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Fall

Prevention

Purpose and Objectives

Purpose:

Review the UC Health Fall Prevention Program.

Objectives:

1. Present evidence about patient safety and falls.

2. Review the UC Health Fall Prevention Policy and

Fall Risk Assessment Tool.

3. Identify current interventions to prevent falls.

4. Take a post-test to verify knowledge competency.

Evidence

• Of all falls, up to 45.2 % occurred during toileting with majority

occurring on the way from the chair/bed to the bathroom (Tzeng

H.M., 2010)

• Individualized and targeted fall prevention strategies in addition

to universal fall prevention interventions work better than

universal interventions alone (Ang et al, 2011)

Regulatory Requirements

• Reducing falls: a UCH Critical Success Factor!

• Magnet re-designation requires inpatient fall rates to be at or

below the median of comparison hospitals

• Falls with major injury are a CMS hospital acquired condition

(HAC). Hospital acquired falls w/injury will impact

reimbursement

– Major injury = fracture, surgery, casting or traction; inter-

cranial injury; internal injuries such as burns, electric shock

or crushing.

• UCH must work hard to keep our fall rate below the national

benchmarks.

– UCH Hospital Goal starting July 1st, 2013 = 2.79

– UHC Consortium Inpatient Benchmark = 3.17

Mrs. Smith (fictitious name) came to UCH with a stroke

and at the time of the expected date of discharge had

accrued expenses of $24,099.

On the day of discharge, she fell and broke her hip. The

additional costs associated with this fall are as follows:

Surgical expenses: $15, 214

Rehab recovery: $24, 005

Total Additional Expenses: $39, 313

Original expenses: $24,099

New Total expenses: $63,412

Instead of going home, Mrs. Smith went to a

nursing home. Her health outcomes are now

uncertain.

Preventing Patient Falls Fall Definitions and

Assessment

What is a Patient Fall? A patient fall is an unplanned descent to the floor with

or without injury. Assisting the patient to the floor is a fall.

What is a Near Miss Fall? A near miss fall is when the patient begins to fall but

does not reach the floor. The patient is assisted to the chair or bed without injury.

What is an Intentional Fall?

Patient falls on purpose or falsely claims to have fallen.

When a patient falls back into bed or into a chair, it is not considered a fall. Click here to review the policy.

Nursing

Fall Prevention Activities

• At UC Health the Fall Risk

Assessment Tool is used across

services and systems.

• This tool was created by Poudre

Valley Hospital and implemented

system wide due to their resounding

success in preventing falls.

• This tool is based on patient

symptoms and gait disturbances.

When to Assess Patient Fall Risk

Inpatient Assessment

• Assess and rate the patient fall risk on admissions and at the

start of each shift.

• Assess and re-rate fall risk if the patient’s condition changes.

This change in condition may include such examples as a newly

ordered medication or altered mental status.

• Reassess immediately after a fall and 24 hours post fall to

ensure there are no delayed injuries.

Ambulatory/Outpatient/Procedural Areas Fall Assessment

• Use the same Fall Risk Assessment Tool as inpatient areas.

• Fall Prevention Interventions will adhere to specific area’s guidelines on Fall Prevention.

Fall Risk

Assessment Tool

This shows the tool and

the different colors

indicate which patient

characteristics correlate

with each fall risk level.

The next slide will show

what the assessment

looks like in EPIC.

Inpatient Fall Assessment Tool

PROPERTIES

On passing, 'Finish' button: Goes to Next Slide

On failing, 'Finish' button: Goes to Next Slide

Allow user to leave quiz: After user has completed quiz

User may view slides after quiz: At any time

User may attempt quiz: Unlimited times

13

Falls Interventions

Low Fall Risk Interventions

Green

• Side rails raised x2 or x3 (x1 for beds with 2 long side

rails)

• Low bed position, brakes on, call light in reach

• Remove obstacles

• Glasses/hearing aids in reach as appropriate

• Assess the patient at a minimum of 1 time per shift

• WARNING!

“Not capable of bed exit” makes the patient automatically a

low risk. Use this very cautiously (i.e. end of life,

quadriplegic, pharmaceutically paralyzed)

Moderate Fall Risk Interventions

Yellow

All of the Low Risk interventions PLUS:

• Check patient every 2 hours

• Offer/encourage toilet every 1-2 hours as appropriate

• Assess for use of standing/transfer devices

High Fall Risk Interventions

Red

All of Low and Moderate interventions PLUS:

• Institute fall-alert marker on door jamb and chart (on bed in ED)

• Place colored fall-alert socks on patient unless contraindicated

(e.g. risk of skin breakdown-heel, excessive swelling-lower

extremity, or cause pain/discomfort)

• 3 side rails raised with bed alarm

• Chair alarm when up in chair

• Remain within reach of the patient when in chair or Check on

bed without alarm (including when in bathroom)

• Check on patient every hour

• Gait belt or up with standby assist

• Additional fall risk interventions as appropriate/available

High Fall Risk Interventions

Side Rail Use in Fall Prevention

All high risk fall patients must have 3 side rails raised with a bed alarm.

