Best Practices in Reducing Falls and Fall Related InjuryPractic… · Best Practices in Reducing Falls and Fall Related Injury e-mail: [email protected] ... Hourly Patient Rounds

nicheprogram.org • 2015 Annual NICHE Conference • Innovation Through Leadership 1

Featuring:

Pat Quigley, PhD, MPH, ARNP,

CRRN, FAAN, FAANP

Associate Director, VISN 8 Patient

Safety Center

Associate Chief for Nursing

Service/Research

Best Practices in Reducing Falls and Fall Related Injury

e-mail: [email protected]

Overview

Illustrate relationship of Complementary

Perspectives of Evidence-based Practice

Differentiate use of scientific hierarchy and evidence

rating scales

Apply rating scales to clinical practice examples

Detail results of synthesized literature reviews for fall

and injury prevention

Translate actionable elements of a Fall Prevention

Program

Segment high-vulnerable populations to protect from

fall related injury

Integration of Complementary Perspectives

Evidence-based Practice

Innovation Diffusion

Knowledge Transfer Knowledge Outcome


Three Perspectives

Evidence-based Practice (Sackett) “…the conscientious use of current best evidence in making decisions about the care of individual patients or the delivery of health services.”

Innovation Diffusion (Rogers) “The process of communicating new ideas through certain channels over time among members of a social system.”

Knowledge Transfer (Dixon) “Sharing of common knowledge, that is the knowledge that employees learn from doing the organization’s tasks.”

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 Technology Transfer

Implement evidence-

based practice

Is evidence strong

enough to warrant

practice change?

Grading Systems

Apply use of scientific

hierarchy and evidence

rating scales.

6


Types of Research: Evidence Hierarchies (Quality of

Evidence)

Agency for Healthcare Research and Quality (AHRQ)

Level I Meta-Analysis (Combination of data from

many studies)

Level II Experimental Designs (Randomized Control

Trials)

Level III Well designed Quasi Experimental Designs

(Not randomized or no control group)

Level IV Well designed Non-Experimental Designs

(Descriptive-can include qualitative)

Level V Case reports/clinical expertise 7

Strength of Evidence: Suggestions for Practice

(www.uspreventiveservicestaskforce.org/uspstf/grades.htm)

United States Preventive Services Task Force

(USPSTF) Grading

A Strongly recommended; Good evidence

B Recommended; At least fair evidence

C No recommendation; Balance of benefits

and harms too close to justify a

recommendation

D Recommend against; Fair evidence is

ineffective or harm outweighs the benefit

I Insufficient evidence; Evidence is lacking or

of poor quality, benefit and harms cannot be

determined 8

Role of RCTs

Parachute use to prevent death and

major trauma related to gravitational

challenge: systematic review of

randomised controlled trials

Gordon C S Smith, Jill P Pell

BMJ 2003;327


Would You or Not?

Who Dies if They Fall?

Very young and very old

BEST PRACTICES: LEVEL OF EVIDENCE

Where are we?


Making Health Care Safer II 2013

Co-Principal Investigators: – Paul G. Shekelle, M.D., Ph.D., RAND Corporation

Evidence-based Practice Center

– Robert M. Wachter, M.D., University of California, San

Francisco

– Peter J. Pronovost, M.D., Ph.D., Johns Hopkins University

Since 2001 report, a vast amount of new

information on PSPs has emerged; more

agreement is now evident on what

constitutes evidence of effectiveness and the

importance of implementation and context.

Obj: To review important patient safety practices for evidence of effectiveness, implementation, and adoption.

Results: From an initial list of over 100 patient

safety practices, the stakeholders identified 41

practices as a priority for this review: 18 in-

depth reviews and 23 brief reviews. Of these,

20 PSPs had their strength of evidence of

effectiveness rated as at least “moderate”

26 PSPs had at least “moderate” evidence of

how to implement them

Evidence Reviews: Rating

Evidence of Effectiveness (low, moderate,

high; benefits outweigh harm)

Evidence of on potential for harmful

unintended consequences (high, moderate,

low, negligble)

Estimate of costs (low, moderate High)

Implementation issues: How Much Do We

Know? How Hard Is It to Implement?


Results con’t:

10 practices were classified by the

stakeholders as having sufficient evidence of

effectiveness and implementation and should

be “strongly encouraged” for adoption

An additional 12 practices were classified as

those that should be “encouraged” for

adoption. This includes Multicomponent

interventions to reduce falls

Chapter 19: Preventing In-Facility Falls

Cochrane Reviews and Oliver, et al, 2006

(updated 2010) Systematic Literature

Reviews – Isomi M. Miake-Lye, B.A.; Susanne Hempel, Ph.D.; David

A. Ganz, M.D., Ph.D.; Paul G. Shekelle, M.D., Ph.D.

17 Multifactorial Trials between 1999-2009

were reviewed.

