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Identification of High Fall Risk Patients in Acute Rehab Running head: HIGH FALL RISK IN ARU 1 Identification of High Fall Risk Patients in Acute Rehab Vanessa Vonderhaar-Picard DNP, MEd, RN, CNML An evidence-based doctoral project presented to the Department of Nursing at Mount St. Joseph University in partial fulfillment of the Degree: Doctor of Nursing Practice Date: May 14, 2019 Susan A. Johnson, PhD, RN - DNP Advisor Copyright by Vanessa Vonderhaar-Picard DNP, MEd, RN, CNML 2019 2 HIGH FALL RISK IN ARU Identification of High Fall Risk Patients in Acute Rehab Vanessa M. Vonderhaar-Picard Mount St. Joseph University 3 HIGH FALL RISK IN ARU Table of Contents Executive Summary………………………………………………………………….……………5 Introduction………………………………………………………………………………………. 6 Problem……………………………………………………………………………………………6 PICOT Question…………………………………………………………………………..…….....9 Literature Review……………………………………………………………………………...…10 Search Description……………………………………………………………………….10 Table 1 Literature Review…………………………………………………………….....11 Summary of Levels of Evidence ………………………………………………………...12 Table 2 Level of Evidence……………………………………………………………….12 Falls………………………………………………………………………………………13 Fall Risk………………………………………………………………………………….13 Acute Rehab Risk Factors for Falls……………………………………………………...15 Psychiatric Risk Factors for Falls ……………………………………………………….16 Morse Fall Scale…………………………………………………………………………17 Table 3 Morse Fall Scale………………………………………………………………...18 Edmonson Psychiatric Fall Assessment Tool.…………..……………………………….18 Table 4 Edmonson Psychiatric Fall Assessment Tool…………………………………..20 Comparison of Edmonson and Morse Fall Scales……………………………………….21 Table 5 Comparison Fall Risk Factors of Edmonson Psychiatric Fall Risk and Morse Fall Risk………………………………………………………………………………………22 Summary of Literature…………………………………………………………………...22 Evidence-Based Practice Model…………………………………………………………………23 Theoretical Framework……………………………………………………………………..……25 4 HIGH FALL RISK IN ARU Integrated Evidence and Theoretical Framework…………………………………….…27 Table 6 Integrated Evidence-Based Practice Model and Theoretical Framework………28 Project Proposal………………………………………………………………………………….28 Participants………………………………………………………………………..……..29 Setting……………………………………………………………………………………30 Intervention………………………………………………………………………………31 Data Collection…………………………………………………………………………..33 Stakeholders……………………………………………………………………………...33 Driving and Restraining Forces………………………………………………………….34 Budget……………………………………………………………………………………35 Table 7 Project Budget…………………………………………………………………..35 Analysis and Results.………………………………………………………………………….…35 Table 8 Results of Falls Per 1,000 Patient Days Comparing First and Fourth Quarter.....36 Table 9 Results of Estimation of Population Ratio…………………….….……………..37 Significance and Implications……………………………………………………………………38 The Future………………………………………………………………………………………..39 Sustainability……………………………………………………………………………..39 Future Projects………………………………………………………………….………..39 Dissemination………………………………………………………………………...….40 Timeline………………………………………………………………………………………….40 Table 10 Project Timeline………………………………………….……………………41 Conclusion……………………………………………………………………………………….41 Acknowledgments………………………………………………...……………………………...42 References……………………………………………………………………………………….43 5 HIGH FALL RISK IN ARU Appendix A Quarter One Age and MFS Data……………………………………………...……47 Appendix B Quarter Four Age and MFS Data………………………………………………..…47 Appendix C Gender Data……………………………………………………………………...…47 Appendix D Admission Diagnosis Quarter One and Four …………………………………..….48 Appendix E Power Point: ARU Staff Education……………………………………………….49 Appendix F Edmonson Handout…………………………………………………………….…..60 Appendix G Edmonson EPIC Handout ……………………………………………………...….63 Appendix H ARU Reminder Flyer………………………………………………………………64 6 HIGH FALL RISK IN ARU Executive Summary Patient falls are a prevalent safety issue worldwide, and are the most frequently reported safety event in hospitals. Falls are a costly and complex issue, and despite much research there is not a simple solution to improving fall rates. Patients in the acute rehabilitation unit (ARU) setting are one of the most at risk populations to falls; however, a screening tool for this specific population has not yet been identified. A tool is needed to identify high fall risk patients in the ARU so appropriate preventative nursing interventions can be implemented. An exhaustive literature search indicates a fall prediction tool should be utilized in the ARU; however, a tool has not been validated in this setting. The Edmonson Psychiatric Fall Risk Assessment Tool (EPFRAT), although indicated for acute psychiatric patients, evaluates age, mental status, elimination, medications, diagnosis, ambulation/balance, nutrition, sleep disturbance, and history of falls, (Edmonson, Robinson, & Hughes, 2011), which are the same risk factors that