C on C ti E Supplement to nu in 1. g S 9 Ed ee cr u PECIAL EPORT p ed ca S R a it ti ge s on 20 ww w.AmericanNurseToda y.com March 2011 Best Practices for Falls Reduction A Practical Guide

This continuing education program is supported by an unrestricted educational grant from Hill-Rom. Because even the best nurses in the world can use some support.

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© 2011 Hill-Rom Services, Inc. ALL RIGHTS RESERVED Meeting the challenge of falls reduction By Melissa A. Fitzpatrick, MSN, RN, FAAN, Vice President and Chief Clinical Officer, Hill-Rom

ing concern. How many times have you and caregiver. By using a safety status hurt your back or shoulder while trying to board to provide visibility to critical proto - move a patient or pick her up from the cols and alarms, nurses can monitor pa - floor after she has fallen? tients from afar and keep them safe from Patient falls are ubiquitous. We must falls. You’ll find other examples and ap - think of new ways to solve this age-old con - proaches in this special report—practical cern. The stakes have never been higher guidelines you can apply where you work. and the need for holistic falls-prevention If patient falls were easy to eliminate, programs has never been greater. we would have eliminated them by now. As This special report describes what we with many clinical challenges, there’s no know about patient falls and how to over - single easy answer to the challenges posed come challenges and barriers to creating by patient falls. Analyzing the data, learn - environments in which patients are safe ing from colleagues’ successes, disseminat - from falling. Articles were written by ing enhanced outcomes, and stomping out thought leaders and experts on patient falls myths and ineffective practices will help you who discuss pertinent evidence and share as you work to reduce patient falls on your reventing patient falls is at the programs, care processes, assessment unit and across your organization. the top of mind for every methods, and outcomes associated with I wish to thank each of the authors for caregiver in every clinical their falls-prevention strategies. We share their contributions to this body of knowl - setting. Multidisciplinary their best practices so that you can use edge. I hope you will draw from their rich teams across the continuum them as a guide as you work to decrease experience as you try to replicate their of care convene each day as falls “champi - patient falls in your organization. strategies and results. All of us at Hill-Rom, ons” to determine the best ways to identify All articles in this special report reflect including the hundreds of nurses, therapists, patientsPat highest risk for falls and to de - the reality that clinical outcomes can im - and ergonomists on our team, are proud to velop falls-prevention strategies. prove—and those improvements can be support this special report on patient falls. Despite heightened national attention to sustained—when the best people, process - We hope you will apply what you learn to this issue, threats to reimbursement, and the es, and technology are employed. Not only your practice so you can continue to make best possible intentions, patient fall rates do the authors share their positive clinical your optimal contribution to patient care. across the United States continue to esca - outcomes; they explain how your efforts At Hill-Rom, we are dedicated to en - late, putting patients and caregivers at in - can contribute to your organization’s bot - hancing outcomes for patients and their creasing risk. The facts are undeniable: tom line by enhancing throughput and ac - caregivers. We know that as we work to - Up to 50% of hospitalized patients are at cess when patient fall rates decline. gether using people, process, and technol - risk for falls, and almost half of those who The ability to build a strong business ogy, we can achieve better clinical out - fall suffer an injury. case for quality is an important tool for all comes with fewer patient complications. While falls have a tremendous impact nurses today. This special report provides Thank you for all you do every day and on the patient, they also directly affect a the language and process to help you artic - thank you for allowing Hill-Rom to be your healthcare organization’s cost per case ulate the difference that quality outcomes partner in patient care. G and length of stay. The average hospital mean for patients, caregivers, and the fi - stay for patients who fall is 12.3 days nancial health of your organization. Also Selected references longer, and injuries from falls lead to a crucial to your success is the ability to un - Bates DW, Pruess K, Souney P, Platt R. Serious falls 61% increase in patient-care costs. derstand the technology available to help in hospitalized patients: correlates and resource uti - Nearly every nurse can recall an inci - keep patients safe from falling, along with lization. Am J Med . 1995;99(2):137-143. dent in which a patient fell, or nearly fell. the ability to use the science behind the Joint Commission. It’s a long way down: reduc - As patients continue to age and present technology to make sound technology deci - ing the risk of patient falls. www.jointcommis - sioninternational.org/Web-Based-Education/Its- with increasing vulnerability and comor - sions. Knowing, for example, when a low A-Long-Way-Down-Reducing-The-Risk-of-Patient- bidities, their potential for harm increases. bed is too low to keep the patient safe Falls/1435/. Accessed January 30, 2011. Likewise, as the American nurse ages, the helps you optimize patient safety. Using Schwendimann R, De Geest S, Millisen K. Evalu - risk of caregiver injury escalates, creating patient-lift technology also optimizes patient ation of the Morse Fall Scale in hospitalised pa - scenarios in which harm could be a grow - handling and safety for both the patient tients. Age Aging . 2006;35(3):311-313. www.AmericanNurseToday.com March 2011 Best Practices for Falls Reduction: A Practical Guide 1 Reducing patient falls: A call to action By John Jorgensen, MPA, RN

fear of falling or of a fall-related injury may be as disabling as a fall itself.

Impact of falls on facilities In today’s evolving pay-for-performance envi - ronment, healthcare facilities have a huge financial stake in reducing the number of patient falls. As of 2008, hospitals no longer receive payments for treating injuries caused by in-hospital falls, based on a 2007 final rule by the Centers for Medicare & Medicaid Services (CMS). The rule is a strong incentive for healthcare providers to implement practices that reduce the number of preventable patient falls. alls and fall-induced injuries lion for fatal falls and $19 billion for nonfa - are among the most common tal fall-related injuries. By 2020, the annual CMS and Joint Commission and serious health problems direct and indirect cost of fall injuries is ex - requirements facing adults age 65 and pected to reach $54.9 billion. CMS requires that a healthcare facility be a older in developed countries. Given the enormous human and finan - safe environment and setting for care. Facili - More than one-third of older adults experi - cial consequences of falls, the need for ro - ties that don’t meet this requirement can be ence falls. In this population, falls are the bust falls-reduction programs across the cited for immediate jeopardy and lose their leadingFcause of injury-related deaths and country has never been greater. eligibility to provide services. CMS also re - the most common cause of injuries and hos - quires that the safety of patients at risk be pital admissions. Impact of falls on patients assessed regularly and corrected if found to Nearly half of those who fall suffer mod - Falls are a major contributor to a patient’s be deficient. A facility that fails to correct erate to severe injuries that limit their mobili - functional decline and increased healthcare deficiencies is violating conditions of partici - ty and increase the risk of premature death. use. Even if a fall doesn’t cause a serious in - pation and could lose its Medicare or Medi - Up to 20% of falls cause serious injury, in - jury, it may triple the patient’s likelihood of caid funding. Patients and their families are cluding fractures and subdural hematomas. requiring placement in a skilled nursing fa - encouraged to contact the CMS or Joint Even when a fall doesn’t lead to death, cility. A serious fall increases the likelihood Commission with a complaint concerning it can necessitate prolonged hospitaliza - of skilled-nursing placement nearly tenfold. patient care, which may trigger a survey or tion. Many victims spend up to a year in A fall can cause lasting pain and suffering at least a site visit from the Department of recovery. Some suffer disability and loss of and may limit function, imposing additional Health. Also, patients and their families may function and are unable to return to their family and societal care burdens. initiate litigation related to a fall. homes; many end up losing their independ - In 2005, the Joint Commission introduced ence. Among older adults who sustain a Fear of falling a national patient safety goal requiring hospi - hip fracture, nearly 50% never regain their An increasing body of evidence suggests tals to reduce the risk of patient harm result - previous level of functioning and 30% die that falls cause psychological problems in ing from falls and to implement a falls-reduc - within 6 months. With the number of older many older people—both fallers and non - tion program. In 2010, this requirement was Americans increasing, the problem of fall- fallers. Psychological consequences include upgraded to a standard. The patient care related injuries is likely to rise substantially fear, self-doubt, activity avoidance, and chapter of Comprehensive Accreditation over the next few decades. loss of confidence, which may lower the Manual for Hospitals (CAMH): The Official Falls carry staggering economic costs. quality of life. Among older adults who Handbook lists two requirements: Annual acute-care costs related to falls are have fallen, an estimated 29% to 92% fear • Element of Performance (EP) 1: The hos - estimated at $1.08 billion; long-term care they’ll suffer another fall. Among those who pital assesses and manages the pa - costs, at $4.9 billion. According to the haven’t fallen, 12% to 65% fear they will tient’s risks for falls. Centers for Disease Control and Preven - fall. More women than men fear falling. • EP 2: The hospital implements interven - tion, medical costs related to falls totaled Fear of falling commonly leads to activi - tions to reduce falls based on the pa - more than $19 billion in 2007 –$179 mil - ty reductions or even avoidance. For some, tient’s assessed risk.

