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Pat Quigley, PhD, MPH, ARNP,
CRRN, FAAN, FAANP
Associate Director, VISN 8 Patient Safety Center
Associate Chief for Nursing Service/Research
e-Mail: [email protected]
1. Differentiate Prevention vs. Protection
2. State of Science related to patient falls
3. Consider a bundled approach to redesigncare
4. Innovations to reduce serious fall-relatedinjuries
Transform healthcare for frailty associated with old age.
Prevent falls identified as an effective strategy.
BUT, major area for improvement in routine practice. ◦ 2003: IOM: Priority areas for
national action: transforming health care quality
Multifaceted and individualized fall prevention programs used inside and outside hospital setting.
Thorough review of the strategies revealed they lack strong empirical evidence. ◦ Clyburn, T.A., & Heydemann,
J.A. (2011). Fall prevention in the elderly: Analysis and comprehensive review of methods used in the hospital and the home. J. of Am. Academy of Orthopedic Surgeons. 19(7): 402-409.
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Prevention
The act of preventing, forestalling, or hindering
Plus Protection
Shield from exposure, injury or destruction (death)
Mitigate or make less severe the exposure, injury or destruction
Clinical trial
to test
interventions
No
Yes
Review Research, Clinical and Laboratory Information
Does
evidence support
clinical trials?
No Yes
Equipment design or redesign with evaluation
Equipment
design or
redesign
Epidemiological study to
identify modifiable risk
factors for adverse events
or descriptive studies to
understand process and
outcomes
OR Is equipment
ready for
Market?
Yes
Implement evidence-
based practice
Technology Transfer
Is evidence strong
enough to warrant
practice change?
Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomized controlled trials
Gordon C S Smith, Jill P Pell
BMJ 2003;327
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AGS, BGS Clinical Practice Guidelines 2010: Prevention of falls in older adults.
Assessment
Interventions
Evidence Grades
Bibliography
www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2010
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Assessment
Interventions
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Clinics in Geriatric Medicine, Nov. 2010. • D. Oliver, et al. Falls and fall-related injuries in hospitals.
(2010, Nov). Clinics in Geriatric Medicine. 645-692 • Becker, C., & Rapp, K. (2010). Falls prevention in Nursing Homes.
Clinics in Geriatric Medicine. 693-704. Clinical Nursing Research, An International Journal. 21(1) Feb.
2012: Special Issue: Falls in the Older Adult. • Spoelstra, S. L., Given, B.A., & Given, C.W. (2012). Fall
prevention in hospitals: An integrative review. Clinical Nursing Research. 21(1). 92-112)
Clyburn, T.A., & Heydemann, J.A. (2011). Fall prevention in the elderly: Analysis and comprehensive review of methods used in the hospital and the home. J. of Am. Academy of Orthopedic Surgeons. 19(7): 402-409.
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30% to 51% of falls result with some injury
80% - 90% are unwitnessed
50%-70% occur from bed, bedside chair (suboptimal or transferring between the two; whereas in mental health units, falls occur while walking
Risk Factors: Recent fall, muscle weakness, behavioral disturbance, agitation, confusion, urinary incontinence and frequency; prescription of “culprit drugs”; postural hypotension or syncope
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Best Practice Approach in Hospitals: ◦ Implementation of safer environment of care for the
whole patient cohort (flooring, lighting, observation, threats to mobilizing, signposting, personal aids and possessions, furniture, footwear
◦ Identification of specific modifiable fall risk factors
◦ Implementation of interventions targeting those risk factors so as to prevent falls
◦ Interventions to reduce risk of injury to those people who do fall
(Oliver, et al., 2010, p. 685)
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Failure to Differentiate Type of Fall ◦ Accidental ◦ Anticipated Physiological ◦ Unanticipated Physiological (Morse 1997)
Failure to Link Assessment with Intervention
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30% to 51% of falls result with some injury 80% - 90% are unwitnessed 50%-70% occur from bed, bedside chair
(suboptimal chair height), or transferring between the two; whereas in mental health units, falls occur while walking
Risk Factors: Recent fall, muscle weakness, behavioral disturbance, agitation, confusion, urinary incontinence and frequency; prescription of “culprit drugs”; postural hypotension or syncope
Implementation of safer environment of care for the whole patient cohort (flooring, lighting, observation, threats to mobilizing, signposting, personal aids and possessions, furniture, footwear
Identification of specific modifiable fall risk factors
Implementation of interventions targeting those risk factors so as to prevent falls
Interventions to reduce risk of injury to those people who do fall (Oliver, et al., 2010, p. 685)
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Until Organizations Know Types of Falls occurring, they cannot know the effectiveness of your program.
