Apold, Julie MA; Quigley, Patricia A. PhD, MPH, ARNP, CRRN, FAAN, FAANP
A CONSIDERABLE body of research on falls and falls prevention in hospitals demonstrates that falling is a complex event that typically involves multiple risk factors.1,2 Therefore, an interdisciplinary and multifaceted approach to falls prevention that targets multiple risk factors is more likely than a single-measure effort to successfully reduce fall rates.3–6 Although a large body of research exists on falls prevention initiatives, there have been difficulties in successfully implementing them.2,4,7 Some of these difficulties include limited staff time to review current research, lack of time and knowledge to translate research into action, and inconsistent implementation of best practices across an organization.
By using the expertise of the Department of Veterans Affairs National Falls Collaborative and Institute for Healthcare Improvement, organizations have successfully implemented interventions to reduce falls and serious fall–related injuries at both the individual and institutional levels.8–10 Successful falls prevention programs that exist in health care settings typically display a combination of medical intervention, rehabilitation, and environmental adaptations, such as:
* assessing patients before and after a fall to identify and address risk factors and/or underlying medical conditions (eg, incontinence and mobility problems);
* implementing population-based interventions (ie, age cohorts, diagnoses and setting) to reduce falls and injuries;
* educating staff about fall and injury risk factors and prevention strategies;
* reviewing medications to reduce fall risks;
* assuring environmental safety to reduce falls and trauma (eg, installing good lighting, handrails, nonslip floor mats, bed alarms); and
* providing patients with protective padding to reduce the impact of fall-related trauma if a fall occurs.2,11–14
The Minnesota Hospital Association (MHA) has used this multifaceted approach to develop, implement, and sustain a statewide effort to reduce patient falls and injury in inpatient settings. This statewide effort, SAFE from FALLS, formally began in early 2007. In 2010, MHA used information learned from SAFE from FALLS and Minnesota's adverse event reporting system to target remaining gaps including the identification of patients at risk for injury from falls and issues related to toileting. This information was translated into the next phase of statewide efforts through SAFE from FALLS 2.0. The purposes of this article are to showcase the MHA statewide fall prevention initiative, present implementation strategies and related outcomes, and discuss challenges and lessons learned.
BURDEN OF FALLS
There are high costs involved with falls in health care settings. According to Wu et al,15 when compared with a nonfaller, a patient with 1 fall without serious injury increases estimated costs by $3500; with 2 or more falls without serious injury, those costs increase to approximately $16 500. One fall with serious injury is the most costly, estimated to be about $27 000 (adjusted to 2010 dollars).15(p752) Serious falls in Minnesota in 2010, based on these estimates, resulted in more than $2 million dollars in additional costs. In 2009, the Centers for Disease Control and Prevention projected the cost of fall injuries among people 65 years and older to reach $43.8 billion by 2020—largely because of the projected increase in the elderly population.16 Wu et al15 projected the cost to be even higher at $47 billion by 2020. Traumatic brain injuries and injuries to the hips, legs, and feet were the most common and costly fatal fall injuries and accounted for 78% of fatalities and 79% of costs.17 In addition to monetary costs, there is a burden of human suffering among patients, their families, and caregivers when falls occur.17
SITUATION IN MINNESOTA
Minnesota enacted the Adverse Health Care Events Reporting Law in 2003, requiring hospitals and ambulatory surgical centers to report to the Minnesota Department of Health when 1 of 27 (now 28) serious adverse health events occurred. Patient death associated with a fall while being cared for in a facility is a reportable event under this law. In the first Adverse Health Events public report issued by the Minnesota Department of Health in January 2005, 20 deaths were reported by Minnesota hospitals across the 27 adverse event types, with 8 of the reported deaths attributable to falls while being cared for in the hospital.18 The law was amended in 2007 to include serious disability associated with a fall. In the first year of reporting falls resulting in serious disability, 95 fall events were reported by Minnesota hospitals with 85 serious disabilities and 10 fall-related deaths.19
When facilities report adverse events to the State, detailed findings from a root-cause analysis and a corrective action plan are also required to be reported. The MHA has an agreement in place with the State that permits interested hospitals to share their event details, findings, and action plans in a de-identified manner with the MHA and other Minnesota hospitals that have agreed to share their data. In the early years of reporting in Minnesota, MHA used this detailed information to develop a number of strategies to address problem issues identified through the reported events and disseminated these findings across the state.
