Fall Prevention in the Acute Care Setting Presented by Lee Jeske MS, GCNS-BC Aurora St. Luke’s Medical Center, Milwauke

1. Fall Prevention in the Acute Care Setting Presented by Lee Jeske MS, GCNS-BC Aurora St. Luke’s Medical Center, Milwaukee, WI

2. Fall prevention in the acute care setting • Objectives • Review process of working with Joint Commission writers • Review the important aspects of acute care fall prevention program • Discuss current state of fall prevention

3. Fall prevention in the acute care setting • Contacted by Joint Commission editor after publishing "Partnering with Patients and Families in Designing Visual Cues to Prevent Falls in Hospitalized Elders," in the Journal of Nursing Care Quality. • Case study in Good Practices in Preventing Patient Falls: A Collection of CaseStudies

4. Collaborating with the Joint Commission • Issues/Concerns? • Administrative support • Process • Questions for preliminary manuscript • Interview • Final review

5. Preliminary information requested • Provide a description about the types of falls and the amount of patient/resident falls that occurred (annual totals) at your facility. • Unit based • Provide a fall definition • An unplanned descent to the floor (or extension of the floor, e.g. trash can or other equipment)during the course of a patient’s hospital stay, with or without injury to the patient.”

6. Information requested cont. Describe how your organization conducted fall risk assessment? Which staff members were involved? Practice Council • Representatives aware of data and issues • Developed Safety Care Plan • Interventions • Staff and Patient Education • Low bed • Bed and chair alarms • Fall calendar

7. Fall calendar

8. Low bed

9. How did you identify risk for the patient? Morse Fall Scale • Developed in mixed group • Cut off score of 45 • Validated in 6 studies • Medical,surgical, cardiac, rehab, long-term care pts. • Sensitivity: 70%-91% • Specificity: 29%-83%

10. What we know about falls • There are three types of falls • Anticipated physiological falls (fall prone)-78% • Unanticipated physiological falls (stroke, seizure) -8% • Accidental (slipping, tripping) –14% • (Morse, 1997)

11. What we know about falls • Significant risk factors have emerged consistently in the literature • Prior fall history-RR 9.1 • Impaired mobility/gait instability • Impaired mental status • Medications (sedative/hypnotics including benzodiazepines • Altered elimination (Agostini et al, 2001, Evans et al, 2001, Oliver et al., 2004)

12. What we know about falls • High percentage of falls occur when the pt. is not in the presence of a caregiver • Most common site is a patient’s bedside, when alone and unassisted, and are elimination related • Hitcho et al., 2004, Oliver et al, 2000

13. What we know about falls Patients who fall: • Those who can participate in fall prevention strategies • Those who cannot or will not participate in fall prevention strategies.

14. What did you implement and who was involved? Project involved working with the patients who will participate in fall prevention • Unit staff wanted to develop a poster to educate patients/families about fall risk and consequences • Black and white • Paragraphs of information

15. Initial poster Stay put, Stay safe Our goal is to help you get better and keep you safe. We want you to call for help when you want to: Get out of bed, Move to the chair, or Go to the bathroom. This prevents injuries. People are often weaker when they are in the hospital. This weakness can be caused by the illness, by the tests, or by new medications. We do not want you to fall. Keeping safe: Sit at the edge of the bed for a few moments before standing up Getting up slowly prevents dizziness Call a staff member for assistance, they will be happy to help you Sit down immediately if you feel dizzy Please ask for assistance to get things that are out of reach Tell the staff if you spilled anything so it can be wiped up If you are having trouble using your call light, soft call lights are available and may be easier to use. While walking: Wear slippers or shoes while walking Use your walker, cane or wheelchair if needed Use the railing for support while walking In the bathroom: Use the handrails in the bathroom Use the pull cord in the bathroom if you need help for anything For family and friends Help us keep your loved one safe. Call for assistance to help your family member or friend get up to the chair, go for a walk, or go to the bathroom. IF YOU DO FALL Try to stay calm. Do not get up. Call for help. Wait for a staff member to come.

16. What did you implement and who was involved? • Interviewed 20 patients/families with specific questions about poster being easily seen, read, and understood. • Too much information • Can’t see it • Add color • 3rd redesign –19 patient/families re-interviewed • Use simple sign like a stop sign • Stay put, Stay safe, You are sick, call for help

17. What did you implement and who was involved? • 4th redesign-26 patients/families • Stay safe, Stay put. You are sick, call for help • 81%-Poster caught attention • 84% stated that the poster was an effective idea for fall prevention • 92% stated the directions were easy to follow and would help prevent falls • Still too small • Enlarged to 15 by 15 inches.

18. Final Sign • Stay Put, • Stay Safe • You are sick • call for help

19. IDENTIFICATION OF PATIENTS AT RISK FOR FALLS IN AN INPATIENT REHABILITATION PROGRAM Lisa Salamon MSN, GCNS-BC, WOCN Aurora Health Care Milwaukee, WI & Kathleen Bobay PhD, RN, CNAA Marquette University & Aurora Health Care, Milwaukee, WI

20. Background More than 75% of the patients admitted to our inpatient rehabilitation program are assessed to be at high risk using the Morse Fall Scale. Concern about the use of traditional means to identify fall risk patients not effective Use of the Morse Fall Scale itself isn’t sensitive enough to identify patients at the highest risk forfalls

21. Definition of Fall • Fall: Unplanned descent to the floor (or extension of the floor, e.g., trash can or other equipment) during the course of a patient’s hospital stay with or without injury to the patient, and occurs on an eligible reporting nursing unit. • Assisted Fall: A fall in which any staff member (whether nursing service employee or not) was with the patient and attempted to minimize the impact of the fall by easing the patient’s descent to the floor or in some manner attempting to break the patient’s falls. “Assisting” the patient back to bed or chair after a fall is not an assisted fall. A fall that is reported to have been assisted by a family member or visitor also does not count as an assisted fall. (ANA-NDNQI, p. 27; JCAHO, p. NSC 3-3) • Sources: ANA-National Database for Nursing Quality Indicators (NDNQI- 2005), • National Quality Forum (NQF-2005) endorsed hospital care performance measures and • Joint Commission on Accreditation of Healthcare Organizations (JCAHO -2005).

