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Department: PATIENT SAFETY

How can policy change guide nursing practice to reduce in-patient falls?

Glogovsky, Danielle MSN, RN, CMSRN

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doi: 10.1097/01.NURSE.0000526903.22874.65
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FALLS IN THE HOSPITAL affect 700,000 to 1 million people a year.1 After people experience a fall with injury, they're at increased risk for further decline, both physically and psychologically. This not only impacts their quality of life but also increases the financial burden.2

Falls still occur despite many efforts to prevent them, including federal and state policies, action plans, and toolkits. A problem of this magnitude requires an interdisciplinary stakeholder approach. Stakeholders must have an interest in the problem, know why their role is essential, and be able to take action. Nurses are a key stakeholder for fall prevention and are accountable to their profession to improve quality metrics tied to nursing care.

To explore the gaps between advocacy, policy, and nursing practice, this article examines fall prevention interventions for older adults and areas for improvement. It seeks to answer this question: How can policy change guide nursing practice to reduce falls?

Nurses' role in preventing falls

To fully understand how to prevent falls, we need to understand why the problem persists. Falls in older adults are a complex problem with many risk factors. These include age, comorbidities, medications, and environment.3

Nurses can assess for risk and implement interventions to prevent falls. Nurses at the bedside are obligated to advocate for fall prevention and prevent other complications after admission to the hospital.

The Agency for Healthcare Research and Quality (AHRQ) has compiled research, expert opinion, and clinician input to develop fall prevention strategies for public use.4 (See Fall prevention strategies.)

Research indicates that nurses perceive that they lack the knowledge and education to implement fall prevention strategies.5 However, when nurses understand fall prevention interventions, their perception is that they are more engaged in the implementation of fall prevention strategies.6 Recommendations include initiatives that emphasize the nurse's role in improving quality outcomes and routine education on fall prevention.5,7

Policy's impact

The current healthcare climate focuses on increasing quality and decreasing costs as part of healthcare reform that was realized with the passing of the Patient Protection and Affordable Care Act (ACA) in 2010. The ACA charges government, insurers, and providers with determining how to improve healthcare and increase access to care, including preventive care, for all Americans while decreasing costs.8

Older adults accounted for 43.1 million of the U.S. population in 2012; by 2050, they're expected to number 83.7 million.9 Since 1965, the Centers for Medicare and Medicaid Services (CMS) has been providing insurance coverage for older adults, and the program has evolved over the years to cover services for additional participants, such as the disabled.10 It was instituted to provide insurance for people at risk for a lapse in coverage due to an inability to work. The government has a vested interest in decreasing costs to protect the federal budget, but it also has an obligation to make sure that cost cutting doesn't affect the quality of care.

Leading up to the passage of the ACA, multiple initiatives were underway with the specific goal of preventing falls in older adults. One of the initial calls for action came from the Falls Free National Action Plan, which was published in 2005 by the National Council on Aging (NCOA), a nonprofit focused on issues affecting older Americans.11 The attention to falls that resulted from this action plan ultimately led to the Safety of Seniors Act of 2007. One section of this law focuses on fall prevention in older adults. It supported identification of fall risk, implementation of fall prevention interventions, and fall data collection. This further shaped initiatives around fall prevention that were beginning to emerge.12

With increased national awareness of falls, CMS used its given power in 2007 to adapt the Deficit Reduction Act of 2005 to include falls in the list of conditions that wouldn't be reimbursed if they weren't present on admission to the hospital.13 This significantly affected hospitals that up until this time were billing for falls that occurred in the hospital. A fall in the hospital can add an estimated 6.3 days to the length of stay and an additional $14,000 to treat a fall-related injury.14

With the change in CMS guidelines and the burden of the cost of inpatient falls shifting to the hospitals, many hospitals attempted to put guidelines in place to decrease falls and change billing to remove conditions that weren't present on admission. However, in 2011, a federal statute mandated states to ensure hospitals were using consistent terminology to report hospital-acquired conditions (HAC) and align their nonpayment policies with CMS criteria.15 Besides the nonpayment ruling, value-based purchasing (a provision of the ACA) requires public reporting of quality data and provides incentives to hospitals based on their quality outcomes since 2013.16

Tools and plans

Aside from enacted legislation aimed at preventing falls, the NCOA issued two action plans, the first in 2010 and an update in 2015.17,18 The latter is intended to help guide fall prevention strategies over the next 10 years.

