Best Practices in Reducing Falls and Fall Related Injury. Overview. Integration of Complementary Perspectives

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1 Best Practices in Reducing Falls and Fall Related Injury Featuring: Pat Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP Associate Director, VISN 8 Patient Safety Center Associate Chief for Nursing Service/Research patricia.quigley@va.gov Overview Illustrate relationship of Complementary Perspectives of Evidence-based Practice Differentiate use of scientific hierarchy and evidence rating scales Apply rating scales to clinical practice examples Detail results of synthesized literature reviews for fall and injury prevention Translate actionable elements of a Fall Prevention Program Segment high-vulnerable populations to protect from fall related injury Integration of Complementary Perspectives Innovation Diffusion Knowledge Knowledge Transfer Outcome Evidence-based Practice nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 1

2 Three Perspectives Evidence-based Practice (Sackett) the conscientious use of current best evidence in making decisions about the care of individual patients or the delivery of health services. Innovation Diffusion (Rogers) The process of communicating new ideas through certain channels over time among members of a social system. Knowledge Transfer (Dixon) Sharing of common knowledge, that is the knowledge that employees learn from doing the organization s tasks. Review Research, Clinical and Laboratory Information Is evidence strong enough to warrant practice change? Yes Implement evidencebased practice No Clinical trial to test interventions Yes Does evidence support clinical trials? Technology Transfer Epidemiological study to identify modifiable risk factors for adverse events or descriptive studies to understand process and outcomes No OR Equipment design or redesign Yes Is equipment ready for Market? Grading Systems Apply use of scientific hierarchy and evidence rating scales. 6 nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 2

3 Types of Research: Evidence Hierarchies (Quality of Evidence) Agency for Healthcare Research and Quality (AHRQ) Level I Meta-Analysis (Combination of data from many studies) Level II Experimental Designs (Randomized Control Trials) Level III Well designed Quasi Experimental Designs (Not randomized or no control group) 7 Level IV Well designed Non-Experimental Designs (Descriptive-can include qualitative) Level V Case reports/clinical expertise 8 Strength of Evidence: Suggestions for Practice ( A B C D I United States Preventive Services Task Force (USPSTF) Grading Strongly recommended; Good evidence Recommended; At least fair evidence No recommendation; Balance of benefits and harms too close to justify a recommendation Recommend against; Fair evidence is ineffective or harm outweighs the benefit Insufficient evidence; Evidence is lacking or of poor quality, benefit and harms cannot be determined Role of RCTs Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials Gordon C S Smith, Jill P Pell BMJ 2003;327 nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 3

4 Would You or Not? Who Dies if They Fall? Very young and very old Where are we? BEST PRACTICES: LEVEL OF EVIDENCE nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 4

5 Making Health Care Safer II 2013 Co-Principal Investigators: Paul G. Shekelle, M.D., Ph.D., RAND Corporation Evidence-based Practice Center Robert M. Wachter, M.D., University of California, San Francisco Peter J. Pronovost, M.D., Ph.D., Johns Hopkins University Since 2001 report, a vast amount of new information on PSPs has emerged; more agreement is now evident on what constitutes evidence of effectiveness and the importance of implementation and context. Obj: To review important patient safety practices for evidence of effectiveness, implementation, and adoption. Results: From an initial list of over 100 patient safety practices, the stakeholders identified 41 practices as a priority for this review: 18 indepth reviews and 23 brief reviews. Of these, 20 PSPs had their strength of evidence of effectiveness rated as at least moderate 26 PSPs had at least moderate evidence of how to implement them Evidence Reviews: Rating Evidence of Effectiveness (low, moderate, high; benefits outweigh harm) Evidence of on potential for harmful unintended consequences (high, moderate, low, negligble) Estimate of costs (low, moderate High) Implementation issues: How Much Do We Know? How Hard Is It to Implement? nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 5