Minnesota's statewide approach
In April 2006, MHA hosted a conference in which hospital professionals throughout the state came together to discuss successes, barriers, models, and tools to help prevent falls. Then in August 2006, the MHA and its board decided that a more comprehensive and focused effort was needed to address important safety concerns in Minnesota hospitals with one of the key topic areas identified as falls prevention.
The SAFE from FALLS Program was funded by the MHA. Hospitals funded key staff to attend the launching conference session. The MHA provided office space and equipment, training, and travel funds for the SAFE from FALLS Program. It also developed a Web site to post resources and provide updates such as upcoming Webinars to participants. Falls experts representing urban, rural, and teaching hospitals volunteered their time to serve on a falls advisory committee. The committee continues to meet on a quarterly basis to review common gaps and develop additional tools and recommendations to assist participating hospitals in addressing identified issues.
SAFE from FALLS
In February 2007, the MHA convened the Falls Advisory Committee with experts from the VISN 8 Patient Safety Center, Veterans Healthcare Administration. Over the next 2 months, the group reviewed research literature, best practice guidelines, and key findings from reported adverse events to develop a comprehensive “road map” of best practices, SAFE from FALLS. Included in the road map are best practices for prevention of falls (the “what”) and strategies to translate these practices into actionable implementation steps (the “how”).
The first half of the SAFE from FALLS Road Map focuses on the practices participating organizations must have in place to develop an infrastructure that will support these patient care best practices. SAFE stands for the following:
S = SAFE teams (eg, interdisciplinary team, physician champion);
A = Access to information (eg, sharing data with team members, physicians, and administration);
F = Facility expectations (eg, establishing clear roles in policies and procedures); and
E = Educate staff and patients (eg, educate patients on their role and what they can expect).
The second half of the road map focuses on how to implement the patient care best practices. The key components that comprise “FALLS” include the following:
F = Fall risk screening,
A = Assessment of risk factors,
L = Linked interventions,
L = Learn from events, and
S = Safe environment.
Within each road map component are actions that the facility needs to put in place as well as specific audit questions that demonstrate whether the facility is meeting each action. The facility answers the audit questions to determine which of the practices are in place at baseline and then provides quarterly updates to track implementation progress. The goal is for the facility to have 100% of the practices in place (all practices identified in the audit questions are answered “yes, we have this in place”). A sample of the SAFE components, specific actions and audit questions are in Figure 1.
In April 2007, Minnesota hospitals were recruited to participate in SAFE from FALLS, with over 100 hospitals agreeing to participate. Each participating facility completed a self-assessment using the SAFE from FALLS Road Map best practice audit questions prior to a 1-day intense learning session for the hospitals. During the session, hospitals learned about the results of the hospital baseline surveys and up-to-date evidence on clinical and organizational practices to reduce falls and fall-related injuries in hospitals; they also set hospital-specific goals for improvement.
Because the overarching aim of the program was to diffuse the falls prevention innovation, the sites received ongoing support throughout the project including conference calls, e-mails, a listserv, and progress reports. The conference calls also were an opportunity for hospitals to share best practices, tests of change, and coach and mentor each other. A comprehensive yet targeted toolkit was developed to support the implementation of each of the road map implementation components. The toolkit included tools from national sources such as the Veterans Affairs National Falls Toolkit as well as sample tools shared by participating hospitals and resources developed by the expert advisory group.
