CANUS Corporation Safet

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1 Fall Prevention Preventing falls among patients and residents in acute and long term care healthcare settings requires a multifaceted approach, and the recognition, evaluation and prevention of patient or resident falls are significant challenges for all who seek to provide a safe environment in any healthcare setting. It is acknowledged that most of the currently available data, research and guidelines on fall prevention are from long-term care settings; however, much is applicable for all healthcare settings. This Web site provides a summary of the issues, strategies and tools to define and measure falls, identify risks and target prevention strategies. Each fall prevention program is likely in a different stage of development, whether initiating a new program or expanding or improving an existing program. The content on this site has been organized into sections that focus on specific aspects of a comprehensive falls prevention program. You may wish to review the topic sections that are most relevant to your program development or revision; and include: Extent of the problem: incidence and costs of falls. Definitions and measurement: trending and benchmarking fall data. Causes of falls: information to assist with identification of risks and prevention. Interventions and prevention strategies: overview of strategies, including use of sitters. Risk assessment: tools for risk and injury assessment. Comprehensive prevention program: tools for program assessment, sample guidelines. If you are looking for specific tools or resources to enhance your program, you may wish to review the following sections on this Web site: Key documents: annotated references, definitions, consensus standards, and classifications from national organizations Sample procedures and tools: fall rate calculations, risk assessment charts, patient sitter guidelines and sample policies and tool kits. Education and training: training programs, handouts, PowerPoint presentations, case studies, fact sheets, and national guidelines. Resources: evidence-based interventions, national quality improvement and benchmarking initiatives To see a complete list and/or download all the resources and tools on this site, go to the Downloads section. Extent of the problem in healthcare settings Falls are a common cause of morbidity and the leading cause of nonfatal injuries and traumarelated hospitalizations in the United States. Falls occur in all types of healthcare institutions and

2 to all patient populations. In hospitals, falls consistently make up the largest single category of reported incidents. Nearly half of all residents in nursing homes fall each year, with many sustaining fractures. Fall-related injuries recently accounted for 6 percent of all medical expenditures for people age 65 and older in the United States. (See Rubenstein LZ in Annotated bibliography (.doc) (106 KB).) The morbidity, mortality and financial burdens attributed to patient falls in hospitals and other healthcare settings are among the most serious risk management issues facing the healthcare industry. For the patient or resident, consequences include, but are not limited to, fracture, soft tissue or head injury, fear of falling, anxiety, and depression. The Centers for Disease Control and Prevention (CDC) quantifies the seriousness of the fall problem (.doc) (29 KB) and provides additional fact sheets on this topic: Falls in nursing homes (.doc) (46 KB) The costs of fall injuries among older adults (.doc) (35 KB) Falls and hip fractures among older adults (.doc) (52 KB) Research finding and references (.doc) (54 KB) Definitions and measurements Definitions Because no universally accepted definition has yet been developed, falls have been defined and reported in different ways. To track and trend fall data accurately and consistently, it is important for each organization to establish a fall definition. References for the fall definitions listed below are provided in the appended resources. Reference for fall definitions from Morris& Isaacs, Kellogg and National Quality Forum (NQF) (.doc) (36 KB) An untoward event which results in the patient coming to rest unintentionally on the ground or other lower surface (Morris & Isaacs) An event that results in the patient or a body part of the patient coming to rest inadvertently on the ground or other surface lower than the patient (Kellogg International Work Group on Prevention of Falls by the Elderly) Patients who experience an unplanned descent to the floor (National Quality Forum (NQF) 2003 Draft National Voluntary Consensus Standards for Nursing-Sensitive Performance Measurement Appendix C-3) Reference for fall definition from Florida Hospital Association (.pdf) (562 KB) An unintended event resulting in a person coming to rest on the ground/floor or other lower level (witnessed), or is reported to have landed on the floor (unwitnessed) not due

