Amy L. Hester PhD(c), BSN, RNC

Dees M. Davis BSN, RNC

� Material resources and travel support for work presented herein was provided by Posey Company. No off label use of their products is presented.

� Amy Hester has financial interest in and is the CEO of HD Nursing, LLC which provides fall and injury management solutions to various organizations.

� Dees Davis has financial interest in and is the COO of HD Nursing, LLC which provides fall and injury management solutions to various organizations.

� All studies described in this presentation were approved by an Institutional Review Board.

� Describe methods for calculating the financial burden of falls on your organization.

� Describe the process of falls and injury management in the hospital setting.

� Describe evidence based strategies for both falls and injury management.

� Falls are the most commonly reported adverse event in hospitals.

� Inpatient fall rates range from 1.4 to 18.2 falls per 1000 patient days.

� A fall without injury costs roughly $3,500

� Injurious falls account for 6 to 44 percent of falls occurring in the hospital

� Approximately 11,000 fatal falls occur in US hospitals annually.

� Falls with injury cost roughly $27,000

� The most serious injuries related to falls in ANY setting are fractures and head injuries.

� It is because these injuries more often result in institutionalization, disability and death than soft tissue or other internal injuries.

� Falls Cost Calculator: www.hdnursing.com

� Our cost savings analysis after 1 year of implementing the HDS fall program:

$1.27 million dollars

� Raw numbers of falls without injury

� Raw numbers of falls with injury

� Falls matter- A LOT!

� The are harmful to patients, your organization, the healthcare system and society.

� Improving fall and injury rates is a win for everyone and the benefits to you as a provider are numerous.

� Is much about common sense.

� But there is science behind falls and injury management.

� The more you understand the science, the more you can improve your own organization’s performance.

� Falls are considered a nurse-sensitive outcome.

� Hospital use two metrics for measuring fall prevention performance: fall rates and injurious fall rates.

� Both are normalized to patient days so they can be benchmarked.

� Normalizing metrics has become increasingly relevant since 2008 when CMS declared injuries resulting from falls in the hospital setting were considered HACs and ceased reimbursement for care rendered as a result of a fall.

� This approach is part of a larger incentive program commonly referred to as “pay for performance” or Value Based Purchasing (VBP).

� VBP is considered a key vehicle in motivating accountability of both physicians and hospitals to improve patient safety and patient outcomes.

� Not unique to CMS, there are over 100 VBP programs underway by various health plans and employer groups which affect an estimated 50 million beneficiaries.

� CMS and other VBP-based providers use reported metrics to compare how hospitals perform against one another on key quality metrics like falls, pressure ulcers, and other HACs. Hospitals that perform poorly in their peer group are reimbursed at a lower rate than hospitals that outperform them .

� National benchmarking is required for Magnet certified hospitals as these organizations have to demonstrate benchmarking on the broadest level possible.

� Benchmarking nationally usually requires licensure through a third party that collects and compares metrics from various organizations and can be an expensive investment.

� Anticipated Physiologic

� Unanticipated Physiologic

� Accidental

� Behavioral

� Developmental

TJC and CMS mandate:

� Risk Assessment

� Must have a fall prevention program (care plan)

� Must have a post fall plan

� Risk Assessment

� Care Planning (including material resources)

� Event Reporting

� Benchmarking

� Started with single interventions to improve our fall rates.

� We found success in fall using alarms but patients were still going on to fall.

� Our risk assessment tool did not identify the right patients that needed fall prevention.

� Are the anchor of your program.

� Are only designed to predict anticipated physiologic falls.

� Are setting specific.

� Require licensure from developer(s).

� Are typically used by nursing in the hospital setting.

� If your fall risk assessment tool is not identifying the correct patients at risk, you are not intervening on the patients that need your care.

� If your fall risk assessment tool is over identifying patients at risk to fall you are intervening on patients that do not need that care.

� Cut ScoresCut ScoresCut ScoresCut Scores---- The recommended score at which a patient is considered to be at risk for falls

� Inter Rater Reliability (IRR)Inter Rater Reliability (IRR)Inter Rater Reliability (IRR)Inter Rater Reliability (IRR)---- The percent of agreement in scoring the risk assessment tool among different caregivers for the same patient

� AUCAUCAUCAUC---- Area Under the CurveArea Under the CurveArea Under the CurveArea Under the Curve---- Statistic that describes the predictive ability of an instrument where .5 is no ability and 1 is a perfect tool

� SensitivitySensitivitySensitivitySensitivity- Percent of fallers who were correctly predicted to be fallers by the tool.