22. Purpose • To determine if we could find a more sensitive way of identifying the highest risk patients for falls • Specifically we wanted to see if we could do this without creating “something else to do”

23. Current Assessments • Morse Fall Scale Score • On admission and then daily • FIM Scores • every day & every shift for applicable items

24. The Morse Scale

25. Functional Independence Measures (FIM) • Eating • Grooming • Bathing • Upper Body Dressing • Lower Body Dressing • Toileting • Bladder: assist level • Bladder: accidents • Bowel : assist level • Bowel : accidents • Bed/chair/wheelchair transfer • Toilet transfer • Tub transfer /Shower transfer • Ambulation : assist level • Wheelchair mobility : assist level • Stairs • Comprehension • Expression • Social Interaction • Problem solving • Memory

26. Functional Independence Measures (FIM) • Detail on the FIM breaks it down onto a 1-7 scale • For example Problem solving • In order to score a 7 • Pt consistently recognizes problems when present • Pt makes appropriate decisions regarding problems • Pt initiates and carries out a sequence of steps to solve complex problems until the task is completed • Pt self-corrects if errors are made • In order to score a 1 • Pt solves routine problems less than 25% of the time • Pt needs direction nearly all of the time • Pt may need a restraint for safety • Pt requires constant 1:1 direction to complete simple daily activities

27. Method • A convenience sample of sixty-seven patients who experienced a fall from January 1, 2007 through June 30, 2007 were included in this pilot project. • The mean age of patients was 66.34 (range 39-89, SD = 14.08).

28. FIM Measures Chosen • Eating • Grooming • Bathing • Upper Body Dressing • Lower Body Dressing • Toileting • Bladder: assist level • Bladder: accidents • Bowel : assist level • Bowel : accidents • Bed/chair/wheelchair transfer • Toilet transfer • Tub transfer / Shower transfer • Ambulation : assist level • Wheelchair mobility : assist level • Stairs • Comprehension • Expression • Social Interaction • Problem solving • Memory

29. Findings • Significant correlations were found when Morse Fall Scale scores were compared against FIM (Functional Improvement Measures) scores. • problem solving (r = .898, p < .000) • score 6 or less • expression (r = .883, p < .000) • score 5 or less • memory (r = .772, p < .000) • score 4 or less

30. Interventions • On line learning module • Focus on FIMs to guide patient specific intervention • Case studies with photo shots of rooms • Patient Intervention laminated poster for rooms • Pocket Cards

31. Next Steps • Follow up data collection • 1 day per week for 5 weeks • Done at random • In the process of evaluating this data • Expected Practice Changes • Nurses individualizing careplans and Overviews based on FIM scores • Has this hightened awareness of patient deficits impacted fall rates

32. Overview Screen / Careplan Therapy Tips Nursing Communication

33. Conclusion • It is believed that by using the Morse score in combination with a FIM score below the identified cut point, high risk patients can be better identified so appropriate interventions individualized to their deficits can be put in place. Step two of this project is to refocus the nurse’s attention on these findings.

34. References Agostini, J., Baker, D., & Bogardus, S. J. (2001) Prevention of falls in hospitalized and institutionalized older people. In K. G. Shojania, B.W. Duncan, K.M. McDonald, & R.M Wachter (Eds.) Making healthcare safer: A critical analysis of patient safety practices. Evidence report/technology assessment no. 43, AHRQ publication no. 01-E058. (pp.281-299). Rockville, MD: Agency for healthcare Research and Quality. Coussement, J., De Paepe, L., Schwendimann, R., Denhaerynck, K., Dejaeger, E., & Milisen, K., (2008). Interventions for preventing falls in acute- and chronic-care hospitals: a systematic review and meta-analysis. Journal of the American Geriatric Society, 56(1), 29-36 Evans, D., Hodgkinson, B., Lambert, L., & Wood, J., (2001). Falls risk factors in the hospital setting: A systematic review. International Journal of Nursing Studies, 39(7), 735-743.

35. References Hitcho, E. B., Krauss, M. J., Birge, S., Claiborne Dunagan, W., Fischer, Il, Johnson, S., et al (2004). Characteristics and circumstances of falls in a hospital setting: A prospective analysis. Journal of General Internal Medicine 19(7), 732-739. Hook, M.L. (2008). Risk for falls in adults in acute care: A synthesis. Unpublished manuscript, Aurora, Cerner, UW-Wisconsin (ACW) Knowledge-Based Nursing Initiative, University of Wisconsin – Milwaukee, College of Nursing. Lee, JE, Stokic DS (2008) Risk factors for falls during inpatient rehabilitation. Am J Physical Medicine & Rehabilitation 87: 341-353. Morse, J. M. (1997). Preventing patient falls. Thousand Oaks, CA: Sage Publications, Inc. Oliver, D., Daly, F., Martin, F.C., & McMurdo, M. E. (2004) Risk factors and risk assessment tools for falls in hospital in-patients: A systematic review. Age and Ageing, 33(2) 1679-1689.