3 to any intentional movement or extrinsic force such as stroke, fainting, seizure. (Florida Hospital Association) Measurements Rates: Comparing fall rates among different institutions is difficult because of varying fall definitions, methods to report data and differences in settings and patient populations, and the lack of risk adjustment. The most reliable and useful approach for any organization is an examination of its own quality indicator data over time -- with the ultimate goal of reducing and eliminating all preventable falls. The most commonly used statistic to measure and track falls is the fall rate, which is calculated as follows: Number of patient falls x 1,000 Number of patient days The fall rate for a specified time period is defined as the total number of eligible falls divided by the total number of eligible patient days, multiplied by a constant or k of 1,000 to create a rate per 1,000 patient days. (The k=1000 enables the use of a whole number as opposed to fractions, permitting easier manipulation of the data.) Note that all falls are included in the formula, not all patients who have fallen, so that repeated falls experienced by the same patient are included in the numerator. The National Quality Foundation (NQF), the Maryland Indicator project, and others use this rate. Other rates (.doc) (25 KB) found in the literature are also used to track and trend fall data and include: The number of patients at risk; The number of patients who fell; and The number of falls per bed. Comparisons Risk adjustment: A variety of rates found in the literature demonstrates the difficulties of comparing studies that use different calculations, and highlight the importance of comparing like rates and determining whether or not they are risk-adjusted. For example, compilations of several relatively recent research studies reported by Morse provide a range of fall rates (per 1,000 bed days) as 2.2 to 7 in acute care hospitals, 11.0 to 24.9 in long-term care hospitals, and 8.0 to 19.8 in rehabilitation hospitals. The range of injury rates (in percentages) has been reported to be 29 to 48, with 4 percent to 7.5 percent resulting in serious injuries. Other reviews suggest that the average rate for acute care hospitals is in the range of 2.5 to 3.5 falls per patient for every 1,000 bed days. In reviewing such studies, it is critical to note the method and whether the data are risk-adjusted.

4 There are a few sources of risk-adjusted data available for comparisons to other external organizations with similar populations, though it should be clear that a facility must risk-adjust its data using similar definitions to make the comparison. Risk-adjusted comparison rates can be found from performance measurement systems such as the Maryland Hospital Association Quality Indicator Project, although access to the information requires a subscription. Trending: Although it is valuable to trend reported patient falls per 1,000 patient days, care should be taken when comparing patient care from unit to unit, or even individual units to the overall organizational rate, much less other organizations, unless rates are risk-adjusted. It may be more valuable to generate control charts for each of the units so that over time, each unit can determine whether their processes are stable. If they are not, the data should trigger an investigation to identify what are the possible causes and remedial actions. Regardless of whether processes are stable within a unit, areas that have relatively high reported fall rates should still look for ways to reduce their median fall rate. This process must consider the nature of the patient population and other factors so that the chosen strategies are appropriate. This approach supports the use of unit trends over time related to the implementation of strategies, and determination of whether selected strategies are effective. A case study (.doc) (41 KB) with an accompanying chart (.bmp) (845 KB) demonstrates how falls, interventions and improvements were measured, compared internally and benchmarked with the QI Project. See Sample Procedures and tools. Cause of falls It has been helpful for some to classify falls based on environmental, as well as physiologic, factors as a way to better understand their causes. One approach, presented by researcher Janice Morse, suggests that falls be classified as accidental, unanticipated physiologic, or anticipated physiologic, as defined below: [See Morse JM, 2002 (.doc) (25 KB)] Accidental falls occur when patients fall unintentionally. For example, they may trip, slip, or fall because of a failure of equipment or by environmental factors such as spilled water or urine on the floor. Unanticipated physiologic falls occur when the physical cause of the falls is not reflected in the patient s risk factor for falls. A fall in one of these patients is caused by physical conditions that cannot be predicted until the patient falls. For example, the fall may be due to fainting, a seizure, or a pathological fracture of the hip. Anticipated physiologic falls occur in patients whose score on risk assessment scales [(e.g. Morse Fall Scale (MFS)] indicates that they are at risk of falling. According to the MFS, these patients have some of the following characteristics: a prior fall, weak or impaired gait, use of a walking aid, intravenous access, or impaired mental status. According to Morse, approximately 14 percent of all falls in hospitals are accidental; another 8 percent are unanticipated physiologic falls; and 78 percent are anticipated physiologic falls.