The action plan speaks to stakeholders, funding for fall prevention programs, suggestions for policies that promote fall prevention, and encouragement for measuring outcomes. This was developed to help with the Healthy People 2020 government campaign, which has the goal of decreasing ED visits by older adults who've experienced a fall by 10%.17

In an effort to translate both legislation and the action plans discussed above into clinical practice, the AHRQ published a toolkit for hospitals to implement in their fall prevention programs. This comprehensive toolkit provides a roadmap to guide users from the initial concept of fall prevention to a hardwired sustainable fall prevention program.4 (See References for a link to this toolkit.)

Another available resource is the Institute for Healthcare Improvement and The Robert Wood Johnson Foundation (RWJF) guide to prevent falls, which came about from their Transforming Care at the Bedside (TCAB) initiative. This guide is based on tested strategies that came about from inpatient units involved in the TCAB initiative. The focus of this guide is the following:

  • ensuring the correct assessment for fall risk is being completed
  • improving communication at the bedside
  • adapting the environment
  • reviewing medications associated with falls
  • gathering team members to support a fall prevention program.19

Stakeholder analysis

To move fall prevention agendas forward and integrate fall prevention strategies into nursing practice, identifying which stakeholders have an interest in the problem is essential. The AHRQ, as part of its falls toolkit, provides tips for determining the stakeholders.4 Stakeholders for fall prevention need to understand the magnitude of the problem, who will lead the proposed change, and their specific accountability for addressing the problem. They'll also need to obtain available resources.

Key stakeholders in preventing falls in older adults in the hospital include nurses, CMS, state policy makers, and older adults themselves because they're the intended beneficiaries of fall prevention initiatives. They need to be aware of the risks that falls pose to their safety and learn about interventions available to protect them. Groups that lobby for this stakeholder include AARP, NCOA, and RWJF. These lobbyists and advocates ensure that older adults are represented at every level of government as policies are developed on their behalf. This group is also represented by the U.S. Department of Health and Human Services (HHS) at the federal level. Under the HHS, the Administration for Community Living, the AHRQ, and CMS work on initiatives that benefit older adults.20

Nurses are also stakeholders in the integration of policy into practice. With over 3 million nurses in the United States, nurses make up the largest of the healthcare professions.21 The American Nurses Association (ANA) is the leading professional nursing organization. The ANA determined falls are a nursing-sensitive indicator and that outcomes are a direct result of nursing care.22 (See Looking into quality metrics.) As a result, nurses are encouraged to buy into the problem and work toward strategies to prevent falls. The ANA is involved with providing education and webinars to reduce falls. The ANA also publishes evidence-based articles about falls in its journal and lobbies federal agencies on behalf of nurses.23

As stakeholders, nurses need to be accountable for the role they play in fall prevention. This includes having an awareness of proven strategies and being proactive in implementing these strategies in their facilities. These stakeholders could be impacted financially in terms of salary and potentially limited hiring because high fall rates can affect a hospital's reimbursement and incentive pay income from CMS.

As the largest insurer of older adults, CMS is another key stakeholder. Since 2007, much of its efforts have been focused on bringing attention to the ability to prevent falls by implementing its nonpayment policy for conditions occurring after admission. CMS has influenced hospitals to improve fall prevention programs. In 2010, under section 3008 of the ACA, CMS established value-based purchasing, which pays incentives for quality outcomes. This put additional pressure on hospitals to prevent HACs.24 However, even with the federal laws supporting fall prevention, in 2013 Medicare paid an estimated 78% of the $34 million cost of treating fall-related injuries.3 CMS is active in publicly reporting laws that have been passed via their website, as well as providing links to resources such as programs, toolkits, and research articles to help prevent falls.25

Finally, state policy makers are essential for bridging the gap between policy and practice. States share responsibility for funding Medicare programs and can benefit from initiatives leading to successful fall prevention. To date, states have been involved in enacting policies, providing education, supporting research, and providing funding for fall prevention initiatives. (See What are individual states doing to prevent falls?)