2 Best Practices for Falls Reduction: A Practical Guide March 2011 www.AmericanNurseToday.com Recommendations for healthcare facilities The Institute for Clinical Systems Improvement recommends that facilities consider the following interventions and Both requirements carry direct-impact sta - processes when developing and implementing falls-prevention programs: tus, meaning they are requirements that, if not 1. Obtain organizational support for the program. met, are likely to create an immediate risk to 2. Establish a process for evaluating hospitalized patients for the risk of falling. patient safety or quality of care. Immediate risk occurs because too few processes or preventa - 3. Perform a risk assessment: • Cognitive dysfunction testing for dementia and delirium tive measures are in place to protect the pa - • Gait and mobility function tient from harm. If these two elements of per - • Potential medication factors formance are unmet at the time of survey, they • Environmental safety assessment must be corrected within 45 days. Also, EP 38 4. Communicate risk factors: in the book’s performance improvement chap - • Use visual communication tools. ter requires that the hospital evaluate the effec - • Communicate with patients and families. tiveness of all falls-reduction activities, includ - • Communicate with all healthcare team members. ing assessment, interventions, and education. 5. Perform risk-factor interventions: To meet this standard, data must be collected • Establish universal fall interventions for all patients. to show the hospital’s effectiveness in prevent - • Add strict fall precautions for patients at risk. ing falls and falls with injury. Examples of data • Implement behavioral interventions. collection include outcome indicators for the • Implement impaired mobility interventions. number and severity of fall-related injuries. • Perform environmental rounds. In 2010, the Joint Commission launched 6. Perform continuous monitoring and reassessment. the Speak Up ™ education campaign, which Source: Institute for Clinical Systems Improvement (ICSI). Health Care Protocol: Prevention of Falls (Acute Care). Bloomington, MN: ICSI; April 2010. emphasizes that falls are a serious problem. The campaign offers tips and suggests ac - tions to help people reduce the risk of falling, Essential to health maintenance hematocrit levels and frequent toileting for whether at home or in a healthcare facility. Falls prevention is an essential component patients with elimination problems. Also, the goal of reducing injuries and of maintaining health. Many effective falls- Falls can be prevented. The need to reduce deaths from falls was a part of the “Healthy prevention programs exist, both in the them has never been more important. G People 2010” program of the U.S. Depart - community and in healthcare facilities ment of Health and Human Services. Similar - across a wide variety of settings. Imple - Selected references ly, the Healthy People 2020 campaign has menting such a program can help reduce Centers for Disease Control and Prevention. Falls among older adults: an overview. www.cdc.gov/ an objective of reducing emergency depart - falls and help older Americans live longer homeandrecreationalsafety/falls/adultfalls.html. ment visits for fall-related events by focusing lives of better quality. (See Recommenda - Accessed January 31, 2011. on improving functional status through physi - tions for healthcare facilities .) To help re - Centers for Disease Control and Prevention. Na - cal therapy and balance screening. duce falls, healthcare facilities may need tional Center for Injury Prevention & Control. Cost to purchase safety equipment and upgrade of falls among older adults. September 9, 2008. Why nurses must speak up their infrastructures with senior-friendly www.cdc.gov/HomeandRecreationalSafety/Falls/ A culture of safety doesn’t just encourage lighting, signage, color schemes, and fallcost.html. Accessed January 28, 2011. nurses to work toward change. It requires other improvements. Department of Health and Human Services. Cen - ters for Medicare & Medicaid Services. 42 CFR them to take action when they see something According to research, effective falls- Parts 411, 412, 413, and 489. Medicare Pro - amiss. This culture has no place for those who intervention programs should take a multi - gram; Changes to the Hospital Inpatient Prospective would say, “Safety isn’t my responsibility. All I faceted approach that incorporates both Payment Systems and Fiscal Year 2008 Rates. Final need to do is file a report and someone else behavioral and environmental compo - rule FY 2007 IPPS (71 FR 47881). www.cms.gov/ will take care of it.” Eventually, pressure comes nents. Exercises to improve the patient’s AcuteInpatientPPS/downloads/CMS-1533-FC.pdf. Accessed January 31, 2011. from all directions—peers as well as leaders. strength and balance are key. The environ - Healthcare organizations can reduce pa - ment both at home and in the hospital Institute for Clinical Systems Improvement (ICSI). Health Care Protocol: Prevention of Falls (Acute tient falls if their leaders are committed to may need to be modified. Patient and Care) . Bloomington, MN: ICSI; April 2010. change and enable staff to openly share family education using patient “teach- Joint Commission. Speak Up: Reduce your risk of safety concerns without fear of retaliation or back” is key to verifying and confirming falling [brochure]. www.jointcommission.org/ reprisal. When an organization lacks such a patient comprehension and compliance Speak_Up__Reduce_Your_Risk_of_Falling /. Ac - culture, nurses and other staff members are with the program. Other elements of an cessed January 31, 2011. reluctant or unwilling to report events and effective falls-intervention program include Visit www.AmericanNurseToday.com/Archives.aspx unsafe conditions that may lead to falls. patient medication reviews and interven - for a complete list of selected references. Some may believe reporting won’t lead to tions that specifically address patient risk change. A culture change takes a long time. factors. Examples include the use of hel - John Jorgensen is a medical-surgical clinical Surveys are available to measure this and mets by patients undergoing chemothera - practice specialist at Covenant Health in Knoxville, gauge its progress. py who have low platelet, hemoglobin, or Tennessee. www.AmericanNurseToday.com March 2011 Best Practices for Falls Reduction: A Practical Guide 3 How to build a successful business case for a falls-reduction program By Joan Forte, BSN, MBA, NE-BC

urses often feel they are out weren’t in a well-understood format and • Compliance controls: daily rounding on of their league when it comes hadn’t been made available to the nursing different shifts by a master’s-prepared to convincing the hospital’s department or hospital executives. To pres - nurse to provide support and reinforce - business units to support a ent the business case, we used simple bar ment; her salary is part of the program’s new program, such as falls graphs showing aggregate workers’ com - ongoing cost. reduction. But building a business case fol - pensation costs tied to patient handling. A full and honest assessment and esti - lows the nursing process: assess, plan, im - (See Workers’ compensation costs related mate of costs shows decision makers your plemeNnt, and evaluate. Critical thinking is to patient handling .) proposal is well thought-out and your num - essential throughout the process, and after These graphs were powerful tools for bers can be trusted. evaluation, data are used to start the cycle educating administrators about the hospi - again. This article guides nurses in creating tal’s current state and the ramifications of Know the basic financial model a business case, using a safe patient-han - not supporting the SPH proposal. Also, the Most organizations depend on a simple in - dling (SPH) program as an example. literature showed other SPH programs could ternal rate of return (IRR) for decision mak - At Stanford Hospital and Clinics in Palo increase staff and patient satisfaction, boost ing. IRR is used to measure and compare Alto, California, the nursing department staff and patient safety, and improve a hos - the profitability of different investments; the created a solid business case for an SPH pital’s reputation. So be sure to do your higher the IRR, the more desirable the proj - program, including measures to reduce homework and document the full range of ect. IRR is calculated by taking the expect - falls. In October 2008, we received more benefits your proposal could yield. ed revenue minus annual expenses, then di - than $3 million to create the program, then viding the result by the total initial cost of designed and implemented it with the sup - Be honest about implementation investment. The finance department usually port of the risk management department. costs completes this analysis based on informa - Data related to the full cost of project imple - tion provided by clinicians. Understand the healthcare mentation is important in building a strong But the analysis is only as good as the environment business case. While it’s tempting to under - information you provide. Consider possible The first step in building the business case estimate costs or omit those that aren’t imme - revenue attained through billing, as well as is to gain a clear understanding of the diately obvious, doing this will only weaken cost avoidance and savings related to regu - challenges hospitals face today, such as your case. lations and fines, less litigation resulting higher costs and pressure to stay competi - The cost of required equipment or tech - from patient falls, and fewer instances of tive. Acknowledging and addressing these nology may be the first expense consid - lost reimbursement for care related to pre - challenges will boost your credibility with ered, but it’s rarely the only one. Be sure to ventable falls. Stanford’s program had an administrators. consider the cost of any education, labor, IRR of 28% based only on reduction of systems redesign, or workflow changes workers’ compensation costs by 30% during Obtain relevant data your proposal might necessitate. Stanford’s the first year. Additional savings related to In an evidence-based culture, data are SPH program had three main components “soft” costs were more difficult to quantify. needed to drive acceptance. The ability that drove the expense of the full program: Although the IRR was crucial in gaining to examine the evidence in favor of a • Engineering controls: costs of equipment support for Stanford’s SPH program, the particular program is a critical skill. You and maintenance as well as the 2-day knowledge that additional cost savings must be prepared to answer this question: equipment fair where staff from all units would accrue drove the proposal’s supporters Why is the program you’re proposing so were able to evaluate the equipment to quantify “soft” costs and hard-to-project important to this facility? and provide input on equipment and costs. Examples include costs related to: Both national and on-site data may be vendor selection. The cost of the fair • reduction in the patient fall incidence available to help you build your case. Ex - was minimal. • decrease in pressure ulcer incidence amples of data you might want to include • Administrative controls: costs of training • increased patient satisfaction are musculoskeletal disorders in healthcare 175 “super users” and 1,963 patient- • improved employee satisfaction. workers. At Stanford, for instance, costs re - care staff members on use of the re - Stanford Risk Consulting, a branch of lated to employee injuries were document - quired SPH equipment and the program our risk management department, worked ed but not well known. These statistics principles with the Strategic Decisions Group to find a

4 Best Practices for Falls Reduction: A Practical Guide March 2011 www.AmericanNurseToday.com Workers’ compensation costs related to patient handling way to deal with the uncertainty of future This table shows projected expenses for years 1 through 4 of the safe patient-handling program (based on historical benefits in these areas and to understand data). The figures in red show actual results for year 1—including a 40% reduction in average workers’ how to increase total value of the pro - compensation (WC) costs. gram—the sum of many contributing fac - tors, such as reduced cost of caring for in - Safe patient handling—direct cost savings for WC jured employees, lower staff turnover, and and replacement staff only reduced recruitment costs; all of these in - crease the value of the proposed program. Year 1 Year 2 Year 3 Year 4 Year 5 Total 5 year They used decision analysis (DA), a proven Average WC expense $832,168 $832,168 $832,168 $832,168 $832,168 $4,160,840 method for understanding uncertainty in Staff replacement cost future value. It also helps identify which fac - Salary $210,824 $210,824 $210,824 $210,824 $210,824 $1,054,120 Benefits $71,680 $71,680 $71,680 $71,680 $71,680 $358,401 tors are the most important drivers of pro - $333,392.20 savings = 40% reduction gram value. Through the use of DA, the ex - Savings WC expense reduction 30% $(249,650) from average WC expense $(249,650) pected value of Stanford’s SPH program WC expense reduction 60% $(499,301) $(499,301) $(499,301) $(499,301) $(1,997,203) rose to $5.2 million. Replacement cost reduction 30% $(84,751) TBD $(84,751) 60% $(169,502) $(169,502) $(169,502) $(169,502) $(678,010) Make the pitch Total savings $(334,402) $(668,803) $(668,803) $(668,803) $(668,803) $(3,009,615) Once you’ve built your case, you must take Operating costs it to stakeholders. While administrators may Staff training $700,000 $700,000 be the decision makers, other departments Education consultants $62,500 $62,500 $125,000 have an investment in and influence over Total costs $762,500 $62,500 $825,000 the proposal. At Stanford, the rehabilitation, Net savings $428,098 $(606,303) $(668,803) $(668,803) $(668,803) $(2,184,615) transport, housekeeping, infection control, In current operational budget and facilities departments would all be af - fected by the SPH program. So we educat - ed staff in these departments, knowing we were also educating and influencing the selves as competing. This results in poorly decreases in the number of nurse injuries vice presidents to whom they reported. implemented programs. Also, timing of the and reduced severity of those injuries. Other lobbying strategies used at Stan - initiative may not be ideal or space con - As for “soft” costs, there have been no ford included: straints may exist. Whatever you think your patient claims or litigation related to falls • saturating the market and remessaging problems might be, have a reasonable plan from program implementation in September it, by identifying whom we had to “mar - to address them up front in your proposal. 2009 to December 2010. Also, Press ket” the idea to and making sure to com - Ganey scores on the question “help getting municate the message to these people Evaluate the program after up to the bathroom” have risen consistently. more than once and in different ways implementation What’s more, our annual Gallup employee • responding quickly to requests to pres - Once a program is funded, there’s a ten - satisfaction survey found a 6.3% increase in ent the initiative dency to move it into implementation and satisfaction in response to the statement, “I • connecting the proposal to other hospi - not report back to stakeholders on whether have the equipment I need to do my job.” tal priorities or initiatives results were delivered. It’s crucial to evalu - At Stanford, we created a solid business • being familiar with the data used to cal - ate the program and report the results ob - case for a clinical program by showing safe culate the IRR jectively, for two reasons: patient handling is right for the caregiver, • finding stories about individuals who could • Evaluation yields insight into what modi - the patient, and the business of health care. be helped by the program and using their fications may be needed to improve the Nurses in every role are powerful patient stories to make the data come alive. program. advocates. Our advocacy must extend past Acknowledging barriers up front also • Providing information to decision mak - the bedside to the boardroom. Learning can strengthen your case. All hospitals have ers acknowledges their support and pro - how to build a strong business case for an to deal with competing priorities. Your or - vides an excellent platform for future ef - SPH program and knowing how to garner ganization may have difficulty sustaining forts. Building a successful track record support are fundamental to your role in initiatives—either because new priorities creates trust in your ideas and ability to delivering safe patient care. G take precedence or because it’s hard to design successful strategies that deliver maintain resources and motivation from as promised. Visit www.AmericanNurseToday.com/Archives.aspx for a list of selected references. year to year. Some organizations work in At the end of the first year (2010), Stan - self-contained “silos,” and departments that ford’s SPH program showed impressive re - Joan Forte is the director of patient care services need to collaborate on an important project sults. It reduced workers’ compensation costs at Stanford Hospital and Clinics in Palo Alto, may communicate poorly or even see them - by 40% (a savings of $333,392) through California. www.AmericanNurseToday.com March 2011 Best Practices for Falls Reduction: A Practical Guide 5 Components of a comprehensive fall -risk assessment By Carole Kulik, MSN, RN, ACNP, CRNP-BC