Measuring infrastructure and outcomes
The MHA developed an electronic survey and reporting system for hospitals to use for this program. This reporting system has remained in operation since 2007. Lead staff from participating hospitals use the online system to complete the SAFE from FALLS audit questions and gauge their progress. At baseline, the facility indicates whether they have each practice in place by selecting yes or no. At the end of the audit, the program indicates the practices that are not in place, asks about barriers to implementation, and leads the hospitals to identify actions they will take during the upcoming quarter to address the identified issues. Each quarter, the hospitals update the audit survey to gauge their progress, identify gaps, and plan their actions for the next quarter. Participating hospitals also report their falls rate and falls with injury rates, and a statewide average is calculated. A report is available to each participant showing their progress over time with a comparison to the statewide benchmarks. Reports also are provided to hospital leaders to show visible progress toward goals individually and collectively.
In addition to the SAFE from FALLS audit data, information learned from the root-cause analyses and action plans reported by hospitals experiencing falls resulting in death or serious disability in their facility is analyzed through qualitative and quantitative methods to identify new trends and key areas that need to be addressed. This iterative cycle of learning from events that occur in individual hospitals and incorporating findings into the best practices for all hospitals is vital to informing the work of the falls advisory group in providing ongoing education and resources.
Data collected through the Web based data collection system for SAFE from FALLS and reported adverse events have demonstrated improvement in processes (implementation of the SAFE from FALLS Road Map best practices) and outcomes (reported falls resulting in death or serious injury). Currently, 121 Minnesota hospitals are participating in the statewide program and have experienced a 38% improvement in implementation of best practices on average across hospitals. At baseline, May 2007, 2 hospitals reported having more than 90% of the recommended best practices in place. As of December 2011, 103 of the 121 participating hospitals reported more than 90% implementation of the practices recommended through the SAFE from FALLS Program. (Figure 2).
In addition to improvement in overall implementation of fall prevention best practices, significant improvements were reported in key areas that had low levels of implementation and awareness at the start of the program. At baseline, only 18% of participating hospitals had a process in place to conduct a postfall huddle following a fall in their hospitals, and 26% had a process to provide at-risk patients and their families discharge instructions about fall prevention strategies at home. Improvements have been seen in implementation of these and other key falls prevention practices, based on higher average scores for 2011 compared with 2007.
Following the initial year of SAFE from FALLS implementation, 2007–2008, an annual adverse health event report published by the Minnesota Department of Health in January 2009 showed 20% fewer falls resulting in serious injury and no fall-related deaths were reported.19 In the most recent report published by the Minnesota Department of Health in January 2012, 71 inpatient falls with an outcome of serious injury or death were reported—a 25% decrease since the 2009 baseline (Figure 3).
Early qualitative analysis of fall deaths reported to the State identified an issue related to postfall neurological management of patients experiencing a fall. Collaborative work by hospitals across the state focused on identification and implementation of best practices related to postfall patient monitoring and early interventions if appropriate. Ongoing analysis of reported falls indicates that a significant factor in the reduction of fall-related deaths appears to be improved postfall monitoring of patients who hit their head on falling (or it was unknown if they had hit their head). This is evidenced by a marked reduction in the number of reported events involving subdural hematomas. In earlier fall-related death reports, a common scenario reported was that a patient hit (or may have hit) his or her head on falling, the patient began to deteriorate, and a computed tomographic scan was performed; however, it was too late in the process and the patient expired from complications related to a subdural hematoma. Currently, 95% of participating hospitals report they have a systematic and enhanced approach to conducting neurological checks in these types of situations, compared with 60% of the hospitals at baseline.
Eliminating serious injuries
In late 2010, the Falls Advisory Committee recommended enhancing the SAFE from FALLS Program to reflect new knowledge related to preventing injury from falls and toileting-related falls and expanding falls prevention beyond the inpatient setting. A revised road map, SAFE from FALLS 2.0, was developed and work began in May 2011. Hospital baseline audit data for SAFE from FALLS 2.0 indicated that participating hospitals had 76% of the best practices outlined in the road map in place.
