Hospital Fall Prevention Strategies

1. Hospital Fall Prevention Strategies Dr Eman Darwish PhD , HCRM Mouwasat Medical Services

2. Highlighted areas • Risk Management program view • Hospital Fall Prevention Strategies

3. RISK MANAGEMENT PROGRAM

4. Safety Iceberg Theory Direct Vs Indirect Costs of Accidents Visible Threat Medical (doctor visits, physical therapy, medicine, etc.) Hidden Danger • Reduced productivity • Accident investigation • Administrative costs • Lost time by supervisor • Costs of training replacement worker • Overtime • Legal fees • Negative publicity • Damage to customer relations 4

5. Risk Management = Good Management

6. How Serious is the Problem of Falling? Centers for Disease Control and PreventionNational Center for Injury Prevention and Control How big is the problem !!

7. According to the Centers for Disease Control and Prevention, in the United States healthcare system 2010: 1 of every 3 adults age 65 or older falls each year. Among individuals age 65 and older: 60% of fatal falls happen at home, 30% occur in public places, and 10% occur in health care institutions How big is the problem !!

8. According to the Centers for Disease Control and Prevention, in the United States healthcare system 2010: 1 of every 3 adults age 65 or older falls each year. Among individuals age 65 and older: 60% of fatal falls happen at home, 30% occur in public places, and 10% occur in health care institutions How big is the problem !!

9. In 2000, 78% of fall deaths, and 79% of total costs, were due to traumatic brain injuries (TBI) and injuries to the lower extremities. Injuries to internal organs were responsible for 28% of fall deaths and accounted for 29% of costs. Fractures were both the most common and most costly nonfatal injuries. Just over one-third of nonfatal injuries were fractures, but these accounted for 61% of total nonfatal costs—or $12 billion. Hip fractures are the most serious and costly fall-related fracture. Hospitalization costs account for 44% of the direct medical costs for hip fractures. Type of injury and treatment setting

10. The morbidity, mortality and financial burdens attributed to patient falls in hospitals and other healthcare settings are among the most serious risk management issues facing the healthcare industry. How big is the problem !!

11. “freedom from accidental injury due to medical care, or medical errors.” (IOM) -Institute of Medicine

12. International Patient Safety Goals Goal 1 -Identify Patients Correctly Goal 2 -Improve Effective Communication Goal 3 -Improve the Safety of High-Alert Medications Goal 4 -Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery Goal 5 -Reduce the Risk of Health Care–Associated Infections Goal 6 - The hospital develops and implements a process to reduce the risk of patient harm resulting from falls

13. Definition of a falls Causes of falls Fall risk assessment for Inpatient Fall risk assessment for Out patient Environmental round Responsibilities of staff Intervention strategies Post fall procedures/management Measuring the efficiency of the program Hospital Falls prevention program

14. Falls have been defined and reported in different ways. To track and trend fall data accurately and consistently, it is important for each organization to establish a fall definition. References for the fall definitions listed below are provided in the appended resources Definition

15. A Fall is defined as a sudden ,uncontrolled, unintentional, downward displacement of the body to the ground or other object .. A near fall is sudden loss of balance that does not result in a fall or other injury .This can include a person who slips .stumbles or trips but is able to regain control prior to falling . A un-witnessed fall occurs when a patient is found on the floor and neither the patient nor anyone else knows how he or she got there . Definition

16. It has been helpful for some to classify falls based on environmental, as well as physiologic, factors as a way to better understand their causes. Causes of Falls

17. Intrinsic risk factors   (i.e integral to the patient’s system; associated with age- related): Previous fall - studies have cited a history of falls as a significant factor associated with patients being more likely to fall again. Reduced vision – vision affected by, for example, a decline in visual acuity, decreased night vision, altered depth perception, decline in peripheral vision, or glare intolerance. Unsteady gait - manner and style of walking. Musculoskeletal system – impact from factors such as muscle atrophy, calcification of tendons and ligaments, and increased curvature of the spine (osteoporosis) are associated with ability to maintain balance and proper posture. Mental status – status affected by confusion, disorientation, inability to understand, and impaired memory. Acute illnesses – rapid onset of symptoms associated with seizures, stroke, orthostatic hypotension, and febrile conditions. Chronic illnesses - conditions such as arthritis, cataracts, glaucoma, dementia, diabetes and Parkinsonism.

18. Extrinsic risk factors(i.e., external to the system and relating to the physical environment): Medications - those that affect the central nervous system, such as sedatives and tranquilizers, benzodiazepines, and the number of administered drugs. Bathtubs and toilets – equipment without support, such as grab bars. Design of furnishings – height of chairs and beds. Condition of ground surfaces - floor coverings with loose or thick-pile carpeting, sliding rugs, upended linoleum or tile flooring, highly polished or wet ground surfaces. Poor illumination conditions - intensity or glare issues. Type and condition of footwear - ill-fitting shoes or incompatible soles such as rubber crepe soles, which, though slip resistant, may stick to linoleum floor surfaces. Improper use of devices - bedside rails and mechanical restraining devices that may actually increase fall risk in some instances. Inadequate assistive devices - walkers, wheelchairs and lifting devices.

