Inpatient fall prevention

Preventing Inpatient Falls (a road map)

The National Council on Aging and the Center for Healthy Aging

The National Council on Aging and the Center for Healthy Aging originated a falls free initiative promoting state legislation and funding in some circumstances to reduce falls in the elderly in all community places, including hospitals. These initiatives vary from state to state. Many states have legislation that requires education of health professionals in fall prevention.

Agency for Healthcare Research and Quality (AHRQ)

The Agency for Healthcare Research and Quality (AHRQ) with a core team of experts in fall prevention from the RAND Corporation, ECRI Institute, and Boston University created a detailed for a fall prevention program toolkit for hospitals. The toolkit, recommends separating fall prevention activities into the following steps:

Universal fall precautions, including scheduled rounding protocols.
Standardized assessment of fall risk factors.
Individualizing the Care plan and interventions to target patient specific risk factors.
Post fall procedures, including a clinical review and root cause analysis.

The AHRQ toolkit recognizes that fall prevention practices need to reflect the specific hospital environment and individual patient needs. The toolkit includes a warning that fall prevention is a standard of good quality patient care. Fall safety must be balanced with the patients need for ambulation to maintain muscle strength and avoid deconditioning. Restraints and sedation, for example, are sometimes believed to prevent falls but in fact can increase serious fall injuries and lead to complication of bedrest (Ganz, et al., 2013).

This AHRQ report provides a comprehensive description fall prevention programs, including a falls clinical pathway. RnCeus recommends reviewing the toolkit as part of this CE course. http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtkover.html

The AHRQ also has a list of steps an organization can take when implementing a fall prevention program that match up with tools and the person who should complete that tool.

Section	Action Steps	Tool That Supports Action	Who Should Use The Tool
Overview	Enlist support of senior leaders	Word Version [30.6 KB]	Senior manager
Section 1	Are you ready for this change?
1.1	Assess the culture of safety in your hospital	Tool 1A, Hospital Survey on Patient Safety Culture; Word Version [49.85 KB]	All interdisciplinary team members
1.2	Evaluate current organizational attention to falls	Tool 1B, Stakeholder Analysis; Word Version [30.26 KB]	Implementation Team leader
1.3	Assess and develop leadership support for the fall prevention program	Tool 1C, Leadership Support Assessment; Word Version [29.62 KB] Tool 1D, Business Case Form; Word Version [29.16 KB]	Implementation Team leader
1.5	Identify resources that are available and resources that are needed	Tool 1E, Resource Needs Assessment; Word Version [28.99 KB]	Implementation Team leader
1.7	Assess your progress on completing readiness for change activities	Tool 1F, Organizational Readiness Checklist; Word Version [29.55 KB]	Implementation Team leader
Section 2	How will you manage change?
2.1	Identify your Implementation Team	Tool 2A, Interdisciplinary Team; Word Version [40.94 KB]	Implementation Team leader
2.2	Assess the current status of fall prevention activities in your hospital	Tool 2B, Quality Improvement Process; Word Version [30.48 KB] Tool 2C, Current Process Analysis; Word Version [30.33 KB] Tool 2D, Assessing Current Fall Prevention Policies and Practices; Word Version [33.9 KB]	Implementation Team leader, individuals designated by the Implementation Team leader
2.2	Determine staff knowledge about fall prevention	Tool 2E, Fall Knowledge Test; Word Version [32.79 KB]	Staff nurses and nursing assistants
2.3	Set goals for improvement based on outcomes and processes	Tool 2F, Action Plan; Word Version [34.66 KB]	Implementation Team leader with quality improvement/safety/risk manager
2.4	Assess your progress on completing the managing change activities	Tool 2G, Managing Change Checklist; Word Version [29.25 KB]	Implementation Team leader
Section 3	Which fall prevention practices do you want to use?
3.1	Identify how fall prevention care processes connect to one another	Tool 3A, Master Clinical Pathway for Inpatient Falls; Word Version [61.8 KB]	Quality improvement/safety/risk manager, staff nurses, nursing assistants
3.2	Implement universal fall precautions	Tool 3B, Scheduled Rounding Protocol; Word Version [29.92 KB] Tool 3C, Tool Covering Environmental Safety at the Bedside; Word Version [36.01 KB] Tool 3D, Hazard Report Form; Word Version [30.13 KB] Tool 3E, Clinical Pathway for Safe Patient Handling; Word Version [61.22 KB]	Unit manager, staff nurses, nursing assistants, facility engineer, hospital employee who enters patient rooms
3.3	Identify important risk factors for falls in your patients	Tool 3F, Orthostatic Vital Sign Measurement; Word Version [32.37 KB] Tool 3G, STRATIFY Scale for Identifying Fall Risk Factors; Tool 3H, Morse Fall Scale for Identifying Fall Risk Factors; Tool 3I, Medication Fall Risk Score and Evaluation Tools;	Staff nurses, pharmacist, nursing assistants
3.4	Use identified fall risk factors to implement fall prevention care planning	Tool 3J, Delirium Evaluation Bundle: Digit Span, Short Portable Mental Status Questionnaire, and Confusion Assessment Method; Tool 3K, Algorithm for Mobilizing Patients; Word Version [96.08 KB] Tool 3L, Patient and Family Education; Word Version [29.6 KB] Tool 3M, Sample Care Plan; Word Version [32.47 KB]	Educators, staff nurses, physicians, nurse practitioners, physician assistants, nursing assistants
3.5	Assess and manage patients after a fall	Tool 3N, Postfall Assessment, Clinical Review; Word Version [33.64 KB] Tool 3O, Postfall Assessment for Root Cause Analysis; Word Version [43.48 KB]	Staff nurses and physicians
3.8	Assess your progress on completing the best practices activities	Tool 3P, Best Practices Checklist; Word Version [29.23 KB]	Implementation Team Leader
Section 4	How do you implement the fall prevention program in your organization?
4.1	Assign staff roles and responsibilities for tasks identified in set of best practices	Tool 4A, Assigning Responsibilities for Using Best Practices; Word Version [29.14 KB] Tool 4B, Staff Roles; Word Version [31 KB]	Implementation Team Leader, Unit manager
4.3	Assess current staff education practices and facilitate integration of new knowledge on fall prevention into existing or new practices	Tool 4C, Assessing Staff Education and Training; Word Version [30.88 KB]	Implementation Team Leader
4.4	Assess your progress on implementing best practices activities	Tool 4D, Implementing Best Practices Checklist; Word Version [29.22 KB]	Implementation Team Leader
Section 5	How do you measure fall rates and fall prevention practices?
5.1	Collect the right data to learn about falls, fall-related injuries, and their causes	Tool 5A, Information To Include in Incident Reports; Word Version [30.61 KB]	Quality improvement/risk manager, information systems staff
5.2	Measure fall prevention practices	Tool 5B, Assessing Fall Prevention Care Processes; Word Version [41.74 KB]	Unit manager and unit champions
5.3	Assess your progress on measuring progress activities	Tool 5C, Measuring Progress Checklist; Word Version [29 KB]	Implementation Team Leader
Section 6	How do you sustain an effective fall prevention program?
6.3	Identify factors need to sustain your fall prevention efforts	Tool 6A, Sustainability Tool; Word Version [32.85 KB]	Implementation Team Leader