individual healthcare professionals. physical or mental status occurs, on trans - For an effective falls-reduction program, fer, and before discharge. Tools are avail - healthcare providers must use appropriate able to aid risk-factor assessment. (See assessment tools consistently, improve com - Risk-assessment tools .) p to 50% of hospital pa - munication and education related to falls, Risk factors for falls break down into tients are at risk for falls, and institute a plan of care. The plan two categories: and those who fall com - must be individualized to each patient and • Intrinsic factors are patient-related and monly have longer hospi - include interventions that address specific encompass such physiologic condi - tal stays. Even more factors identified in the risk assessment. In - tions as vision disturbances, dizziness, alarming, during the first month after dis - cluding the patient’s family and the interdis - incontinence, muscle weakness, men - charge, injuries related to falls account ciplinary team is crucial. The plan should tal impairment, gait and balance dis - for abUout 15% of all readmissions. call for regular patient assessment and orders, polypharmacy, and older age. As the number of patient risk factors in - reevaluation, mobility monitoring, exercise • Extrinsic factors are environmentally creases, so does the likelihood of falling. alternating with rest, safe toileting prac - related and include room clutter, loose Therefore, identifying patients at risk for tices, maintaining a safe environment, med - electrical cords, and spills. falling can significantly improve a hospi - ication evaluation, educating the patient tal’s fall rate. Yet fall-risk assessment alone and family about falls, and communicating Assessment components isn’t enough; it’s just one piece in an over - adequately with other care providers. A patient’s fall risk can be decreased all falls-reduction plan. Following through through a comprehensive medical assess - with strategies to reduce patient risk Risk categories ment, medication review and management, based on assessment findings is crucial for The patient’s fall risk should be assessed environmental safety assessment and modi - healthcare facilities as a whole and for on admission, whenever a change in fication, and exercise and safety programs.

6 Best Practices for Falls Reduction: A Practical Guide March 2011 www.AmericanNurseToday.com Risk-assessment tools Staff must follow through with actions that Many assessment tools are available to determine a patient’s risk of falling in the hospital or community, including address the identified risks. the Conley Scale, Morse Fall Scale, and Hendrich II Fall Risk Model ™. Most assess for age, number of diseases, prescribed medications, usual place of residence, place of presentation, physical ability, vision, history of falls, and Medical assessment environment. Medical assessment should include simple Many home-healthcare programs use the acronym DAME to categorize fall risk factors. Each letter indicates an tests of vision, hearing, mobility, periph - individual risk factor or a risk-factor category. eral sensation, muscle force, reaction D: Drugs and alcohol use time, gait, and balance. Many acute and A: Age-related physiologic status chronic medical conditions increase the risk of falls. Stay alert for a history of agi - M: Medical problems tation, delirium, orthostatic hypotension, E: Environment impaired mobility or vision, dizziness, The National Center for Patient Safety recommends the Morse Fall Scale (available at www.va.gov/ncps/CogAids/ physical weakness, and a recent history FallPrevention/index.html#topofpage&page=page-4). Be aware, though, that this scale isn’t designed for of falls. long-term use because of its sensitivity, which populates all high-risk triggers. The Hendrich II Fall Risk Model (http://consultgerirn.org/uploads/File/trythis/try_this_8.pdf) is appropriate for both acute and long-term Medication review and care settings. management Assess and reassess the patient’s medica - tions, as needed. Medications most likely to increase the risk of falls include benzo - are up, falls may be more likely, as mary prevention method for keeping pa - diazepines, antipsychotics, diuretics (part - some patients try to climb over them to tients safe and establishing a culture of ly because they cause frequent urination), get out of bed. Keep the bed at the safety. Incorporating risk-assessment find - antidepressants (particularly tricyclics), right height to minimize the risk of ings into the patient’s plan of care pro - neuroleptics, opioids, insulin, and oral hy - falls —100% to 120% of the patient’s motes safety through best practices. G poglycemics. Cardiac drugs and antihy - lower leg length. pertensives also increase the fall risk be - • Arrange objects according to patient Selected references cause they can cause an orthostatic blood preference and requirements. Keep Conley D, Schultz AA, Selvin R. The challenge of pressure drop. the call light, TV remote control, and predicting patients at risk for falling: develop - ment of the Conley Scale. Medsurg Nurs . 1999; personal items within the patient’s (6):348-354. Environmental assessment reach and provide easy access to eye - ECRI Institute. Medication safety. Healthcare Risk To help ensure patient safety and a safe glasses, dentures, and hearing aids. Control . November 4, 2007: Pharmacy and care environment, conduct a 360-degree • Keep such equipment as I.V. poles, medications 1:1-31. overview of the patient’s room each time oxygen tubing, and plugged-in devices Hendrich A. How to try this: predicting patient you enter and leave. Give the patient a out of the patient’s pathway. falls: Using the Hendrich II Fall Risk Model in clin - chance to speak up to express a need or • Make sure a walker, cane, or other ical practice. Am J Nurs .2007;107(11):50-58. make a request. mobility aid (if needed) is fitted appro - Mahoney JE, Palta M, Johnson J, et al. Temporal Conduct the environmental assessment priately to the patient. association between hospitalization and rate of in light of history findings and the pa - • Have the patient wear safe, well-fitting falls after discharge. Arch Intern Med . 2000; 160(18):2788-2795. tient’s personal preferences. For example, footwear. ask how frequently the patient voids; this • Keep hallways and railings unobstructed. Medication assessment: one determinant of falls risk. Pa Patient Saf Advis . 2008;5(1):16-18. knowledge can help staff ensure an unob - • Know that for a safe bathroom envi - structed path to the bathroom and plan ronment, toilets should be raised, toilet Rowland M, Tozer TN. Clinical Pharmacokinetics and Pharmacodynamics . 4th ed. Philadelphia, for timed interventions. Keep the room seats should be secure, and handrails PA: Lippincott Williams & Wilkins; 2010. temperature comfortable so the patient should be strong enough to support the Schwendimann R, De Geest S, Millisen K. Evalu - isn’t tempted to get out of bed to make patient. ation of the Morse Fall Scale in hospitalised pa - adjustments. tients. Age Ageing . 2006;35(3):311-313. Follow these additional guidelines to Exercise and safety Stevens JA, Corso PS, Finkelstein EA, Miller TR. help make the environment safe: Assess the patient’s energy level. In most The costs of fatal and nonfatal falls among older • Eliminate environmental hazards, such cases, exercise and other patient activities adults. Inj Prev . 2006;12(5):290-295. as clutter, inappropriate lighting, and should be scheduled for the morning, when VA National Center for Patient Safety. www.pa - flooring problems (such as dampness energy and endurance levels are higher. tientsafety.gov. Accessed February 11, 2011. or uneven surfaces). Evaluate the patient’s energy and en - • Keep the bed in a low position with durance throughout the day, as fatigue Carole Kulik is director of Patient Care Services, wheels locked and side rails down (or may contribute to an increased risk of falls. Professional Practice and Education at Stanford per facility policy). When side rails Using tools to assess fall risk is a pri - Hospitals & Clinics in Stanford, California. www.AmericanNurseToday.com March 2011 Best Practices for Falls Reduction: A Practical Guide 7 Focusing on staff awareness and accountability in reducing falls By Carol Payson MSN, RN, NE-BC; Ashley Currier, BSN, RN, CMSRN; and Marisa Streelman, BSN, RN, CMSRN, OCN

vidence suggests many falls engage their teams to identify at-risk pa - tient for assistance to the bathroom, repo - can be prevented in acute- tients, select and implement appropriate sitioning, or obtaining personal items. care settings. Despite our or - interventions, and transition patients safe - We’ve found that the more our patients ganization’s persistent efforts ly from one risk level to another. When a see their caregivers, the less likely they to improve outcomes, our fall occurs, champions assist with appro - are to try to ambulate or perform toileting fall rate remained above the best decile priate action and follow-up. Leading post- without assistance. performance for falls of the National Data - fall “safety huddles,” they partner with In twice-daily safety huddles, staff dis - base oEf Nursing Quality Indicators ®. We the clinical coordinator to enlist all unit cuss patients at highest risk for falls. The knew we needed a comprehensive organi - staff to participate in a mini–root cause departing shift relates anticipated concerns zation-wide approach to address staff analysis. Besides making all staff aware or needs to the oncoming shift. (See How awareness and accountability for falls and that a fall has occurred, this analysis safety huddles and careboards can im - related injuries. serves as an opportunity to discuss learn - prove patient outcomes .) In our ongoing effort, we’ve successfully ing opportunities related to the event and integrated safety into our patient-centered helps nurses create an optimal individual - Education and training care model. Falls prevention is a universal ized plan of care using targeted interven - Education and training occur in multiple goal throughout the organization—not a tions to keep the patient safe for the venues. We support our staff through mes - separate program that applies only to cer - remainder of his or her stay. Post-fall hud - saging (articulating the “why”), mentoring tain patients. This structure holds staff mem - dles commonly involve direct-care staff, (real-time coaching and feedback), and bers accountable for patient safety. In - but also may include physical therapists, modeling (ensuring falls-champion repre - creased staff accountability and awareness unit secretaries, and even environmental sentation from all areas). With our dynamic promotes a consistent approach to reduc - services staff. shared-leadership structure and unit-based ing harm to patients at the unit level. All quality committees, targeted education and employees know that keeping patients safe Anticipating and coordinating care data-sharing are ongoing and contribute to is everyone’s responsibility; each person Our model focuses on anticipating and co - improved outcomes. plays a crucial part. Our strategy promotes ordinating care and engaging patients and We partnered with technology experts a climate of transparency that helps every - families. We do this through: to increase awareness of patient mobility- one learn from falls, which in turn can help • bedside handoffs at shift change related risks, medication effects, and acute prevent future falls. • individualized goal setting mental-status changes (such as delirium). Staff accountability begins with engag - • “careboard” (whiteboard) communication This approach helps nurses assess patients ing all staff in understanding why all pa - • hourly rounds appropriately. (See The fight against falls: tients are at risk for falling. It continues • safety huddles. Risk assessment and actions .) with giving staff the knowledge and ability A key component of these activities is to articulate this risk with patients and fam - discussion of the patient’s risk of falling Refining the patient-assessment ilies. Also, staff members receive support and optimal safety interventions. Bedside process when they experience challenging situa - reporting helps the nurse on the oncoming In 2007, we realized the fall-risk assess - tions (for example, when a patient refuses shift visualize the patient and environment ment in the electronic medical record was to adhere to safety interventions). Man - during handoff, ensuring appropriate missing key components that contribute to agers and the falls-prevention team carry safety interventions are activated and in patient falls. So we modified the assess - out inspections, comparing documentation place. It also allows the patient and fami - ment to include information about acute of interventions with in-room assessments. ly to get involved in planning and partici - changes in mental status and functional Real-time feedback and coaching realign pating in the patient’s goals and safety mobility. We incorporated data from the expectations of staff. plans for the day. confusion assessment method (CAM, a Hourly rounds are particularly helpful bedside tool to detect acute mental-status Role of champions in preventing falls, as they help staff antic - changes and delirium signs and symp - In our facility, falls-reduction champions ipate and address patient needs. We en - toms) and the short portable mental-status were recruited on each care unit to help courage direct-care staff to prompt the pa - questionnaire (SPMSQ). Mental status