Types of falls are: ◦ Accidental ◦ Anticipated Physiological ◦ Unanticipated Physiological (Morse , J. 1997. Preventing patient falls. Sage publication.)
◦ Intentional Falls Failure to Link Assessment with Intervention
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Morse Fall Scale
Risk Factor Scale Score
History of Falls Yes 25
No 0
Secondary Diagnosis Yes 15
No 0
Ambulatory Aid Furniture 30
Crutches / Cane / 15
None / Bed Rest / Wheel Chair /
Nurse
0
IV / Heparin Lock Yes 20
No 0
Gait / Transferring Impaired 20
Weak 10
/ Bed Rest / Immobile 0
Mental Status Forgets Limitations 15
Oriented to Own Ability 0
History of Falls ◦ Screen: yes or no
◦ Assessment: based on positive or negative screen response
Assessment must be comprehensive
Required for rest of nursing process
April 22, 2008 Fall Risk Assessment Template 21
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The 85 y/o who says No to a history of recent falls?
The patient who gets admitted because of a fall?
The patient who falls in our care?
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Reducing the risk of falling can positively affect residents’ quality of life to a considerable extent
Mean Fall rate 1.7 falls per person-year (range 0.6-3.6), considerably higher than community-based fall rate (mean 0.65; range, 0.3-1.6)
In a facility with 100 beds, a fall can be expected about qod.
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More than three-fourths of all falls occur in rooms or bathrooms of residents
Sit-to-stand or stand-to-sit transfers were associated w/ higher percentage of falls (42%) than walking (35%)
Nearly 25% of falls required MD or hospitalization
Falls in LTC result in more serious complications: 10-25% resulting in fractures or lacerations; most serious – hip fractures
Other injuries (fx pelvis, UE, Spine or skull) result in considerable suffering
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Risk factors: All are high risk (unless immobile or in coma)
Well-established risk factors: ◦ muscular weakness, balance and gait deficits, poor vision,
delirium, cognitive and functional impairment, orthostatic hypotension, urinary urge incontinence, and nocturia.
◦ Comorbidities (dementia, depression, stroke, PD) may lead to attention deficits, executive dysfunction, or visual field loss – result in higher propensity to fall.
◦ Side effects and interactions of drugs
Risk of fractures lowest in residents with the most limited physical function
Risk for fracture greatest in the immediate period after admission (1 mo)
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Risk Screening vs. Assessment ◦ Over reliance on screening tools
Differential Diagnosis Individualized Care Planning Identify fallers from non-fallers Identify those with injury hx or at risk for injury Protecting Patients Implementing: ◦ Bed Alarms ◦ Sitters ◦ Intentional / Purposeful Rounding
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In nursing homes, focus on modifiable individual and institutional risk factors
Assessment performed within 1st days of admission and after a fall
(Becker & Rapp) Best Practice Approach in Hospitals (applies to LTC): ◦ Implementation of safer environment of care for the whole patient
cohort (flooring, lighting, observation, threats to mobilizing, signposting, personal aids and possessions, furniture, footwear
◦ Identification of specific modifiable fall risk factors ◦ Implementation of interventions targeting those risk factors so as
to prevent falls ◦ Interventions to reduce risk of injury to those people who do fall (Oliver, et al., 2010, p. 685)
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Screening ◦ Disease Detection
◦ Who should undergo diagnostic testing for confirmation- Cut off point to be negative or positive
Assessment ◦ Data for differential Diagnosis
Failure to Differentiate Type of Fall ◦ Accidental ◦ Anticipated Physiological ◦ Unanticipated Physiological (Morse 1997)
◦ Intentional Falls
Failure to Link Assessment with Intervention
1. Basic preventive and universal falls precautions for all patients
2. Assessment of all patients for risk of falling and sustaining injuries from a fall in the hospital
3. Cultural infrastructure
4. Hospital protocols for those identified at risk of falling
5. Enhanced communication of risk of injury from a fall
6. Customized interventions for those identified at risk of injury from a fall
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Moderate to High Risk –most Vulnerable Fallers
◦ Interventions that combine
Prevention
Detection
Protection
Assessment ◦ Universal Fall Precautions ◦ Care planning
Arm bands
Signage for high risk for injury
Other ◦ Report/Assignment sheets/Handoffs ◦ Intentional Rounds every hour ◦ Environmental Rounds ◦ Video Monitoring ◦ Mattresses-beveled edges
Alarms ◦ Chairs
oPull cord alarms
oVoice activated alarms
oOne arm seat belt alarms
oSensor mats- light weight ◦ Bed
oPull cord alarms
oMattress sensor mats
oLight weight
oBuilt in bed alarms
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o Bathrooms
• Call system attachment
• Toilet seat alarm
• Clips on Emergency Cords?