https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/roadmap.html

Instant Feedback:

Many government and other health agencies have specific fall prevention resources that can be helpful in developing a fall prevention program.

Specific fall prevention recommendations

The Rand report

The standard goal for hospitals has been to reduce the fall rate to 3 per 1000 patient days. Most hospitals reporting success in reducing the number of falls per patient days were able to achieve that goal with one reducing their fall rate to 1.37 per 1000 days (Gutierrez et al., 2008). Since some hospitals are able to reduce the fall risk below 2 per 1000 patient days, the goal of the fall prevention program in a hospital should be to reduce the risk to 1 per 1000 patient days instead of 3, setting the goal appropriately just beyond the current reach.

The basic components of the successful fall programs analyzed in the RAND studies have been:

Use of a valid and reliable fall assessment tool
Education of the staff, family and patient of the fall risk
Posting signs in the room indicating fall risk as well as the use of a yellow bracelet also indicating fall risk.

Example of a fall prevention program

Krauss et al. (2008) studied fall rates in 4 general medicine floors in a 1300 bed tertiary care academic hospitals. There were 135 patients in the intervention group and 78 patients in the control group. The intervention group received the following interventions:

Daily risk assessment (Morse Fall Scale)
Patient education
Modification of the environment to make it safer
Alert signs above bed and/or wrist band
Patient / family education
Toileting schedule
2 hour safety rounds
Medication review
Walking aid
Other measures (e.g., bed alarm system, request that family sit with patient)
Staff education

The control group received the usual care which included: daily risk assessment, pt / family education, signs, other measures. The results showed a statistically significant difference between the rate of falls in the intervention group before and after the intervention. A rate of 6.84 was reduced to 3.81 falls per 1000 patient days at the 5 month interval. However, the change did not remain after 9 months.

Hawthorne Effect

Many of the studies reported the positive effects of the interventions tapering off after a few months. This may represent the Hawthorne Effect, where staff altered behavior as a result of participating in a study.

It is important that the issue of fall prevention be continuously reinforced. The three-month progress report of falls, used in many hospitals, is too long an interval to provide continuous reinforcement. Each unit should display a weekly fall report of their unit. This is one of the most valuable variables for reducing falls.

Instant Feedback:

Which of the following are components of a fall prevention program?

References

Christiansen, T. L., Lipsitz, S., Scanlan, M., Adelman, J., Bates, D. W. & Dykes, P. C. (2020). Patient Activation Related to Fall Prevention: A Multisite Study. The Joint Commission Journal on Quality and Patient Safety. 46(3), 129-135.

The Joint Commission (TJC). (2015). Sentinel Event Alert Preventing falls and fall-related injuries in health care facilities. Issue 55, September 28, 2015. 12/10/2015 retrieved from
http://www.jointcommission.org/assets/1/18/SEA_55.pdf

National Council On Aging (NCOA). Center for Healthy Aging: model health programs for communities. Advancing and Sustaining a State-Based Falls Prevention Agenda: The Role of Legislation, Policy, and Regulation. (2010)

Overview. January 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtkover.html

Hempel, S. et al. (2012). Review of the evidence on falls prevention in hospitals. Santa Monica, CA: Rand Health.

Gutierrez, F. & Smith, K. (2008). Reducing falls in a Definitive Observation Unit: an evidence-based practice institute consortium project. Crit Care Nurs Q. 31(2), 127-39.

Krauss, M. J., Tutlam, N., Costantinou, E., Johnson, S., Jackson, D. & Fraser, V. J. (2008). Intervention to prevent falls on the medical service in a teaching hospital. Infect Control Hosp Epidemiol. 29(6), 539-45.