8 Best Practices for Falls Reduction: A Practical Guide March 2011 www.AmericanNurseToday.com How safety huddles and careboards can improve can change quickly (even in a patient patient outcomes with normal cognitive functioning on ad - Inevitably, some staff members are better able than others when it comes to leading and participating in safety mission). Therefore, we decided staff huddles and in using in-room careboards for communication. To optimize the use of these methods and thus improve should assess patients for mental-status patient outcomes, unit leaders can coach and mentor their teams, as described below. changes daily. Thus, CAM and SPMSQ are completed on all patients daily, as Calling a safety huddle well as on admission. The SPMSQ alerts All staff on both incoming and outgoing shifts should participate in the huddle. Other disciplines may be included if nurses on admission that a particular pa - needed. Huddles are led by the clinical coordinator, charge nurse, or quality committee member, with other staff tient might be at high risk for falling due participating actively. to altered cognitive function. Another The huddle should be organized around relevant questions posed by the leader, with answers provided by the staff. change was to include the patient’s list Who: Who are the patients we are most worried about? of current medications in the falls assess - Why: Why are these patients at risk? ment; now caregivers can see at a What: What is the safety plan? glance if the patient is receiving fall risk- Example: “In regard to fall risk, which patients are we most worried about? Why are we worried about them? What actions can we take to prevent them from falling?” increasing drugs (FRIDs). Other patient considerations besides falls can be addressed in the huddle, including risks for pressure ulcers, Functional mobility assessment elopement, and confusion; visitor restrictions, do-not-resuscitate status, or unique needs (such as social, With the help of physical therapists, we language, or sensory impairments); restraints; name alerts; and service recovery issues. After discussion, these considerations should be recorded on a safety whiteboard at the nurses’ station, where they can be updated as developed a functional mobility assessment the patient’s status changes. to be completed daily on all patients; re - sults are added to the fall-risk assessment The leader should communicate expectations through an optimal method (for instance, role-playing) and align expectations through real-time coaching and feedback. To promote an environment of awareness, the leader form. This assessment has six progressive should use examples of near misses or identified safety issues to highlight learning opportunities of which all steps for identifying a patient’s mobility staff should be aware. level. It starts with independent sitting and moves to dangling, kicking and pointing, Using a careboard standing, stepping forward and stepping The careboard in the patient’s room should clearly communicate to all team members the plan of care for the shift back, and walking independently. Incorpo - and who is accountable for completing activities to help achieve the patient-centered goal. The board should be rating these components into one form cre - updated during bedside change-of-shift report or as needed throughout the shift. It should include all important ated a more comprehensive assessment fields—date, day, RN, patient care technician, MD, procedure, scheduled activities, mobility plan, pain plan, patient- and a more systematic approach to pre - centered goal, diet, physician rounding time, and next hourly round. Don’t use medical abbreviations or terminology venting falls. the patient may not understand. As with safety huddles, real-time feedback and rewards should be used to recognize exceptional careboards. Education for all staff members Explain to the patient what’s on the careboard; for example: “Mr. Smith, you can have your pain medication every 4 We conducted organization-wide training hours. I’ve written on your board the time of your last dose and when you can have the next one.” Make fields specific to educate staff about the technology - to the patient; for example: “ Mobility plan: Walk one lap three times today.” related changes—and to change our cul - ture to one where everyone takes accounta - bility for patient safety. We emphasized the need for bedside nurses to think critically delved into the fundamental reasons our clips of the six steps and a discussion of about their crucial role in fall prevention. patients were falling and raised bedside case studies. Education on medication ef - With the help of experts, we developed nurses’ awareness of how they can help fects focused on identifying patients at a 3-hour education session to disseminate prevent falls. high risk for falls based on their medica - information on CAM and SPMSQ, func - Education related to acute mental-sta - tion profile and implementing interven - tional mobility, and FRIDs, along with an tus changes focused on defining the differ - tions to prevent falls by decreasing the explanation of how to complete the new ences between dementia and delirium, patient’s FRIDs. falls assessment. Medical-surgical, oncolo - identifying patients at risk, and choosing gy, neurology, and intensive-care unit appropriate interventions to maintain pa - Outcomes nurses attended the training. Support for tient safety and help reorient patients. For After education sessions, staff showed an training came from our educational de - functional mobility, educational objectives increased awareness of falls and a sense of partment, the Northwestern Memorial included reinforcing how to complete an urgency toward fall prevention they didn’t Academy. effective mobility assessment, evaluate a have before the training. These sessions The falls task force educated selected patient’s ability to move through the six proved successful, resulting in a decreased staff nurses to help train other staff in a steps of functional mobility assessment, fall rate throughout the organization—from “train-the-trainer” format; this led to the and identify interventions for each step. 2.9 to 2.1 per 1,000 patient days. creation of “super-users.” The training This teaching was delivered through video We continue to raise the bar to keep www.AmericanNurseToday.com March 2011 Best Practices for Falls Reduction: A Practical Guide 9 The fight against falls: Risk assessment and actions All patients are considered at risk for falling. To aid the care team in planning appropriate interventions, patients ties that help us modify our practice to en - should be evaluated for the risk factors below and steps should be taken to lower risk. sure safety.

Assessment Partnering with patients and By answering these questions, the nurse helps ensure the patient is placed in the appropriate risk category. families We’ve used similar strategies with patients Factors YN and families, with the goal of helping them Has the patient ever fallen? keep themselves safe in the hospital. By ex - Does the patient have impaired functional mobility? plaining to patients why they are at risk for Does the patient have an altered mental status or a cognitive impairment? falling and how they can benefit by follow - Is the patient on medications or a combination of medications that increase ing safety interventions, we raise their the risk of falling? awareness that falls can happen to anyone at any time. Does the patient disregard safety instructions or demonstrate a desire for independence? Enhancing the partnership between the care team and the patient and family is an important part of our strategy. Our role is Interventions to transition patients safely from the inpa - Based on assessment findings, appropriate interventions should be chosen, such as those listed below. tient setting back to the home or other care • Conduct purposeful hourly rounding, addressing patient’s pain, position, and bathroom needs. facility. We want them to stay safe while in • Keep bed in proper position with wheels locked. our care, and we teach them ways to stay • Ensure a safe environment, with room free of clutter and a clear path to the door and bathroom. safe after they leave the hospital. We’ve • Place all necessary items (such as call light, telephone, and water) within patient’s reach. found great value in taking the time to ex - • Educate patient and family about safe mobility practices (for instance, how to move safely with I.V. pole, plain the “why” behind our actions—and indwelling urinary catheter, or drain). this has created a strong partnership be - • Provide patient and family with safety tips to prevent falls. tween the care team and patient. • Activate bed exit alarm at night or when patient is sleeping. We continue to evolve, moving our or - • Place side rails up at night or when patient is sleeping. ganizational culture toward a full under - • Modify mobility sign to appropriate option (such as “assistive device” or “assist”). standing that all patients are at risk for • Activate exit alarm on bed or on pad placed under patient that sets off alarm when weight is removed. falling and that falls aren’t acceptable in • Teach patient how to use call light for assistance before ambulating. (Tell patient to call and then wait for assistance.) the hospital. Each day we strive to move • Keep door and curtain open. closer to zero falls. With our concentrated • Stay with patient while he or she is ambulating or is in bathroom. interdisciplinary efforts, we believe this is • Collaborate with physician to identify appropriate fall-prevention plan. Discuss specific factors that may contribute G to patient’s fall risk (medications, procedures) and select appropriate interventions. now a more realistic goal. • Discuss patient in safety huddle, noting fall risk, rationale, and interventions. Selected references • Consider increasing rounding time. Dykes PC, Carroll DL, Hurley AC, Benoit A, Mid - • Consider placing patient close to nurses’ station. dleton B. Why do patients in acute care hospi - tals fall? Can falls be prevented? J Nurs Adm . 2009;39(6):299-304. Harrington L, Luquire R, Vish N, et al. Meta patients safe. Literature and our own data ducting post-fall assessments and unit-level analysis of fall-risk tools in hospitalized adults. J show all inpatients are at an elevated risk root cause analysis, and sharing data and Nurs Adm . 2010;40(11):483-488. for falling at some time during their stay, lessons learned with other colleagues. Inouye SK, Van Dyck CH, Alessi CA, Balkin S, simply because they’re in a new environ - Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for ment, receiving medications, and undergo - Storytelling detection of delirium. Ann Intern Med .1990; ing medical procedures. Knowing that falls We use the power of storytelling to engage 113(12):941-948. occur in patients of all ages and both sexes the hearts of our staff and remind them that Joint Commission. National patient safety goals. and across the spectrum of functional mo - falls can happen to anyone regardless of http://www.jointcommission.org/standards_ bility status and cognition, we put in place age, mental status, or mobility status. We information/npsgs.aspx. Accessed February 8, 2011. a standardized set of interventions. We also use storytelling to promote our culture Kolin MM, Minnier T, Hale KM, Martin SC, continue to educate bedside nurses to think of transparency. With this approach, staff Thomspson LE. Fall initiatives: redesigning best critically about safety and take ownership learn through each other’s experiences, practice. J Nurs Adm . 2010;40(9):384-391. of falls prevention on their units and with both positive and negative, and we have The authors work at Northwestern Memorial their patient populations. We’re seeing created a safer environment as everyone Hospital in Chicago, Illinois. Carol Payson is more professional accountability, as demon - works collaboratively. Our organization patient care director. Ashley Currier and Marisa strated by staff calling safety huddles, con - acknowledges errors as learning opportuni - Streelman are patient care managers.

