls—100% to 120% of the patient’s lower leg length.
    • Arrange objects according to patient preference and requirements. Keep
      the call light, TV remote control, and personal items within the patient’s reach and provide easy access to eyeglasses, dentures, and hearing aids.
    • Keep such equipment as I.V. poles, oxygen tubing, and plugged-in devices out of the patient’s pathway.
    • Make sure a walker, cane, or other mobility aid (if needed) is fitted appropriately to the patient.
    • Have the patient wear safe, well-fitting footwear.
    • Keep hallways and railings unobstructed.
    • Know that for a safe bathroom environment, toilets should be raised, toilet seats should be secure, and handrails should be strong enough to support the patient.

Exercise and safety

Assess the patient’s energy level. In most cases, exercise and other patient activities should be scheduled for the morning, when energy and endurance levels are higher. Evaluate the patient’s energy and endurance throughout the day, as fatigue may contribute to an increased risk of falls.
Using tools to assess fall risk is a primary prevention method for keeping patients safe and establishing a culture of safety. Incorporating risk-assessment findings into the patient’s plan of care promotes safety through best practices.

Selected references

Conley D, Schultz AA, Selvin R. The challenge of predicting patients at risk for falling: development of the Conley Scale. Medsurg Nurs. 1999;
(6):348-354.

ECRI Institute. Medication safety. Healthcare Risk Control. November 4, 2007: Pharmacy and medications 1:1-31.

Hendrich A. How to try this: predicting patient falls: Using the Hendrich II Fall Risk Model in clinical practice. Am J Nurs.2007;107(11):50-58.

Mahoney JE, Palta M, Johnson J, et al. Temporal association between hospitalization and rate of falls after discharge. Arch Intern Med. 2000;
160(18):2788-2795.

Medication assessment: one determinant of falls risk. Pa Patient Saf Advis. 2008;5(1):16-18.

Rowland M, Tozer TN. Clinical Pharmacokinetics and Pharmacodynamics. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.

Schwendimann R, De Geest S, Millisen K. Evaluation of the Morse Fall Scale in hospitalised patients. Age Ageing. 2006;35(3):311-313.

Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and nonfatal falls among older adults. Inj Prev. 2006;12(5):290-295.

VA National Center for Patient Safety. www.patientsafety.gov. Accessed February 11, 2011.

Carole Kulik is director of Patient Care Services, Professional Practice and Education at Stanford Hospitals & Clinics in Stanford, California.

Focusing on staff awareness and accountability in reducing falls

By Carol Payson MSN, RN, NE-BC; Ashley Currier, BSN, RN, CMSRN; and Marisa Streelman, BSN, RN, CMSRN, OCN

Evidence suggests many falls can be prevented in acute-care settings. Despite our organization’s persistent efforts to improve outcomes, our fall rate remained above the best decile performance for falls of the National Database of Nursing Quality Indicators®. We knew we needed a comprehensive organization-wide approach to address staff awareness and accountability for falls and related injuries.

In our ongoing effort, we’ve successfully integrated safety into our patient-centered care model. Falls prevention is a universal goal throughout the organization—not a separate program that applies only to certain patients. This structure holds staff members accountable for patient safety. Increased staff accountability and awareness promotes a consistent approach to reducing harm to patients at the unit level. All employees know that keeping patients safe is everyone’s responsibility; each person plays a crucial part. Our strategy promotes a climate of transparency that helps everyone learn from falls, which in turn can help prevent future falls.

Staff accountability begins with engaging all staff in understanding why all patients are at risk for falling. It continues with giving staff the knowledge and ability to articulate this risk with patients and families. Also, staff members receive support when they experience challenging situations (for example, when a patient refuses to adhere to safety interventions). Managers and the falls-prevention team carry out inspections, comparing documentation of interventions with in-room assessments. Real-time feedback and coaching realign expectations of staff.

Role of champions

In our facility, falls-reduction champions were recruited on each care unit to help engage their teams to identify at-risk patients, select and implement appropriate interventions, and transition patients safely from one risk level to another. When a fall occurs, champions assist with appropriate action and follow-up. Leading post-fall “safety huddles,” they partner with the clinical coordinator to enlist all unit staff to participate in a mini–root cause analysis. Besides making all staff aware that a fall has occurred, this analysis serves as an opportunity to discuss learning opportunities related to the event and helps nurses create an optimal individualized plan of care using targeted interventions to keep the patient safe for the
remainder of his or her stay. Post-fall huddles commonly involve direct-care staff, but also may include physical therapists, unit secretaries, and even environmental services staff.

Anticipating and coordinating care

Our model focuses on anticipating and coordinating care and engaging patients and families. We do this through:

• • • bedside handoffs at shift change
    • individualized goal setting
    • “careboard” (whiteboard) communication
    • hourly rounds
    • safety huddles.

A key component of these activities is discussion of the patient’s risk of falling and optimal safety interventions. Bedside reporting helps the nurse on the oncoming shift visualize the patient and environment during handoff, ensuring appropriate safety interventions are activated and in place. It also allows the patient and family to get involved in planning and participating in the patient’s goals and safety plans for the day.

Hourly rounds are particularly helpful in preventing falls, as they help staff anticipate and address patient needs. We encourage direct-care staff to prompt the patient for assistance to the bathroom, repositioning, or obtaining personal items. We’ve found that the more our patients see their caregivers, the less likely they are to try to ambulate or perform toileting without assistance.

