Learning Objectives Define and classify falls that may occur within rehabilitation settings. More Falls in Rehab Due to: 2/27/2016

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1 Learn How to Decrease Patient Falls and Fall Related Injuries Within the Rehabilitation Setting Learning Objectives Define and classify falls that may occur within rehabilitation settings. Discuss risk factors that contribute to falls for the rehabilitation patient. Cookie Gender, RN, MSN, CRRN, Administrator/CNO Discuss interdisciplinary interventions for reducing falls and injuries. Identify data elements that may be collected to analyze the success of a safety and fall reduction program. More Falls in Rehab Due to: Physical and cognitive impairments Learning mobility tasks Coping with new trauma or disease (overwhelmed, stressed, fatigue, sleep deprived, disoriented, etc.) There is no single approach to a successful fall program. It depends on the characteristics of the provider, facility and type of patients. Audrey L. Nelson PhD, RN, FAAN Goal is to protect patients from falls with injury. CHRISTUS St. Michael Rehabilitation Hospital 50 bed freestanding Rehab hospital ADC: Dedicated Diagnostic Teams Ortho Stroke/BI SCI/general rehab 1

2 Fall Definition An unplanned descent to the floor or extension of the floor, with or without injury to the patient. NDNQI Fall Statistics 1 in 3 adults aged 65 and older fall each year. 20% 30% have moderate to severe injuries. Medicare costs per fall average $13,797 $20,450 (in 2012 dollars.) Hip fractures are the most serious and costly fall related fractures. No One is Immune Nancy Reagan Hillary Clinton broken elbow Dr. Robert Atkins Atkins diet head injury John Glenn concussion Ed McMahon concussion, gash on head Kelsey Grammer Frasier Paula Abdul American Idol Judge fractured toe, broken nose, bruising Beyonce Knowles Fall Prevention History 1960 s First research conducted Fall prevalence defined and identified as a problem in elderly Large prospective studies to identify risk factors, causes and prevention techniques Patient safety a concern In 2005, TJC made fall prevention the 9 th national patient safety goal. In 2006, TJC required implementation and evaluation of a Falls Reduction Program. In October 2008, CMS made it one of the never events and stopped paying for costs associated with hospital acquired injuries due to falls in acute hospitals. In 2015, TJC devoted an entire chapter to Patient Safety Systems Falls Not usually due to a single cause Intrinsic risk factors Decreased vision Mobility impairment/unsteady gait Spatial/depth perception Hearing problems Depression/behavioral disturbance Short term memory problems Muscle weakness Vitamin D deficiency Arthritis, etc. Urinary frequency or incontinence Postural hypotension 2

3 Falls continued Extrinsic risk factors Medications Height of bed Bedrails Slippery floor Poor illumination Inadequate assistive devices Poor footwear, etc. Morse Fall Categories 1. Accidental Extrinsic 2. Unanticipated physiologic i.e. new onset stroke, syncopy 3. Anticipated physiologic Intrinsic FALLS IN REHAB Studies report prevalence rates of and higher in Rehab Increased risk due to promotion of mobility and independence FALLS IN REHAB CONT. Stroke patients fall more than any other diagnosis Older Impulsive Cognitive impairments Neurological impairments Poor balance Incontinence Sedating and psychotropic meds Right hemisphere lesions have higher risk of falls Research on Falls Female stroke patients more likely to incur injuries Depressed patients more likely to fall Patients on diuretics also more likely to fall No correlation in Rehab with a higher RN mix and fall reductions Units with less experienced nurses have higher rate of falls in some studies. Many falls occur on day shift and during 1 st week of admission. Low admission mobility and cognitive FIM scores tend to indicate a higher risk for falls. (<3 on problem solving and memory) Fall Prevention and Reduction Program Support by senior leaders Interdisciplinary Team Rehab nurses PT, OT, Speech Case managers Quality Medical Director 3

4 Process begins with pre admission evaluation to alert team of prior falls Fall risk screening tools Hendrick Morse Johns Hopkins Individual facility developed tools The predictability of the tool depends on the setting. Nursing clinical judgment is better than tools. The focus should be on interventions for the patient s identified risk factors. Oliver, 2012 Fall Prevention and Reduction Program Fall Risk Assessment Tool Scores patients into: Low Risk 0 6 No armband Moderate Risk 7 17 Yellow armband High Risk 18 Yellow with black stripes Colored magnets on room door frame What is driving the fall assessment score? Tailor interventions to address person s need If the patient falls, are they at high risk for injury? Osteoporosis Blood thinners Previous cerebral hemorrhage Incisions Fall risk level checked on patient care Cardex High Risk for Injury Possible Interventions Universal Fall Prevention Interventions Mat beside bed Anti tip bars on wheelchair Room near nursing station Hip protectors Call Before You Fall signs Hourly rounding and 4 P s (pain, potty, position and placement of items within reach) Bedside reporting Toileting program if urgency or neurogenic bladder Self release wheelchair safety belts Orient to physical set up of room Bed exit on patients non affected side Overbed table on side away from exit Elevated toilet seat if needed for transfers 4