� SpecificitySpecificitySpecificitySpecificity- Percent of non fallers who were correctly predicted to be non fallers by the tool

� Treatment Paradox and Specificity

MORSE3

CONLEY1

HENDRICH II2

HDS5

SCHMID4

Initial Paper Validation 1987 1999 2003 2010 1990

Revalidated in EMR no no no yes no

Optimum cut score 45 2 5 10

Inter Rater Reliability .68-.86 .8 1 .9 .88

AUC 0.62 n.d. n.d. 0.78 n.d.

Sensitivity 73% 71% 75% 91% paper

90% EMR

95%

Specificity 75% 59% 74% 47% paper

65% EMR

66%

Assessment frequency Admission

Each Shift

Change in

condition

Admission Admission

Each Shift

Admission

Each Shift

Change in

condition

n.d.

Table 5. Psychometric Statistics of Commonly Used Adult Outpatient Fall Risk Assessment Tools a

Scale Name

Berg Balance

Test

Elderly Fall

Screening Test

Dynamic Gait Index

Timed Get Up and Go

Tinetti Performance

Oriented Mobility

Sample size

nd

361

133

30

79

Optimum cut score

49 3 19 14 10

IRR

.95 nd nd .98 .9

Sensitivity 77% 93% 85% 87% 80%

Specificity 86% 78% 38% 87% 74%

Abbreviation: nd, no data; IRR, Inter Rater Reliability a Data from Vassallo, Vignaraja, Sharma, Briggs, Allen 31

Tool Developed By Description Citation Validated Setting Outcomes IRR Sensitivity Specificity

General Risk Assessment for

Pediatric Inpatient Falls (Graf-PIF)

Children's Memorial Hospital

Chicago, IL

LOS

No IV/Heparin Lock

PT/OT

Antiepileptic Medications

Ortho/Muscular/Skeletal Diagnosis

Score > 2 indicates high risk

Elaine Graf, 2005 Yes inpatient 84% 75% 76%

CHAMPSSt. Francis Hospital

Tulsa OK

C = Changes in mental status or dizziness

H = History of previous falls at home or in the hospital

A = Age < 3 years old

M = Mobility problems in walking or moving

P = Parental or primary care giver involvement in care

S = Safety actions in place

Copeland, 2007

In pilot

testing

phase

84%

Humpty Dumpty

Miami Children's Hospital

Miami, FL Score > 12 indicates high riskHill-Rodrigues et al.,

2009

Inpatient

Outpatient

28% reduction in

falls

CummingsPhoenix Children's Hospital

Phoenix, AZ

History of Falls

Physical Alterations/Impairments

Functional Status

Equipment

Cognitive/Psychological

Medications that Alter Equilibrium

Score > 8 indicates high risk

Roni Cummings InpatientAdmission 83%

Time of Fall 87%

Admission 50%

Discharge

Children's National Medical Center Washington, DC

Triggers:<24 hours post-op

Visual impairment

Weakness

Motor Sensory Deficits

Medications

Developmental Age

Focus on high risk-infant to preschool age

CNMC, 2005 Inpatient

IM SAFEDenver Children's Hospital

Denver, CO

Assessment done on every patient despite clinical

presentation

Neiman at el.,2011 Inpatient

Preimplimentatio

n fall rate = .67

falls/1000 pt.

days

Postimplimentati

on fall rate .51

falls/1000 pt.days

Heidi Fields, MSN, RN, CPNP St. Louis Children’s Hospital

� Edmonson Psychiatric Fall Risk Assessment Tool (EPFRAT)◦ Sensitivity 63% (Compared to Morse at 49%)

◦ Specificity 86% (Compared to Morse at 85%)

◦ No other reliability or validity metrics reported

� IRRIRRIRRIRR- Case Studies◦ Scenario presented to multiple staff where the staff is asked to assess fall risk based on the scenario. You will have a predetermined value of what they should score. The percent of agreement is your inter rater reliability (seen as a kappa level (κ) in the literature)