• The 4th side rail is considered a restraint and would require a

restraint order if used. May be used with specialty mattresses for

safety (not requiring a restraint order).

• You must follow the policies: “Fall Prevention” and “Physical

Restraint Non-behavioral”

Beds and Fall Strategies Look, Listen, Feel to make sure properly alarmed

(for med/surg beds)

Look:

Green light means the bed

alarm is set, bed is low, locked

and both side rails up

Yellow light means the bed

alarm is set but 1 of the other

parameters is not set

Listen:

One solid beep, bed alarm is

set!

Feel:

Zero bed and weigh each new

patient

Key Points about Patient Falls

• Keeping patients safe requires vigilance and teamwork. Work

closely with patient, family and inter-professional team to maintain

successful surveillance.

• Educate the patient and family. Keep them informed about the

patient’s fall rating. Engage them in helping prevent injury.

Review room signage.

• Learn ALL components of the Fall Prevention Program and

policy. Your patient’s safety depends on it!

• When in doubt of risk, rate patient higher not lower to rate patient

risk. May use “RN-Increased Risk Level”.

21

Key Points about Patient Falls EPIC auto calculates the fall risk based on the fall assessment form. This

then directs interventions, but it is up to the nurse to ensure high fall risk

interventions are in place! EPIC populates moderate and high fall risk

banners for patients on their patient summary tab (see screen shot).

22

Preventing Patient Falls

Strategies to Prevent Falls

• Keep patient environment free of clutter; clean up spills with the

assistance of Environmental Services

• Report any equipment issues impacting falls to Anytime,

Anywhere (88351)

• Use bed or chair alarm. Check bed

alarm system connection to head wall by

pushing the nurse call button on bed rail

• Familiarize yourself with equipment in use

in your area (bed alarms, chair alarms)

…..continued

Strategies to Prevent Falls, Continued

On inpatient services, 35% to 40% of falls relate to toileting.

• Implement toileting checks during hourly rounds, schedule toileting

to prevent falls!

• Use commodes

• If the patient is a high risk for falling,

remain within arms reach of patient in bathroom;

this is not considered a fall prevention

intervention----it is nursing protocol and the

patient cannot refuse

• Complete and document hourly rounding on all high fall risk

patients

Check out the Fall Prevention Resources website!

From the HUB home page, click on the Departments and Services

tab. Then click on the Champions / Committees link and lastly the

Fall Prevention Champions link.

Many helpful

resources

relating to fall

prevention

may be found

here under the

“Resources

and Documents”

link.

Medical Surgical Units

EBP Intervention: Purposeful

Hourly Rounding

UCH implementing on Medical Surgical Units

5 P’s of Purposeful Hourly Rounding (on all patients) (see next

slide)

Rounding helps prevent falls, improve patient satisfaction,

decrease call light frequency, decrease skin breakdown and

improve pain control

………continued

27

Purposeful Hourly Rounding, continued

5 Ps of Purposeful Hourly Rounding

• Pain: address pain scale

• Potty: ask patient if he/she needs to go to the bathroom

• Position: complete turning or ask patient if he/she is comfortable

• Personal Needs: make sure bedside table & all belongings are

within reach. Ensure call light is with patient.

• Presence: let patient know you are available & have time.

Hourly rounding is expected on every patient (per service excellence)

but documentation of safety checks/hourly rounding is based on fall

risk

Medications and Fall Risk

• It is known that certain medications and interactions between

multiple medications can increase patient fall risk.

• RN must assess patient fall risk as it relates to prescribed

medications. An RN can order a pharmacy consult for pharmacy

staff medication review at any time and is required to order one

after any patient fall.

• Partner with your physicians to discuss medications and fall

risks!

Post Fall Actions It is critical to assess any patient who falls, regardless of inpatient or

outpatient setting

• Do not move patient until it is safe.

• Take vital signs.

• Call the MD or LIP provider; ensure F/U tests ordered and completed

as indicated.

• Reassess patient frequently for changing condition.

• Inform family as soon as possible.

• Provide comfort and support to patient.

• Complete PSN

• Analyze cause of fall to prevent 2nd fall; post fall huddle with debriefing

form

• Reassess patient in 24 hours to assure there are no lingering effects

from patient fall.

