Dod Fall Reduction Tools

Department of Defense Department of Defense Patient Safety CenterPatient Safety Center

Patient Fall Reduction ToolsPatient Fall Reduction Tools

DoD Patient Safety CenterDoD Patient Safety CenterArmed Forces Institute of PathologyArmed Forces Institute of Pathology

Why DoD Fall Reduction ToolsWhy DoD Fall Reduction Tools

•• Our commitment to making our MTFs as safe as Our commitment to making our MTFs as safe as possible by reducing patient fallspossible by reducing patient falls

•• Our MTFs have asked for tools that promote Our MTFs have asked for tools that promote standardization while allowing flexibility in their usestandardization while allowing flexibility in their use

•• Our need to save valuable MTF resourcesOur need to save valuable MTF resources

The challengeThe challenge

•• Patient Falls Patient Falls -- #1 harm event reported to DoD Patient #1 harm event reported to DoD Patient Safety CenterSafety Center

•• Falls are #1 cause of accidental deaths (CDC National Falls are #1 cause of accidental deaths (CDC National Vital Statistics, (Sept 2003 report)Vital Statistics, (Sept 2003 report)

•• Death from falls accounted for over 10% of all accidental deathsDeath from falls accounted for over 10% of all accidental deaths•• Accidents 5Accidents 5thth leading cause of death in the U.S.leading cause of death in the U.S.

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

•• Assess and periodically reassess each patient's risk for fallingAssess and periodically reassess each patient's risk for falling, , including the potential risk associated with the patient's medicincluding the potential risk associated with the patient's medication ation regimenregimen

•• Take action to address any identified risksTake action to address any identified risks

Where we lookedWhere we looked

•• Literature (Researched 60+ articles)Literature (Researched 60+ articles)•• Most studies in geriatric and long term care populationsMost studies in geriatric and long term care populations•• Limited outcomes research in acute healthcare settings Limited outcomes research in acute healthcare settings

(hospitals and ambulatory care)(hospitals and ambulatory care)

•• Web sites (Good resources exist)Web sites (Good resources exist)• VA Nat’l Center for Patient Safety 2004 Falls Toolkit: Falls

Notebook((http://www.va.gov/ncps/SafetyTopics/fallstoolkit/index.htmlhttp://www.va.gov/ncps/SafetyTopics/fallstoolkit/index.html))

•• Premier Fall prevention Premier Fall prevention ((http://www.premierinc.com/all/safety/resources/falls/ http://www.premierinc.com/all/safety/resources/falls/ ))

•• CDC CDC –– Health Topic: Fall Related Injuries Health Topic: Fall Related Injuries ((http://www.cdc.gov/doc.do/id/0900f3ec80277b9chttp://www.cdc.gov/doc.do/id/0900f3ec80277b9c))

•• Registered Nurses Association of Ontario Registered Nurses Association of Ontario -- Prevention of Falls Prevention of Falls and Injuries in the Older Adult (and Injuries in the Older Adult (http://www.rnao.orghttp://www.rnao.org) )

•• Surveys/site visits Surveys/site visits –– 11 military and civilian facilities11 military and civilian facilities

What we foundWhat we found

Policy and Procedure VariationsPolicy and Procedure Variations•• Risk factors considered (~50% use Morse scale)Risk factors considered (~50% use Morse scale)•• Family teaching provided Family teaching provided •• Staff education/training conductedStaff education/training conducted•• Communication e.g., fall status covered during Communication e.g., fall status covered during

change of shift change of shift •• Availability and use of technologyAvailability and use of technology•• Multidisciplinary (or lack thereof) approach to fallsMultidisciplinary (or lack thereof) approach to falls

•• Delineated responsibilitiesDelineated responsibilities

What we didWhat we did

•• Picked the best each had to offerPicked the best each had to offer•• Elicited and incorporated Service and MTF feedback Elicited and incorporated Service and MTF feedback

on draft toolkiton draft toolkit•• Provided toolkit that allows individual MTF choice as Provided toolkit that allows individual MTF choice as

to execution while encouraging standardization to execution while encouraging standardization

These are DoD patient fall reduction tools These are DoD patient fall reduction tools NOT DoD standards NOT DoD standards