◦ For Hendrich II users, the following resource is available: http://www.nursingcenter.com/prodev/ce_article.asp?tid=751712

Ms. Tonya Jones is 48 years old admitted to the hospital with diagnosis of nausea

and vomiting. She is allergic to penicillin. Her only significant medical history is

that she is a newly diagnosed diabetic. She wears glasses and ambulates without the

use of furniture. During your initial assessment and completion of the admission

database, the patient tells you she tripped over an old rug at home a couple of months

ago but says she has always been a little clumsy. She tells you she doesn’t have

issues with walking except she doesn’t feel well enough to get up on her own right

now. Upon assessing the patient’s mobility status, you determine she currently

requires the assistance of one person for safe ambulation.

She is alert and oriented times 3 and follows commands cooperatively.

She has a foley catheter and she has accuchecks ordered. She has not had anything

by mouth for the last 48 hours. Her IV rate is currently 150cc per hour.

VS are BP 80/49, HR120, RR18, Temp98.7, Pox97%. Blood sugar is 253.

Abnormal labs from the most recent lab draw include a potassium of 3.0.

� Check the IRR of your fall risk assessment tool. It should be no less than 80% agreement between clinicians.

� Look at your fall events. Evaluate how many were assessed as being at risk when they fell. If less than 80% of your fallers were identified as being at risk prior to the fall either your staff are not using the tool appropriately or the tool is not working for you.

Questions?

� The purpose of care planning is to mitigate the factors causing risk to fall thereby preventing the fall.

� Should be modifiable based on patient needs.

� Can be approached based on level of risk, individual factors or both. This can depend on what information your risk assessment tool provides.

� Is not Universal Fall Precautions:◦ Call light/ belongings in reach, bed in low position and locked, wheelchairs and chairs locked, use non-slip footwear, SR up X2, adequate lighting, clutter free room, educate on level of risk, educate to call for assistance.

� Should include interventions for both fall and injury management.◦ How do you know when your patient is at risk for injury? ABCS- Age Bones Coagulants Surgery

◦ Although not a scientific approach, and coagulants and surgery are not supported by the literature as being associated with injurious falls, using this acronym is a helpful approach to injury management.

� Behavioral Health◦ Different environments that have to meet distinctive regulatory requirements

� ICU◦ Assessing risk in sedated and comatose patients

◦ Universal High Risk Precautions

� Pediatrics◦ Dealing with attention spans

◦ Parental engagement

� Pediatrics- establish caregiver (family) ability to set appropriate behavior

� Should inform patient and family not just of the risk to fall but why and also about fall protocols and goals related to care (strokes and fractures)

� Family need reinforcement, too� When documenting family education, it is helpful to document which family were educated

� Are they: Reliable? Fatigued? Able? Willing?

� Up to 15% of 30 day readmissions are due to falls after discharge.

� Care planning should continue throughout transitions to care and can be supported via:◦ Handoff communication (including family)

◦ Maintenance of visual cues- socks, bands, blankets

◦ Patient education

� All patients and families should be educated on risk for falling.

� This universal teaching can be done in many ways:◦ Admission brochures

◦ Patient video channels

◦ In room posters

� Individualized education should occur based on what factors are creating the patient’s risk to fall.

� Education should be provided using teach back methodology or motivational interviewing.

� A form of counseling found to be effective in changing behaviors

� Elicit-Provide-Elicit- a motivational interviewing (MI) technique for educating pts

� The platform of EPE is to inform the patient using knowledge the patient already has about the topic using open-ended questions

� From Jennifer Woodard at Indiana University Health

� 1.ELICIT the patient’s knowledge of their own risk for falling while in the hospital. Use an open-ended question.

� 2. PROVIDE the patient the information-building from step 1.

� 3. ELICIT another open-ended question to gain the patient’s perception or understanding of the information provided.

� 1.Elicit: “What do you already know about your risk for falling in the hospital?”

� 2.Provide: Fill in the gaps based on response in step 1. Correct misconceptions of patient specific risk factors, explain meaning of identifiers, alarms, communicate risk factors specifically to the patient that provides the likelihood of a fall in the hospital

� 3.Elicit: “What does this mean to you?” or “What more would you like to know about remaining free from a fall while staying in the hospital?”