In twice-daily safety huddles, staff discuss patients at highest risk for falls. The departing shift relates anticipated concerns or needs to the oncoming shift. (See How safety huddles and careboards can improve patient outcomes by clicking the PDF icon above.)

Education and training

Education and training occur in multiple venues. We support our staff through messaging (articulating the “why”), mentoring (real-time coaching and feedback), and modeling (ensuring falls-champion representation from all areas). With our dynamic shared-leadership structure and unit-based quality committees, targeted education and data-sharing are ongoing and contribute to improved outcomes.

We partnered with technology experts to increase awareness of patient mobility-related risks, medication effects, and acute mental-status changes (such as delirium). This approach helps nurses assess patients appropriately. (See The fight against falls: Risk assessment and actions by clicking the PDF icon above.)

Refining the patient-assessment process

In 2007, we realized the fall-risk assessment in the electronic medical record was missing key components that contribute to patient falls. So we modified the assessment to include information about acute changes in mental status and functional mobility. We incorporated data from the confusion assessment method (CAM, a bedside tool to detect acute mental-status changes and delirium signs and symptoms) and the short portable mental-status questionnaire (SPMSQ). Mental status can change quickly (even in a patient with normal cognitive functioning on admission). Therefore, we decided staff should assess patients for mental-status changes daily. Thus, CAM and SPMSQ are completed on all patients daily, as well as on admission. The SPMSQ alerts nurses on admission that a particular patient might be at high risk for falling due to altered cognitive function. Another change was to include the patient’s list of current medications in the falls assessment; now caregivers can see at a glance if the patient is receiving fall risk-increasing drugs (FRIDs).

Functional mobility assessment

With the help of physical therapists, we developed a functional mobility assessment to be completed daily on all patients; results are added to the fall-risk assessment form. This assessment has six progressive steps for identifying a patient’s mobility level. It starts with independent sitting and moves to dangling, kicking and pointing, standing, stepping forward and stepping back, and walking independently. Incorporating these components into one form created a more comprehensive assessment and a more systematic approach to preventing falls.

Education for all staff members

We conducted organization-wide training to educate staff about the technology-related changes—and to change our culture to one where everyone takes accountability for patient safety. We emphasized the need for bedside nurses to think critically about their crucial role in fall prevention. With the help of experts, we developed
a 3-hour education session to disseminate information on CAM and SPMSQ, functional mobility, and FRIDs, along with an explanation of how to complete the new falls assessment. Medical-surgical, oncology, neurology, and intensive-care unit nurses attended the training. Support for training came from our educational department, the Northwestern Memorial Academy.

The falls task force educated selected staff nurses to help train other staff in a “train-the-trainer” format; this led to the creation of “super-users.” The training delved into the fundamental reasons our patients were falling and raised bedside nurses’ awareness of how they can help prevent falls.

Education related to acute mental-status changes focused on defining the differences between dementia and delirium, identifying patients at risk, and choosing appropriate interventions to maintain patient safety and help reorient patients. For functional mobility, educational objectives included reinforcing how to complete an
effective mobility assessment, evaluate a patient’s ability to move through the six steps of functional mobility assessment, and identify interventions for each step. This teaching was delivered through video clips of the six steps and a discussion of case studies. Education on medication effects focused on identifying patients at high risk for falls based on their medication profile and implementing interventions to prevent falls by decreasing the patient’s FRIDs.

Outcomes

After education sessions, staff showed an increased awareness of falls and a sense of urgency toward fall prevention they didn’t have before the training. These sessions proved successful, resulting in a decreased fall rate throughout the organization—from 2.9 to 2.1 per 1,000 patient days.

We continue to raise the bar to keep patients safe. Literature and our own data show all inpatients are at an elevated risk for falling at some time during their stay, simply because they’re in a new environment, receiving medications, and undergoing medical procedures. Knowing that falls occur in patients of all ages and both sexes and across the spectrum of functional mobility status and cognition, we put in place a standardized set of interventions. We continue to educate bedside nurses to think critically about safety and take ownership of falls prevention on their units and with their patient populations. We’re seeing more professional accountability, as demonstrated by staff calling safety huddles, conducting post-fall assessments and unit-level root cause analysis, and sharing data and lessons learned with other colleagues.

Storytelling

We use the power of storytelling to engage the hearts of our staff and remind them that falls can happen to anyone regardless of age, mental status, or mobility status. We also use storytelling to promote our culture of transparency. With this approach, staff learn through each other’s experiences, both positive and negative, and we have created a safer environment as everyone works collaboratively. Our organization acknowledges errors as learning opportunities that help us modify our practice to ensure safety.

Partnering with patients and families

We’ve used similar strategies with patients and families, with the goal of helping them keep themselves safe in the hospital. By explaining to patients why they are at risk for falling and how they can benefit by following safety interventions, we raise their awareness that falls can happen to anyone at any time.

Enhancing the partnership between the care team and the patient and family is an important part of our strategy. Our role is to transition patients safely from the inpatient setting back to the home or other care facility. We want them to stay safe while in our care, and we teach them ways to stay safe after they leave the hospital. We’ve found great value in taking the time to explain the “why” behind our actions—and this has created a strong partnership between the care team and patient.

