Evidence-Based Interventions for Preventing Falls in Acute Care Hospitals. By LeeAnna Spiva, PhD, RN, PLNC Patricia Hart, PhD, RN

Transcription

1 Evidence-Based Interventions for Preventing Falls in Acute Care Hospitals By LeeAnna Spiva, PhD, RN, PLNC Patricia Hart, PhD, RN

2 Evidence-Based Interventions for Preventing Falls in Acute Care Hospitals Abstract Abstract Falls are the most frequently reported safety event among United States hospitalized patients. A quality improvement initiative was conducted to determine the effectiveness of a fall prevention program using education and a fall prevention kit on fall reduction. Eight nursing units were identified based on National Database Nursing Quality Indicators fall rates from the four community hospitals. The program included on line staff education, leadership training, team training exercises, and a fall prevention kit. Prior to implementation, a half day training session was held. Each unit identified a champion who had a strong commitment to fall prevention. The champion facilitated team building, change management, and was accountable for outcomes. Several units prepared patient rooms displaying safe and unsafe environments. A postfall debriefing assessment tool was implemented. A non-reusable fall prevention kit was implemented for patients screened as a high-risk to fall and included: yellow gown, yellow wristband, signage, yellow non-skid slippers, and glow in the dark urinal for male patients. Fall rates decreased but not significantly post-intervention compared to pre-intervention. The findings support the use of education and a fall prevention kit as effective approaches to reduce falls. Background Falls are the most frequently reported safety event among hospitalized patients in the United States, 1 with rates between four to 12 falls per 1,000 patient days occurring each year. 2,3 Falls are associated with increased risk of mortality and morbidity 4,5 and an estimated cost of $20 billion a year. 6 By 2020, the Centers for Disease Control and Prevention estimated that the annual direct and indirect costs of falls will reach $54.9 billion. 6 The Agency for Healthcare Research and Quality (AHRQ), the National Quality Forum (NQF), the Institute for Health Improvement (IHI), the Joint Commission, and the Centers for Medicare and Medicaid Services (CMS) have taken action to prevent hospital acquired falls and to reduce fallrelated injuries. Falls that occur in the hospital and consist of a fracture, dislocation, intracranial injury, or result in death are reasonably preventable by following evidence-based guidelines. CMS will no longer reimburse hospitals for treatment related to these conditions. 7 The Joint Commission cited inadequate patient assessments and lack of communication as primary causes of preventable falls. There are numerous studies about falls risk factors, 8 interventions to reduce falls, 3,9,10 guidelines and systematic reviews for prevention of falls in hospitalized adults. 11,12,13,14,15 VHA Pilot with Medline Industries, Inc. 2