10 Best Practices for Falls Reduction: A Practical Guide March 2011 www.AmericanNurseToday.com Creating a culture of safety: Building a sustainable falls-reduction program The Magnet ™ Model’s five components can serve as the program’s framework. By Sharon Stahl Wexler, PhD, RN, GCNS-BC; Catherine O’Neill D’Amico, PhD, RN, NEA-B; and Elizabeth Rolston, MA, MS, RN

mong the most common errors reported in hospi - tals, falls account for up to 30% of adverse events reported to regulatory agencies. In older adults, roughly 10% of fatal falls occur in hospitals. The Centers for MedAicare and Medicaid Services (CMS) has identified falls and related in - juries as “never events”—hospital-ac - quired conditions whose related expenses CMS no longer pays. Preventing harm from falls is one of the Joint Commission’s national patient safety goals; to meet the Commission’s accreditation standards, hospitals must implement a falls-preven - tion program. No easy method exists for sustaining a falls-prevention program. Nor is there an ideal fall-risk assessment tool applicable to all settings. But a recent pilot study in a community academic medical center found that a multifaceted approach can reduce falls significantly. Embracing a culture of safety begins with a recommitment to a professional practice model that puts the patient and family at the center of care. We recom - ment of safety and falls prevention may knowledge, innovation, and initiatives; mend facilities use the Magnet ™ Model of make the patient fear falling. and (5) empirical outcomes. Implementing the American Nurses Credentialing Center a sustainable falls-reduction program en - (ANCC) to develop and sustain a falls-pre - Magnet Model as the framework compasses five steps that reflect these vention program in acute-care settings. Excellence in clinical nursing practice, pa - components. The nurse-patient relationship centers tient care, and safety are the hallmarks of on unconditional positive regard and indi - ANCC’s Magnet Recognition Program ®. Step 1: Transformational vidualized care. If a patient falls, positive The Magnet Model provides a framework leadership: Getting the regard may weaken and the patient may for developing a falls-prevention program organization’s commitment lose the sense of protection and safety that consistently yields high-quality patient The first step is to obtain the organiza - perceived as integral to the hospital set - outcomes and sustains and demonstrates a tion’s commitment. Positioning falls reduc - ting. At the same time, the nurse may feel culture of safety in acute-care settings. tion as a major goal recognizes the prob - guilty after a patient falls. Some nurses The Magnet Model has five compo - lem and alerts all staff to the importance may even blame the patient for falling, in nents: (1) transformational leadership; of the initiative. Recognizing it as a priori - the belief that the patient disregarded im - (2) structural empowerment; (3) exemplary ty also may garner a greater commitment portant teaching. And ongoing reinforce - professional practice (EPP); (4) new of human and material resources. www.AmericanNurseToday.com March 2011 Best Practices for Falls Reduction: A Practical Guide 11 After a suitable period of data collection Step 4: New knowledge: and trend evaluation , the council Designing the falls-reduction program determines if the program is a success Once major structures are established, core components of the falls-reduction or if additional work needs to be done. program should be determined based on policies and procedures developed from the evidence. Policies and procedures To attain organizational support, ini - collaboration, evidenced-based practice, need to be introduced to all staff; in many tiative sponsors should collect and ana - benchmarking, and quality improvement. cases, staff education is required as well lyze data pertaining to the incidence of It challenges them to demonstrate how di - to ensure compliance and proper initia - falls in the facility, with a description of rect-care nurses collaborate with other dis - tion. During this phase, FRC members, fall type and severity, population most ciplines to ensure comprehensive, coordi - staff educators, and advanced practice affected, and most common injuries. Such nated, collaborative care. Organizations nurses help others in the organization un - data help identify a reasonable cost- must provide empirical outcomes to show derstand the evidence and its relationship benefit analysis for preventing rather than how they outperform national-database to the new policies and procedures so treating falls and injuries—as well as benchmarks related to all safety issues, in - they can apply the new standards of care identifying factors that may be unique to cluding falls. to their practices. the facility, staff, or patient population. Thus, the next step is to identify clear - Gathering such data before the falls- ly defined program goals. This helps FRC Step 5: Empirical outcomes: reduction program is established aids the members focus on the work that needs Continuous quality-monitoring literature search to be done during step to be done, evaluate the program’s tools 3, by providing potential key words and progress, and determine when goals The next step is to design or select quality- phrases for the search. have been achieved. Goals should de - monitoring tools to provide ongoing rive from the falls data collected earlier, feedback on the program’s success. Step 2: Structural empowerment: which establish a baseline for comparing Goals and objectives set at the begin - Establishing a falls-reduction the success of the interventions and poli - ning of this process serve as the basis council cy and procedural changes subsequently for developing unit- and facility-based Forming an interdisciplinary committee put in place. monitoring tools. Organizational leaders that includes frontline caregivers is the During step 3, a search for literature will look to the FRC to measure the pro - next step in establishing a falls-reduction on patient falls and falls with injury in gram’s success against previous perform - program. Designating this committee as a acute-care settings should be conducted ance and nationally recognized bench - falls-reduction council (FRC) positions it as so the most recent evidence can be in - marks. To monitor overall outcome, a unit a continuing forum that helps sustain the corporated into organizational policies or the facility as a whole may decide to program. The council initiates and sus - and practices. After this search, the FRC develop new tools or customize tools tains subsequent steps. discusses and analyzes the information from national organizations. Customizing The FRC should include nurses at all and current evidence-based practices. tools may make it easier to report pro - levels, nursing assistants, unit clerks, and This step is central to creating the struc - gram successes. representatives from other services, such ture and processes that ensure the group The FRC continues to meet regularly to as medicine, physical therapy, pharmacy, begins to “own” its clinical nursing prac - examine data, identify trends in falls and nutrition, housekeeping, transportation, tice as it helps the FRC become a cohe - injuries, and determine if particular units and risk management. This diversity pro - sive body. Nursing staff at all levels and require more education or assistance to motes the gathering of ideas and evi - other FRC members are encouraged to carry out policies. Such data should be dence from all corners of the organization discuss and share the evidence with staff made available to staff members who pro - and makes more personnel accountable in their respective units or departments. vide direct patient care. (See Hardwiring for preventing falls and related injuries. Such discussion and evidence distribu - falls reduction into the organization .) Each FRC member brings specific knowl - tion provide feedback to the FRC and edge from his or her discipline and can help it adapt recommendations from the Celebrating excellence take the council’s work back to his or her literature to the facility’s culture and envi - After a suitable period of data collection own department. ronment. During this working phase, FRC and trend evaluation, the FRC determines members develop and revise policies, if the program is a success or if addition - Step 3: EPP: Putting the evidence protocols, and tools related to reducing al work needs to be done. If it’s deemed to work the incidence of falls and injuries based a success, the FRC may be disbanded or EPP requires that organizations demon - on the evidence and feedback from oth - incorporated into the facility’s quality strate a culture of safety, interdisciplinary ers in the organization. monitoring processes.

12 Best Practices for Falls Reduction: A Practical Guide March 2011 www.AmericanNurseToday.com Hardwiring falls reduction into the organization The facility should celebrate the success At our community hospital, much work had already been done to reduce falls and injuries. The various initiatives both of individual units and the FRC. Cele - yielded short-term results, but fall and injury rates shot up again when attention shifted elsewhere. We recognized brating excellence provides an impetus to that to sustain the improvements, the falls-reduction program had to become an integral part of the organization. continue the initiative and start other initia - At the same time, our facility was starting its Journey to Magnet Excellence ®, which we saw as a chance to “hardwire” tives to show the facility’s overall commit - falls reduction into the organization. ment to excellent care. Success should be We formed an interdisciplinary falls-reduction council (FRC) with unit-level representation from many other celebrated at an institutional level. departments and services; FRC representatives sat on the hospital safety committee. To identify trends and address This approach to falls reduction sup - issues unique to our facility, the FRC reviewed falls data from the last 10 years and reviewed policies, procedures, and ports ANCC initiatives for a multidiscipli - processes of care to investigate opportunities for improvement. Its work was discussed at unit-based shared nary team approach and involvement of di - governance councils and department meetings. rect caregivers in improving patient care. With emphasis on applying an evidence- A fall is everyone’s business based practice model through point-of-ser - The FRC used every opportunity to publicize its work and shift the focus toward fall prevention. It adopted the motto vice solutions, innovations, and collabora - “A fall is everybody’s business.” Falls-prevention education was included in orientation for all hospital employees as tion, the approach departs from the well as in the annual educational renewal. traditional top-down method for quality-im - Initially, the program was implemented on two pilot units with the highest fall and injury rates. Preliminary results provement initiatives. Empowering and in - showed significant reductions (a 71% decrease in falls on the orthopedic unit). The graph below shows monthly volving staff from the onset, disseminating patient fall rates during the pilot project. data, involving staff in work groups, and Then the program was implemented throughout the hospital. Staff from all departments showed an increased educating colleagues help ensure that staff awareness of falls-reduction efforts and demonstrated ownership of the initiative. The hospital integrated the FRC’s “own” the program and incorporate its val - work into all public forums, displayed results on unit-based quality boards, and presented them to the board of ues into their practice. G directors, nursing and medicine grand rounds, town hall meetings, and National Safety Week presentations.

Selected references American Nurses Credentialing Center (ANCC). Fall rates on project units Overview of ANCC Magnet Recognition Pro - gram ® New Model. Silver Spring, MD: ANCC; Project start 14 -

2008. www.nursecredentialing.org/Docu - s y

ments/Magnet/NewModelBrochure.aspx. Ac - a 12 - d

cessed January 27, 2011. t

n 10 - e

Cameron ID, Murray GR, Gillespie LD, Robert - i t son MC, Cumming RG, Kerse N. Interventions a 8 - Ortho/neuro p for preventing falls in older people in nursing 0 6 - Oncology 0

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Web-based injury statistics query and reporting F 0 - system (WISQARS ™). www.cdc.gov/injury/ wisqars/index.html. Accessed January 27, 2011. Jul Aug Sep Oct Nov Dec Jan Feb Mar 07 07 07 07 07 07 08 08 08 Coussement J, De Paepe L, Schwendimann R, Denhaerynck K, Dejaeger E, Milisen K. Inter - ventions for preventing falls in acute- and chronic-care hospitals: a systematic review and meta-analysis. J Am Geriatr Soc . 2008; 56(1):29-36. 18/NPSG_Chapter_Outline_FINAL_HAP_2010. Brody P, Huang Z. The ruby red slipper pro - Eldridge C. Evidence-Based Falls Prevention: A pdf Accessed January 27, 2011. gram: an interdisciplinary fall management pro - Study Guide for Nurses . Danvers, MA: HCPro, National Quality Forum (NQF). Serious Re - gram in a community academic medical center. Inc.; 2004. portable Events in Healthcare, 2006 Update: Medsurg Nurs . In press. Gray-Miceli D. Preventing falls in acute care. In: A Consensus report . Washington, DC: NQF; Capezuti E, Zwicker D, Mezey M, Fulmer T, eds. 2007. Sharon Stahl Wexler is an assistant professor at Evidence-Based Geriatric Nursing Protocols for Oliver D, Healy F, Haines T. Preventing falls and Pace University’s Lienhard School of Nursing in Best Practice . 3rd ed. New York. NY: Springer; fall-related injuries in hospitals. Clin Geriatr New York, New York. Catherine O’Neill D’Amico is 2008:161-198. Med . 2010;26(4):645-692. an assistant professor at Hunter-Bellevue School Harrington L, Luquire R, Vish N, et al. Meta- Stevens JA, Mack KA, Paulozzi LJ, Ballesteros of Nursing in New York, New York. Elizabeth analysis of fall risk tools in hospitalized adults. MF. Self-reported falls and fall-related injuries Rolston is director of Nursing Education, J Nurs Adm . 2010;40(11):483-488. among persons aged ≥ 65 years—United States. Research, and Performance Improvement at Joint Commission. National patient safety goals. 2006. MMWR . 2008;57(9):225-229. Mount Sinai Queens Hospital in Long Island City, 2010. www.jointcommission.org/assets/1/ Wexler SS, D’Amico CO, Foster N, Cataldo K, New York.