We continue to evolve, moving our organizational culture toward a full understanding that all patients are at risk for falling and that falls aren’t acceptable in the hospital. Each day we strive to move closer to zero falls. With our concentrated interdisciplinary efforts, we believe this is now a more realistic goal.

Selected references

Dykes PC, Carroll DL, Hurley AC, Benoit A, Middleton B. Why do patients in acute care hospitals fall? Can falls be prevented? J Nurs Adm. 2009;39(6):299-304.

Harrington L, Luquire R, Vish N, et al. Meta analysis of fall-risk tools in hospitalized adults. J Nurs Adm. 2010;40(11):483-488.

Inouye SK, Van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990; 113(12):941-948.

Joint Commission. National patient safety goals. http://www.jointcommission.org/standards_information/npsgs.aspx. Accessed February 8, 2011.

Kolin MM, Minnier T, Hale KM, Martin SC, Thomspson LE. Fall initiatives: redesigning best practice. J Nurs Adm. 2010;40(9):384-391.

The authors work at Northwestern Memorial Hospital in Chicago, Illinois. Carol Payson is patient care director. Ashley Currier and Marisa Streelman are patient care managers.

Creating a culture of safety: Building a sustainable falls-reduction program

The Magnet™ Model’s five components can serve as the program’s framework.

By Sharon Stahl Wexler, PhD, RN, GCNS-BC; Catherine O’Neill D’Amico, PhD, RN, NEA-B; and Elizabeth Rolston, MA, MS, RN

Among the most common errors reported in hospitals, falls account for up to 30% of adverse events reported to regulatory agencies. In older adults, roughly 10% of fatal falls occur in hospitals. The Centers for Medicare and Medicaid Services (CMS) has identified falls and related injuries as “never events”—hospital-acquired conditions whose related expenses CMS no longer pays. Preventing harm from falls is one of the Joint Commission’s national patient safety goals; to meet the Commission’s accreditation standards, hospitals must implement a falls-prevention program.

No easy method exists for sustaining a falls-prevention program. Nor is there an ideal fall-risk assessment tool applicable to all settings. But a recent pilot study in a community academic medical center found that a multifaceted approach can reduce falls significantly.

Embracing a culture of safety begins with a recommitment to a professional practice model that puts the patient and family at the center of care. We recommend facilities use the Magnet™ Model of the American Nurses Credentialing Center (ANCC) to develop and sustain a falls-prevention program in acute-care settings.

The nurse-patient relationship centers on unconditional positive regard and individualized care. If a patient falls, positive regard may weaken and the patient may lose the sense of protection and safety perceived as integral to the hospital setting. At the same time, the nurse may feel guilty after a patient falls. Some nurses may even blame the patient for falling, in the belief that the patient disregarded important teaching. And ongoing reinforcement of safety and falls prevention may make the patient fear falling.

Magnet Model as the framework

Excellence in clinical nursing practice, patient care, and safety are the hallmarks of ANCC’s Magnet Recognition Program®. The Magnet Model provides a framework for developing a falls-prevention program that consistently yields high-quality patient outcomes and sustains and demonstrates a culture of safety in acute-care settings.

The Magnet Model has five components: (1) transformational leadership; (2) structural empowerment; (3) exemplary professional practice (EPP); (4) new knowledge, innovation, and initiatives; and (5) empirical outcomes. Implementing a sustainable falls-reduction program encompasses five steps that reflect these components.

Step 1: Transformational leadership: Getting the organization’s commitment

The first step is to obtain the organization’s commitment. Positioning falls reduction as a major goal recognizes the problem and alerts all staff to the importance of the initiative. Recognizing it as a priority also may garner a greater commitment of human and material resources.

To attain organizational support, initiative sponsors should collect and analyze data pertaining to the incidence of falls in the facility, with a description of fall type and severity, population most affected, and most common injuries. Such data help identify a reasonable cost-benefit analysis for preventing rather than treating falls and injuries—as well as identifying factors that may be unique to the facility, staff, or patient population. Gathering such data before the falls-reduction program is established aids the literature search to be done during step 3, by providing potential key words and phrases for the search.

Step 2: Structural empowerment: Establishing a falls-reduction council

Forming an interdisciplinary committee that includes frontline caregivers is the next step in establishing a falls-reduction program. Designating this committee as a falls-reduction council (FRC) positions it as a continuing forum that helps sustain the program. The council initiates and sustains subsequent steps.

The FRC should include nurses at all levels, nursing assistants, unit clerks, and representatives from other services, such as medicine, physical therapy, pharmacy, nutrition, housekeeping, transportation, and risk management. This diversity promotes the gathering of ideas and evidence from all corners of the organization and makes more personnel accountable for preventing falls and related injuries. Each FRC member brings specific knowledge from his or her discipline and can take the council’s work back to his or her own department.

Step 3: EPP: Putting the evidence to work

EPP requires that organizations demonstrate a culture of safety, interdisciplinary collaboration, evidenced-based practice, benchmarking, and quality improvement. It challenges them to demonstrate how direct-care nurses collaborate with other disciplines to ensure comprehensive, coordinated, collaborative care. Organizations must provide empirical outcomes to show how they outperform national-database benchmarks related to all safety issues, including falls.

