Fall prevention: Applying the evidence By Kathleen Fowier, MSN, RN, CMSRN Quality Improvement Manager UPMC St. Margaret, Pittsburgh, Pennsylvania As told to Janet Boivin, BSN, RN S u c c e s s f u l fall pre­ vention program s use m u lti­ m odal interventions, such as detailed fall risk assessments, fre q u e n t m o n ito rin g by staff, and a p p ro p ria te use o f equipm en t. Healthcare facilities typically im p le m e n t best practices in b un­ dles, m aking it often d iffic u lt to determ ine which in­ terventions are the m ost effective. UPMC St. M argaret Hospital in Pittsburgh, Penn­ sylvania jo in e d the Pennsylvania Hospital Engage­ m ent N etw ork (PA HEN) in A pril 2012 to reduce falls w ith injury. This set us on a path th a t resulted in a 75% reduction in falls w ith serious injuries. (See graph.) Here is how we accom plished this reduction. Analysis: Role of data and best practices A fte r jo in in g PA HEN, we fo rm e d a m ultidisciplinary team tasked w ith review ing and investigating all fall events, extracting and analyzing data, and evaluat­ ing best practices im p le m e n te d as a result o f root cause analysis. Case study This case study illustrates our fall team in action An 80-year-old fem ale p a tie n t w ith im paired cognitive function and m u ltip le risk factors— including an unsteady gait, im paired vision, and m u ltiple m edications— was assessed as a high fall risk when a d m itte d to our facility. The nursing staff im plem ented a bed alarm to alert them when the p a tie n t was g e ttin g up w ith o u t using the call light. They also m oved her closer to the nurse's station and used purposeful rounding to anticipate and attend to her needs. The average response tim e fo r alerts w ith this p a tie n t was a rapid 10 seconds. D espite these steps, the patient's bed alarm sounded several tim es to alert staff, who fou n d her standing beside the bed. The nurses reached o u t to the fall team fo r support. The team reviewed th e bed-alarm settings (three sensitivity settings— low, m edium , and high) and sim ulated alarm tim e studies w ith the nursing staff. Their efforts revealed m isperceptions in em ployee understanding o f bed-alarm settings. For example, the staff th o u g h t the bed alarm w ould alert them th a t the p a tie n t was o ff the p e rim e te r o f the mattress no m atter what the sensitivity setting. The fall team used sim ulated bed-alarm scenarios to educate the staff and help to change practice. The nursing staff learned it's not enough to sim ply engage the alarm; the alarm also needs to be at the a p p ropriate setting. The staff began using more sensitive settings fo r patients w ith im pulsive behaviors. We learned an im p o rta n t lesson: How well em ployees understand facility equipm ent, its variations, and how to use it are im p o rta n t considerations when analyzing p a tie .

1. Fall prevention:
Applying the evidence By Kathleen Fowier, MSN, RN, CMSRN
Quality Improvement Manager
UPMC St. Margaret, Pittsburgh, Pennsylvania
As told to Janet Boivin, BSN, RN
S u c c e s s f u l fall pre-
vention program s use m u lti-
m odal interventions, such as detailed
fall risk assessments, fre q u e n t m o n ito rin g by
staff, and a p p ro p ria te use o f equipm en t. Healthcare
facilities typically im p le m e n t best practices in b un-
dles, m aking it often d iffic u lt to determ ine which in-
terventions are the m ost effective.
UPMC St. M argaret Hospital in Pittsburgh, Penn-
sylvania jo in e d the Pennsylvania Hospital Engage-
m ent N etw ork (PA HEN) in A pril 2012 to reduce
falls w ith injury. This set us on a path th a t resulted
in a 75% reduction in falls w ith serious injuries.
(See graph.) Here is how we accom plished this
reduction.
Analysis: Role of data and best practices
A fte r jo in in g PA HEN, we fo rm e d a m ultidisciplinary
team tasked w ith review ing and investigating all fall
events, extracting and analyzing data, and evaluat-
ing best practices im p le m e n te d as a result o f root
cause analysis.