5 It is generally accepted that patient falls are caused by multiple factors. Another popular classification scheme of falls is based on the assumption that they result from a complex interaction of intrinsic and/or extrinsic risk factors as illustrated in the figure below. The summary list that follows is derived from many studies incorporating different methodologies, settings, samples and overall quality. Individual risk factors may not be generalized across all settings and may not be applicable to a particular organization. Intrinsic risk factors (i.e., integral to the patient s system, many of which are associated with age-related changes): Previous fall - studies have cited a history of falls as a significant factor associated with patients being more likely to fall again. Reduced vision vision affected by, for example, a decline in visual acuity, decreased night vision, altered depth perception, decline in peripheral vision, or glare intolerance. Unsteady gait - manner and style of walking. Musculoskeletal system impact from factors such as muscle atrophy, calcification of tendons and ligaments, and increased curvature of the spine (osteoporosis) are associated with ability to maintain balance and proper posture. Mental status status affected by confusion, disorientation, inability to understand, and impaired memory. Acute illnesses rapid onset of symptoms associated with seizures, stroke, orthostatic hypotension, and febrile conditions. Chronic illnesses - conditions such as arthritis, cataracts, glaucoma, dementia, diabetes and Parkinsonism. Extrinsic risk factors (i.e., external to the system and relating to the physical environment): Medications - those that affect the central nervous system, such as sedatives and tranquilizers, benzodiazepines, and the number of administered drugs. Bathtubs and toilets equipment without support, such as grab bars. Design of furnishings height of chairs and beds. Condition of ground surfaces - floor coverings with loose or thick-pile carpeting, sliding rugs, upended linoleum or tile flooring, highly polished or wet ground surfaces. Poor illumination conditions - intensity or glare issues. Type and condition of footwear - ill-fitting shoes or incompatible soles such as rubber crepe soles, which, though slip resistant, may stick to linoleum floor surfaces. Improper use of devices - bedside rails and mechanical restraining devices that may actually increase fall risk in some instances. Inadequate assistive devices - walkers, wheelchairs and lifting devices. Interventions and prevention strategies General safety interventions

6 Given the numerous intrinsic and extrinsic factors leading to falls, it is possible to consider each factor and identify positive steps and safe interventions proven effective for preventing falls. A few examples of general interventions might be helpful before discussing measurement and development processes for risk assessment or a comprehensive program to reduce fall incidents. Interventions: Instruct the patient or resident to request assistance as needed. Instruct the patient to wear non-skid footwear, considering the type and condition of footwear such as ill-fitting shoes or incompatible soles Provide an appropriate armchair with wheels locked at the patient s bedside. Ensure that the pathway to the restroom is free of obstacles and properly lighted. Ensure the hallways are clear of obstacles. Place assistive devices such as walkers and canes within a patient s or resident s reach. Raise the side rails as appropriate for access to bed controls, support and repositioning. Evaluate chair and bed height. Consider peak effect for prescribed medications that affect level of consciousness, gait and elimination when planning patient care. Observe environment for potentially unsafe conditions, such as loose carpeting and water on the floor. Notify appropriate department(s) of hazardous conditions. Do not leave at risk patients or residents unattended in diagnostic or treatment areas. Ensure patients or residents being transported by stretcher/bed have all side rails in the up position during transport, or if left unattended briefly while awaiting tests or procedures. Inform and educate patients and /or family members regarding a plan of care to prevent falls. Include the patient s family in the development of an individualized safety plan, considering age-specific criteria and patient cognition when planning care. Collaborate with the patient s or resident s family to provide assistance as needed while maintaining the patient s independent functioning. Communicate the patient s at risk status during shift report and with other disciplines as appropriate. Sitters Patients or residents with an impaired ability to understand or follow directions, or appreciate the potential for self-harm as a consequence of his/her actions, may have a sitter prescribed by a physician to provide continuous one-to-one observation. Sitters are responsible for observing the patient and maintaining a safe environment. When sitters are used, they are under the direction and delegation of a registered nurse who monitors the patient s or resident s actions. Sitters may be non-licensed patient care staff, or other hospital employees who have completed sitter competencies. Guidelines (.doc) (54 KB) and sample competency quiz (.doc) (54 KB) are available.

7 Risk assessment Implementing a successful falls prevention program requires a systematic method for identifying patients or residents who are at a higher risk for falling, so that fall prevention resources can be targeted where they are most needed. There are a variety of available risk assessment tools that may provide guidance in the development of a fall prevention program for each setting and population. When to conduct a risk assessment The assessment for risk factors, which is usually performed by nurses, commonly utilizes a system that assigns points to specific risk factors. The level of risk and subsequent fall precaution measures such as standard or high risk precautions are then initiated based on the range in which the patient scores (e.g., low, medium or high risk). Suggested timing for risk assessments include: On admission - risk assessment data should be entered into the admission database as soon as possible after admission. Changes in a patient s status - (physiological, functional or cognitive change). Whenever a fall occurs - data should be entered anytime a patient or resident experiences a fall. Periodically during a hospital stay, or when transported, including transfers to another patient care unit Quarterly, at minimum, or other defined time periods in long-term, chronic and residential care settings. Instruments to conduct a risk assessment A comprehensive list is available for fall risk factor elements (.doc) (28 KB) that have been incorporated in various instruments. The particular variables one would include in a risk assessment instrument depend on the patient characteristics of the particular healthcare setting. The Morse Fall Scale is a relatively easy instrument to use and has been demonstrated to be reliable and valid across a variety of healthcare settings (acute medical and surgical units, long term care areas, rehabilitation hospitals). Hill-Rom provides a CD that provides a full program on the use of the Morse Instrument and Fall Scale and a copy can be requested by sending an to safetyprograms@hill-rom.com. See also: Additional instruments and tools for preventing patient falls are available from the Department of Veterans Affairs National Center for Patient Safety (VA NCPS)