Post Fall Huddle

Fall Huddle debriefing immediately after a fall or by end of the shift

• Acts as a way for teams to debrief and analyze fall

• Look at ways to prevent the fall from happening again

• Fall Huddle Debriefing Form helps ensure that all post fall

actions are completed

Fall Huddle Form

Fall Huddle/Debriefing Form Perform Huddle in Pt’s room with Pt’s input!

Unit: _______Room#______ Date/Time of fall: ________ Patient Sticker

Primary RN_______________________

Diagnosis:_________________________

Situation Staff Present for Huddle: ______________________________________________________________________

Who fell? How did it happen? __________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

Pt States: ____________________________________________________________________________________

Vital Signs/Pain Level: ________________________________________________________________________

Was the Fall Assisted by staff? Yes No Injury Level: No Harm Minor Moderate Severe

Injury Location/locations:______________________________________________________________________

***How would you prevent this fall from happening in the future?____________________________________

Fall Prevention Strategies in Place at Time of the Fall

Last Documented Fall Score: New Fall Score:

Was the Pt. scored appropriately? Yes No If no,_______________________________________________

Was the Pt. CAM/CAM ICU + per charting? Yes No Is the Pt. CAM/CAM ICU + now? Yes No

Hourly rounding completed. Yes No If no,__________________________________________________

-When was the last time staff was in the room? _________________________________________________

-When was the last time the patient was toileted?_______________________________________________

-Was the unit fully staffed with CNA’s? Yes No If no, CNA: Pt ratio: ___________________________

List ALL High Fall Risk medications the Pt. received in the last six hours:_____________________________

____________________________________________________________________________________________

Red/High Risk Interventions

(if red prior to fall) If not in place explain:

Bed/Chair Alarm ON. Yes No If no,____________________________________________

-If bed/chair alarm on was it functioning appropriately? Yes No, What type of bed? Old New

-Did alarm ring through the call bell system? Yes No

-If NO to either, contact Mechanic on Duty 8-4845 or Engineering 8-8351.

Red Socks on. Yes No If no,____________________________________________

Red Sticker on door/chart. Yes No If no,____________________________________________

Toilet with assistance. Yes No If no,____________________________________________

3rd

SR up. Yes No If no,____________________________________________

4th

SR up. Circle one: Safety/Rest Yes No If no,____________________________________________

Environmental Adjustment Yes No If no,____________________________________________

Pharmacy Consult Yes No If no,____________________________________________

Sitter Yes No If no,____________________________________________

Post Fall Task List What New Intervention(s) are in place to prevent future falls? _____________________________________

Complete PSN

MD called to see pt

Document Fall under Clinician Communication

Reassess Fall NIC, automatic 16 points

Place pt sticker on this form

Order “IP Consult to Pharmacy” in EPIC (RN to put in order).

Fax this form to Risk Management 40457

Inform Patients Family of fall within 6 hours of fall

Ensure this form is delivered to unit Fall Champion or placed in unit Fall Notebook

ON OFF HOURS (weekends and nights): page Hospital Manager (Business hours) page Unit Manager. (Form Revised 1/28/13 NH)

Post Fall Actions, continued

• If, despite all best efforts, a patient fall happens, the RN or other

provider must report the fall using the Patient Safety Net database

• Each item on the form must be filled out completely to provide

accurate information to departments managing fall data; if PT/OT

involved, include this in the narrative

• Document the fall in EPIC under Notes → New Note → Types →

Significant Event.

• Any fall resulting in serious injury or death should be called

immediately to Professional Risk Management at ext. 4-7475

(4RISK), in addition to completing the PSN report

• Transport orders, including Ticket to Ride, in

EPIC must include fall risk information

• Document Patient/Family education in EPIC

• Always use a gait belt when mobilizing

patient for the first time. Gait belt use is

encouraged with all high fall risk patients

• Document assessment and interventions

accurately

• If you believe your patient needs a sitter,

consult with the charge RN

Patients fall at UCH because:

• Inconsistency in charting/ shift report that pt. previously

fell

• Bed alarm not turned on or not plugged into call system

• Patient cognitive status changes; does not follow instructions

• Medication interactions that are not detected or known to increase

risk for falling

• Assuming patient mobility is better than reality

• Toileting, toileting, toileting! Patient may need schedule,

commode, support and presence to prevent falling

References

• Ang, E., Mordiffi, S.Z., & Wong, H.B. (2011). Evaluating the use of a

targeted multiple intervention strategy in reducing patient falls in an

acute care hospital: a randomized controlled trial. Journal of

Advanced Nursing. 67(9). P. 1984-1992.

• Tzeng, H.M. (2010). Understanding the prevalence of inpatient falls

associated with toileting in adult acute care settings. J Nurse Care

Qual. 25(1). P.22-30.

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