To encourage valuable policy change, policy makers are promoting changes on a state level through the National Conference of State Legislatures (NCLS). This bipartisan group helps states strategize solutions for problems needing immediate attention, such as falls. It provides insight into the state's role in reducing falls. The NCLS provides links to resources for both providers and patients on its website.26

Considering policy options

The AHRQ recommends looking at process mapping to determine how to translate evidence-based practice into nursing care.4 Process mapping helps to identify potential gaps in nursing knowledge and practice that contribute to persistent inpatient falls. Some potential barriers to consider include lack of adequate fall prevention training, thorough information for nurses about fall prevention strategies, and clear assignment of responsibility regarding implementation of interventions.

For example, process mapping could be used to draft a diagram that outlines the current workflow for fall prevention. This allows users to determine if necessary elements of a process are being missed, have been duplicated, or are unnecessary.

Another tool that can be used to assist with quality improvement is DMAIC, a Six Sigma tool, that stands for Define, Measure, Analyze, Improve, and Control.27 To use the tool for the problem of falls, persistent falls must first be defined and the current falls data must then be measured and analyzed. From this information, an improvement plan can be initiated, and a control can be developed to guide sustainment plans for continued fall prevention.

The first policy option would be to mandate that nurses receive training and prove competency for fall prevention. This would provide a forum to make sure nurses are aware of their role in fall prevention and are up to date on evidence-based fall prevention strategies.

An example is a Minnesota law that requires education for providers caring for at-risk older adults (Minnesota HB 1233).26 Although currently this law applies to nonprofessionals, its benefit would be required training and competencies with regard to fall prevention. Besides the law enacted by Minnesota to assist with fall prevention, the NCOA recommends that regulatory agencies mandate that nurses complete continuing education before renewing their license and/or certification. However, this isn't standard practice to date.28

The benefits of ensuring that nurses are both educated and competent include an increase in the number of providers with specific geriatric knowledge that could improve health outcomes in this age group. Potential roadblocks include insufficient funding to provide training.

The second policy option would be to require states to have an interdisciplinary commission that reviews fall rates for the state and takes responsibility for drafting an annual report with evidence-based fall prevention strategies and disseminating the information from the report to all stakeholders. Massachusetts allocates funding for such a commission.26 The commission was designed to accomplish its initial task within two phases. Phase one examined the current state of falls in Massachusetts and phase two produced recommendations for fall prevention strategies to be used statewide. In the 2016 annual report, the commission stated that it's continuing to hold meetings, is kept up to date on current fall prevention strategies, is committed to stakeholder participation, and anticipates a report on compiled fall data within a year.29

The benefit of a state-run commission is that strategies are specific to the trends and population of that particular state. Information can be disseminated to make sure nurses statewide are aware of the latest evidence-based practices. The roadblocks to this policy option include lack of funding because states will need to align their budget to support this commission. With competing state priorities, value would need to be measured to support a fall prevention watchdog for individual states.

Although hospitals may be reluctant to report their metrics publicly, public databases such as National Database of Nursing Quality Indicators (NDNQI) are increasingly transparent.22 Further support for this policy option is the recommendation from the NCOA that the Department of Public Health provide funding for surveillance of fall trends and supply information to identified key stakeholders. This would ensure education is reaching the stakeholders and that local and state officials have the information needed to budget for fall prevention programs.28

The third policy recommendation is to require nursing schools to include fall prevention in their curricula. This was recognized by the NCOA in its toolkit to promote policy change.28 This policy benefits all new-to-practice nurses who'll enter the work force knowing about fall prevention strategies.

Recommendations to reduce falls

To integrate effective fall prevention strategies into nursing, mandating continuing education as a requirement for renewing licensure and/or geriatric-specific certifications would be a viable first approach. This recommendation recognizes the diligent work of key stakeholders to advocate for fall prevention and the realization that many clinical nurses aren't aware of these efforts. Other policy options may also be beneficial, but they would require additional costs and time to implement. Policy-mandated continuing education can help standardize nursing practices for fall prevention and bridge the gap between policy and practice, bringing awareness to current evidence-based practices.

