need it done in 24 hours PICO Question already done in assignment. Must use both articles APA format

Sylvain Trepanier Julie Hilsenbeck

A Hospital System Approach At Decreasing Falls with Injuries

And Cost Executive Summary

► Falls and fall-related injuries continue to challenge every health care organization.

^ Falls are a nurse-sensitive quality outcome.

^ Patient falls are a leading cause of injuries in hospitals, considered to be among the most expensive adverse event, and continue to be a patient safety concern.

^ Researchers analyzed the impact of a standardized fall prevention program across 50 acute care hospitals in 11 states.

^ The implementation of a stan­ dardized multifactorial program for adult patients appears to have reduced falls with injuries by 58.3% over a 2-year period, allowing for a potential cost avoidance reduction of $776,064 in 2013 dollars.

SYLVAIN TREPANIER, DNP, RN, CENP, is Senior Director of Patient Care Services, Tenet Healthcare Services, Dallas, TX.

JULIE HILSENBECK, DNS, RN, is Senior Director of Patient Care Services, Tenet Healthcare Services, Dallas, TX.

P ALLS AND FALL-RELATED injur­ ies continue to challenge health care organizations around the world to pro­

vide safer environments. Falls re­ main a primary health concern for older adults (Resnick & Junlapeeya, 2004], Risk factors for falling in­ clude age-related changes such as sensory alterations, muscle weak­ ness, gait and balance disturban­ ces, use of four or more prescrip­ tion m edications, alteration in activities of daily living, depres­ sion, and history of falling. As the population continues to age, the risk factors are almost inescapa­ ble. The time for serious inquiry into fall prevention and mitigation strategies is now.

International research demon­ strates falls in inpatient acute care settings continue to be a safety threat. Research, however, fails to demonstrate how hospital fall pre­ vention programs actually reduce fall rates (Koh, Hafizah, Lee, Loo, & Muthu, 2009; Lee, Chang, & Mackenzie, 2002; Semin-Goossens, van der Helm, & Bossuyt, 2003). In their groundbreaking report, Agostini, Baker, and Bogardus (2001) collected and described existing evidence on current pa­ tient safety practices. Since falls

and falls with injury are a serious threat to our patients, and create a cost burden for hospitals, there is a need to identify the quality and financial impact of a standardized fall prevention program for adult patients in the acute care setting. The results of a quality improve­ ment study aimed at identifying the effectiveness of a multifactori­ al fall prevention program in the acute care setting for adult patients is reported in this article.

Implications of Falls For the purpose of this study,

a fall is defined as “an uninten­ tional coming to rest on the ground, floor, or other lower level, but not as a result of syncope or over­ whelming external force” (Agostini et al., 2001, p. 281). Furthermore, we define and differentiate between an accidental, anticipated, and unanticipated fall (Morse, 2009) (see Table 1). Patient falls are a lead­ ing cause of injuries in hospitals, considered to be among the most expensive adverse events, and con­ tinue to be a patient safety concern (Evans, Hodgkinson, Lambert, & Wood, 2001; Paradis, Stewart, Bayley, Brown, & Bennett, 2009). When a fall occurs, there are mul­ tiple possible resulting complica-

NURSING ECONOMIC$/May-June 2014/Vol. 32/No. 3 135

Table 1. Falls Definitions

Accidental Fall

A fall that occurs unintentionally (e.g., slip, trip). Patients at risk for these falls cannot be identified prior to a fall and generally do not score at risk for falling on a predictive instrument. These falls may be prevented through providing a safe environment.

Unanticipated Fall

A fall that occurs when the physical cause of the fall is not reflected in the patient’s assessed risk factors for falls.

Anticipated Fall

A fall that occurs in patients whose risk factor score indicated the patient is at risk of falling. Controlled sliding down a wall to the ground or utilization of a physio­ logic structure is considered a fall.

SOURCE: Morse, 2009.

tions: bone fracture, soft tissue injury, and patient fear of falling in the future (Agostini et al., 2001; Liang, 2002). In addition, a fall during a hospital stay “threatens the effectiveness, efficiency, and timeliness of care” (Poe, Cvach, Gartrell, Radzik, & Joy, 2005, p. 107) and can increase the length of stay (Greene et al., 2001; Poe et al., 2005). In all inpatient falls, injur­ ies are reported to occur from 6% to 44% of the time (Hitcho et al., 2004; Resnick & Junlapeeya, 2004). Fall rates range from 1.7 to 25 falls per 1,000 patient days in the adult inpatient setting (Halfon, Eggli, Van Melle, & Vagnair, 2001). In the United States, the total number of falls resulting in injury is predict­ ed to be as high as 17,293,000 by the year 2020 at a cost of $85.37 billion per year (Englander, Hodson, & Terregrossa, 1996). The mean cost of hospitalization due to a fall was estimated at $17,483 in 2004 dollars (Roudsari, Ebel, Corso, Molinari, & Koepsell, 2005).