www.AmericanNurseToday.com March 2011 Best Practices for Falls Reduction: A Practical Guide 13 Current and emerging innovations to keep patients safe Technological innovations play a leading role in falls-prevention programs. By Patricia Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP, and Lisa Goff, MSPT

vidence shows that the most seizure). These falls can’t always be pre - tient’s current medications for those that effective falls-prevention pro - vented—one reason why organizations may affect balance, cognition, gait, or low - grams for healthcare organi - can’t expect to achieve a 0% fall rate. er-extremity sensation or that promote or - zations are multifactorial • Intentional falls occur when patients in - thostasis. If the patient takes any of these and interdisciplinary. For tentionally fall to the floor, as when act - drugs, caregivers need to have access to optimal effectiveness, an organization- ing out behaviorally. safe mobility equipment so they can inter - wide program should incorporate patient- When healthcare providers at all levels vene quickly if the patient starts to fall. safety Eequipment and devices, including and in all roles understand the different Assessment also helps identify the need both current and emerging innovations as types of falls, the effectiveness of falls- for transfer aids, such as lifts. (See Algo - appropriate. This article describes types of prevention programs can be evaluated. rithms to aid patient safety .) falls and patient assessment, then gives an While unanticipated physiologic falls and overview of technological innovations intentional falls generally aren’t preventa - Patient transfers healthcare organizations can use to pro - ble, accidental and anticipated physiolog - Even when using technological aids, care - mote patient safety. ic falls are, at least in many cases. To pre - givers still have to ensure safe patient vent accidental falls, an organization must transfers. Nurses may perform various Categorizing falls create and sustain a safe, clean environ - transfers, such as those described below. Falls occur in several types: ment, confirmed by environmental checks • The squat pivot transfer can be used • Accidental falls result from external en - on hourly nursing rounds. Preventing antici - for a patient who’s too weak to stand. vironmental factors, such as clutter, tub - pated physiologic falls requires interdisci - The patient rises from a sitting position ing, or spills that cause the patient to plinary assessment and management, with to a partial stand to keep the center of slip or trip. nurses taking leadership. gravity relatively low. • Anticipated physiologic falls stem from • The stand pivot transfer resembles the known intrinsic factors (such as or - Assessment squat pivot transfer, except the patient thostasis, dementia, and gait or bal - Before appropriate technology and equip - pushes up to a full standing position. ance deficits) or extrinsic factors (for in - ment can be chosen to help prevent falls, For safety, transfer the patient to the stance, certain medications or the patient’s fall risk, functional readiness, stronger side with the wheelchair at ap - improper ambulatory aids). and mobility must be assessed. (See After proximately a 45-degree angle from • Unanticipated physiologic falls are the fall. ) Fall risk is multifactorial and com - the bed. caused by unexpected or unknown med - plex, so patient assessment must be multi - • The lateral scoot with transfer board can ical episodes (such as sudden myocar - factorial as well. It should be built on ini - be used for patients unable to bear dial infarction, stroke, syncope, or tial risk-screening results and involve not weight through the lower extremities due just nurses but an interdisciplinary team of to weakness, paraplegia, spinal-cord in - physicians, pharmacists, and physical and jury, or amputated limbs or after ortho - occupational therapists. pedic surgery necessitated by trauma. After the fall To evaluate functional mobility, assess For this transfer, place one end of the the patient’s ability to move to a standing transfer board under the patient between Four categories of adults are at risk for suffering serious position, sit, transfer from one surface to the buttocks and back of the thigh; place injuries after a fall: another, turn, reach, and ambulate. To the other end in the chair seat. Have the • those age 85 and older evaluate balance and gait, use both history patient push up with the arms while • those with known osteoporosis or osteoporosis risk findings and functional mobility assess - slightly lifting the buttocks and slowly factors ment. Relevant history findings include fac - moving toward the wheelchair. For prop - • those receiving anticoagulants tors that suggest an increased fall risk (for er weight distribution, instruct the patient • postsurgical patients. instance, a history of peripheral neuropa - to lean the head and shoulders in the di - thy or a recent fall). Also review the pa - rection opposite the movement.

14 Best Practices for Falls Reduction: A Practical Guide March 2011 www.AmericanNurseToday.com Gait belts Some care providers prefer to use a gait ven when using technological aids , (transfer) belt to hold the patient more se - E curely during transfer tasks, such as re - caregivers still have to ensure maining seated and sliding from one sur - face to another; obtaining a standing position; turning and sitting onto another safe patient transfers. surface; or standing, walking to a new lo - cation, and then turning and sitting onto a new surface. The belt is a better choice than the alternative—placing one arm un - keep patients safe. Some hospital beds have ness may be timeliness of rescue rather der the patient’s arm for the lift and hold - “brake-not-set” alarms that sound to alert than fall prevention. ing onto the patient’s clothing or gown, staff. Alarms also warn patients, family, and which can injure the arm or shoulder. staff when a patient moves without assis - Smart beds The nursing staff should consult a physi - tance. They serve as early-warning devices Available for medical-surgical and critical- cal or occupational therapist to provide a that alert caregivers when a patient tries to care units, “smart beds” offer a range of training class to ensure the competency of get out of bed or get up from a chair. technological features to help prevent falls. all nurses before they attempt transfers Alarms may be located in pads placed on These beds may communicate by wires or they believe may not be safe. chairs, on wheelchairs, on beds, or in the wirelessly into the nurses’ call system, pro - bed’s special features. Some alarms attach viding a variety of data, such as patient Bed and toileting safety to an ankle or other body part. weight, brake settings, and position of Height-adjustable beds, safety rails, and Alarm features and settings vary. The bedrails and head of the bed. (See photo raised toilet seats can reduce falls associat - alarm may sound when the patient moves, below.) Other examples of smart-bed capa - ed with bed mobility and toileting. Many nears an edge, or releases a strap. The bilities are the ability to transmit surface hospitals instruct nursing staff to keep nursing staff can set alarm features to the data, as when vibration or rotation therapy height-adjustable beds in the lowest posi - patient’s specific needs. Some alarms have is engaged, and use of turn assist to help tion to reduce the distance a patient may both audible and visual features, so the nurses position patients more easily. Data fall from the bed. But many older adults alarm can be silenced while the visual can be displayed on an electronic board in have muscle weakness that causes difficul - flashing feature remains intact (as with the the unit’s central station. From there, nurses ty safely standing from a low-bed position. call-light system). Some beds connect di - can change settings, such as rotation mode Therefore, maintain the bed at a height rectly to the hospital’s data system, en - and alerts. that allows the patient to sit on the edge of abling information display at the nurses’ Smart-bed data, such as the time when the bed with knees flexed 90 degrees and station and direct notification of the nurse the patient was turned, also enter the pa - feet planted firmly on the floor for better by remote device, which saves walking tient’s electronic health record, saving balance. To promote safety when the pa - time. For example, if a patient’s side rail is charting time. Data can be aggregated for tient stands or for transfers, raise the bed down when it’s supposed to be up, the quality-improvement initiatives—for exam - higher. Otherwise, a weak patient who alarm notifies the nurse of the problem. ple, ensuring caregivers comply with rec - tries to stand could fall back onto the bed Some alarms even measure how much time ommendation to elevate the head of the or, even worse, the floor. Bed and transfer elapses from alarm generation to rescue. bed for intubated patients to help prevent safety requires an important modifica - During a patient’s episode of care, tion—installation of a half side rail. nurses can correlate alarm patterns with Similarly, for safe standing and trans - patient needs, such as toileting or wan - fers onto and off a toilet, fixed raised toilet dering patterns. This helps them anticipate seats and safety rails on either side of the patient needs and ultimately may help toilet are needed. Patients can hold onto prevent falls. The alarm promotes quick these to steady themselves when transition - rescue, preventing prolonged ing from a standing to a sitting position, episodes of a patient lying and to push off from while standing after on the floor after an toileting. Of course, if the patient is unable unwitnessed fall, for to safely ambulate with assistance to the instance. bathroom, provide a bedside commode. Falls occur so quickly Bed and chair alarms that the Available since the early 1990s, bed and truest measure chair alarms are another tool that can help of alarm effective - Smart bed www.AmericanNurseToday.com March 2011 Best Practices for Falls Reduction: A Practical Guide 15 Algorithms to aid patient safety Clinical practice algorithms aid mobility assessment and help guide selection of lateral transfer aids and devices to walker, two-wheeled walker, four-wheeled promote safe standing and sitting. You can download algorithms at www.visn8.va.gov/visn8/patientsafety walker, four-wheeled walker with a seat, center/safePtHandling/default.asp . Simply click on the “Assessment Form and Algorithms” link under and U-shaped walker. U-shaped walkers, “Algorithms for Safe Patient Handling and Movement.” This document contains algorithms covering various situations, which provide increased stability, have been such as transfer from a bed to a chair or a chair to the toilet and repositioning a patient in bed. You’ll even find available since the 1990s, but you may not algorithms specific to bariatric and orthopedic patients. The sample algorithm below addresses various patient transfers. be familiar with a specific type called the U-Step Walking Stabilizer. (See photo be - low.) With its U-shaped base lending a sta - Algorithm: Transfer patient to and from bed to chair, chair to toilet, chair to chair, or car to chair ble foundation of support in every direction, this unique rolling walker (rollator) makes Start here users feel safe and secure while allowing them to retain mobility and independence. It addresses the unique needs of patients with Parkinson’s disease, amyotrophic later - Can al sclerosis, progressive supranuclear palsy, patient Caregiver assistance not needed; bear Fully stand by for safety as needed. multiple sclerosis, brain injuries, balance weight? disorders, and multiple-system atrophy. No The rolling seated walker also pro - Partially motes safe patient mobility and should be Stand-and-pivot technique made available on units. With this walker, Is the using a gait/transfer belt the nurse can walk next to the patient as patient Yes (1 caregiver) or powered cooperative? stand-assist lift he or she ambulates. A patient who uses a Is the (1 caregiver). patient four-wheeled walker with seat must lock cooperative? the brakes when ready to sit or transfer No No and complete the activity. Patients who be - Use full-body sling Yes lift and 2 come dizzy from nausea or orthostasis can caregivers. easily turn and sit on the seat without falling. This arrangement is much safer Does the patient No have upper-extremity than having another staff member trail be - strength? I For seated transfer aid, must have chair with arms that recess or are hind with a wheelchair and lower the pa - removable. tient to the wheelchair seat if he or she be - Yes I For full body sling lift, select a lift specifically designed to access a patient from the car (if the car is the starting or ending destination). comes fatigued or dizzy or loses balance. I If patient has partial weight-bearing capacity, transfer toward stronger side. Seated transfer aid; may use I A four-wheeled walker with seat may gait/transfer belt until the Toileting slings are available for toileting. patient is proficient in I Mesh slings are available for bathing. not be appropriate for all patients, espe - completing transfer I During any patient-transferring task, if any caregiver is required to lift more independently. than 35 lbs of a patient’s weight, the patient should be considered fully cially those with memory problems, as it dependent and assistive devices should be used for the transfer. requires users to remember to apply the brakes to slow down or sit down safely (if www.visn8.va.gov/patientsafetycenter/fallsTeam/default.asp using as a seat). If you’re unsure whether