contribute to Acute Rehab falls. Literature supported evaluating the EPFRAT tool in the ARU to identify high fall risk patients. Accurate identification of high falls risk patients in ARU allows for implementation of correct nursing interventions to prevent falls. Utilization of the EPFRAT in conjunction with the Morse Fall Scale (MFS) resulted in a decrease of falls per 1,000 patient days, from 9.025 in the first quarter, to 1.947 in the fourth quarter of 2018. In the first quarter, there were 10 falls on the ARU when only the MFS was used. During the fourth quarter when both scales were used, there were only 2 falls. Results indicate that with 95% confidence, using the EPFRAT scale in addition to the MFS decreases in the average number of falls per 1,000 patient days by between 0.44 and 13.9. Further evaluation of the EPFRAT is needed at the site level and should be trialed in another ARU to see if comparable results are reproduced. Falls remain a significant safety issue in the ARU setting, however, use of the EPFRAT assisted in decreasing falls. 7 HIGH FALL RISK IN ARU Identification of High Fall Risk Patients in Acute Rehab Introduction The incident of patient falls has become a worldwide, healthcare epidemic. Despite much time, attention, and use of resources, patients are still suffering from the effects of falls. The most frequently reported adverse events in hospitals are falls, and injuries related to falls (Ambutas, Lamb, & Quigley, 2017). According to Clancy (2013) “each year, between 700,000 and 1 million people experience a fall in US hospitals” (p. 195). Christopher, Trotta, Yoho, Strong, and Dubendorf (2014) predict by 2020, the annual total cost for fall related injuries could increase to 34.4 billion, and Rosario and colleagues predict cost of 54.9 billion (Rosario, Kaplan, Khonsari, & Patterson, 2014). According to the National Database of Nursing Quality Indicators (NDNQI) (2017), the fall rate per 1,000 patient days for ARU (units peer group bed size 100-199) is 1.8 – 9.81 with the median of 5.02. Upon literature review, it is clear that falls are a significant issue facing nursing today; however, there is not one answer or solution to solve this challenging and complex issue. Currently in the ARU at The Jewish Hospital, more than 80% of the patients on the unit are identified as being high fall risk with the current screening tool. The need for a tool to identify high fall risk patients is needed so that the appropriate prevention interventions can be implemented for this population. Fall risk assessment tools are the foundational element of fall prevention programs (Feil & Gardner, 2012). The purpose of this practice change project is to appropriately identify high fall risk patients in the ARU setting. Problem Nationally falls are highly prevalent in the ARU setting with estimated rates between 2.92 and 15.9 falls per 1,000 patient days (Frisina, Gullnitz, & Alverzo, 2010). In 2017, The Jewish Hospital (TJH) ARU experienced a fall rate of 4.67, and in 2018 through February, the 8 HIGH FALL RISK IN ARU fall rate spiked to a high of 13.05, despite a focus on fall reduction. The fall rate in February 2018 was 16.2 per 1,000 patient days, thus remaining above 2017 and exceeds NDNQI median fall rate of 5.02 for similar ARU units (NDNQI, 2017). Many different reasons contribute to why these ARU patients are a higher fall risk compared to other areas. Patients on acute rehabilitation units embody “one of the most at-risk populations for falls during hospitalization” (Rosario et al., 2014, p. 86). Active promotion of both mobility and independence in the ARU setting contributes to the increased risk of falls (Rabadi, Rabadi, & Peterson, 2008). ARU patients have more risk factors compared to general hospital patients (Gilewski, Roberts, Hirata, & Riggs, 2007). During therapy, rehab patients are taught to be as independent as possible but then are limited by safety measures put in place and instruction to not get up without assistance (Cournan, Fusco-Gessick, & Wright, 2018). In addition, patients who fall in the ARU have multiple risk factors, and are often cognitively impaired and impulsive, similar to those in the acute psychiatric setting. Despite research confirming increased risk of falls in the ARU setting, currently no validated tool to determine fall risk has been identified specific to ARU patients. Often in ARU settings, tools that are utilized, such as the MFS, were intended for the medical surgical hospital setting and identify most ARU patients as high risk, which makes it challenging to determine the true fall risk of patients in ARU (Rosario et al., 2014). When using the MFS in an ARU setting, 75%-90% of patients are identified as high fall risk (Rosario et al., 2014). On average, 80% of patients in TJH ARU
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