3 Problem An in-depth falls assessment was conducted at the integrated healthcare system that included: an extensive literature review, a review of falls risk assessment tools, policy review, and in-depth analysis of the organization s falls data (National Database of Nursing Quality Indicators (NDNQI )), 16 and in-depth chart review of hospital-acquired falls. Findings revealed prior to the fall, a majority of patients had taken three or more high-risk medications (i.e., anticonvulsants, hypnotics/ sedatives, tranquilizers, etc), falls resulted in no injury, and falls occurred in the bathroom. Hospital-acquired falls that were not reimbursed by CMS were investigated. Extrinsic and intrinsic risk factors were identified: multiple high-risk medications prescribed resulting in confusion, bathroom-related falls, prior fall history, confusion secondary to disease processes and incorrect falls risk assessment screening. Although, based on the organization s falls data, a majority of the nursing units were outperforming NDNQI 16 comparison means for total falls per 1,000 patient days. However, organizational leaders felt that there were opportunities for improvement in the area of falls prevention. Intended Quality Improvement The healthcare system identified several opportunities from the in-depth falls assessment that included: identification of a reliable and valid falls risk assessment tool; identification of a falls champion from each hospital; formation of a multidisciplinary falls team; revision of the organization s falls policy; development of a falls plan of care, post-falls documentation, and falls prevention education that were all included in the electronic medical record; partnership with pharmacy to monitor high-risk medications prescribed to patients; revision of the online event reporting system to collect fall specific data; lift equipment inventory; and partnership with Medline Industries, Inc. to trial an evidence-based falls prevention program. Quality Improvement Initiative Purpose The quality improvement (QI) initiative purpose was to assess the effectiveness of a falls prevention program using evidence-based education and a fall prevention kit on falls reduction. Methods Setting. The QI initiative was conducted from August 2011 to March 2012 in an integrated healthcare system located in a southeastern state. The integrated healthcare system consists of four community hospitals, a long-term care facility, physician practice groups, and outpatient services. Eight nursing units were identified based on NDNQI 16 falls rates from the four community hospitals. The units included two orthopedic units, two neurology units, one medical-surgical unit, one behavioral health and medical unit, one oncology unit and one cardiac telemetry unit. Intervention. After approval was obtained by the chief nurse executive, the organization partnered with Medline Industries, Inc. to trial an evidencebased falls prevention program. The program included online educational modules for staff, leadership training, team training exercises and a falls prevention tool kit. The intervention included: Identification of a falls prevention champion on each unit Environmental falls risk assessments Implementation of immediate safety huddles post-fall Improved collaboration and communication among the four hospitals (bi-monthly web/ telephone conferences) Increased frequency (every one to two hours) of rounds (visits by staff to check patients for toileting needs, pain, and overall condition) Integration of the instructional technique called teach back- asking the patient/family to repeat what was just taught Implementation of a falls prevention tool kit 3 VHA Pilot with Medline Industries, Inc.

4 Prior to the QI initiative implementation, a Medline representative met with the unit representatives and provided a half-day training session. Table 1 provides a timeline of the QI initiative. Each unit representative was provided with a program manual to support falls prevention efforts. The following elements were included in the manual: Overview of team roles and responsibilities that supported a multidisciplinary approach in falls prevention Staff education that applied evidence-based falls prevention interventions Sample tools: Weekly falls dashboard, hourly rounding tool, post-falls debriefing tool, environmental falls risk assessment tool and falls prevention pledge The falls education was provided in an effort to support the anticipated outcomes in falls prevention. All staff completed the online falls education modules via Medline University (www. medlineuniversity.com). The online module learning objectives included: identification of patients at high-risk to fall, defined risk factors associated with patient falls, described benefits of hourly rounding, advantages of having a falls team, defined education for patients and families and a post-falls debriefing assessment tool. In addition, leadership training included: rounding on patient care units to speak with staff about falls prevention interventions, ensuring that a post-falls debriefing occurred immediately after the patient was stabilized and celebrations for units that demonstrated zero falls or decreased falls. Each unit identified a falls prevention champion. The role of the falls prevention champion included a nurse or clinical care partner in the unit who had a strong commitment to falls prevention. This individual possessed a positive influence over clinical practice, clinical processes and clinical care. The champion facilitated team building, change management, and was accountable for outcomes. The champion was responsible for VHA Pilot with Medline Industries, Inc. 4 rewarding positive behavior and identified areas for improvement. All staff signed a falls prevention health system pledge. All staff made an effort to uphold the following: supervise all patients in the hospital, remain with the patient at all times during toileting and conduct hourly rounding. The pledge was not a legally binding contract, but rather an agreement between staff and the organization. In addition, several units prepared patient rooms displaying safe and unsafe environments. Patient rooms had patient handling equipment, signage, oxygen tubing, bedside commodes, urinals and electrical cords. Staff identified extrinsic and intrinsic factors that were associated with a high risk for patient falls. The Medline product trial occurred in November Staff used the fall prevention kit for patients screened as a high-risk to fall. The fall prevention kit was a non-reusable package including: yellow wristband, signage, yellow non-skid slippers, gait belt and a glow-in-the-dark portable urinal for male patients. Yellow patient gowns were also used for all patients who were screened as a high risk to falls. Signage included the following: yellow dot placed outside the patient door, reset bed alarm sign placed at the head of the patient s bed to remind staff to reset the alarm, and please call don t fall sign displayed in front of the patient s hospital bed as a reminder to the patient/family/ visitors/staff that the patient was at risk to fall. Methods of Evaluation and Analysis Falls rates were monitored weekly and monthly for each unit. Fall rate calculation methodology was congruent with NDNQI. 16 In addition, environmental falls risk assessments were conducted at two of the hospitals. Falls were tracked using the hospital s internal electronic falls database and the NDNQI 16 quarterly falls report that included falls risk assessment scores, fall characteristics, and nursing

