This document summarizes efforts to reduce falls on inpatient psychiatry units through implementing evidence-based strategies. A review found falls were highest in female patients over 65 with dementia. Several changes were then made, including standardized fall definitions, revised guidelines and care plans, education, and exercises. While some goals were partially met, additional data collection and evaluation is needed to fully benchmark falls and assess the effectiveness of changes.

1. Falls in Psychiatry: Toward Evidence-based Prevention Ruth Mawyer, APRN, Aimee Strong, RN, Kathy Fletcher, APRN FAAN, Deborah Cox, APRN

2. Performance Improvement Goals Describe falls on two inpatient psychiatry units and recommend changes Compare rates of falls across inpatient settings Identify the patient population at highest risk on a gero-psychiatry unit Identify evidenced-based strategies for fall reduction and injury prevention Implement evidenced-based strategies for fall reduction and injury prevention

3. Method Three month aggregate review of falls documentation in Psychiatry Three year analysis of quality data related to falls on the gero-psychiatry unit Review of literature on evidenced-based strategies for fall reduction and injury prevention Evaluation of current fall prevention strategies using a Root Cause Analysis and Quality Support Team Model

4. Findings Chart Review: July to September 2002 Fallers compared to non-fallers In a three month retrospective review of falls on two inpatient adult and geriatric psychiatry units, Fletcher and Cobb found that greater than half of the falls occurred while the patient was ambulating and 33% around the bed. There were no restrictions on mobility in most of the fallers. Fallers were compared to non-fallers related to assessment for risk to fall. Twenty-five percent of the non-fallers had been identified as being at risk to fall during the admission assessment whereas 42 % of those that fell had been identified as having a risk for falling at the time of the fall. All fallers were on psychotropic medications and almost 20% were also on cardiovascular medications. Both are known to increase the risk of falls. Although there were no serious injuries during the sample period, 27% of the sample sustained minor injuries. Fletcher, K APRN, Senior Services and Cobb, B APRN Float Pool

5. Findings, continued Three year analysis of quality data related to falls on the gero-psychiatry unit Falls are declining overall on the gero-psychiatry unit: Rate in 2003: 10.6 per 1000 patient days, in 2002: 11.8 , and 2001: 16.5. Possible contributing factors include possible declining rates of geriatric admissions, changes in the definition of a fall to be reported, enhanced falls awareness, and installation of video monitors to enhance patient safety.

6. Findings continued Females older than 65 years old diagnosed with dementia have the highest prevalence of falls and serious fall related injury Of 938 Admissions in 2002, 56.7% were female Falls N=69 65% or 28 of 43 falls in patients > 55 years old were in patients with Dementia 90% of falls in patients >55 were patients >65 years old 72% of these were females Patients with Dementia, Depression and Delirium accounted for most of the falls

7. Findings, continued Review of literature on evidenced-based strategies for fall reduction and injury prevention Limited evidence-base of effective strategies. Unable to benchmark due to non-standard reporting methods. Gait and balance strengthening exercises most effective. Hip protectors showing promise in reducing catastrophic hip fractures. Falls contribute substantially to Medicaid and Medicare Costs.

8. Findings, continued Evaluation of current fall prevention strategies Areas identified for improvement Guidelines were non-specific and difficult to chart against Plan of care did not specify which precautions to implement Documentation of patient education related to fall prevention strategies was missing Patient education resources on fall prevention were needed Exercises to strengthen gait and balance could be taught in Recreation Therapy Medical and Nursing Staff needed reeducation on practice changes and fall prevention Hipsters were not stocked and needed to be more easily available Falls needed a broader and more specific analysis and could be associated with staffing effectiveness Video monitoring of patients at high risk was found to be inadequate

9. Practice Changes Implemented Medical Center standardized fall definition (Oct 2002) Revised the Falls Precaution Guideline (May 2003) Revised the Plan of Care (September 2003) Revised the Interdisciplinary Education Record to include falls prevention Gait and Balance exercises and education provided to patients (June 03) Patients identified as high risk for catastrophic injury from falls on admission and during hospitalization (>65 with dementia, depression or delirium) given hipsters (June 2003) Stocked hipsters (June 2003) Ongoing staff re-education on fall prevention (June 2003) Piloted new fall alert alarms and additional floor pad (June 2003) New unit to be equipped with 8 low beds, soft floor, and hand rails (June 2004) Eliminated intermittent video monitoring of patients at high risk for injury related to falling (June 2003) More detailed analysis and trending of falls including relationship of falls to staffing effectiveness (October 2003)