ventilator-associated pneumonia. Hospitals der. If it isn’t at the proper height for the pa - considering purchasing smart beds need to tient, has broken brakes or is missing rubber carefully compare the options to determine caps at the ends, contact a physical therapist benefits, connectivity with the nurses’ call for further evaluation. All mobility devices system, clinical needs, and costs. should be adjusted to the patient’s height and other characteristics as appropriate. Mobility devices Standard canes provide balance assis - Various mobility devices can assist with am - tance. They’re available in various hand - bulation (such as canes and walkers) and grips, weights, and heights. An adjustable wheelchair mobility (such as electric wheel - cane is recommended so it can be adapt - chairs, manual wheelchairs, and scooters). If ed to the patient’s hip height. a patient arrives on your unit with such a de - vice, make sure it has been evaluated and Walkers deemed appropriate and in good working or - Walkers come in various forms: standard U-Step Walking Stabilizer

16 Best Practices for Falls Reduction: A Practical Guide March 2011 www.AmericanNurseToday.com Tech aids that provide visual cues your patient should use this type of walker, Patients who have “freezing” episodes, such as those with Parkinson’s disease, may benefit from using the U-Step contact a physical therapist. Walking Stabilizer with the LaserLight option. When a freezing episode occurs, the patient simply presses a red button on the handlebar, creating a bright red line on the floor that guides each step. The red line gives the patient a target Walking stabilizers to step through, thereby improving step length. Walking stabilizers include tension-con - The LaserLight also can be purchased separately from the U-Step for patients with worsening Parkinson’s disease. The trolled gait aids, which show promise in LaserLight and similar visual cues on ambulatory devices enhance stride length in patients whose Parkinson’s disease ataxia management. With their unique has progressed to impede walking. Preliminary tests showed that subjects improved their stride length when they saw brake design, they put the user in full con - the red line on the floor. trol. To use the stabilizer, patients squeeze Another type of visual stimulus that may improve intentional gait is a ground line, which requires the patient to focus the brake slightly, causing the unit to move; attention on increased step length. Ground lines can be marked on the ground with paint, tape, or other markers, when they want to stop, they simply let go providing a visual cue for stepping and walking. of the brake. This feature aids standing up or sitting down and is particularly effective in helping users walk more efficiently. to lock the wheelchair and lift the foot - Rehabilitation management of Friedreich ataxia: The U-Step Walking Stabilizer has ten - plates before getting up and transferring lower extremity force-control variability and gait sion-controlled wheels and a reverse brak - out of the wheelchair. To maximize patient performance. Neurorehab Neural Repair . 2004; 18(2):117-124. doi:10.1177/088843900 ing system. Tested in a case study with a safety, self-locking wheelchairs with remov - 4267241. 14-year-old girl with Friedreich ataxia (a able leg rests are preferred. Hoenig H. Assistive technology and mobility disorder of progressive loss of voluntary aids for the older patient with disability. Ann muscle coordination), the stabilizer was Interdisciplinary collaboration LongTerm Care . 2008;9(12). www.annalsof - found to reduce her gait deviations and Be sure to collaborate with interdiscipli - longtermcare.com/article/3403?page=0,3& falls from ten episodes per month to three. nary team members when assessing the mobify=0. Accessed February 13, 2011. (See Tech aids that provide visual cues .) patient’s readiness to ambulate. Before ini - Lebold CA, Almeida QJ. Evaluating the contribu - A new ambulatory device called the tiating mobility, consider all factors that tions of dynamic flow to freezing of gait in Parkinson’s disease. Parkinsons Dis . 2010. Arti - Walkabout rollator has undergone trials in can affect safe mobility, such as orthosta - cle ID 732508. doi:10.4061/2010/732508. elderly and disabled patients and those sis, and consult the physical or occupation - Martorello L, Swanson E. Effectiveness of an automat - with Parkinson’s disease. It’s designed for al therapist regarding the patient’s current ic manual wheelchair braking system in the preven - people who can stand but can’t walk with - level of functioning. tion of falls. Assist Technol . 2006;18(2):166-169. out assistance; it’s not intended to be used Remember—nurses are responsible for Morse JM, Tylko SJ, Dixon HA. Characteristics of while seated. The Walkabout completely keeping patients safe from harm, adverse the fall-prone patient. Gerontologist . 1987; encircles the user, opening easily to let the events, and injury. This responsibility in - 27(4):516-522. user walk inside and close the gate. The cludes ensuring safe ambulation. To up - Nelson AL, Motacki K, Menzel N. The Illustrated top rail is approximately at waist height to hold it, you must integrate and test the Guide to Safe Patient Handling and Movement . provide stability and a place to rest the equipment and devices—including both New York, NY: Springer; 2009. arms. The footprint of the base has a larger current and emerging technology—that Quigley P, Neily J, Watson M, Strobel K, Wright circumference than the top rail, with four have the potential to reduce falls and in - M. Measuring fall program outcomes. OJIN . legs attached at an angle to provide maxi - jury risk. G 2007;12(2):1-17. mum stability. If the user loses balance, the Tideiksaar R, Feiner CF, Maby J. Falls prevention: the efficacy of a bed alarm system in an acute-care safety seat prevents a fall. The adjustable Selected references American Nurses Association. Nursing’s Social setting. Mt Sinai J Med . 1993;60(6):522-527. seat, made of strong nylon webbing, at - Policy Statement: The Essence of the Profession. Tsuei T-H, Wang H-L, Jao C-L, Yu C-H. Develop a taches to the top rail. The Walkabout al - 2010 Edition. 3rd ed. Silver Spring, MD: Ameri - visual stimulus with ambulatory device for Parkin - lows patients to walk in an upright position can Nurses Association; 2010. son’s patients to improve stride length. J using a natural gait. It has shown prelimi - Bryant MS, Rintala DH, Lai EC, Raines ML, Pro - Biomech . 2007;219:63-69. nary success in helping Parkinson’s patients tas EJ. Evaluation of a new device to prevent doi:10.1016/S0021-9290(07)70433-5. with more severe disabilities to walk further falls in persons with Parkinson’s disease. Disabil Wolfe RR, Jordan D, Wolfe D. The WalkAbout: a than they otherwise could, and may help Rehabil Assist Technol . 2009;4(5):357-363. new solution for preventing falls in the elderly doi:10.1080/17483100903038576. prevent falls in this population. and disabled. Arch Phys Med Rehabil . 2004; Foster E, Hillegass LJ, Phillips SL. Demonstration 85:2067-2069. program: An interdisciplinary approach at falls Wheelchairs and mobility clinic. Ann Longterm Care . 2004: Both authors work at the James A. Haley Just as a falls-prevention program must be 12(5):27-32. Veterans’ Hospital in Tampa, Florida. Patricia individualized, wheelchair prescriptions Hanley A, Silke C, Murphy J. Community-based Quigley is associate director of nursing service must be customized to each patient; no health efforts for the prevention of falls in the eld - for research and associate director of the standard wheelchair works for all patients. erly. Clin Interv Aging . 2011;6:19-25. doi: Veterans Integrated Service Network 8 Patient For instance, a dementia patient with mem - 10.2147/CIA.S9489. Safety Center of Inquiry. Lisa Goff is a physical ory deficits can’t be expected to remember Harris-Love MO, Seigel KL, Paul SM, Benson K. therapist. www.AmericanNurseToday.com March 2011 Best Practices for Falls Reduction: A Practical Guide 17 CASE STUDY Using technology to reduce falls By Bea Leyden, BSN, RN, MBA, and Dan Singleton, BSN, RN

t Aria Health in Pennsyl - tion; they were hard to hear and, in some We designed the study and Hill-Rom vania, we continually cases, nurses had trouble determining provided “smart beds” that met our seek ways to lower our which room an alarm was coming from. needs. The beds continuously send data patient fall rate . Our falls The falls task force partnered with Hill- to the call system so nurses know imme - task force has implement - Rom to explore bed technology options, diately if a problem exists; an alarm ed many improvements, including redesign - particularly a bed exit alarm that communi - sounds in the nurses’ station and the ing fall risk assessment, implementing visu - cated with the team center. From there, the call light comes on. The beds also allow al cues (Asuch as wristbands) to identify idea expanded to designing a study to automated documentation, which saves at-risk patients, focused rounding, toileting determine the impact of this technology time. Before the study began, we pre - regimens, and alarms. on falls prevention and skin integrity. We sented in-service classes on the new Challenges. Some patient rooms in chose a unit with a challenging layout. beds and our established falls-prevention our hospitals aren’t within direct sight or Conducting the study would give us a interventions. earshot of the nursing units’ team centers— chance to lower the rates of patient falls, Outcomes. To collect, store, and ana - a safety concern. Also, our bed exit alarms falls with injuries, and unit-acquired pres - lyze information from the study, a data - didn’t communicate with the nursing sta - sure ulcers. base was developed that supported both manually collected and electronic data. A flowchart was created to map all data points. (See Flowchart for data points .) Flowchart for data points Data were incorporated from our electron - ic event reporting (Web-based external) This flowchart shows all points where data were collected. In phase C, admission assessment for emergency- system and our integrated nurse call sys - department (ED) and direct-admission patients included falls score and level and necrosis scores; for patients tem. This nurse communications module transferred to the unit, it included fall risk-level reevaluation and a necrosis score within 24 hours of unit admission. Phase D data included bed position, alarm use, bed locks, and rail position. In phase E, daily assessments included the uses staff-locator badges and a central patient fall risk level and necrosis score. Discharge information in phase F included falls score, falls level, and necrosis dispatch to alert staff to patient calls for score. Such information would be helpful for any organization assessing the impact of a new bed system. assistance. While these items provided useful in - formation, alone they couldn’t determine the effect of the bed technology on pa - Patient Direct admit tient outcomes. SMART (Simple, Meaning - admitted ful, Accurate, Realistic, Timely) audits to unit Admission assessment Patient were used to capture additional vital in - ED admit information formation, such as falls, fall risk level, input into NCM pressure ulcers, necrosis score, and inter - Transfer from vention compliance. Although we’re still another unit Falls reevaluation analyzing data and interpreting results, we’ve noted a trend toward reduced falls Assessment daily on the study unit. Next steps. Information from the final study results will be used to guide development of additional falls-prevention interventions, with the goal of creating a Discharge NCM = nurse communication model synergy of interventions that further re - duces falls. G

Transfer off unit Discharge Expired Both authors work at Aria Health in Patient flow through unit Philadelphia, Pennsylvania. Bea Leyden is director of nursing performance improvement. Dan Singleton is nursing performance improvement coordinator.