Thus, the next step is to identify clearly defined program goals. This helps FRC members focus on the work that needs to be done, evaluate the program’s progress, and determine when goals have been achieved. Goals should derive from the falls data collected earlier, which establish a baseline for comparing the success of the interventions and policy and procedural changes subsequently put in place.

During step 3, a search for literature on patient falls and falls with injury in acute-care settings should be conducted so the most recent evidence can be incorporated into organizational policies and practices. After this search, the FRC discusses and analyzes the information and current evidence-based practices. This step is central to creating the structure and processes that ensure the group begins to “own” its clinical nursing practice as it helps the FRC become a cohesive body. Nursing staff at all levels and other FRC members are encouraged to discuss and share the evidence with staff in their respective units or departments. Such discussion and evidence distribution provide feedback to the FRC and help it adapt recommendations from the literature to the facility’s culture and environment. During this working phase, FRC members develop and revise policies, protocols, and tools related to reducing the incidence of falls and injuries based on the evidence and feedback from others in the organization.

Step 4: New knowledge: Designing the falls-reduction program

Once major structures are established, core components of the falls-reduction program should be determined based on policies and procedures developed from the evidence. Policies and procedures need to be introduced to all staff; in many cases, staff education is required as well to ensure compliance and proper initiation. During this phase, FRC members, staff educators, and advanced practice nurses help others in the organization understand the evidence and its relationship to the new policies and procedures so they can apply the new standards of care to their practices.

Step 5: Empirical outcomes: Continuous quality-monitoring tools

The next step is to design or select quality-monitoring tools to provide ongoing feedback on the program’s success. Goals and objectives set at the beginning of this process serve as the basis for developing unit- and facility-based monitoring tools. Organizational leaders will look to the FRC to measure the program’s success against previous performance and nationally recognized benchmarks. To monitor overall outcome, a unit or the facility as a whole may decide to develop new tools or customize tools from national organizations. Customizing tools may make it easier to report program successes.

The FRC continues to meet regularly to examine data, identify trends in falls and injuries, and determine if particular units require more education or assistance to carry out policies. Such data should be made available to staff members who provide direct patient care. (See Hardwiring falls reduction into the organization by clicking on the PDF icon above.)

Celebrating excellence

After a suitable period of data collection and trend evaluation, the FRC determines if the program is a success or if additional work needs to be done. If it’s deemed a success, the FRC may be disbanded or incorporated into the facility’s quality monitoring processes.

The facility should celebrate the success both of individual units and the FRC. Celebrating excellence provides an impetus to continue the initiative and start other initiatives to show the facility’s overall commitment to excellent care. Success should be celebrated at an institutional level.

This approach to falls reduction supports ANCC initiatives for a multidisciplinary team approach and involvement of direct caregivers in improving patient care. 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.

Selected references

American Nurses Credentialing Center (ANCC). Overview of ANCC Magnet Recognition Program® New Model. Silver Spring, MD: ANCC; 2008. www.nursecredentialing.org/Documents/Magnet/NewModelBrochure.aspx. Accessed January 27, 2011.

Cameron ID, Murray GR, Gillespie LD, Robertson MC, Cumming RG, Kerse N. Interventions for preventing falls in older people in nursing care facilities and hospitals. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD005465.

Centers for Disease Control and Prevention. Web-based injury statistics query and reporting system (WISQARS™). Accessed January 27, 2011.

Coussement J, De Paepe L, Schwendimann R, Denhaerynck K, Dejaeger E, Milisen K. Interventions for preventing falls in acute- and chronic-care hospitals: a systematic review and meta-analysis. J Am Geriatr Soc. 2008; 56(1):29-36.

Eldridge C. Evidence-Based Falls Prevention: A Study Guide for Nurses. Danvers, MA: HCPro, Inc.; 2004.

Gray-Miceli D. Preventing falls in acute care. In: Capezuti E, Zwicker D, Mezey M, Fulmer T, eds. Evidence-Based Geriatric Nursing Protocols for Best Practice. 3rd ed. New York. NY: Springer; 2008:161-198.

Harrington L, Luquire R, Vish N, et al. Meta-analysis of fall risk tools in hospitalized adults. J Nurs Adm. 2010;40(11):483-488.

Joint Commission. National patient safety goals. 2010. www.jointcommission.org/assets/1/18/NPSG_Chapter_Outline_FINAL_HAP_2010.pdf Accessed January 27, 2011.

National Quality Forum (NQF). Serious Reportable Events in Healthcare, 2006 Update: A Consensus report. Washington, DC: NQF; 2007.

Oliver D, Healy F, Haines T. Preventing falls and fall-related injuries in hospitals. Clin Geriatr Med. 2010;26(4):645-692.

Stevens JA, Mack KA, Paulozzi LJ, Ballesteros MF. Self-reported falls and fall-related injuries among persons aged = 65 years—United States. 2006. MMWR. 2008;57(9):225-229.

Wexler SS, D’Amico CO, Foster N, Cataldo K, Brody P, Huang Z. The ruby red slipper program: an interdisciplinary fall management program in a community academic medical center. Medsurg Nurs. In press.

