Clancy, Carolyn M. MD
PREVENTING FALLS in the hospital is a high-priority patient safety and quality improvement goal for health care organizations. The reasons are unambiguous: each year, between 700 000 and 1 million people experience a fall in US hospitals.1 Between one-third and one-half of inpatient falls are estimated to result in some injury, with 1% to 3% resulting in a fracture.2 Even when falls result in no physical harm to the patient, they can have other negative effects. Older patients who fall without incurring injury can become more afraid of falling and begin to limit their activities. This fear, in turn, can inhibit patients' willingness to participate in activities to regain strength and independence.
Since 2008, the Centers for Medicare & Medicaid Services no longer pays hospitals for the additional costs of treating patients who die or become disabled as a result of a fall.3 Accordingly, health care organizations have raised staff awareness about fall prevention and put numerous programs and interventions into place that identify patients at risk and attempt to reduce the occurrence of falls.
MULTIPLE FACTORS, MULTIPLE CHALLENGES
Nurses are assigned the most responsibility to identify patients at risk for falls and to carry out fall prevention programs in their units. To a certain degree, this is logical—nurses' 24/7 interaction with patients gives them a unique awareness of and insight into patients' risk for falls. Nurses also understand how factors such as medication side effects, poor eyesight, impaired mobility or strength, confusion or dementia, and frequent toileting needs can put patients at a greater fall risk.
Nursing staff or nurse managers typically use tools that translate risk factors into a simple score that attempts to predict which patients are at high or low risk for falls. While these risk scores are helpful in boosting organizations' efforts to assess fall risks among patients, systematic reviews suggest that even the best validated fall risk scores have relatively low sensitivity and specificity and even weaker positive predictive value.4
These are not merely interesting statistical conundrums. Translated into the hectic world of nursing care for vulnerable patients, low sensitivity and specificity of the risk scores can give false reassurance that patients are being properly identified and overlook opportunities for fall prevention efforts. A weak positive predictive value suggests that fall prevention programs are spread too thinly, possibly created when many patients are scored as belonging to a one-size-fits-all, high-risk category.5
Although further research is needed on the effectiveness of targeted fall prevention programs, it is clear that nurses will always play a major role in their implementation. Yet, given the multiple and varied needs of patients who are at risk for falls, the involvement of physicians, nursing assistants, physical and occupational therapists, pharmacists, housekeeping, and management is also needed. To get the maximum impact from fall prevention programs, organizations should consider interdisciplinary, systems-like approaches that draw from a wide range of expertise and permit flexibility for each patient's specific risk profiles.
Recognizing this challenge and the scarcity of literature on implementation, the Agency for Healthcare Research and Quality has developed a new evidence-based toolkit that helps clinicians negotiate the change process at their organization.6 It was created by a team with expertise both in fall prevention and in organizational change, including staff from the RAND Corporation, ECRI Institute, and Boston University.
The Web-based toolkit focuses on falls that occur within the hospital, drawing on a systematic review of the literature and expert opinion about best practices in fall prevention. Designed to be a flexible resource for hospitals regardless of their level of expertise, the toolkit can be adapted to meet organizations' different needs, staffing patterns, and specific quality improvement objectives. An expert panel, along with the authors' expertise, provided input on key aspects of care and implementation strategies. To test this expertise in the real world, 6 hospitals tested the toolkit as part of the project and their feedback influenced the final version.
The toolkit's core document is an implementation guide that is organized under 6 major questions to be addressed by the staff (referred to as the implementation team) who will put new practices into place. Intended to gauge an organization's ability to improve fall prevention on a sustained basis, the questions ask:
* Are you ready for this change?
* How will you manage change?
* Which fall prevention practices do you want to use?
* How do you implement the fall prevention program in your organization?
* How do you measure fall rates and fall prevention practices?
* How do you sustain an effective fall prevention program?
Each major question is organized by a series of more detailed questions to guide the implementation team through the improvement process. For example, under question 4 (How do you implement the fall prevention program in your organization?), the toolkit encourages teams to:
* Define which roles and responsibilities staff will have in preventing falls.
* Identify which fall prevention practices go beyond the unit.
* Determine how to put the new practices into operation.
Tools, checklists, worksheets, and links to resources are included in each section and provide additional context and amplification of key concepts. For instance, a tool is included that shows how specific individuals or groups can be assigned to each task. Among other responsibilities, nurses would conduct and supervise assessment of fall risk factors on admission, daily, and if the patient's condition deteriorates; certified nurse assistants would need to ensure the environment around the bed is free of clutter; and physical or occupational therapists would determine need for assistive devices and exercise programs and educate the patient and family about safety with transfers and ambulation.
A section is also included on sustaining practice changes. It acknowledges a major, if not always acknowledged, truth about quality improvement, which is the difficulty of ensuring that changes become woven into the day-to-day fabric of operations. The guide offers questions, examples, and resources that can help organizations anticipate and address barriers to maintaining improvements in their fall prevention program.
Attaining significant improvements in safety and quality across an organization is not a linear process. Consequently, the guide authors acknowledge that certain sections may not be as relevant to hospitals that have already embarked on fall prevention programs. On average, the authors suggest that organizations need about a year to develop, incorporate, and consolidate new fall prevention practices.
As the body of evidence on fall prevention increases, it is useful to identify both the interventions that reduce risks and those that do not. A study published in 2012 and funded by the National Institute on Aging found that increasing the use of bed alarm systems to prevent falls had no clinically significant effect on the number of patients who fell, the rate of injurious falls, or the use of physical restraints. The randomized trial was conducted at 16 nursing units in an urban community hospital and conducted at 16 medical, surgical, and specialty units.7
While technology clearly has an important role to play in patient safety and quality improvement, it cannot on its own foster a culture of safety across an organization. Instead, safety improvements are inspired by learning environments that promote teamwork, communication, respect for a range of expertise, and sustainability of effort.
Similar to health care–acquired infections, patient falls were once thought of as an inevitable, if not unfortunate, consequence of a hospital stay. Evidence has shown these claims to be false. Nurses, who have long championed the cause of reducing fall risks, are an invaluable asset in implementing this systems approach to fall prevention in hospitals.
1. Estimate from Currie LM. Fall and injury prevention. In: Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No 08-0043.
2. Schwendimann R, Buhler H, De Geest S, et al. Falls and consequent injuries in hospitalized patients: effects of an interdisciplinary falls prevention program. BMC Health Serv Res. 2006;6:69.
4. Haines TP, Hill K, Walsh W, Osborn R. Design-related bias in hospital fall risk screening tool predictive accuracy evaluations: systematic review and meta-analysis. J Gerontol A Biol Sci Med Sci. 2007;62:664–672. http://www.ncbi.nlm.nih.gov/pubmed/17595425
. Accessed March 21, 2013.
7. Schorr RI, Chandler AM, Mion LC, et al. Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients: a cluster randomized trial. Ann Intern Med. 2012;157(10):692–699. http://annals.org/article.aspx?articleID=1392191
. Accessed March 21, 2013.