2. Case study
This case study illustrates our fall team in action
An 80-year-old fem ale p a tie n t w ith im paired cognitive
function and m u ltip le risk factors— including an
unsteady gait, im paired vision, and m u ltiple
m edications— was assessed as a high fall risk when
a d m itte d to our facility.
The nursing staff im plem ented a bed alarm to alert
them when the p a tie n t was g e ttin g up w ith o u t using
the call light. They also m oved her closer to the nurse's
station and used purposeful rounding to anticipate and
attend to her needs. The average response tim e fo r
alerts w ith this p a tie n t was a rapid 10 seconds. D espite
these steps, the patient's bed alarm sounded several
tim es to alert staff, who fou n d her standing beside
the bed.
The nurses reached o u t to the fall team fo r support.
The team reviewed th e bed-alarm
settings (three sensitivity settings— low,
m edium , and high) and sim ulated alarm
tim e studies w ith the nursing staff. Their
efforts revealed m isperceptions in
em ployee understanding o f bed-alarm
settings. For example, the staff th o u g h t
the bed alarm w ould alert them th a t the
p a tie n t was o ff the p e rim e te r o f the
mattress no m atter what the sensitivity
setting.
The fall team used sim ulated bed-alarm
scenarios to educate the staff and help
to change practice. The nursing staff

3. learned it's not enough to sim ply engage
the alarm; the alarm also needs to be at the
a p p ropriate setting. The staff began using more
sensitive settings fo r patients w ith im pulsive behaviors.
We learned an im p o rta n t lesson: How well em ployees
understand facility equipm ent, its variations, and how
to use it are im p o rta n t considerations when analyzing
p a tie n t fall events.
AmericanNurseToday.com July 2016 American Nurse Today 21
The multidisciplinary
fall team implemented prevalence
rounding and post fall debriefing. Despite
best practice implementation, we discovered
variations and inconsistencies in our practice envi-
ronment. We found that making sense of the data
collected through a revised post-fall debriefing and
delivering the information to staff in an easily under-
stood format was the "magic bullet" in our success
story.
Strategy: Debriefing
Debriefing engages staff, patients, and families while
providing educational opportunities. Our debriefing
process was critical for abstracting usable data. The
facilitator who is responsible for debriefing the fall
event needs to have expertise in the debriefing
process to ensure data integrity. He or she must be
objective and promote a nonjudgmental atmosphere

4. of inquiry. The goal is to engage all participants, in-
cluding the patient and family. A t the end of the de-
briefing, the facilitator determines root causes and
shares them with team members. Identifying root
causes is invaluable to the debriefing process.
Root causes are then converted into frequency
charts, which are useful for analysis and clearly illus-
trate the variables with the greatest impact on partic-
ular outcomes. Our team focused on tangible root
causes, such as safety equipment, which proved suc-
cessful in reducing falls in our facility. (See Case
study.)
Multiple bed manufacturers
and sensitivity variations of
bed alarms; lack of
standardization
If staff is not familiar with a
particular type of bed, they're
less likely to use the equipment
properly, if at all. We educated
staff so they would develop an
awareness of variations and use
bed alarms correctly.
Insufficient ratio of bed
alarms to chair alarms
A patient who needs an alarm
when in bed also needs one
when sitting in a chair. So we
added a chair alarm* in each
room to ensure our fall
prevention efforts were

5. consistent.
Lack of available or
accessible equipment
If equipment is not available or
accessible, staff won't use it.
We streamlined the process for
obtaining equipment. For
example, disposable pads used
with the chair alarms were
stocked in each department.
Variations with the nurse
call system bed/chair
alarm alerts
The multidisciplinary team
collaborated to standardize
visual and auditory alerts that
resulted in improved alarm
response times.
‘ M anufa ctu re d by Posey
Outcomes: Falls reduction
In the first year of our initiative, we had a 50% reduc-
tion in falls with injuries and won the 2013 Hospital
Strategy: Enhancing equipment use
Commonly used fall prevention equipment includes
bed alarms, chair alarms, low beds, floor mats, and
nurse call system/alarm integration. Based on its
analysis of various types of falls and process-improve-
ment initiatives, the team put interventions in place
that essentially resolved identified equipment issues.