Sharon Stahl Wexler is an assistant professor at Pace University’s Lienhard School of Nursing in New York, New York. Catherine O’Neill D’Amico is an assistant professor at Hunter-Bellevue School of Nursing in New York, New York. Elizabeth Rolston is director of Nursing Education, Research, and Performance Improvement at Mount Sinai Queens Hospital in Long Island City, New York.

Current and emerging innovations to keep patients safe

Technological innovations play a leading role in falls-prevention programs.

By Patricia Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP, and Lisa Goff, MSPT

Evidence shows that the most effective falls-prevention programs for healthcare organizations are multifactorial and interdisciplinary. For optimal effectiveness, an organization-wide program should incorporate patient-safety equipment and devices, including both current and emerging innovations as appropriate. This article describes types of falls and patient assessment, then gives an overview of technological innovations healthcare organizations can use to promote patient safety.

Categorizing falls

Falls occur in several types:

• • • Accidental falls result from external environmental factors, such as clutter, tubing, or spills that cause the patient to slip or trip.
    • Anticipated physiologic falls stem from known intrinsic factors (such as orthostasis, dementia, and gait or balance deficits) or extrinsic factors (for instance, certain medications or improper ambulatory aids).
    • Unanticipated physiologic falls are caused by unexpected or unknown medical episodes (such as sudden myocardial infarction, stroke, syncope, or seizure). These falls can’t always be prevented—one reason why organizations can’t expect to achieve a 0% fall rate.
    • Intentional falls occur when patients intentionally fall to the floor, as when acting out behaviorally.

When healthcare providers at all levels and in all roles understand the different types of falls, the effectiveness of falls-
prevention programs can be evaluated. While unanticipated physiologic falls and intentional falls generally aren’t preventable, accidental and anticipated physiologic falls are, at least in many cases. To prevent accidental falls, an organization must create and sustain a safe, clean environment, confirmed by environmental checks on hourly nursing rounds. Preventing anticipated physiologic falls requires interdisciplinary assessment and management, with nurses taking leadership.

Assessment

Before appropriate technology and equipment can be chosen to help prevent falls, the patient’s fall risk, functional readiness, and mobility must be assessed. (See After the fall.) Fall risk is multifactorial and complex, so patient assessment must be multifactorial as well. It should be built on initial risk-screening results and involve not just nurses but an interdisciplinary team of physicians, pharmacists, and physical and occupational therapists.

To evaluate functional mobility, assess the patient’s ability to move to a standing position, sit, transfer from one surface to another, turn, reach, and ambulate. To evaluate balance and gait, use both history findings and functional mobility assessment. Relevant history findings include factors that suggest an increased fall risk (for instance, a history of peripheral neuropathy or a recent fall). Also review the patient’s current medications for those that may affect balance, cognition, gait, or lower-extremity sensation or that promote orthostasis. If the patient takes any of these drugs, caregivers need to have access to safe mobility equipment so they can intervene quickly if the patient starts to fall.

Assessment also helps identify the need for transfer aids, such as lifts. (See Algorithms to aid patient safety, by clicking the PDF icon above.)

Patient transfers

Even when using technological aids, caregivers still have to ensure safe patient transfers. Nurses may perform various transfers, such as those described below.

• • ,li>The

squat pivot transfer

• • can be used for a patient who’s too weak to stand. The patient rises from a sitting position to a partial stand to keep the center of gravity relatively low.
    • The stand pivot transfer resembles the squat pivot transfer, except the patient pushes up to a full standing position. For safety, transfer the patient to the stronger side with the wheelchair at approximately a 45-degree angle from the bed.
    • The lateral scoot with transfer board can be used for patients unable to bear weight through the lower extremities due to weakness, paraplegia, spinal-cord injury, or amputated limbs or after orthopedic surgery necessitated by trauma. For this transfer, place one end of the transfer board under the patient between the buttocks and back of the thigh; place the other end in the chair seat. Have the patient push up with the arms while slightly lifting the buttocks and slowly moving toward the wheelchair. For proper weight distribution, instruct the patient to lean the head and shoulders in the direction opposite the movement.

Gait belts

Some care providers prefer to use a gait (transfer) belt to hold the patient more securely during transfer tasks, such as remaining seated and sliding from one surface to another; obtaining a standing position; turning and sitting onto another surface; or standing, walking to a new location, and then turning and sitting onto a new surface. The belt is a better choice than the alternative—placing one arm under the patient’s arm for the lift and holding onto the patient’s clothing or gown, which can injure the arm or shoulder. The nursing staff should consult a physical or occupational therapist to provide a training class to ensure the competency of all nurses before they attempt transfers they believe may not be safe.

Bed and toileting safety

Height-adjustable beds, safety rails, and raised toilet seats can reduce falls associated with bed mobility and toileting. Many hospitals instruct nursing staff to keep height-adjustable beds in the lowest position to reduce the distance a patient may fall from the bed. But many older adults have muscle weakness that causes difficulty safely standing from a low-bed position. Therefore, maintain the bed at a height that allows the patient to sit on the edge of the bed with knees flexed 90 degrees and feet planted firmly on the floor for better balance. To promote safety when the patient stands or for transfers, raise the bed higher. Otherwise, a weak patient who tries to stand could fall back onto the bed or, even worse, the floor. Bed and transfer safety requires an important modification—installation of a half side rail.

