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Slideshow from 2010 Dimensions in Geriatrics conference in May and November 2010, addressing current literature and evidence-bassed practice in preventing patient falls.

Slideshow from 2010 Dimensions in Geriatrics conference in May and November 2010, addressing current literature and evidence-bassed practice in preventing patient falls.

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  • In my role as Evidence-Based Practice Fellow, I'm examining the extent to which Abbott Northwestern Hospital's Fall Prevention Program reflects the most current research. While my focus is on inpatient acute care, I believe there are principles that are applicable to any practice setting.
  • That there is little consensus concerning optimum fall prevention strategies will become glaringly apparent when we start discussing the literature.
  • My initial selection of documents yielded a stack more than 4 inches thick, with 168 separate references. I was able to narrow that to 67 references as I attempted to narrow the field based on the question, “What does this tell us we need to change about ANW's current fall prevention plan?” Even with that, it becomes very easy to conclude that “anything will work” or “nothing will work.” Most of the literature describes a program a facility put in place, and what kind of result they saw as a result. In most cases, the program is successful, at least initially. Few studies document the effectiveness of the program for longer than 12 months, and fewer still show sustained success over the course of years. The number of assessment tools available is truly legion! They range from the carefully, prospectively validated to the home-brewed “it just feels right.” There are also published arguments that none of the available tools are adequately tested to be of any use, so why bother? However, even within this morass of conflicting data, there are some themes common to successful programs. It is my belief that when programs address all of these issues, optimal patient fall prevention results. As we proceed, I invite to consider your facility's fall prevention program, and consider how well it stacks up.
  • My initial selection of documents yielded a stack more than 4 inches thick, with 168 separate references. I was able to narrow that to 67 references as I attempted to narrow the field based on the question, “What does this tell us we need to change about ANW's current fall prevention plan?” Even with that, it becomes very easy to conclude that “anything will work” or “nothing will work.” Most of the literature describes a program a facility put in place, and what kind of result they saw as a result. In most cases, the program is successful, at least initially. Few studies document the effectiveness of the program for longer than 12 months, and fewer still show sustained success over the course of years. The number of assessment tools available is truly legion! They range from the carefully, prospectively validated to the home-brewed “it just feels right.” There are also published arguments that none of the available tools are adequately tested to be of any use, so why bother? However, even within this morass of conflicting data, there are some themes common to successful programs. It is my belief that when programs address all of these issues, optimal patient fall prevention results. As we proceed, I invite to consider your facility's fall prevention program, and consider how well it stacks up.
  • My initial selection of documents yielded a stack more than 4 inches thick, with 168 separate references. I was able to narrow that to 67 references as I attempted to narrow the field based on the question, “What does this tell us we need to change about ANW's current fall prevention plan?” Even with that, it becomes very easy to conclude that “anything will work” or “nothing will work.” Most of the literature describes a program a facility put in place, and what kind of result they saw as a result. In most cases, the program is successful, at least initially. Few studies document the effectiveness of the program for longer than 12 months, and fewer still show sustained success over the course of years. The number of assessment tools available is truly legion! They range from the carefully, prospectively validated to the home-brewed “it just feels right.” There are also published arguments that none of the available tools are adequately tested to be of any use, so why bother? However, even within this morass of conflicting data, there are some themes common to successful programs. It is my belief that when programs address all of these issues, optimal patient fall prevention results. As we proceed, I invite to consider your facility's fall prevention program, and consider how well it stacks up.
  • Many falls prevention programs address some of these elements. Very few address them all. However, only those that do address them all have a high level of sustained effectiveness.
  • A number of studies have demonstrated that the judgment of the clinician is at least as accurate at identifying patients at risk for falls as any assessment tool. However, delving deeper into the data shows that this is true only for the experienced, expert nurse. The reason tools are needed is we can't guarantee expert assessment 24/7. A tool also helps focus attention on fall risk, and makes assessment for it systematic. However, it's important to use a tool that is appropriate to your patient population. Granted, this often starts with a “best guess,” but can't stop there. How can you make the best “best guess”? Pick a tool, and learn how to use it correctly. Then go around your facility, to a variety of areas, and see if it works on the broadest variety of patients. Do you get a result consistent with expert observation of reality? Once you select a tool, rigorous training is needed, with regular refreshers. Even the best tool is useless if it is used inconsistently or incorrectly. Remember, you're selecting a tool, not getting married to it. If you find a tool isn't working in your situation, find a better tool!