5 Universal Fall Prevention Interventions Cont. Room free of clutter Equipment available in room (i.e. walker, reachers) Pharmacy consults for 4 or more medications Consider side effects of medications (ie blurred or impaired vision, dizziness, confusion) Multiple medications/polypharmacy Starting, stopping or changing meds risk can be 3 times higher for falls in 2 days following a medication change Was a medication given before or after a fall? Lower doses better No slip footwear Teach patients to make position changes slowly Bed, wheelchair and commode alarms Universal Fall Prevention Interventions Cont. Toilet patients before giving pain medication PT test balance, improve strength and balance OT Safety in the Home Tips for Preventing Accidents Moderate Fall Risk Interventions May use bed or wheelchair alarms Use of a low bed Don t leave unattended in bathroom stand within arm s length May use bedside commode in room High Fall Risk Interventions Monitoring must include use of bed and wheelchair alarm Place in camera room or close to nursing station Bedside commode next to bed Hand off system Diversional activities One to one sitters Stop sign on back of wheelchair Do not leave unattended Consider moving to a room with specialized flooring or use of a bedside mat Moderate/High Risk Fall Prevention Education Other Initiatives to Help Prevent Falls Educate patient/family on what is causing them to screen out as a risk What is the main problem putting them at fall risk? What do they need to do to keep from falling? (Interventions) Why is it important to do this? Ask them to teach back. Fall ambassador Daily safety huddles Rounding techs Daily meetings with nurse and therapy manager to identify high risk patients screened from admission the day before. Meet with RN Check that interventions are in place Bedside functional sheets Annual Fall Prevention training 5

6 PI Fall Analysis Tool Huddle within 15 minutes of fall Ask patient why they fell Root cause Friday Falls Meeting Nurse manager and nurse involved with fall report (or call in) Learning opportunity Non punitive Safe Patient Handling Patient lifts Safe Patient Handling Program Use of algorithms Conclusion Systems approach Always in process of improving Continue to search for Evidence Based Interventions References Bouldin, E.D. et.al. (2013). Falls among adult patients hospitalized in the United States: Prevalence and trends. Journal of Patient Safety, 3(9), Corley, D. et.al. (2014). The Baptist health high risk falls assessment. a methodological study. The Journal of Nursing Administration, 44(5), Forrest, G.P., Chen, E., Huss, S. & Giesler, A (2013). A comparison of the functional independence measure and Morse fall scale as tools to assess risk of fall on an inpatient rehabilitation. Rehabilitation Nursing, 38(4), Mitchell, M.D., Lavenburg, J.G., Trotta, R.L. & Umscheid, C.A. (2014). Hourly rounding to improve nursing responsiveness. The Journal of Nursing Administration, 44(9), Murphy, M.P., Carmine, H. & Kolakowsky-Hayner, S. (2013). Modifiable and nonmodifiable risk factors for falls after traumatic brain injury: An exploratory investigation with implications for medication use. Rehabilitation Nursing, 39(3), Oliver, D., Healey, F., & Haines, T.P. (2010). Preventing falls and fall-related injuries in hospitals. Clinics in Geriatric Medicine, 26(4) References (cont.) Rosario, E.R., Kaplan, S.E., Khonsari, S., & Patterson, D. (2013). Predicting and assessing fall risk in an acute inpatient rehabilitation facility. Rehabilitation Nursing, 39(2), Salamon, L.A., Victory, M. & Bobay, K. (2012). Identification of patients at risk for falls in an inpatient rehabilitation program. Rehabilitation Nursing, 37(6), Staggs, V.S. & Dunton, N. (2013). Associations between rates of unassisted inpatient falls and levels of registered and non-registered nurse staffing. Interventional Journal of Quality in Health Care, (Nov 2013), 1-6. Williams, T. Szekendi, M. & Thomas, S. (2014). An analysis of patient falls and fall prevention programs across academic medical centers. Journal of Nursing Care Quality, 29(1),