Similarly, for safe standing and transfers onto and off a toilet, fixed raised toilet seats and safety rails on either side of the toilet are needed. Patients can hold onto these to steady themselves when transitioning from a standing to a sitting position, and to push off from while standing after toileting. Of course, if the patient is unable to safely ambulate with assistance to the bathroom, provide a bedside commode.

Bed and chair alarms

Available since the early 1990s, bed and chair alarms are another tool that can help keep patients safe. Some hospital beds have “brake-not-set” alarms that sound to alert staff. Alarms also warn patients, family, and staff when a patient moves without assistance. They serve as early-warning devices that alert caregivers when a patient tries to get out of bed or get up from a chair. Alarms may be located in pads placed on chairs, on wheelchairs, on beds, or in the bed’s special features. Some alarms attach to an ankle or other body part.

Alarm features and settings vary. The alarm may sound when the patient moves, nears an edge, or releases a strap. The nursing staff can set alarm features to the patient’s specific needs. Some alarms have both audible and visual features, so the alarm can be silenced while the visual flashing feature remains intact (as with the call-light system). Some beds connect directly to the hospital’s data system, enabling information display at the nurses’ station and direct notification of the nurse by remote device, which saves walking time. For example, if a patient’s side rail is down when it’s supposed to be up, the alarm notifies the nurse of the problem. Some alarms even measure how much time elapses from alarm generation to rescue.

During a patient’s episode of care, nurses can correlate alarm patterns with patient needs, such as toileting or wandering patterns. This helps them anticipate patient needs and ultimately may help prevent falls. The alarm promotes quick rescue, preventing prolonged episodes of a patient lying on the floor after an unwitnessed fall, for instance. Falls occur so quickly that the truest measure of alarm effectiveness may be timeliness of rescue rather than fall prevention.

Smart beds

Available for medical-surgical and critical-care units, “smart beds” offer a range of technological features to help prevent falls. These beds may communicate by wires or wirelessly into the nurses’ call system, providing a variety of data, such as patient weight, brake settings, and position of bedrails and head of the bed. (See photo below.) Other examples of smart-bed capabilities are the ability to transmit surface data, as when vibration or rotation therapy is engaged, and use of turn assist to help nurses position patients more easily. Data can be displayed on an electronic board in the unit’s central station. From there, nurses can change settings, such as rotation mode and alerts.

Smart-bed data, such as the time when the patient was turned, also enter the patient’s electronic health record, saving charting time. Data can be aggregated for quality-improvement initiatives—for example, ensuring caregivers comply with recommendation to elevate the head of the bed for intubated patients to help prevent ventilator-associated pneumonia. Hospitals considering purchasing smart beds need to carefully compare the options to determine benefits, connectivity with the nurses’ call system, clinical needs, and costs.

Mobility devices

Various mobility devices can assist with ambulation (such as canes and walkers) and wheelchair mobility (such as electric wheelchairs, manual wheelchairs, and scooters). If a patient arrives on your unit with such a device, make sure it has been evaluated and deemed appropriate and in good working order. If it isn’t at the proper height for the patient, has broken brakes or is missing rubber caps at the ends, contact a physical therapist for further evaluation. All mobility devices should be adjusted to the patient’s height and other characteristics as appropriate.

Standard canes provide balance assistance. They’re available in various handgrips, weights, and heights. An adjustable cane is recommended so it can be adapted to the patient’s hip height.

Walkers

Walkers come in various forms: standard walker, two-wheeled walker, four-wheeled walker, four-wheeled walker with a seat, and U-shaped walker. U-shaped walkers, which provide increased stability, have been available since the 1990s, but you may not be familiar with a specific type called the
U-Step Walking Stabilizer. With its U-shaped base lending a stable foundation of support in every direction, this unique rolling walker (rollator) makes users feel safe and secure while allowing them to retain mobility and independence. It addresses the unique needs of patients with Parkinson’s disease, amyotrophic lateral sclerosis, progressive supranuclear palsy, multiple sclerosis, brain injuries, balance disorders, and multiple-system atrophy.

The rolling seated walker also promotes safe patient mobility and should be made available on units. With this walker, the nurse can walk next to the patient as he or she ambulates. A patient who uses a four-wheeled walker with seat must lock the brakes when ready to sit or transfer and complete the activity. Patients who become dizzy from nausea or orthostasis can easily turn and sit on the seat without falling. This arrangement is much safer than having another staff member trail behind with a wheelchair and lower the patient to the wheelchair seat if he or she becomes fatigued or dizzy or loses balance.

A four-wheeled walker with seat may not be appropriate for all patients, especially those with memory problems, as it requires users to remember to apply the brakes to slow down or sit down safely (if using as a seat). If you’re unsure whether your patient should use this type of walker, contact a physical therapist.

Walking stabilizers

Walking stabilizers include tension-controlled gait aids, which show promise in ataxia management. With their unique brake design, they put the user in full control. To use the stabilizer, patients squeeze the brake slightly, causing the unit to move; when they want to stop, they simply let go of the brake. This feature aids standing up or sitting down and is particularly effective in helping users walk more efficiently.

The U-Step Walking Stabilizer has tension-controlled wheels and a reverse braking system. Tested in a case study with a 14-year-old girl with Friedreich ataxia (a disorder of progressive loss of voluntary muscle coordination), the stabilizer was found to reduce her gait deviations and falls from ten episodes per month to three. (See Tech aids that provide visual cues By clicking the PDF ico above.)