� Make sure:◦ Staff have clear expectations for what education to provide and where to document it.◦ Forms are easily available to staff.◦ You have forms available in all applicable languages.◦ You have family education forms separate from patient education forms.◦ Your staff are providing the education on admission and reinforcing during patient and family encounters. ◦ The readability is appropriate for your patients.

� Care plan documentation should reflect individualization

� Side rail use� Education and re education, material handouts and archival of those documents

� Family presence� When and what material resources are in use� Compliance (ADHERANCE) with instructions� Noncompliance (NONADHERANCE)

� Hip Protectors- briefs and pants

� Helmets

� Floor Matting- bevel vs. non beveled

� Lap Belts

� Chair Wedges

� Footwear-single vs. double sided

� Arm Bands

� Door Signage

� Blankets

� Bed Alarms

� Enclosure beds

Standard room Not so standard room…

We merged the Sitter Select with Vocera

� Look at the current plans of care in your organization: are they up to date? Evidence based?

� How are you approaching fall prevention: level of risk, individual factors, both?

� Does your documentation reflect the care provided?

� Do you have technologies that you could integrate/ interface?

� Do you have decision support built into your plans of care so that staff are very clear as to when to implement and withdraw the use of material resources?◦ If not, the use of these resources is variable, unreliable and results in equipment sitting on the shelf.

Questions?

� The primary purpose of event reporting is to learn from experience as having a greater understanding of falls and their causes is essential to developing more effective prevention methods.

� Falls are reported through both internal and external variance reporting systems.

� If falls are not reported externally, no external benchmarking can occur.

� Internal reporting is useful for keeping staff aware of hazards and is important for monitoring one’s progress in efforts to reduce fall events.

� External reporting allows sharing of event knowledge so that others can avoid the same issues in care .

� Not only should fall events be reported for tracking purposes, they should be reported between and among clinicians caring for the patient.

� Having a history of falls is a significant predictor of future falls and has been shown by several studies to be associated with injurious falls in particular.

� Clinician knowledge of previous falls is therefore of great relevance for both assessing fall risk and for care planning.

� Lack of time

� Fear of punishment

� Lack of perceived benefit

� Studies have shown that nursing staff fail to report falls as much as 39% of the time. 15

� Care must be taken to ensure that all staff feels comfortable in reporting events and they do not fear retribution either because the event occurred or because they reported it.

� If organizations use event reporting punitively, frontline staff will be discouraged from reporting, whereas when organizations are open with staff and ensure staff are aware of how event reports are used to improve safety and care, staff are more likely to be adherent to reporting events.

� Benchmarking is important for organizations to gauge their performance as it provides a standard for comparison.

� National benchmarking is required for Magnet certified hospitals as these organizations have to demonstrate benchmarking on the broadest level possible.

� Benchmarking nationally usually requires licensure through a third party that collects and compares metrics from various organizations and can be an expensive investment.

� Ensuring that you are being adequately compared to other organizations at the unit level

� Not all organizations report all fall types

� Benchmarking between collaboratives is still not yet possible as there is no harmonization between agencies with regard to how falls are operationally defined

� Participants within the benchmarking collaborative all use consistent operational definitions for fall and injury events.

� Benchmarking on a national level prevents stagnation in self improvement.

� Does your current variance reporting system provide you all the information about fall events that you need to know?

� Do your frontline managers know how to USE the reports?

� Are variance reports part of routine meetings between middle and upper management?

� Do staff know how to complete reports?

� How do you know if your fall events are being reported?

Questions?

� Challenges in maintenance:◦ Push Back

◦ Buy In

◦ Engagement

◦ Lack of enough resources to really make it happen

◦ Lack of feedback

� It doesn’t apply to me.

� My patients don’t fall.

� I am too busy.

� This equipment doesn’t work.

� You cannot rely on it being done just because it’s the right thing to do. So, there are other motivators.◦ Regulations

◦ Reimbursement

◦ Litigation

◦ Time spent to prevent a fall is far less than cleaning one up.

� You now have the resources (risk assessment tool, care planning and materials), when you don’t use them, you own the fall.

� Telling the story of why

� Seeing is believing

� Recognition

� Do you have enough?

� Keeping it in the right place

� Lost and tossed equipment

� Close the feedback loop.