Incorporating continuing education into policy will add costs to organizations that will supply the education, such as hospitals, and to nurses who may be required to pay for the education. Prioritizing fall prevention education as a mandate for nurses must be weighed against competing priorities, including other nursing-sensitive indicators.

Despite the possible roadblocks, the pursuit of this policy option is feasible. The NCOA provides recommendations on ways to influence policy makers to mandate continuing education. These recommendations would help to close the gap between policy and practice. They include how mandated nursing continuing education can assist with the comprehension of the quality goals of the ACA and can bring awareness of how reimbursement and value-based purchasing are tied to fall prevention.28 Although the ACA and CMS are driving quality, access, and cost nationally, nurses need to apply the knowledge from those efforts to translate policy to practice.8

Bridging the gap

Policy changes that both support fall prevention and assist with integration into nursing practice are essential to help bridge the gaps between advocacy, policy, and nursing practice.

Fall prevention strategies4

According to the AHRQ, these include the following:

  • using a fall risk assessment tool
  • improving clinician communication
  • modifying the environment
  • reviewing medications
  • using bed and chair alarms
  • applying a patient fall risk bracelet
  • providing patient education.

Looking into quality metrics22

To further define quality metrics, in 1999 the ANA included falls in its original list of nursing-sensitive indicators. Their outcomes were proven to be based on direct nursing care. The ANA was also responsible for developing the NDNQI in 1998; these evolved to the database for collecting quality data and comparing outcomes with those of other institutions.

What are individual states doing to prevent falls?26

Examples of legislation enacted as a result of policy makers include the following:

  • a Connecticut law supports professional fall education and research (Conn. Gen. Stat. §17b-33)
  • an Illinois law encourages hospitals to report falls that occurred in the inpatient setting (Ill. Rev. Stat. ch. 210 §155/20)
  • a Maine law supports research to prevent falls in older adults and education for professionals to prevent falls in this population (2005 House Bill 1214)
  • a resolution in New Jersey recognizes the third week in September as Falls Prevention Week (N.J. Assembly Joint Resolution 52, 2010).

Bonus content

Visit www.nursing2017.com for more information about preventing falls.

REFERENCES

1. Hospitals in Pursuit of Excellence. Health Research and Educational Trust. Preventing patient falls: a systematic approach from the Joint Commission Center for Transforming Healthcare project. 2016. http://www.hpoe.org/Reports-HPOE/2016/preventing-patient-falls.pdf.

2. Ang E, Mordiffi SZ, Wong HB. Evaluating the use of a targeted multiple intervention strategy in reducing patient falls in an acute care hospital: a randomized controlled trial. J Adv Nurs. 2011;67(9):1984–1992.

3. CDC. National Center for Injury Prevention and Control. Costs of fall among older adults. 2015. http://www.cdc.gov/homeandrecreationalsafety/falls/fallcost.html.

4. AHRQ. Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care. 2013. http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html.

5. Tzeng HM, Yin CY. Frequently observed risk factors for fall-related injuries and effective preventive interventions: a multihospital survey of nurses' perceptions. J Nurs Care Qual. 2013;28(2):130–138.

6. Wilson DS, Montie M, Conlon P, Reynolds M, Ripley R, Titler MG. Nurses' perceptions of implementing fall prevention interventions to mitigate patient-specific fall risk factors. West J Nurs Res. 2016;38(8):1012–1034.

7. Schreuders L, Bremner AP, Geelhoed E, Finn J. Nurse perceptions of the impact of nursing care on patient outcomes: an exploratory study. Contemp Nurse. 2012;41(2):190–197.

8. Assistant Secretary for Public Affairs, Health and Human Services. About the Affordable Care Act. 2017. http://www.hhs.gov/healthcare/facts-and-features/fact-sheets/aca-and-older-americans/index.html.

9. Ortman JM, Velkoff VA, Hogan H. An aging nation: the older population in the United States. Current population reports. U.S. Census Bureau. 2014:25–1140. https://http://www.census.gov/prod/2014pubs/p25-1140.pdf.