5 process for falls prevention. An eight-item online evaluation with two free-text questions was developed by Medline and the organization. The items were rated on a five-point Likert scale from 1 (Disagree Strongly) to 5 (Agree Strongly). The mean score was calculated for the evaluation. The Cronbach s alpha was 0.83 for the evaluation. Data were analyzed with descriptive and inferential statistics using SPSS for Windows Release Descriptive statistics (means and standard deviations) and inferential statistics paired samples t-tests were used. A p value of.05 was considered statistically significant. A total of 73 staff (30% response rate) completed the online evaluation from November 16, 2011 to November 25, A majority of the staff responded to the evaluation questions as agree to strongly agree. Average mean ratings ranged from 3.39 to Staff liked having all the falls prevention tool kit interventions available in one package to use for each patient. The staff liked the yellow gowns, the glow-in-the-dark portable urinal, the bed alarm reminder sign and large lettering call don t fall signs posted in the patient room. Aspects of the program the staff felt could be improved included: modification of the sign adhesive (left residue on the wall after removal) and the yellow gown needed to be a softer yellow with an added strap to the shoulder, longer, and larger sizes available. Results Pre-QI initiative (February-August 2011) data revealed the units had 146 falls and 110 falls post-qi initiative (September 2011-March 2012) with a possible cost-savings of $450,000. (Table 2). The cost was based on 2009 cost analysis conducted at the organization with an average cost of $12,500 per fall. A paired t test was conducted to examine the effect the intervention had on fall rates. Fall rates decreased but not significantly post-intervention (M= 2.65, SD = 1.29) compared to pre-intervention (M = 3.62, SD = 1.44) (t = 1.70, P =.134). Post-fall huddle forms were turned in and analyzed. Assessment findings included several intrinsic and extrinsic factors that may have contributed to the fall occurring. Intrinsic factors included: prior fall, unsteady gait, musculoskeletal weakness/illness impacting balance and posture, confusion and advanced age. Extrinsic factors included: patient not screened as high- risk to fall, multiple highrisk medications (ranging from anticoagulation to narcotic/anesthetics), bed alarm not re-activated, bathroom toileting and one patient refused to wear yellow socks. Table Timeline Feb-Aug Aug Sept Oct Nov Dec Jan-March Pre-Pilot Data Collection Unit Representatives Trained Staff Education Conducted Falls Tool Kit Trial Post-Pilot Data Collection 5 VHA Pilot with Medline Industries, Inc.