Fall reduction tool kit addressesFall reduction tool kit addresses

•• Assessment and periodic reassessmentAssessment and periodic reassessment

•• Identify risks associated with medical regimenIdentify risks associated with medical regimen

•• Develop actions to address identified risksDevelop actions to address identified risks

Validated Fall Assessment Tools

Morse Fall Scale Hendrich Fall Scale

77% 78%

72% 83%

96% 98%

Sensitivity

Specificity

Inter-rater reliability

Risk Factors includeRisk Factors include

•• AgeAge•• Fall historyFall history•• MobilityMobility•• EliminationElimination•• Mental status changesMental status changes•• Medications (e.g., psychotropics, anticonvulsants, Medications (e.g., psychotropics, anticonvulsants,

diuretics/carthartics, opiates/narcotics, diuretics/carthartics, opiates/narcotics, antihypertensives)antihypertensives)

•• Patient care equipment (e.g. IV, chest tube, indwelling Patient care equipment (e.g. IV, chest tube, indwelling catheter)catheter)

•• Diagnoses (e.g. stroke, Parkinson’s, Alzheimer’s) Diagnoses (e.g. stroke, Parkinson’s, Alzheimer’s)

What’s in the tool kit?What’s in the tool kit?

•• Model Patient Fall Policy (may be tailored to MTF needs)Model Patient Fall Policy (may be tailored to MTF needs)•• MultidisciplinaryMultidisciplinary•• Role specificRole specific•• Simple definitionsSimple definitions•• Fall reduction/prevention guidelines by risk categoryFall reduction/prevention guidelines by risk category

•• Proposed standing ordersProposed standing orders•• Patient and family/carePatient and family/care--provider teachingprovider teaching•• Measuring success Measuring success –– guidance on collecting fall data for guidance on collecting fall data for

use in quality improvementuse in quality improvement

Examples of data related improvementsExamples of data related improvements

•• Changing routine diuretic administration to 6am/6pm to Changing routine diuretic administration to 6am/6pm to minimize nocturesisminimize nocturesis

•• Changing clinical guidelines for treating alcoholics to Changing clinical guidelines for treating alcoholics to minimize DT related fallsminimize DT related falls

•• Changing priority status for offChanging priority status for off--unit procedures for high unit procedures for high fall risk patientsfall risk patients

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

•• Bed alarms/personal alarms/chair alarmsBed alarms/personal alarms/chair alarms•• Special flooringSpecial flooring•• Special beds/low bedsSpecial beds/low beds•• Cushions/wedgesCushions/wedges•• Nurse call systemsNurse call systems•• Video camera surveillance Video camera surveillance •• Hip protectorsHip protectors

Other resourcesOther resources

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

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

Facilities SurveyedFacilities Surveyed

•• Walter Reed Army Medical CenterWalter Reed Army Medical Center•• Wilford Hall USAF Medical CenterWilford Hall USAF Medical Center•• National Naval Medical Center BethesdaNational Naval Medical Center Bethesda•• Naval Medical Center San DiegoNaval Medical Center San Diego•• Tripler Army Medical CenterTripler Army Medical Center•• 5252ndnd Medical Group, Spangdahlem ABMedical Group, Spangdahlem AB•• Wright Patterson USAF Medical CenterWright Patterson USAF Medical Center•• Dewitt Health Care NetworkDewitt Health Care Network•• Howard University HospitalHoward University Hospital•• Johns Hopkins HospitalJohns Hopkins Hospital•• Veterans Administration (D.C.)Veterans Administration (D.C.)

Additional SlidesAdditional Slides

PurposePurpose

●● Develop/Improve Fall Reduction ProgramDevelop/Improve Fall Reduction Program

●● Develop/Revise Fall Policy Develop/Revise Fall Policy

● Utilize Fall Assessment Tools● Utilize Fall Assessment Tools

● Take action on identified fall risks● Take action on identified fall risks

● Satisfy the JCAHO NPSG #9 requirements● Satisfy the JCAHO NPSG #9 requirements

ObjectiveObjective

•• Identify patients at riskIdentify patients at risk•• Provide a safe environmentProvide a safe environment•• Identify interventions to prevent or manage fallsIdentify interventions to prevent or manage falls•• Educate patients, staff and family on fall risk and Educate patients, staff and family on fall risk and

preventionprevention•• Communicate and document fall assessment Communicate and document fall assessment •• Perform a post fall assessment Perform a post fall assessment •• Identify actions that will minimize or eliminate Identify actions that will minimize or eliminate

the reoccurrence of fallsthe reoccurrence of falls

ActionsActions

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

•• Multidisciplinary involvementMultidisciplinary involvement•• General responsibilitiesGeneral responsibilities•• Education (staff/patient/family)Education (staff/patient/family)•• Simple definitionsSimple definitions