10. CMS. History, CMS' program history. 2015. https://http://www.cms.gov/About-CMS/Agency-Information/History/index.html?redirect=/History.

11. National Council on Aging. Falls free: promoting a national falls prevention action plan. 2005. https://http://www.ncoa.org/wp-content/uploads/FallsFree_NationalActionPlan_Final.pdf.

12. Safety of Seniors Act of 2007, Public Law 110-202, 122 STAT. 697. 2008. https://http://www.congress.gov/110/plaws/publ202/PLAW-110publ202.pdf.

13. Mattie AS, Webster BL. Centers for Medicare and Medicaid Services' “never events”: an analysis and recommendations to hospitals. Health Care Manag (Frederick). 2008;27(4):338–349.

14. The Joint Commission. Preventing falls and fall-related injuries in health care facilities. Sentinel Event Alert. 2015;(55):1–5. http://www.jointcommission.org/assets/1/18/SEA_55.pdf.

15. CMS. Medicaid program; payment adjustment for provider-preventable conditions including health care-acquired conditions. Final rule. Fed Regist. 2011;76(108):32816–32838.

16. CMS. Hospital value-based purchasing. 2015. https://http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf.

17. Cameron K, Schneider E, Childress D, Gilchrist C. National Council on Aging Falls Free National Action Plan. 2015. https://http://www.ncoa.org/wp-content/uploads/FallsActionPlan_2015-FINAL.pdf.

18. National Council on Aging. Falls Free Initiative: Advancing and Sustaining a State-Based Falls Prevention Agenda: The Role of Legislation, Policy, and Regulation. 2010. https://http://www.ncoa.org/wp-content/uploads/State-Fall-Prevention-Legislative-and-Policy-Initiatives.pdf.

19. Boushon B, Nielsen G, Quigley P, et al. How-to Guide: Reducing Patient Injuries from Falls. Cambridge, MA: Institute for Healthcare Improvement; 2012. https://http://www.ihconline.org/media/cms/HowtoGuideReducingPatientInjuriesfromFalls_copy.pdf.

20. Assistant Secretary for Public Affairs, Health and Human Services. HHS organizational chart. 2017. http://www.hhs.gov/about/agencies/orgchart/index.html.

21. AACN. Nursing fact sheet. 2011. http://www.aacnnursing.org/News-Information/Fact-Sheets/Nursing-Fact-Sheet.

22. American Sentinel University. The 3 types of nursing sensitive indicators. 2011. http://www.americansentinel.edu/blog/2011/11/02/what-are-nursing-sensitive-quality-indicators-anyway.

23. American Nurses Association. Policy and advocacy. 2017. http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy.

24. CMS. Hospital-Acquired Condition Reduction Program (HACRP). 2017. https://http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/HAC-Reduction-Program.html.

25. CMS. Resources. Injury and falls from immobility. https://partnershipforpatients.cms.gov/p4p_resources/tsp-injuriesandfallsfromimmobility/toolinjuriesandfallsfromimmobility.html.

26. National Conference of State Legislatures. Elderly falls prevention legislation and statutes. 2016. http://www.ncsl.org/research/health/elderly-falls-prevention-legislation-and-statutes.aspx.

27. iSixSigma. Six Sigma DMAIC Roadmap. https://http://www.isixsigma.com/new-to-six-sigma/dmaic/six-sigma-dmaic-roadmap.

28. Beattie BL, Schneider ES. State Policy Toolkit for Advancing Falls Prevention. Washington, DC: National Council on Aging; 2012. https://http://www.ncoa.org/wp-content/uploads/State-Policy-Toolkit-for-Advancing-Fall-Prevention.pdf.

29. Massachusetts Department of Public Health. Massachusetts Commission on Falls Prevention. 2016 Annual Report. 2016. https://mcoaonline.com/wp-content/uploads/2017/05/dph_legislative_report_-_ma_commission_on_falls_prevention_2016.pdf.

RESOURCES

CDC. National Center for Injury Prevention and Control. Risk factors for falls. 2017. https://http://www.cdc.gov/steadi/pdf/risk_factors_for_falls-a.pdf.

CDC. National Center for Injury Prevention and Control. Important facts about falls. 2017. http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html.

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