  • One of the bigger bugaboos is using the tool correctly. Some of the problem is the user, some of it's the tool, and a lot of it is the system. At Abbott, we used the Hendrich 2 scale. Unfortunately, it is not set up in Excellian to assure correct use, especially in ICU. When we have a patient who is sedated and paralyzed, the “Get up and go” test should be scored as “0,” because it can't be assessed. Usually they are scored “4,” because they can't stand without assistance, and end up being identified as high fall risk. If the only way a patient will fall is if we drop them, they aren't a fall risk! Part of the problem is the system: “Unable to assess-0 points” isn't an option. Part of the problem is the tool, in that it didn't come with that option built-in, even though Ann Hendrich herself has written that's what should happen. Part of the problem is our unwillingness to work around these shortcomings to use the tool correctly. How do we know we are using the tool correctly? This requires ongoing monitoring. We need to monitor the tool's results to assure inter-rater reliability. If a patient's condition is unchanged, the results obtained by different caregivers should be consistent. We also need to make sure the results are consistent with expertly assessed reality. By “expertly assessed” think “clinical specialist.” While data collected after a patient fall often includes this information, how often to we actually look at the patient's fall risk score before the fall had occured? Statistical monitoring of this information allows us to evaluate the predictive power of the tool we use. Ideally, every patient who experiences a fall has been previously identified as being at high risk.
  • So we've identified the patient at risk, now what? We select interventions that work. It's easier said than done, for a number of reasons. When we've identified a patient as being at high risk for falls, we don't start with one intervention, see if it works, add another, see if it works, and so on. We select several interventions that “seem to make sense” from a long, not well-organized list and start them all at once. Assuming we're using the tool correctly and the patient is indeed at high risk, and they don't fall, we can never really be sure which intervention worked. The exception is if we pilot a single intervention, in addition to the usual stew of interventions we select. One of our telemetry units saw a marked decrease in falls when they decided to activate the bed exit alarm for all patients identified as high falls risk. However, such clear results are rare. What is often lacking is consideration of “why might this patient fall?” What are the specific contributing factors? This would allow us to...
  • All of our interventions fall into two categories: decrease the number and intensity of fall risk factors, and interrupt behaviors that increase the patient's risk of falling. This takes some careful, critical thinking. For example, “altered elimination” is often cited as a falls risk factor, but why? A unit treating ambulatory Alzheimer's patients recognizes that when a patient gets up to the bathroom, he voids en route, then slips and falls. While supervised regular toileting helps, non-slip footware proves optimally effective. A med-surg unit finds it's because a patient is willing to brave the risks in a desperate attempt to get to the toilet. Different interventions are called for, depending on the nature of the urgency. Five bucks says no one has tried this: “Here is your call light, please call for help if you need to get up to the toilet. Someone will come and help you as soon as possible. If no one comes soon enough, and you can't hold it any longer, can you promise me that you'll go in the bed?” Of course, that long list of interventions doesn't make things easier. Perhaps we can borrow a page from Infection Control, and have universal and risk-specific interventions, such as balance precautions or strength precautions.
  • Do your housekeepers know what to do around patients who are at high fall risk? Your dietary personnel? Your respiratory therapists? Tranditionally, fall prevention has been “nursing's job,” to the extent that patient falls are a “nursing-sensitive outcome.” If part of your falls risk intervention is “frequent observation,” they need to be observed by everybody! The first step is to make sure everyone knows what a patient needs to stay safe, within seconds of encountering a patient. Clever, evasive symbols don't cut it, spell it out! This is no more a compromise of confidentiality than a “protective precautions” sign. Second, facility staff with even transient patient contact need to have role-specific training for patient falls prevention. Finally, empower families and other visitors by welcoming them to your Falls Prevention Team, and teach them their role in preventing falls not just for their loved one, but for all patients. I would love to place a big mirror in the front lobby, with a sign saying, “Welcome to the Abbott Northwestern Falls Prevention Team!”
  • Finally, we must monitor our effectiveness.

Transcript

  • 1. The Elements of Patient Fall Prevention: A Literature Synthesis Damon Gates, BSN, RN, CCRN-CMC Evidence-Based Practice Fellow Staff Nurse, H4200 Medical Cardiac Intensive Care Heart Hospital Abbott Northwestern Hospital Minneapolis, MN
  • 2. The Scope of the Problem
    • Patient fall risk identification and fall prevention have been identified as an urgent need in countries across the globe by regulatory agencies, payers, and patient care advocates.
    • A multitude of falls risk assessment tools and fall prevention programs have been developed to address this need.
    • There is very little consensus on a single, effective, broadly applicable fall prevention strategy.
  • 3. The Scope of the Literature
    • Searches of PubMed, CINAHL, guidelines.gov, and the Cochrane Library yielded 168 citations, of which 68 were applicable to the question, “What does current research tell us we should be doing to prevent patient falls?”
    • Current literature describes over 30 different falls risk assessment scales, in varying levels of testing and validation.
    • A distinct divide is evident between the research literature and clinical case studies concerning identifying and managing falls risk.
  • 4. The Great Divide
    • Research studies conclude: [a] Falls risk assessment tools have inadequate predictive power and are therefore clinically useless, and [b] Falls prevention interventions cannot be individually tested for validity, and therefore cannot be trusted as useful or effective.
    • Clinical case studies demonstrate that these “useless” assessment tools and interventions still somehow yield a decrease in falls frequency and injury severity.
    • So who's right?
  • 5. And the Winner Is...
    • Research concerning the effectiveness of falls risk assessment tools is confounded by contamination and by a poor understanding of “risk factors.” The “gold standard” of double-blind studies of risk assessment tools and interventions is often impractical, as well as unethical.