o Floor/Door Alarms • Floor Mat alarms
• Cordless Motion Detecting Beams over bed
• Passive Infrared Alarms on beds
• Pull cord alarm to doors
o Wander Detection Devices
o Placement
o Wrist/ankle
o Wheelchair
Video Monitoring
Ambulatory ◦ Wander detection devices/Monitors
Partially Ambulatory ◦ Bed/Chair Alarms/Monitors
Non Ambulatory/Bed rest ◦ Bed Alarms/Monitors
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Floor mats-size?
◦ Length
◦ Thickness
◦ Beveled edges
◦ Non-slip/Hygienic
◦ Night time glow strip
Special Flooring
Helmets- Hard or Soft
◦ Reusable
◦ Available for PRN use
Hip protectors
◦ Soft pads and hard shell
◦ External or Undergarments
◦ Sweat pants and shorts
Beds / Wheelchairs Chairs / Toilet
o Low Beds
o Wheel chair
o Size/features
o Brake extensions
o Anti -tippers
o Front and Back
o Auto Brakes?
◦ Chairs/cushions’
Right height
Right cushion
Anti slip materials
Seat lifts
◦ Toilet Seat elevation/lifts
◦ Swing Away/Up Grab bars
Educates patients / families / staff ◦ Remember 60% of falls happen at home, 30% in the
community, and 10% as inpts. ◦ Take opportunity to teach
Remove sources of potential laceration ◦ Sharp edges (furniture)
Reduce potential trauma impact ◦ Use protective barriers (hip protectors, floor mats)
Use multifactorial approach: COMBINE Interventions
Hourly Patient Rounds (comfort, safety, pain)
Examine Environment (safe exit side)
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Education: Teach Back Strategies Assistive Devices within reach Hip Protectors Floor Mats Height Adjustable Beds (low when resting
only, raise up bed for transfer) Safe Exit Side Medication Review
Hip Protectors
Low Beds
Floor Mats
Evaluation of Osteoporosis
Evaluate Use of Anticoagulation: Risk for DVT/Embolic Stroke or Fall-related Hemorrhage
Patient Education
TBI and Anticoagulation: Helmets
Wheelchair Users: Anti-tippers
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Pre-op Education: ◦ Call, Don’t Fall
◦ Call Lights
Post-op Education
Pain Medication: ◦ Offer elimination prior to pain medication
Increase Frequency of Rounds
Post Fall Analysis ◦ What was different this time?
◦ When
◦ How
◦ Why
◦ Prevention: Protective Action Steps to Redesign the Plan of Care
Understanding the “rate of splat” and its
impact on injury
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NOA Floor Mat
CARE Pad
bedside fall cushion Posey Floor Cushion
Soft Fall bedside mat Tri-fold bedside mat
Roll-on bedside mat
Bedside Mats – Fall Cushions
Feet First Fall from Bed
• No Floor Mat fall over top of bedrails: ~40% chance of severe head injury
• No Floor Mat, low bed (No Bedrails): ~25% chance of severe head injury
• Low bed with a Floor Mat: ~ 1% chance of severe head injury
Summary of Results
Bedside floor mats protect patients from injuries associated with bed-related falls.
Targeted for VA providers, this web-based guidebook will include: searchable inventory, evaluation of selected features, and cost.
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Safehip
HipGuard
KPH
CuraMedica
Hip Protectors – Examples
HIPS
This web-based toolkit will include: prescribing guidelines standardized CPRS orders selection of brands and models sizing guidelines protocol for replacement policy template laundering procedure stocking procedure monitoring tools patient education materials provider education materials
AirPro Alarm Bed & Chair Alarm Chair Sentry
Economy Pad
Alarm Floor Mat
Monitor Keep Safe
Assistive technology for safe mobility-Bed &
Chair Monitors
QualCare Alarm Safe-T Mate
Alarmed Seatbelt
Locator Alarm