6. Association of Pennsylvania Achievement Award for
Patient Safety.
We've achieved the following reductions over the
past 4 years:
• 75% reduction in falls that resulted in serious injuries
• 60% reduction in falls that resulted in injuries
• 25% reduction in all falls.
Our ability to sustain these improvements keeps
patients safer during hospitalization.
This is the first in a series o f three case studies illustrating
success stories in preventing falls and injuries from falls.
The series is brought to you by Posey (http://www.posey.com).
Watch fo r the next case study in the September issue
of American Nurse Today.
22 American Nurse T o d a y Volume 11, Number 7
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individual use.

7. ACUTE PERSPECTIVE
David Oliver: Do bed and chair sensors really stop falls
in hospital?
David Oliver consultant in geriatrics and acute general medicine
Berkshire
In December a coroner’s narrative verdict was widely covered
in the media. “Frail hospital patients put at risk for want of
basic
equipment costing less than £100, coroner warns,” reported the
Telegraph.1 The verdict concerned Ken Swift, 80, a retired
nurse
who had been admitted to York Hospital with pneumonia. He
fell from his hospital bed and sustained a hip fracture, which
the coroner said was likely to have contributed to his death.
Bed and chair sensors had been recommended as part of Swift’s
care plan. These devices trigger an alarm or warning light if
patients leave their bed or chair for a few seconds. Staff can
then, in theory, respond quickly and intervene to prevent a fall
or assist the patient. Maybe the alarm reminds the patient (if
not too confused) to sit back down or alerts visitors or other
patients in the ward bay. The coroner noted that such devices
cost under £90, that over 30 of the hospital’s patients were on
a waiting list for one, but that the hospital didn’t have enough
sensors.
Clinical trials give us a considerable evidence base around
interventions to prevent falls in institutional settings, set out
clearly by the Cochrane Collaboration,2 the National Institute
for Health and Care Excellence,3 and detailed evidence
commentaries.4 What emerges is that, in trials, even
multi-pronged approaches to preventing falls will reduce them
by around 20% at best. Trials are rarely powered sufficiently
to detect reductions in serious injuries such as fractures, even
when pooled for meta-analysis. They rarely incorporate

8. balancing measures around potential harms from immobility
and loss of function.
If we look specifically at evidence from clinical trials of bed
and chair sensors and fall alarms we find only very weak
evidence that such sensors work at population level, even if
some staff or individuals at risk may be helped or reassured by
them.5-7 The routine use of sensors isn’t recommended in good
practice guidance.8 9
We should also consider their downsides. For many patients
who have dementia or incident delirium, having an alarm sound
every time they try to leave their bed or chair could worsen
their
distress and disorientation and could be considered a form of
restraint. Alarms are also unsettling for patients in other
beds—adding to noise pollution, poor sleep, and their own risk
of delirium. If we’re trying to improve patients’ independence
after acute illness or injury, sensors could actually worsen the
cycle of immobility and deconditioning.
We can’t engineer falls, or the risk of them, from
systems. Their occurrence doesn’t automatically
represent poor care
We can look outside the evidence from randomised clinical
trials, with pre-specified intervention protocols and time limited
interventions. Some examples of pragmatic quality improvement
approaches are promising, such as “safety huddles” or care
bundles, where interventions are refined and implemented
through “plan-do-study-act-evaluate” cycles.10 11 I totally
support
such pragmatic approaches, although we still need to look at
the opportunity cost from focusing excessively on fall
prevention.
Falls and subsequent injuries will happen among older, frailer

9. people admitted to hospitals and living in care homes—many
with cognitive or sensory impairment, previous falls, impaired
gait, muscle strength and balance problems, acute intercurrent
illness, faints, or dizziness. We can’t engineer falls, or the risk
of them, from systems. Their occurrence doesn’t automatically
represent poor care. Hospitals or care homes are no more
“places
of safety” than being back at home.
Marketing materials from companies that manufacture sensors
are not credible evidence. And coroners should have a basic
grasp of research evidence before making controversial
pronouncements.
Competing interests: See www.bmj.com/about-bmj/freelance-
contributors/david-oliver.
Provenance and peer review: Commissioned; not externally peer
reviewed.
Follow David on Twitter: @mancunianmedic
[email protected]
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oliver
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1 Donnelly L, Moore A. Frail hospital patients put at risk for
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doi:10.1093/ageing/aft155. https:
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