6 Results con t: 10 practices were classified by the stakeholders as having sufficient evidence of effectiveness and implementation and should be strongly encouraged for adoption An additional 12 practices were classified as those that should be encouraged for adoption. This includes Multicomponent interventions to reduce falls Chapter 19: Preventing In-Facility Falls Cochrane Reviews and Oliver, et al, 2006 (updated 2010) Systematic Literature Reviews Isomi M. Miake-Lye, B.A.; Susanne Hempel, Ph.D.; David A. Ganz, M.D., Ph.D.; Paul G. Shekelle, M.D., Ph.D. 17 Multifactorial Trials between were reviewed. Supplemented by 3 more recent large scale studies Ambulatory Care AGS, BGS Clinical Practice Guidelines 2010:in Assessment Interventions Evidence Grades Bibliography als/clinical_practice/clinical_guidelines_recommenda tions/2010 nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 6

7 AGS Guidelines 2010 Assessment Interventions: Must Reads Clinics in Geriatric Medicine, Nov D. Oliver, et al. Falls and fall-related injuries in hospitals. (2010, Nov). Clinics in Geriatric Medicine Becker, C., & Rapp, K. (2010). Falls prevention in Nursing Homes. Clinics in Geriatric Medicine Clinical Nursing Research, An International Journal. 21(1) Feb. 2012: Special Issue: Falls in the Older Adult. Spoelstra, S. L., Given, B.A., & Given, C.W. (2012). Fall prevention in hospitals: An integrative review. Clinical Nursing Research. 21(1) ) Clyburn, T.A., & Heydemann, J.A. (2011). Fall prevention in the elderly: Analysis and comprehensive review of methods used in the hospital and the home. J. of Am. Academy of Orthopedic Surgeons. 19(7): Hospital Falls: we know. (D. Oliver, et al. Falls and fall-related injuries in hospitals. (2010, Nov). Clinics in Geriatric Medicine. 30% to 51% of falls result with some injury 80% - 90% are unwitnessed 50%-70% occur from bed, bedside chair (suboptimal height) or transferring between the two; whereas in mental health units, falls occur while walking Risk Factors: Recent fall, muscle weakness, behavioral disturbance, agitation, confusion, urinary incontinence and frequency; prescription of culprit drugs ; postural hypotension or syncope nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 7

8 Most effective, fall prevention interventions should be targeted at both point of care and strategic levels Best Practice Approach in Hospitals: Implementation of safer environment of care for the whole patient cohort (flooring, lighting, observation, threats to mobilizing, signposting, personal aids and possessions, furniture, footwear Identification of specific modifiable fall risk factors Implementation of interventions targeting those risk factors so as to prevent falls Interventions to reduce risk of injury to those people who do fall (Oliver, et al., 2010, p. 685) Limits to Science Failure to Differentiate Type of Fall Accidental Anticipated Physiological Unanticipated Physiological (Morse 1997) Intentional Falls Failure to Link Assessment with Intervention What are we doing? Why? Risk Screening vs. Assessment Over reliance on screening tools Differential Diagnosis Individualized Care Planning Identify fallers from non-fallers Identify those with injury hx or at risk for injury Protecting Patients Implementing: Bed Alarms Sitters Intentional / Purposeful Rounding nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 8

9 Morse Fall Scale (Morse, 1997, Preventing Patient Falls Morse Fall Scale Risk Factor Scale Score History of Falls Yes 25 No 0 Secondary Diagnosis Yes 15 No 0 Ambulatory Aid Furniture 30 Crutches / Cane / 15 None / Bed Rest / Wheel Chair / Nurse 0 IV / Heparin Lock Yes 20 No 0 Gait / Transferring Impaired 20 Weak 10 / Bed Rest / Immobile 0 Mental Status Forgets Limitations 15 Oriented to Own Ability 0 26 April 22, 2008 Fall Risk Assessment Template Prevention + Protection Prevention: The act of preventing, forstalling, or hindering Plus Protection Shield from exposure, injury or destruction (death) Mitigate or make less severe the exposure, injury or destruction nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 9

10 Interventions 1. Basic preventive and universal falls precautions for all patients 2. Assessment of all patients for risk of falling and sustaining injuries from a fall in the hospital 3. Cultural infrastructure 4. Hospital protocols for those identified at risk of falling 5. Enhanced communication of risk of injury from a fall 6. Customized interventions for those identified at risk of injury from a fall Protect from Injury Protecting Patients from Harm - Our Moral Imperative Moderate to Serious Injury Those that limit function, independence, survival Age Bones (fractures) Bleeds (hemorrhagic injury); or C (anticoagulation) Surgery (post operative) nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 10