Suggested Inclusions in PolicySuggested Inclusions in Policy

•• Risk Factors Risk Factors •• Family teaching Family teaching •• Staff education/trainingStaff education/training•• Communication Communication –– during change of shift, during change of shift,

specific to fall status/precautionsspecific to fall status/precautions•• Use of technologyUse of technology•• Multidisciplinary approach to fallsMultidisciplinary approach to falls•• Delineated responsibilities Delineated responsibilities •• Medication ReviewMedication Review

ActionsActions

•• Assess all patients, identifying those that are at Assess all patients, identifying those that are at risk for fallsrisk for falls

•• Implement fall reduction strategiesImplement fall reduction strategies•• Educate patients, families and healthcare Educate patients, families and healthcare

providers on fall prevention and managementproviders on fall prevention and management•• Reassess patients when their status changes or Reassess patients when their status changes or

upon transferupon transfer•• Document and report fall events Document and report fall events •• Address identified fall risksAddress identified fall risks

ActionsActionsPatient Care ManagementPatient Care Management

•• Perform Fall Assessment using a reliable fall scale (e.g. Perform Fall Assessment using a reliable fall scale (e.g. Morse or Hendrich)Morse or Hendrich)

•• Identify and alert the patient, healthcare providers and Identify and alert the patient, healthcare providers and family/surrogates to any fall risks related to the family/surrogates to any fall risks related to the medication regimemedication regime

•• Assess and identify any potential fall hazards within the Assess and identify any potential fall hazards within the patient’s environment patient’s environment

•• Orient patient to surroundings and ensure that both the Orient patient to surroundings and ensure that both the patient and family/surrogates are educated on fall patient and family/surrogates are educated on fall reduction reduction

Assessment ToolsAssessment Tools

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

Nonvalidated Fall Assessment ToolsNonvalidated Fall Assessment Tools•• FacilityFacility--specific fall assessment toolspecific fall assessment tool•• VA (modified Morse), Johns Hopkins, and other VA (modified Morse), Johns Hopkins, and other

fall risk assessment tools (see DoD Patient fall risk assessment tools (see DoD Patient Safety web site)Safety web site)

If you develop your own tool, Perrell (2002)If you develop your own tool, Perrell (2002)recommends selection or creation of tools to aidrecommends selection or creation of tools to aidnurses in the assessment of falls that are:nurses in the assessment of falls that are:•• straightforward straightforward •• easy to use easy to use •• quick to usequick to use•• have levels of interventions appropriate for the have levels of interventions appropriate for the

particular patient care settingparticular patient care setting•• focus on better application of the existing toolfocus on better application of the existing tool

Morse Fall ScaleMorse Fall Scale©©

(Adapted with permission, SAGE Publications) (Adapted with permission, SAGE Publications) Available at: http://www.premierinc.com/all/safety/resources/falAvailable at: http://www.premierinc.com/all/safety/resources/fallsls

015

6. Mental statusOriented to own abilityForgets limitations

01020

5. Gait/TransferringNormal/ bed rest /immobileWeakImpaired

No 0Yes 204. IV/Heparin Lock

01530

3. Ambulatory aidBed rest/nurse assistCrutches/cane/walkerFurniture

No 0Yes 152. Secondary diagnosis

No 0Yes 251. History of falling; immediate or within 3 months

ScoringScaleItem

0No

3YesPoor Judgment (if not confused)

0No

2YesPoor Mobility/Generalized Weakness

0No

3YesDizziness/Vertigo

0No

4YesDepression

0No

3YesConfusion/Disorientation

0No

3YesAltered Elimination (incontinence, nocturia, frequency)

0No

7YesRecent History of Falls

ScoreScaleRisk Factor

Hendrich Fall Risk Assessment