    • Case studies demonstrate a wide variety of programs that meet with varying degrees of success. Comparisons of these successes allow for common elements to be identified.
    • Using all these element will most likely produce the greatest improvements in falls prevention.
  • 6. The Elements of Patient Falls Prevention
    • Use a Falls Risk Assessment Tool
    • Assure the Tool is used correctly
    • Use interventions that work
    • Tailor interventions to the patient
    • Fall prevention is everyone's job
    • Monitor your program, change as needed
  • 7. Use a Falls Risk Assessment Tool
    • Tools allow for more inexperienced clinicians to identify patients at risk as well as more expert colleagues.
    • Tools allow for systematic attention to be paid to falls risk assessment.
    • Tools must be appropriate to the patient population.
    • Regular, thorough training in use of the tool is required.
    • Tool selection is not a “marriage.”
  • 8. Assure the Tool is Used Correctly
    • Have system elements in place to assure the tool is used correctly.
    • Monitor how tool is used: 1. Consistency of results (inter-rater reliability) 2. Results consistent with observable reality
    • Monitor results and association with actual falls events.
  • 9. Use Interventions that Work
    • Easy to say, difficult to do.
    • Interventions are often “bundled,” making it difficult to identify the “effective” interventions.
    • Consideration must be given to the mechanism of patient falls.
    • Start with the obvious!
  • 10. Tailor Interventions to the Patient
    • Consider physical, environmental, and behavioral elements that place this patient at higher risks for falls.
    • Your falls risk assessment tool may guide you, but it is often insufficient.
    • Set up intervention selection methods to simplify selection process.
    • Again, start with the obvious!
  • 11. Falls Prevention is Everyone's Job!
    • Clearly communicate patients' fall risk status to everyone who has even transient contact with the patient.
    • Have clear, role-specific expectations and training for all clinical and non-clinical personnel regarding fall prevention.
    • Welcome the patient, family members, and other visitors to your facility's “Patient Falls Prevention Team.”
  • 12. Monitor Your Program, Change as Needed
    • Monitor your Falls Risk Assessment Tool to make sure it is properly capturing patients at risk.
    • Monitor interventions to make sure the are properly selected and rigorously enforced.
    • Critically analyze patient falls events to assure tool accuracy and that appropriate preventions measures were taken, and to identify additional opportunities.
    • Monitor trends in patient falls.
  • 13. Bad News, Good News
    • Not all patient falls are predictable or preventable.
    • There is no perfect risk assessment tool.
    • There is no single, globally effective intervention.
    • An effective falls prevention program entails difficult and tedious work.
    • A substantial percentage of patient falls can be prevented.
    • A population-specific risk assessment tool can be selected or developed that has a high level of accuracy.
    • Carefully selected clusters of interventions can be effective.
    • Falls prevention can substantially improve patient care value.
  • 14. Selected References
    • Diduszyn, J., Hofmann, M., Naglac, M., & Smith, D.(2008) Use of a wireless nurse alert fall monitoring system to prevent inpatient falls. JCOM 15(6), 293-296
    • Dykes, P., Carroll, D., Hurley, A., Benoit, A., & Middleton, B. (2009) Why do patients in acute care hospitals fall? Can falls be prevented? Journal of Nursing Administration 39(6), 299-304
    • Gowdy, M., Godfrey, S. (2003) Using tools to assess and prevent inpatient falls. Joint Commission Jouranl on Quality and Safety (2003) 29(7). 363-368.
    • Healey, F., Monro, A., Cockram, A., Adams, V., Heseltime, D. (2004) Using Targeted risk factor reduction to prevent falls in older in-patients: a randomised controlled trial. Age and Aging 33(4) 390-395.
    • Hendrich, A. (2007) Predicting patient falls: using the Hendrich II Fall Risk Model in clinical practice. Am Jnl of Nsg 107(11) 50-58
    • Hendrich, A., Bender, P., & Nyhuis, A. (2003) Validation of the Hendrich II fall risk model, a large concurrent case/control study of hospitalized patients. Applied Nursing Research 16(1), 9-21.
    • Institute for Clinical Systems Improvement (ICSI) (2008) Prevention of falls (acute care) [health care protocol]. Bloomington (MN): Institute for Clinical Systems Improvement.
    • Myers, H. (2003) Hospital fall risk assessment tools: a critique of the literature. Internat’l Jnl of Nsg Practice 9, 223-235.
    • Myers, H., Nikoletti, S., (2003) Fall risk assessment: a prospective investigation of nurses’ clinical judgment and risk assessment tools in predicting patient falls. International Journal of Nursing Practice 9, 158-165
    • Oliver, D. (2006) Assessing the risk of falls in hospitals: time for a rethink? Canadian Journal of Nursing Research 38(2), 89-94
    • Oliver, D., Daly, F., Martin, F., McMurdo, M (2004) Risk factors and risk assessment tools for falls in hospital in-patients: a systematic review. Age and Aging 33, 122-130
    • Vassallo, M., Stockdale, R., Sharma, S., Briggs, R., & Allen, S. (2005) A comparative study of the use of for fall risk assessment tools on acute medical wards. J of the American Geriatrics Soc. 53:1034-1038