6 Table 2. Pilot Nursing Units: Pre-Post Mean Fall Rates (Falls per 1,000 Patient Days) and Actual Falls. Pre-Fall Pre-Actual Post-Fall Post-Actual Rates Falls Rates Falls Orthopedic (hospital 1) Neurology (hospital 1) Neurology (hospital 2) Behavioral Health & Medical (hospital 2) Oncology (hospital 2) Orthopedic (hospital 3) Cardiac Telemetry (hospital 3) ,29 14 Medical-Surgical (hospital 4) Totals Environmental assessments were conducted at Dykes et al. 18 found that using a fall prevention tool two hospitals. Findings indicated that hospitals kit in hospitals compared with usual care reduced implemented necessary falls prevention strategies. fall rates. Each hospital completed lift equipment inventories and a future meeting is planned with the company to Similar to other researchers19,20,21 formation of discuss purchasing additional lift equipment. an interdisciplinary falls prevention team composed of nursing, pharmacy, risk management, physical Discussion therapy, nutrition, physicians, senior leaders and The findings show a decrease in falls related to other disciplines has been instrumental to the implementing education and a fall prevention kit. organization in decision- making and executing Fall rates decreased for all units except for one unit. evidence-based interventions. The organization s The increased fall rates for the neurology unit may interdisciplinary system fall s committee developed have resulted in a majority of patients having periodic and approved the post-fall huddle form, fall policy, confusion, multiple high-risk medications, and and electronic plan of care, fall education, and postfall patients having limited mobility. documentation. The committee also approved the organization to change from a modified fall Contrary to Clyburn and Heydemann s17 findings risk assessment tool to the Hendrich II fall risk that there is no conclusive medical evidence that assessment model. multifactorial falls prevention programs in the acute care setting were effective, findings indicated Similar to other researchers, patients that fell were that falls can be reduced by a multifactoral falls prescribed multiple high-risk medications and falls prevention program. While this QI initiative was occurred in the patient bathroom. 22, 23,24 The most specific to an acute care setting, it is reasonable to consistently identified falls risk factors included: prior believe that education and a fall prevention kit could fall, muscle weakness, confusion and prescription be replicated in other healthcare settings. Furth more, of high-risk medications. 20 The most successful VHA Pilot with Medline Industries, Inc. 6

7 interventions included: post-fall debriefing, patient and staff education, remaining with the patient in the bathroom and the falls prevention tool kit. The success of this QI initiative will ultimately be measured through sustainability. To determine the degree that the training and evidence-based interventions have positively impacted a reduction in patient falls, fall rates will continued to be monitored monthly and quarterly following the interventions. In addition, it is imperative that all team members have knowledge of falls data in order to understand the reasons behind performing falls prevention interventions. Limitations The quality improvement initiative proposed an obligation of the nursing units to become actively involved and engaged in the pilot for three months. Long-range planning was required by the units to ensure conflicts did not interfere with the pilot. Unpredictable environmental factors included coordination with ongoing unit-based initiatives, staffing, room availability and patient acuity. Conclusion Completing an in-depth falls assessment allowed the organization to identify opportunities and implement appropriate evidence-based interventions to reduce falls. Training staff and leaders in the organization to provide fall prevention awareness, prevention and response is extremely important. Creating a culture that fosters a work environment where all leaders and staff have accountability and alignment will produce optimal patient outcomes and support the best possible patient experience. Funding Medline Industries, Inc. provided falls prevention program content and supplies. Pilot program implementation, data interpretation and publication of the manuscript were conducted by the healthcare system. 7 About the author: LeeAnna Spiva, PhD, RN, PLNC, is director of nursing research for WellStar HealthSystem in Atlanta, GA. She will be presenting a poster based on this paper at The American Nurses Association s (ANA) National Center for Nursing 7th Annual Nursing Quality Conference February 6-8, 2013, in Atlanta. Patricia Hart, PhD, RN is an Assistant Professor of Nursing at Kennesaw State University in Kennesaw, Georgia. References 1. Healey F, Monro A, Cockram A, Adams V, & Heseltine D. Using targeted risk factor reduction to prevent falls in older in-patients: A randomized controlled trial. Age and Ageing. 2004; 33(4): Cozart HC & Cesario SK. Falls aren t us: state of the science. Critical Care Nursing Quarterly, 2009;32(2): Inouye SK, Brown CJ, & Tinetti ME. Medicare nonpayment, hospital falls, and unintended consequences. New England Journal Medicine. 2009; 360(23): Gribbin J, Hubbard R, Smith C, Gladman J, & Lewis S. Incidence and mortality of falls amongst older people in primary care in the United Kingdom. Quality Journal Medicine, 2009; 102: Skelton DA & Todd CJ. What are the main risk factors for falls amongst older people and what are the most effective interventions to prevent these falls? Copenhagen: Health Evidence Network, World Health Organization Centers for Disease Control and Prevention. Costs of falls among older adults Available at: Falls/fallcost.html. Accessed August 9, Centers for Medicare and Medicaid Services. Hospital-acquired conditions Available at: hospital_conditions.asp. Accessed August 9, VHA Pilot with Medline Industries, Inc.

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