8 Organization of risk assessment information Depending on the assessed fall risk of patients or residents using the MFS or other scales, the next essential part of a successful falls prevention program is to organize and implement patientspecific fall prevention strategies. One Falls Assessment Chart (.pdf) (10 KB) is also available from the Foundation of Nursing Studies Web site. This excellent algorithm depicts the full circle of activities initiated by the assessment. Fall assessment is implemented shortly after hospitalization. Level of fall risk is determined. Patient-specific fall prevention strategies are organized. Prevention strategies are implemented. Communication of key players and fine-tuning of plan. Formal fall reassessment. A similar approach to fall risk assessment considers all factors that place the patient or resident at risk for injury. Such as assessment includes falls as one preventable injury among others. For example, the Detroit Medical Center (DMC) has instituted such a patient injury assessment tool (.doc) (41 KB) and implemented a related policy (.doc) (57 KB). Comprehensive prevention program There is no simple fall prevention strategy that will work for all patients and residents across the spectrum of healthcare. In general, it has been difficult to study and evaluate the merits of specific interventions because of logistical considerations such as varying populations, simultaneously employed multiple interventions, and confounding variables. As falls appear to happen because of a complex interaction of intrinsic and extrinsic risk factors, interventions require a multi-faceted approach. A strong fall prevention strategy that encompasses a number of different interventions and targets multiple risk factors is more likely to be successful. Thus, the success of a program appears to be not as dependent on a specific intervention but on a comprehensive interdisciplinary program. The Florida Hospital Association s Patient Steering Committee has provided a useful outline of the key components for a comprehensive program: Assessing and screening for risk factors for falls. Using triggers to implement a falls prevention protocol. Implementing protocols according to patient needs. Assessing and reassessing patient and modifying as appropriate. Reporting falls (internal and external). Measuring/monitoring fall rates.

9 Improving the falls prevention program. Additionally all staff should be required to complete competencies. As noted above, there is no single fall prevention care plan that will work for all patients and residents and for all situations or settings. Based on a falls risk assessment, the healthcare team should tailor patient-specific prevention strategies. As eloquently stated by Morse: Because patients fall in a variety of situations, and these falls are due to innumerable causes, there cannot be one routinized care plan to prevent falls. Although some prevention strategies are obvious and may be used with many patients, other patients present more of a challenge and demand creative and innovative solutions to ensure patient safety. Numerous resources, including the National Guideline Clearinghouse (.doc) (67 KB) and the University of Texas Health Science Center (.doc) (140 KB), provide examples of frequently used fall prevention strategies identified in the literature. Healthcare professionals who would like an in-depth review of the myriad of specific intervention and prevention strategies should consider the following resources. Note that there is significant overlap between interventions that may be effective in acute versus long-term care settings, such as environmental strategies (.doc) (53 KB) and reviewing medications (.doc) (25 KB) for their risks/benefits and their proper dosages. Thus, one may want to research each category as appropriate for a particular practice setting. A summary of several reviews is provided below for both acute care and long-term care: Guidelines and reviews in acute and long-term care settings. Download guidelines (.doc) (42 KB) Full documents may be downloaded directly: Falls in acute hospitals A systematic review (Evans) (.pdf) (566 KB) Reducing patient falls in an acute general hospital (Barnet) (.pdf) (136 KB) Guideline for the prevention of falls in older persons (AGS) (.pdf) (174 KB) Prevention of falls and fall injures in the older adult (Registered Nurse Association Canada full document) (.pdf) (2.8 MB), and Summary of Recommendations (.pdf) (151 KB) Restraints Given the increasing recognition that restraint use does not contribute to fall reduction, this issue and its associated regulatory aspects are addressed elsewhere in Patient Safety. The use and abuse of restraints in healthcare has been a long-standing controversy. Major risk management issues include quality of care, quality of life, patient rights and patient and staff safety. Injuries prompt restraint standards

10 y One facet of patient safety relates to injuries that may result from the use of patient restraint devices. Studies continue to reinforce a growing consensus that restraint use does not prevent fall injuries. JCAHO and the Centers for Medicare and Medicaid Services (formerly known as Health Care Financing Administration, or HCFA), have issued standards to ensure that patients' rights involve key safety aspects relating to "restraints and seclusion." For further discussion and additional resources, see Patient Safety. You may check back on this topic since it is being regularly updated.