11 Universal Injury Prevention Educates patients / families / staff Remember 60% of falls happen at home, 30% in the community, and 10% as inpts. Take opportunity to teach Remove sources of potential laceration Sharp edges (furniture) Reduce potential trauma impact Use protective barriers (hip protectors, floor mats) Use multifactorial approach: COMBINE Interventions Hourly Patient Rounds (comfort, safety, pain) Examine Environment (safe exit side) Age: > 85 years old Education: Teach Back Strategies Assistive Devices within reach Hip Protectors Floor Mats Height Adjustable Beds (low when resting only, raise up bed for transfer) Safe Exit Side Medication Review Bones Hip Protectors Height Adjustable Beds (low when resting only, raise up bed for transfer) Floor Mats Evaluation of Osteoporosis nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 11

12 AntiCoagulation/Bleeds Evaluate Use of Anticoagulation: Risk for DVT/Embolic Stroke or Fall-related Hemorrhage Patient Education TBI and Anticoagulation: Helmets Wheelchair Users: Anti-tippers Surgical Patients Pre-op Education: Call, Don t Fall Call Lights Post-op Education Pain Medication: Offer elimination prior to pain medication Increase Frequency of Rounds Post Fall Safety Huddles Post Fall Analysis What was different this time? When How Why Prevention: Protective Action Steps to Redesign the Plan of Care nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 12

13 Accident Theory Outcomes of Post Fall Huddles Specify Root Cause (proximal cause) Specify Type of Fall Identify actions to prevent reoccurrence Changed Planned of Care Patient (family) involved in learning about the fall occurrence Prevent Repeat Fall Reduce Repeat Fall Rate nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 13

14 Autonomy What does this mean to you? What choices do you have? What are the consequences of your choices? What choice do you think you will you make? What happens after a fall? 40 Post Fall Huddle Resources VA: Falls Toolkit Post Fall Huddles AHRQ Falls Toolkit 2013 Tools Post Fall Huddle Process Decision Tree Post Fall Huddle Form Determine Preventability Case Study Exercises nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 14

15 Biomechanics of Fall-Related Injuries Understanding the rate of splat and its impact on injury Falls from High Bed: Head First Falls from High Bed: Foot First nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 15

16 Falls from Low Bed: Foot First Bedside Mats Fall Cushions CARE Pad bedside fall cushion NOA Floor Mat Posey Floor Cushion Tri-fold bedside mat Roll-on bedside mat Soft Fall bedside mat Summary of Results Feet First Fall from Bed No Floor Mat fall over top of bedrails: ~40% chance of severe head injury No Floor Mat, low bed (No Bedrails): ~25% chance of severe head injury Low bed with a Floor Mat: ~ 1% chance of severe head injury nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 16

17 Technology Resource Guide: Bedside Floor Mats Bedside floor mats protect patients from injuries associated with bed-related falls. Targeted for VA providers, this web-based guidebook will include: searchable inventory, evaluation of selected features, and cost. Hip Protectors Examples Safehip KPH CuraMedica HipGuard HIPS Hip Protector Toolkit This web-based toolkit will include: prescribing guidelines standardized CPRS orders selection of brands and models sizing guidelines protocol for replacement policy template laundering procedure stocking procedure monitoring tools patient education materials provider education materials nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 17

18 Assistive technology for safe mobility-bed & Chair Monitors AirPro Alarm Locator Alarm Bed & Chair Alarm Chair Sentry Economy Pad Alarm Floor Mat Monitor Keep Safe QualCare Alarm Safe-T Mate Alarmed Seatbelt Emerging Technology and Aging Remote Patient Monitoring Mobility and Wandering Location Tracking Fall Detection Real-time Surveillance Wireless Camera Systems Ambulatory Aides Laser Light Wheelchair-Related Falls Current Fall-Risk Assessment tools not effective Features of Wheelchairs contribute to risk Most common site of injury is NOT hip, but rather fractures of extremities Head injury/mortality W/c safety and Dementia nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 18

19 Pat And Her Mom Getting ready to dance I Fall A lot! Why? nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 19