� Staff need to know how they are doing, especially when it is positive results.

� Remediate when necessary and tell staff what you see.

� Reassess your current level of equipment.� Reassess the need for different resources.� Fall Carts� Standardize quality reporting and make it a true priority.

� Assess the competency of your staff. � Bring the vendor back on a routine basis.� Make sure everyone is at the table for decision making◦ Materials Management◦ Risk Management◦ Staff◦ Patients and Families

� Build training into your orientation

� Flexibility◦ Available and supportive

◦ Hospital staff are a 24/7 endeavor so getting everyone trained can mean late nights and weekend commitments.

� Using “superusers” or “champions” can buffer this when you have engaged frontline staff.

� How do you determine who needs what resource?◦ Patient Population

◦ Unit Size

◦ Number of at risk patients

◦ Staffing considerations

◦ Other available technologies

� How do you ensure adequate accessibility?◦ Fall carts

� Staff must be involved

� Trials and evaluations

� Try more than one type of product if staff want to

� Look into other evidence both from the vendor and in the literature (but be a good consumer of published studies)

Quality and Performance Improvement Summary Report

Data for Oct. 08 Metric/IndicatorMonitoring

Period

October

Compliance

November

Compliance

December

Compliance

January

ComplianceTarget Goal

MeanTREND

Critical Lab Value

Documentation

Called to MD within 1 hour, call

Documented, MD Noted by

Name-Yellow within 5% of goal

or improving

Monthly 100% 75% 100% 100% 90%

Lab Labeling Errors Lab Labeling Errors Monthly 1 1 3 2 2 11/23

Individualization of Care PlansCare Plans Reviewed for

DocumentationMonthly 81% 85% 94% 81% 90%

Blood Culture

Contamination Rates% Contaminated-Yellow is

improving or .5% within goal

Previous

Monthly1.52% 0.00% 4.26% 0.00% 2.50%

Falls from PSN with

Goal calculated from

NDNQI

Falls- Yellow improving or within 1.0 of goal

Monthly 6 1 1 1 3.67

Data for Oct. 08 Metric/IndicatorMonitoring

Period

October

Compliance

November

Compliance

December

Compliance

January

ComplianceTarget Goal

MeanTREND

Press Ganey Nurse

Sensitive Indicators

Unit Performance to

UHC Peer Group Mean

Green= On Target

Yellow= Improving or

within 5 points

Friendliness of the Nurses Monthly 86.9 90.8 96.2 91.7 92.1

Promptness Response to Call Monthly 82.5 89.6 89.1 87.1 85.3

Nurses Attitude Toward

RequestsMonthly 83.8 90.1 94.5 91.4 89.4

Attention to Special/Personal

NeedsMonthly 84.5 89.2 93.8 89.8 87.9

Nurses Kept You Informed Monthly 84.5 87.8 90.6 85.5 87.1

Skill of the Nurses Monthly 86.9 91.9 95.5 92.7 91.2

Nurse Sensitive/Responsive to

PainMonthly 77.1 89.4 95 87.5 90

Nurse check ID Monthly 88.5 91 94.1 95.6 92.9

Extent felt ready to discharge Monthly 86.3 79 87.9 87.1 85.9

Speed of the discharge process Monthly 67.9 79.6 83.3 80.5 80.2

Instructions for Care at Home Monthly 90.5 77 85.6 85.2 86.7

How Well Your Pain was

ControlledMonthly 85 81.3 90.6 87.9 86.8

Staff clean their hands before

examMonthly 86.3 87.5 93.1 88.3 90.2

NDNQI Metric/IndicatorMonitoring

Period4 Quarter 10 1 Quarter 11 2 Quarter 11 3 Quarter 11

Target Goal

MeanTREND

NDNQITotal Falls per 1000 Patient

DaysQuarterly 4.34 6.57 2.76 1.16 3.55

NDNQI% of all Falls that were

Moderate or greater InjuryQuarterly 0 0 0 0 3.04

NDNQI% of patients with Physical

RestraintsQuarterly 0 0 0 3.33 0.64

NDNQI% RNs with National

certificationQuarterly 7.89 7.89 7.89 5.26 10.41

NDNQI% Patients with Unit Acquired

Pressure UlcersQuarterly nd nd nd 7.14 1.16