19. Fall prevention program

20. Changing the Concept: ‘‘Why Patients Fall’’ to ‘‘Preventing Patients From Falling’’

21. Fall Risk Assessment Develop interventions based on the fall-risk assessment. Staff Training & Orientation Patients & Family Education Post Fall Intervention. Monitor the effectiveness of the program. Components of Fall Prevention Program

22. Individualized assessment and individualized plan of care were key to quality care A number of controlled studies have revealed that detecting a history of falls and performing a fall-related assessment are likely to reduce future probability of falls when coupled with interventions. (Guideline for Prevention of Falls in Older Persons, American Geriatrics Society, British Geriatrics Society and American Academy of Orthopaedic Surgeons Panel on Falls Prevention, May 2001). 1. Fall Risk Assessment

23. Prevention strategy There are a number of fall risk assessment tools available with a reasonable amount of evidence to support their use No single tool can be recommended for implementation in all settings or for all subpopulations within each setting Fall Risk Assessment Tools

24. Morse Fall Scale Hendrich Fall Risk Model Humpty Dumpty Scale Fall Risk Assessment Tools

27. Comparing Morse and Hendrich Assessment : Morse ; Intervention standardized by level of risk Not designed for long term patient ( All patient at high risk) Hendrich ; Focuses interventions on specific area of risk rather than general risk score There is 2 category of patient ( high –risk /low-risk )

28. Humpty Dumpty Scale http://www.safekids.org/tier3.

29. Review Tools and scoring Prevention Strategy II • Review the tools scoring based on the hospital falls incident report .

30. Review Tools and scoring • Review the tools scoring based on the hospital falls incident report .

31. Communication • Identify at every shift the patients most at risk of moderate to serious injury from a fall by simple reminder by using ABCS assessment : • A: Age • B: Bones • C: anticoagulation • S: recent Surgery

32. Level of Consciousness/ Mental Status History of Falls Ambulation/ Elimination Status Vision Status Gait & Balance Orthostatic Changes Medications Predisposing Diseases Equipment Issues Parameters of Assessment

33. When to conduct Risk Assessment and Re-assessment: - - Upon admission; - Change in a patient condition:- • If patient start to become weak patient more likely to fall; • If patient begins to experience vertigo; • Patient who just came back from surgery and recovery room; • Patients who received conscious sedation. • Addition of medication or change in medication • Each day or with each shift change for some high risk patients, assessment must be done to implement specific intervention; • Immediately following a fall • When patient is transferred to another unit

34. Interventions based on the fall-risk assessment

35. a. Monitoring gait and mobility. b. Bladder/ Bowel Training Program c. Fall Alert Medication d. Maintaining a safe environment. e. Assistive Devices Monitoring. 2. Intervention Based on the Fall-Risk Assessment

36. Normal/Safe Gait & Balance Balance Problem while Standing Balance Problem while Walking Change in Gait Pattern while Walking through doorway Jerking/ Unstable when Making Turn Requires an Assistance a. Monitoring Gait and Balance

37. 45% Falls Identified as Toileting related (Tzeng, 2010) Is a training technique for bladder and bowel to decrease urgency and incontinence based on behavioral modification treatment techniques that involves placing patient on toileting schedule. > 60 Years Old On Laxative Bed Ridden Postoperative b. Bladder /Bowel Training Program

38. Pharmacist are responsible for reviewing medication and supplements to ensure that the risk of falls is reduced Notify the for Drug that depress the central nervous system may cause sedation, drowsiness, ataxia, as well as paradoxical effects Antihistamine Antiepileptic Antidepressant Anticonvulsant Cardiovascular drugs c. Medication Fall Alert …………… MEDICATIONS FALL ALERT

39. Environmental hazards or hazardous activities are described as primary causes for approximately half of all falls, which includes: Walking on slippery/rough surfaces, Obstacles Inadequate light Loose carpets Trip Hazard regarding to medical care ( IV Tubing, Urinary Catheter, ) Such hazards are likely to cause trips or slips in any age group but pose a particular risk for community- dwelling elderly persons who may already have multiple intrinsic risk factors for falls. d. Maintaining a Safe Environment

40. Hospital Bed The first hazardous interaction 39 % of the Falls are Bed Related ( Tzeng, 2010) the use of adjustable- height; high- low beds ( Joint Commission, 2005) Lowering the bed height after Completing Healthcare Treatment The use of prone position instead of traditional sitting-standing position(Tzeng, 2007) Minimize the use of side rail , consider bed entrapment e. Assistive Devices Monitoring 60 CM 30 CM

41. Assistive Devices Monitoring Hospital Bed Entrapment

42. Assistive Devices Monitoring Hospital Bed Entrapment

43. Assistive Devices Monitoring Nurse Call Bell

44. Assistive Devices Monitoring

45. Fall Risk Assessment for Outpatient • Can be done in two levels ,the primary care giver can do initial screening ,then refer patient that are at risk to PT or OT to perform a more in-depth balance assessment

46. Initial screening include : • Send the patient a “self report” and review at the appointment • Perform the timed up & GO test Note: Allow the patient to practice one time , if took > 8 sec , should be referred to PT

47. Staff orientation and education

48. Lack of Staff training & communication issues among care giver are the leading root cause for patients fall 1995-2004 : 35incidences out 144 falls related to communication among caregivers (Joint Commissions, 2004) 3.Staff Training and Orientation

49. “Fall Alert” Sign

50. Patient education is important in patient-centered care. Encouraging patients’ active involvement in their own care Both written and verbal education as a fall prevention strategy for patients and families are recommended (National Institute for Clinical Excellence, 2004) 4.Patient and Family Education