Supplemented by 3 more recent large

scale studies

Ambulatory Care

AGS, BGS Clinical Practice Guidelines 2010:in

Assessment

Interventions

Evidence Grades

Bibliography

www.americangeriatrics.org/health_care_profession

als/clinical_practice/clinical_guidelines_recommenda

tions/2010

http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2010




AGS Guidelines 2010

Assessment

Interventions:

Must Reads

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.

Hospital Falls: we know…. (D. Oliver, et al. Falls and fall-related injuries in hospitals. (2010, Nov). Clinics in Geriatric Medicine.

30% to 51% of falls result with some injury

80% - 90% are unwitnessed

50%-70% occur from bed, bedside chair (suboptimal 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


Most effective, fall prevention interventions should be targeted at both point of care and strategic levels

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)

Limits to Science

Failure to Differentiate Type of Fall – Accidental – Anticipated Physiological – Unanticipated Physiological (Morse 1997)

– Intentional Falls

Failure to Link Assessment with Intervention

What are we doing? Why?

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


Morse Fall Scale (Morse, 1997, Preventing Patient Falls

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

April 22, 2008 Fall Risk Assessment Template 26

Prevention + Protection

Prevention:

The act of preventing, forstalling, or hindering

Plus Protection

Shield from exposure, injury or destruction

(death)

Mitigate or make less severe the exposure,

injury or destruction


Interventions

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

Protecting Patients

from Harm -

Our Moral Imperative

Protect from Injury

Moderate to Serious Injury

Those that limit function, independence,

survival

Age

Bones (fractures)

Bleeds (hemorrhagic injury); or C

(antiCoagulation)

Surgery (post operative)


Universal Injury Prevention

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)

Age: > 85 years old

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

Bones

Hip Protectors

Height Adjustable Beds (low when resting only, raise up bed for transfer)

Floor Mats

Evaluation of Osteoporosis


AntiCoagulation/Bleeds

Evaluate Use of Anticoagulation: Risk for

DVT/Embolic Stroke or Fall-related

Hemorrhage

Patient Education

TBI and Anticoagulation: Helmets

Wheelchair Users: Anti-tippers

Surgical Patients

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 Safety Huddles

Post Fall Analysis

– What was different this time?

– When

– How

– Why

– Prevention: Protective Action Steps to Redesign

the Plan of Care


Accident Theory

Outcomes of Post Fall Huddles

Specify Root Cause (proximal cause)

Specify Type of Fall

Identify actions to prevent reoccurrence

Changed Planned of Care

Patient (family) involved in learning about the fall occurrence

Prevent Repeat Fall

Reduce Repeat Fall Rate


Autonomy

What does this mean to you?

What choices do you have?

What are the consequences of your choices?

What choice do you think you will you make?

What happens after a fall?

40

Post Fall Huddle Resources

VA: Falls Toolkit

Post Fall Huddles

www.patientsafety.va.gov

AHRQ Falls Toolkit 2013

Tools

Post Fall Huddle Process

Decision Tree

Post Fall Huddle Form

Determine Preventability

Case Study Exercises

http://www.patientsafety.va.gov/


Biomechanics of

Fall-Related Injuries

Understanding the

“rate of splat” and its

impact on injury

Falls from High Bed: Head First

Falls from High Bed: Foot First


Falls from Low Bed: Foot First

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


Technology Resource Guide: Bedside Floor Mats

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.

Safehip

HipGuard

KPH

CuraMedica

Hip Protectors – Examples

HIPS

Hip Protector Toolkit

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

http://www.hiprotector.com/safehipw.html

http://www.hiprotector.com/hipguard.html

http://www.hiprotector.com/safehipm.html

http://www.hiprotector.com/kphw.html

http://www.hiprotector.com/curamedica.html

http://www.hiprotector.com/kphm.html

http://www.hiprotector.com/wkit.html

http://www.hiprotector.com/mkit.html


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

Emerging Technology and Aging

Remote Patient Monitoring

– Mobility and Wandering – Location Tracking

– Fall Detection

Real-time Surveillance

– Wireless

– Camera Systems

Ambulatory Aides

– Laser Light

Wheelchair-Related Falls

Current Fall-Risk Assessment tools not effective

Features of Wheelchairs contribute to risk

Most common site of injury is NOT hip, but rather fractures of extremities

Head injury/mortality

W/c safety and Dementia


Pat And Her Mom

Getting ready to dance

I Fall A lot! Why?

Best Practices in Reducing Falls and Fall Related InjuryPractic… · Best Practices in Reducing Falls and Fall Related Injury e-mail: [email protected] ... Hourly Patient Rounds

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