Examples of key areas with less than 50% of hospitals reporting they have these best practices in place include the following:
* the falls prevention program includes additional screening beyond the fall risk screening tool to determine an individual patient's risk for fall-related injury, and
* for patients assessed as high risk for falls, the facility has the following intervention options in place: (1) review by a physician and/or pharmacist of high fall risk medications and timing of medication administration, (2) a plan to reduce the use of sedative hypnotics for sleep, and (3) structured criteria for identifying patients who should have staff remain “within arm's reach” of them when toileting.
These identified gaps are providing rich opportunities for focused collaborative work during this next phase of the statewide fall prevention program.
Over the past 5 years, the MHA has learned a number of lessons related to large-scale implementation of patient safety best practices on the basis of feedback from participants and implementation successes. Key lessons learned include the following:
* Quality over quantity. There are a number of best practice recommendations and resources available on key patient safety topics; however, health care organizations often do not have the resources available to inventory and evaluate the vast amount of available information to determine best practices and key resources for their individual programs. SAFE from FALLS participants have reported that one of the keys to success has been the collaborative work to analyze available information and provide all hospitals with a common set of key strategies that need to be implemented to have an effective program. Participants also report that it is essential to present a targeted set of tools that can be used for implementation rather than a large number of tools and resource links.
* Minimize burden; maximize implementation time. One of the goals of the SAFE from FALLS program has been to minimize burden and maximize time available for implementation of best practices. Strategies to achieve this goal included selecting one process measure (the SAFE from FALLS Road Map audit questions) and an outcome measure that was already being reported (mandatory reporting of falls resulting in death or serious disability) and creating tools and resources in a format that participants could use with minimal adaptation needed.
* Collaboration and persistence. When the SAFE from FALLS Program began, the common “collaborative model” was to work with approximately 12 facilities over a 12- to 18-month period. SAFE from FALLS participants have reported that 2 key strengths of the program have been (1) the ability to collaborate with colleagues from across the state to learn from each other and create a “community standard” of best practices that help sustain the best practices across organizations, and (2) ongoing learning from implementation efforts and events that occur and using that information to develop solutions.
The robustness of any prevention program is reflected in the views of those who implement it. Although their views are more intangible and anecdotal than those provided by the hard numbers of outcome evaluation, they are nonetheless compelling in assessing how a project's goals are being achieved. The MHA SAFE from FALLS Program has been perceived as helpful by the site teams. In a survey conducted by the Minnesota Department of Health in November 2011, more than 90% of respondents reported that the MHA programs, as described earlier, were useful with more than 71% reporting these efforts were a “very useful” resource.18
Transportability to other community and cultural contexts
The number of visits to the electronic version of the SAFE from FALLS resources is tracked at the MHA. The Safe from Falls Road Map and related tools have been accessed thousands of times in a variety of settings and countries by individuals, institutions, and agencies focused on falls preventions.
FUTURE DIRECTIONS AND CONCLUSIONS
The risk of falling and sustaining injury increases with the increasing fall and injury risk factors.2,20 Therefore, organizational and clinical interventions must interface to create safe environments, expand multidisciplinary resources and infrastructure, and develop expert clinical practices that estimate patients' risks of falling and guide prevention and protection efforts.4 Given the aging of our patients, it is important for nurses to disseminate and build on the preventive work presented in this article. Effective fall prevention programs are sensitive to nursing leadership and clinical expertise. Implementing effective falls prevention programs at a local level is a major challenge due to the complex relationships among individual, organizational, and cultural factors of the target populations' changing and diverse needs. Hospital associations, administrators, clinicians, patient safety officers, and researchers are continually reassessing and building on their work. Falls and fall-related injuries are a significant cause of morbidity and mortality among seniors that call for user-friendly and flexible interventions such as the MHA SAFE from FALLS Program.