Department of Defense Patient Safety Center

Patient Fall Reduction Tools
DoD Patient Safety Center Armed Forces Institute of Pathology

Why DoD Fall Reduction Tools

Our commitment to making our MTFs as safe as possible by reducing patient falls Our MTFs have asked for tools that promote standardization while allowing flexibility in their use Our need to save valuable MTF resources

The challenge

Patient Falls - #1 harm event reported to DoD Patient Safety Center Falls are #1 cause of accidental deaths (CDC National Vital Statistics, (Sept 2003 report)
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Death from falls accounted for over 10% of all accidental deaths Accidents 5th leading cause of death in the U.S.

JCAHO 2005 National Patient Safety Goal #9 – Reduce the risk of patient harm resulting from falls

Assess and periodically reassess each patient's risk for falling, including the potential risk associated with the patient's medication regimen Take action to address any identified risks

Where we looked

Literature (Researched 60+ articles)
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Most studies in geriatric and long term care populations Limited outcomes research in acute healthcare settings (hospitals and ambulatory care) VA Nat’l Center for Patient Safety 2004 Falls Toolkit: Falls Notebook (http://www.va.gov/ncps/SafetyTopics/fallstoolkit/index.html) Premier Fall prevention (http://www.premierinc.com/all/safety/resources/falls/ ) CDC – Health Topic: Fall Related Injuries (http://www.cdc.gov/doc.do/id/0900f3ec80277b9c) Registered Nurses Association of Ontario - Prevention of Falls and Injuries in the Older Adult (http://www.rnao.org)

Web sites (Good resources exist)

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Surveys/site visits – 11 military and civilian facilities

What we found
Policy and Procedure Variations • Risk factors considered (~50% use Morse scale) • Family teaching provided • Staff education/training conducted • Communication e.g., fall status covered during change of shift • Availability and use of technology • Multidisciplinary (or lack thereof) approach to falls

Delineated responsibilities

What we did
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Picked the best each had to offer Elicited and incorporated Service and MTF feedback on draft toolkit Provided toolkit that allows individual MTF choice as to execution while encouraging standardization

These are DoD patient fall reduction tools NOT DoD standards

Fall reduction tool kit addresses

Assessment and periodic reassessment Identify risks associated with medical regimen Develop actions to address identified risks

Validated Fall Assessment Tools
Morse Fall Scale Hendrich Fall Scale

Sensitivity Specificity

77% 72%

78% 83% 98%

Inter-rater reliability 96%

Risk Factors include
• • • • • •

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Age Fall history Mobility Elimination Mental status changes Medications (e.g., psychotropics, anticonvulsants, diuretics/carthartics, opiates/narcotics, antihypertensives) Patient care equipment (e.g. IV, chest tube, indwelling catheter) Diagnoses (e.g. stroke, Parkinson’s, Alzheimer’s)

What’s in the tool kit?

Model Patient Fall Policy (may be tailored to MTF needs)
• • • •

Multidisciplinary Role specific Simple definitions Fall reduction/prevention guidelines by risk category

• • •

Proposed standing orders Patient and family/care-provider teaching Measuring success – guidance on collecting fall data for use in quality improvement

Examples of data related improvements

Changing routine diuretic administration to 6am/6pm to minimize nocturesis Changing clinical guidelines for treating alcoholics to minimize DT related falls Changing priority status for off-unit procedures for high fall risk patients

A few words on fall reduction and injury prevention technology
• • • • • • •

Bed alarms/personal alarms/chair alarms Special flooring Special beds/low beds Cushions/wedges Nurse call systems Video camera surveillance

Hip protectors

Other resources
DoD Patient Safety Program (http://dodpatientsafety.usuhs.mil)
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DoD Patient fall reduction tool kit Sample MTF policies Other tools from the field

Coming to the Patient Safety website
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Ambulatory patient fall reduction tools (Mar/Apr 2005) Pediatric fall reduction tools (Mar/Apr 2005) Discussion group (May/Jun 2005)

Facilities Surveyed
• • • • • • • • • • •

Walter Reed Army Medical Center Wilford Hall USAF Medical Center National Naval Medical Center Bethesda Naval Medical Center San Diego Tripler Army Medical Center 52nd Medical Group, Spangdahlem AB Wright Patterson USAF Medical Center Dewitt Health Care Network Howard University Hospital Johns Hopkins Hospital Veterans Administration (D.C.)

Additional Slides

Purpose
● Develop/Improve Fall Reduction Program
● Develop/Revise Fall Policy

● Utilize Fall Assessment Tools ● Take action on identified fall risks ● Satisfy the JCAHO NPSG #9 requirements

Objective
Identify patients at risk Provide a safe environment Identify interventions to prevent or manage falls Educate patients, staff and family on fall risk and prevention • Communicate and document fall assessment • Perform a post fall assessment • Identify actions that will minimize or eliminate the reoccurrence of falls
• • • •

Actions
Review present policy, or develop a policy, to include:
• • • •

Multidisciplinary involvement General responsibilities Education (staff/patient/family) Simple definitions

Suggested Inclusions in Policy
• • • • • • • • Risk Factors Family teaching Staff education/training Communication – during change of shift, specific to fall status/precautions Use of technology Multidisciplinary approach to falls Delineated responsibilities Medication Review

Actions
• Assess all patients, identifying those that are at risk for falls • Implement fall reduction strategies • Educate patients, families and healthcare providers on fall prevention and management • Reassess patients when their status changes or upon transfer • Document and report fall events • Address identified fall risks

Actions
Patient Care Management
• Perform Fall Assessment using a reliable fall scale (e.g. Morse or Hendrich) • Identify and alert the patient, healthcare providers and family/surrogates to any fall risks related to the medication regime • Assess and identify any potential fall hazards within the patient’s environment • Orient patient to surroundings and ensure that both the patient and family/surrogates are educated on fall reduction

Assessment Tools
Validated Fall Assessment Tools
• Morse/Modified Morse Fall Scale • Hendrich Fall Risk Assessment Scale

Nonvalidated Fall Assessment Tools
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Facility-specific fall assessment tool VA (modified Morse), Johns Hopkins, and other fall risk assessment tools (see DoD Patient Safety web site)

If you develop your own tool, Perrell (2002) recommends selection or creation of tools to aid nurses in the assessment of falls that are: • straightforward • easy to use • quick to use • have levels of interventions appropriate for the particular patient care setting • focus on better application of the existing tool

Morse Fall Scale©
(Adapted with permission, SAGE Publications) Available at: http://www.premierinc.com/all/safety/resources/falls

Item
1. History of falling; immediate or within 3 months 2. Secondary diagnosis 3. Ambulatory aid Bed rest/nurse assist Crutches/cane/walker Furniture

Scale
No Yes No Yes 0 25 0 15

Scoring

0 15 30

4. IV/Heparin Lock 5. Gait/Transferring Normal/ bed rest /immobile Weak Impaired 6. Mental status Oriented to own ability Forgets limitations

No Yes

0 20 0 10 20

0 15

Hendrich Fall Risk Assessment
Risk Factor Recent History of Falls Scale Yes No Altered Elimination (incontinence, nocturia, frequency) Yes No Confusion/Disorientation Yes No Depression Yes No Dizziness/Vertigo Yes No Poor Mobility/Generalized Weakness Yes No Poor Judgment (if not confused) Yes No Score 7 0 3 0 3 0 4 0 3 0 2 0 3 0

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