A new ambulatory device called the Walkabout rollator has undergone trials in elderly and disabled patients and those with Parkinson’s disease. It’s designed for people who can stand but can’t walk without assistance; it’s not intended to be used while seated. The Walkabout completely encircles the user, opening easily to let the user walk inside and close the gate. The top rail is approximately at waist height to provide stability and a place to rest the arms. The footprint of the base has a larger circumference than the top rail, with four legs attached at an angle to provide maximum stability. If the user loses balance, the safety seat prevents a fall. The adjustable seat, made of strong nylon webbing, attaches to the top rail. The Walkabout allows patients to walk in an upright position using a natural gait. It has shown preliminary success in helping Parkinson’s patients with more severe disabilities to walk further than they otherwise could, and may help prevent falls in this population.

Wheelchairs

Just as a falls-prevention program must be individualized, wheelchair prescriptions must be customized to each patient; no standard wheelchair works for all patients. For instance, a dementia patient with memory deficits can’t be expected to remember to lock the wheelchair and lift the footplates before getting up and transferring out of the wheelchair. To maximize patient safety, self-locking wheelchairs with removable leg rests are preferred.

Interdisciplinary collaboration

Be sure to collaborate with interdisciplinary team members when assessing the patient’s readiness to ambulate. Before initiating mobility, consider all factors that can affect safe mobility, such as orthostasis, and consult the physical or occupational therapist regarding the patient’s current level of functioning.

Remember—nurses are responsible for keeping patients safe from harm, adverse events, and injury. This responsibility includes ensuring safe ambulation. To uphold it, you must integrate and test the equipment and devices—including both current and emerging technology—that have the potential to reduce falls and injury risk.

Selected references

American Nurses Association. Nursing’s Social Policy Statement: The Essence of the Profession. 2010 Edition. 3rd ed. Silver Spring, MD: American Nurses Association; 2010.

Bryant MS, Rintala DH, Lai EC, Raines ML, Protas EJ. Evaluation of a new device to prevent falls in persons with Parkinson’s disease. Disabil Rehabil Assist Technol. 2009;4(5):357-363. doi:10.1080/17483100903038576.

Foster E, Hillegass LJ, Phillips SL. Demonstration program: An interdisciplinary approach at falls and mobility clinic. Ann Longterm Care. 2004:
12(5):27-32.,/p>

Hanley A, Silke C, Murphy J. Community-based health efforts for the prevention of falls in the elderly. Clin Interv Aging. 2011;6:19-25. doi:
10.2147/CIA.S9489.

Harris-Love MO, Seigel KL, Paul SM, Benson K. Rehabilitation management of Friedreich ataxia: lower extremity force-control variability and gait performance. Neurorehab Neural Repair. 2004; 18(2):117-124. doi:10.1177/0888439004267241.

Hoenig H. Assistive technology and mobility aids for the older patient with disability. Ann LongTerm Care. 2008;9(12). www.annalsoflongtermcare.com/article/3403?page=0,3&mobify=0. Accessed February 13, 2011.

Lebold CA, Almeida QJ. Evaluating the contributions of dynamic flow to freezing of gait in Parkinson’s disease. Parkinsons Dis. 2010. Article ID 732508. doi:10.4061/2010/732508.

Martorello L, Swanson E. Effectiveness of an automatic manual wheelchair braking system in the prevention of falls. Assist Technol. 2006;18(2):166-169.

Morse JM, Tylko SJ, Dixon HA. Characteristics of the fall-prone patient. Gerontologist. 1987; 27(4):516-522.

Nelson AL, Motacki K, Menzel N. The Illustrated Guide to Safe Patient Handling and Movement. New York, NY: Springer; 2009.

Quigley P, Neily J, Watson M, Strobel K, Wright M. Measuring fall program outcomes. OJIN. 2007;12(2):1-17.

Tideiksaar R, Feiner CF, Maby J. Falls prevention: the efficacy of a bed alarm system in an acute-care setting. Mt Sinai J Med. 1993;60(6):522-527.

Tsuei T-H, Wang H-L, Jao C-L, Yu C-H. Develop a visual stimulus with ambulatory device for Parkinson’s patients to improve stride length. J Biomech. 2007;219:63-69. doi:10.1016/S0021-9290(07)70433-5.

Wolfe RR, Jordan D, Wolfe D. The WalkAbout: a new solution for preventing falls in the elderly and disabled. Arch Phys Med Rehabil. 2004;
85:2067-2069.

Both authors work at the James A. Haley Veterans’ Hospital in Tampa, Florida. Patricia Quigley is associate director of nursing service for research and associate director of the Veterans Integrated Service Network 8 Patient Safety Center of Inquiry. Lisa Goff is a physical therapist.

Case study

Using technology to reduce falls

By Bea Leyden, BSN, RN, MBA, and Dan Singleton, BSN, RN

At Aria Health in Pennsylvania, we continually seek ways to lower our patient fall rate. Our falls task force has implemented many improvements, including redesigning fall risk assessment, implementing visual cues (such as wristbands) to identify at-risk patients, focused rounding, toileting regimens, and alarms.