18 Best Practices for Falls Reduction: A Practical Guide March 2011 www.AmericanNurseToday.com CASE STUDY An ongoing campaign to reduce patient falls By Constance Esper-Kanze, BS, RN, CPHQ, and Richard Cardente, BSN, RN, MBA

aint Thomas Hospital (STH) in Nashville, Tennessee has been involved in an ongoing Declining fall rate journey to reduce patient This graph shows the number of falls with serious injury on a rolling 12-month basis at Saint Thomas Hospital in Nashville. falls. Part of Ascension Each circle represents falls for the previous 12 months. Milestones in the hospital’s falls-reduction program appear at right. Health, STH is an acute-care hospital with 526 acute-care beds and 15 neurobehav - ioral beSds. Falls with serious injury rate Campaign kickoff. As part of As - Implementation (rolling 12-month average, excluding milestones

cension Health’s “Healthcare That Is Safe” Neuro-Beahvioral Medicine Unit) s y Oct 2007 a initiative, STH in 2007 became one of d BBE training 1.20 - t n e eight alpha sites for a program aimed at i t

a March 2008

1.10 - p preventing falls and eliminating falls with REV 3 approved v i u

injury. Initially, STH implemented four q

0.80 - e July 2008

d New beds (5B/7C/7D)

strategies: e t 0.60 - s u • assessment and reassessment of patient j May 2009 d

a New beds (all med/surg)

risk factors for falls 0.40 - 0 0 0 • visual identification of high-risk patients , August 2009 0

0.20 - 1 New beds (all critical /

using a yellow wrist band, red treaded s

l care) l a socks, and “SAFE” (“Stay Alert for Fall 0.00 - F December 2009 Event”) signs on patient room doors Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct 07 07 08 08 08 08 09 09 09 09 10 10 10 10 Online falls training • communication of patient fall-risk status BBE: Behavioral-based expectations May 2010 • education of patients, families, and staff REV 3: Sedative use and reversal protocol Chair alarms 5B/6C/7D: Specific nursing units on fall prevention. Safe Care. October 2007 marked the beginning of a renewed hospital-wide safety effort called Safe Care, designed to nurses can use them more frequently know - ticipation. Staff education consists of annu - bring behavior-based error-prevention tools ing that fewer false alarms are likely. Also, al competency enhancement through both and techniques into practice and to lever - the alarm has a more distinctive sound, giv - computerized and hands-on training. age lessons learned from high-reliability in - ing earlier warning of a potential fall. Outcomes. Between fiscal years (FY) dustries. While not specifically targeting Better communication. Another Safe 2008 and 2009, falls decreased 53.8%. patient falls, Safe Care focused on key Care initiative, the safety huddle, was imple - During this time, we saw the launch of Safe behavioral concepts, including better ac - mented in the fall of 2008. The safety hud - Care, the new medication policy, and the countability, communication, and attention dle is a gathering of staff (day and night new beds in high-risk units. In FY 2010, to detail. shifts) at shift change to discuss patients at the falls with serious injury rate (FSIR) High-risk drug policy. In March risk for falling, bed and chair alarm use, dropped another 14.4% as the new beds 2008, we partnered with physicians on a and patient and family understanding of became fully deployed and online training new policy designed to improve handling and participation in fall prevention. began. So far in FY 2011, we’ve seen falls of high-risk medications, such as sedatives Falls-prevention team meeting. decline another 10.4% with deployment of and hypnotics. Key interventions to reduce In the fall of 2009, a bimonthly meeting chair alarms. Cumulatively, our FSIR is patient falls included automatic starting- was initiated to review all falls and the de - down by 78.6%. (See Declining fall rate .) dose reductions for at-risk patients, removal briefing tool that staff members fill out after Since inception of the falls-prevention of long-acting benzodiazepines from the a fall. Individual cases, trends, and oppor - program, STH has greatly improved its safe formulary, and time restrictions on adminis - tunities for improvement are discussed. and caring environment. G tering sedatives and hypnotics. Education. Clinical staff use a one- Both authors work at Saint Thomas Hospital in New beds. We reached additional page fall-prevention tool that teaches pa - Nashville, Tennessee. Constance Esper-Kanze is a milestones with the purchase of new beds tients and families how to prevent falls, re - director of quality and risk management. Richard equipped with better alarms. The alarms minds them when to call for assistance, Cardente is assistant director of orthopedics and have three separate sensitivity settings; and stresses the importance of family par - neurosciences. www.AmericanNurseToday.com March 2011 Best Practices for Falls Reduction: A Practical Guide 19 POST-TEST • Best practices for falls reduction: A practical guide CE Earn contact hour credit online at www.americannursetoday.com/ContinuingEducation.aspx (ANT1103011 ) CE: 1.9 contact hours This continuing education program is supported by an unrestricted educational grant from Hill-Rom. Melissa A. Fitzpatrick is a manager at Hill-Rom. No other authors or planners of this continuing nursing education (CNE) activity have disclosed any relevant financial relationships with any commercial companies pertaining to this CNE. All content underwent peer review to eliminate bias. CE POST-TEST — Best practices for falls reduction: A practical guide Provider accreditation Instructions The American Nurses Association Center for Continuing Education and Profes - To take the post-test for this article and earn contact hour credit, please go to sional Development is accredited as a provider of continuing nursing education www.AmericanNurseToday.com/ContinuingEducation.aspx . Simply use your by the American Nurses Credentialing Center’s Commission on Accreditation. Visa or MasterCard to pay the processing fee. (ANA members $15; nonmembers ANA is approved by the California Board of Registered Nursing, Provider $20.) Once you’ve successfully passed the post-test and completed the evaluation Number 6178. form, you’ll be able to print out your certificate immediately . Contact hours: 1.9 Purpose/goal Expiration: 12/31/13 Post-test passing score is 75%. To enhance nurses’ ability to reduce falls through individual and organiza - tional interventions ANA Center for Continuing Education and Professional Development’s accredited provider status refers only to CNE activities and does not imply that there is real Objectives or implied endorsement of any product, service, or company referred to in this (1.) Define the impact of falls on patients and hospitals. activity nor of any company subsidizing costs related to the activity. This CNE ac - (2.) Describe how to assess a patient’s risk of falling. (3.) Identify people, process, and technology factors for reducing falls. tivity does not include any unannounced information about off-label use of a (4.) State how to develop a falls-reduction program. product for a purpose other than that for which it was approved by the Food and Drug Administration (FDA).

Please mark the correct answer online. c. dividing the total cost of the 11. Falls that are related to known factors and can be prevented are known as: 1. Falls account for approximately what investment by the expected revenue a. purposeful falls. percentage of adverse events reported to and subtracting annual expenses. b. intentional falls. regulatory agencies? d. dividing the expected revenue of the total cost of the investment and c. anticipated psychological falls. a. 5% adding the annual expenses. d. anticipated physiologic falls. b. 10% c. 20% 7. Which statement about a falls- 12. Which statement about the use of d. 30% reduction committee is correct? alarms to prevent falls is correct? a. Alarms should be set within the same 2. What percentage of hospital patients a. It should be set up as a 2-month parameters for all patients. who fall suffer an injury? committee to encourage fast remedial action. b. Alarms can be connected to the call- a. 20% b. It should focus on implementation light system. b. 30% and not discuss literature-based c. Alarms cannot be used for patients in c. 50% information. wheelchairs. d. 80% c. It should consist of a diverse group d. Alarms have only audio options. 3. An example of an extrinsic risk factor of staff, including nurses and 13. Which statement about “smart beds” for falling is: personnel from other services. is accurate? a. dizziness. d. It should consist of nurses from one a. Their data can be loaded directly b. a loose electrical cord. particular specialty. into the patient’s electronic health c. a gait disorder. 8. Continuous quality monitoring for falls record (EHR). d. incontinence. fits best under the Magnet™ Model b. Their data are kept separately from 4. How high should a patient’s bed be component of: the patient’s EHR. kept? a. structural empowerment. c. Surface data cannot be transmitted. a. 100% to 120% of the patient’s lower b. empirical outcomes. d. Remote patient weights cannot be leg length c. celebrating excellence. obtained. b. 80% to 90% of the patient’s lower d. transformational leadership. 14. When performing a stand pivot leg length 9. Within a healthcare organization, who transfer, you should transfer the patient: c. Lowest possible level is accountable for patient falls? a. to the weaker side, with the d. Halfway point between the highest a. Board of directors wheelchair at about a 75-degree and lowest settings b. Every employee angle from the bed. 5. An example of a common falls risk c. Upper manager b. to the stronger side, with the assessment tool is the: d. Middle managers wheelchair at about a 30-degree a. functional reach test. angle from the bed. 10. Which statement about safety huddles b. Berg test. c. to the stronger side, with the is correct? c. Carter Scale. wheelchair at about a 45-degree a. Post-falls safety huddles usually d. Morse Fall Scale. angle from the bed. include direct-care staff. d. to the weaker side, with the 6. The internal rate of return for a b. Safety huddles are effective only for wheelchair at about a 45-degree project is calculated by: post-falls analysis. angle from the bed. a. taking the expected revenue minus c. Questions should vary each time a annual expenses, then dividing the safety huddle is held. 15. Which patient is most at risk for result by the total cost of the d. Safety huddles should consist of suffering a serious injury after a fall? investment. nurses on the same shift. a. A patient who walks 2 miles daily b. taking the annual expenses minus the b. A 50-year-old patient expected 2-year revenue divided by c. A 25-year-old patient the total cost of the investment. d. A patient on an anticoagulant

20 Best Practices for Falls Reduction: A Practical Guide March 2011 www.AmericanNurseToday.com Because you can’t be with your patients all of the time.

The NaviCare® Status Board. Part of Hill-Rom’s No Falls™ Program. See exactly what’s going on in all of your patients’ rooms without being there. e bed status display lets you know at a glance if the patient’s bed is in a safe or unsafe position. Help prevent falls before they occur by knowing the status of your patient’s bed when work takes you away from the bedside.

Find out more about the NaviCare Status Board and the Hill-Rom® No Falls Program at hill-rom.com.

© 2011 Hill-Rom Services, Inc. ALL RIGHTS RESERVED Because getting in and out of bed should be easy as possible.

The VersaCare® Bed. Part of Hill-Rom’s No Falls™ Program. Many patients have di culty getting in and out of bed, which can lead to falls. Hill-Rom’s VersaCare Bed is at chair height in its lowest position, allowing ingress and egress that’s easier and more comfortable for patients and their caregivers.

Find out more about the VersaCare Bed and the Hill-Rom® No Falls Program at hill-rom.com.

© 2011 Hill-Rom Services, Inc. ALL RIGHTS RESERVED