10. Status of Accomplishment Toward Performance Improvement Goals Describe falls on two inpatient psychiatry units and recommend changes Partially achieved. Data continues to be analyzed Compare rates of falls across inpatient settings Rates could not be compared because cohort groups could not be identified from available data leading to recommended changes in the hospital data base

11. Status of Accomplishment, continued Identify the patient population at highest risk on a gero-psychiatry unit Females older than 65 years old diagnosed with dementia had the highest prevalence of falls and associated injury Identify evidenced-based strategies for fall reduction and injury prevention Gait and balance exercises had the most evidence for effectiveness in preventing falls Implement evidenced-based strategies for fall reduction and injury prevention Several practice changes were implemented

12. Recommendations for Additional Practice Changes Include age of patient in Univerisity falls Quality Data Base to allow for reasonable comparison of falls by risk groups. National Standardized Falls Data Base for bench marking Evaluate the effectiveness of Unit Practice Changes

13. References Review: Multiple risk factor modification reduces falls in elderly persons. ( May-June, 1998) ACP Journal Club v128:69. Review: Intrinsic and environmental risk-factor modification reduces falls in elderly persons. , (July/August, 2002), ACP Journal Club . v137(1):9. Buchner D. M. and Larson E. B.(1987) Falls and fractures in patients with Alzheimer-type dementia. JAMA . 257(11):1492-5. Center for Disease Control, Injury Fact Book, Falls Among Older Adults,. http://www.cdc.gov/ncipc/fact_book/15_Falls_Among_Older_Adults.htm , retrieved 3/1/2003. Elder Fall Prevention Act of 2002. http://www.theorator.com/bills107/hr3695.html 10/08/2002, retrieved 3/1/2003

14. References continued Evans D, Hodgkinson B., Lambert, L., Wood, J., Kowanko, I. (1998) Falls in acute hospitals: a systematic review, 1-71 in anonymous: DARE (2002) v. 4. Retrieved from OVID 3/10/02. Frels C., Williams P., Narayanan S., Gariballa S.E., Postgraduate Medicine Journal (2002) Aug:487-9. Gardner MM; Robertson MC, Campbell AJ, Exercise in preventing falls and fall related injuries in older people; a review of randomised controlled trials (RCT ), British Journal of Sports Medicine . (2000 Feb 3), 4(1):7-17. Gregg EW, Pereira MA, Caspersen DJ. (2000, Aug) Physical activity, falls, and factures among older adults: a review of the epidemiologic evidence. Journal of the American Geriatrics Society . 48(8):883-93. Joo, J.H., Lenze, E. J., Mulsant, B. H., Begley A.E., Weber, E. M., Stack J.A., Mazumdar, S., Renolds, CF 3 rd , Pollock, B. G. (2002) Journal of Clinical Psychiatry . 63(10):936-41. Manly DT . Oakley SP Jr . Bloch RM . (2000 Summer) Electroconvulsive therapy in old-old patients. American Journal of Geriatric Psychiatry. 8(3):232-6. Oliver D, Hopper A, Seed P. Do hospital fall prevention programs work: a systematic review. Journal of the American Geriatrics Society (2000) 48 (12), 1679-1689. In DARE Volume 4 December (2002). Retrieved from OVID 3/10/02.

15. References continued Parker, MJ ; Gillespie, LD ; Gillespie, WJ (2002) Cochrane Musculoskeletal Injuries Group Hip protectors for preventing hip fractures in the elderly. Cochrane Database of Systematic Reviews. Issue 4. Retrieved from OVID, 3/11/02. Province MA, Hadley EC et al. The effects of exercise on falls in elderly patients. (1995 May 3) JAMA . 273(17):1341-7. Rubenstein, L. Z., Robbins, A. S. Schulman, B. L., Rosado, J. Osterweil, D. and Josephson, K. R. (1988). Falls and instability in the elderly. Journal of the American Geriatrics Society, 36(3)266-278. Schneider, D. C. and Mader, S. L. Falls in Ham, R. J., Sloane, P. D., and Warshaw, G. A. Primary Care Geriatrics (4 th ed.) Mosby, Philadelphia, 2002.

16. Related Documents Table of Rucker 3 findings Three year trend in falls on Rucker 3 Falls Analysis Form Falls and Staffing Effectiveness 1st Quarter 2003 Documentation Changes Fall Precaution Guideline Plan of Care Interdisciplinary Education Record Proposed fall record template