Challenges. Some patient rooms in our hospitals aren’t within direct sight or earshot of the nursing units’ team centers—a safety concern. Also, our bed exit alarms didn’t communicate with the nursing station; they were hard to hear and, in some cases, nurses had trouble determining which room an alarm was coming from.,/p>

The falls task force partnered with Hill-Rom to explore bed technology options, particularly a bed exit alarm that communicated with the team center. From there, the idea expanded to designing a study to determine the impact of this technology on falls prevention and skin integrity. We chose a unit with a challenging layout. Conducting the study would give us a chance to lower the rates of patient falls, falls with injuries, and unit-acquired pressure ulcers.

We designed the study and Hill-Rom provided “smart beds” that met our needs. The beds continuously send data to the call system so nurses know immediately if a problem exists; an alarm sounds in the nurses’ station and the call light comes on. The beds also allow
automated documentation, which saves time. Before the study began, we presented in-service classes on the new beds and our established falls-prevention interventions.

Outcomes. To collect, store, and analyze information from the study, a database was developed that supported both manually collected and electronic data. A flowchart was created to map all data points. (See Flowchart for data points, by clicking the PDF icon above.) Data were incorporated from our electronic event reporting (Web-based external) system and our integrated nurse call system. This nurse communications module uses staff-locator badges and a central dispatch to alert staff to patient calls for assistance.

While these items provided useful information, alone they couldn’t determine the effect of the bed technology on patient outcomes. SMART (Simple, Meaningful, Accurate, Realistic, Timely) audits were used to capture additional vital information, such as falls, fall risk level, pressure ulcers, necrosis score, and intervention compliance. Although we’re still analyzing data and interpreting results, we’ve noted a trend toward reduced falls on the study unit.

Next steps. Information from the final study results will be used to guide development of additional falls-prevention interventions, with the goal of creating a synergy of interventions that further reduces falls.

Both authors work at Aria Health in Philadelphia, Pennsylvania. Bea Leyden is director of nursing performance improvement. Dan Singleton is nursing performance improvement coordinator.

Case study

An ongoing campaign to reduce patient falls

By Constance Esper-Kanze, BS, RN, CPHQ, and Richard Cardente, BSN, RN, MBA

Saint Thomas Hospital (STH) in Nashville, Tennessee has been involved in an ongoing journey to reduce patient falls. Part of Ascension Health, STH is an acute-care hospital with 526 acute-care beds and 15 neurobehavioral beds.

Campaign kickoff. As part of Ascension Health’s “Healthcare That Is Safe” initiative, STH in 2007 became one of eight alpha sites for a program aimed at preventing falls and eliminating falls with injury. Initially, STH implemented four strategies:

• • • assessment and reassessment of patient risk factors for falls
    • visual identification of high-risk patients using a yellow wrist band, red treaded socks, and “SAFE” (“Stay Alert for Fall Event”) signs on patient room doors
    • communication of patient fall-risk status
    • education of patients, families, and staff on fall prevention.

Safe Care. October 2007 marked the beginning of a renewed hospital-wide safety effort called Safe Care, designed to bring behavior-based error-prevention tools and techniques into practice and to leverage lessons learned from high-reliability industries. While not specifically targeting patient falls, Safe Care focused on key behavioral concepts, including better accountability, communication, and attention to detail.

High-risk drug policy. In March 2008, we partnered with physicians on a new policy designed to improve handling of high-risk medications, such as sedatives and hypnotics. Key interventions to reduce patient falls included automatic starting-dose reductions for at-risk patients, removal of long-acting benzodiazepines from the formulary, and time restrictions on administering sedatives and hypnotics.

New beds. We reached additional milestones with the purchase of new beds equipped with better alarms. The alarms have three separate sensitivity settings; nurses can use them more frequently knowing that fewer false alarms are likely. Also, the alarm has a more distinctive sound, giving earlier warning of a potential fall.

Better communication. Another Safe Care initiative, the safety huddle, was implemented in the fall of 2008. The safety huddle is a gathering of staff (day and night shifts) at shift change to discuss patients at risk for falling, bed and chair alarm use, and patient and family understanding of and participation in fall prevention.

Falls-prevention team meeting. In the fall of 2009, a bimonthly meeting was initiated to review all falls and the debriefing tool that staff members fill out after a fall. Individual cases, trends, and opportunities for improvement are discussed.

Education. Clinical staff use a one-page fall-prevention tool that teaches patients and families how to prevent falls, reminds them when to call for assistance, and stresses the importance of family participation. Staff education consists of annual competency enhancement through both computerized and hands-on training.

Outcomes. Between fiscal years (FY) 2008 and 2009, falls decreased 53.8%. During this time, we saw the launch of Safe Care, the new medication policy, and the new beds in high-risk units. In FY 2010, the falls with serious injury rate (FSIR) dropped another 14.4% as the new beds became fully deployed and online training began. So far in FY 2011, we’ve seen falls decline another 10.4% with deployment of chair alarms. Cumulatively, our FSIR is down by 78.6%. (See Declining fall rate, by clicking the PDF icon above.)

Since inception of the falls-prevention program, STH has greatly improved its safe and caring environment.

Both authors work at Saint Thomas Hospital in Nashville, Tennessee. Constance Esper-Kanze is a director of quality and risk management. Richard Cardente is assistant director of orthopedics and neurosciences.