Risk Factors for Falls Risk factors for falls have been

identified throughout the litera­ ture. Evans and colleagues (2001) conducted a systematic review and identified 27 risk factors. Oliver, Daly, Martin, and McMurdo (2004) conducted a systematic re­

view of risk factors and risk assessment tools of hospital inpa­ tient settings and identified five risk factors.

The initial work conducted by Evans and colleagues (2001) in­ cluded risk factors such as age, gender, length of hospitalization, specific primary and secondary diagnosis, mobility aids, having three or more ward transfers, and unit type. None of these were identified in the work completed by Oliver and associates (2004). Both identified common risk fac­ tors such as unsteady gait, toilet­ ing needs, confusion, sedative- hypnotics usage, and history of falling. During the development of the Morse Fall Score, Morse (2009), identified six discriminate variables (risk factors): history of falling, presence of a secondary diagnosis, use of intravenous ther- apy, type of gait, type and use of ambulatory aids, and mental sta­ tus.

Multiple Interventions and Fall Prevention

The evidence supports the need for interventions that aim at reducing the risk for falls and decrease the actual number of events and the severity of patient outcomes. Falls are one of the nursing quality indicators moni­

tored by the National Database of Nursing Quality Indicators®, the National Quality Forum, and the Collaborative Alliance for Nursing Outcome. In 2005, The Joint Com­ mission added a requirement for both acute and long-term care facilities to assess and periodical­ ly reassess patients for fall risk. In May 2006, the Centers for Medi­ care & Medicaid Services (CMS) announced a program to reduce and prevent “never events” from occurring. A “never event” is a serious, preventable, and costly medical error, and death associat­ ed with a fall while being cared for in a health care facility is on the list of “never events” (CMS, 2006).

In 2001, Agostini and co­ authors reviewed five specific interventions targeting a multi- component falls prevention pro­ gram: use of identification brace­ lets, use of restraints, use of bed alarms, use of special flooring, and utilization of hip protectors. Since then, several other systematic reviews and meta-analyses have been conducted to examine fall prevention interventions (Cameron et al., 2012; Chang et al., 2004; Coussement et al., 2008; Currie, 2006; Gillespie et al., 2003; Oliver et al., 2007). All reported multifac­ torial assessments and programs were the most effective at reduc­ ing the proportion of older people who fall as well as the rate of falls in elderly living at home or in res­ idential institutions or nursing homes.

Chang and colleagues (2004) and Oliver and co-authors (2007) reported no evidence of the inde­ pendent effectiveness of “environ­ mental” modification (specialty lighting, side rails, etc.). Chang and colleagues (2004) included 40 randomized control trials in their meta-analysis. In addition, they explored the relative effectiveness of intervention components. This is a major improvement as com­ pared to the previous meta-analy- sis. Of note, this analysis was con­ ducted using indirect methods, thus leading to less-powerful

136 NURSING ECONOMIC$/May-June 2014A/ol. 32/No. 3

results and the validity can be questioned. Oliver and associates (2007) conducted similar work and included 43 studies in the meta-analysis. Of those, 13 studies were multifaceted interventions to prevent falls in hospital settings. Three of the 13 studies were con­ sidered high quality, demonstrat­ ing an 18% reduction in fall rates and no comparable effect on frac­ tures post fall. In addition, the study allowed the authors to iden­ tify gaps in the evidence that will warrant future research such as the effect of single interventions like medication review and use of alarms.

Jensen, Lundin-Olsson, Nyberg, and Gustafson (2002) studied the effect of a comprehensive fall risk assessment including visual eval­ uation, medication evaluation, and delirium screening by all members of the health care team. The study demonstrated such interventions reduced the fall rate by 51% and injuries by 77%. Although promising, the study was conducted in a residential care setting and therefore limits the ability to generalize the find­ ings for the acute care hospital environment. In addition, the study did not estimate the indi­ vidual effect of the prevention measures studied and complete randomization was not achieved. Of note, the authors disclosed the possibilities that not all falls were reported, therefore introducing a bias in the overall fall rate.

Healey, Monro, Cockram, Adams, and Heseltine (2004) also demon­ strated a statistically significant decrease in falls (RR 0.71) when applying a tailored plan of care for those identified at risk for falls and no significant change to overall injury rate. Since only a small number of falls result in injury, it would require a very large sample size to demonstrate a statistically significant change in falls with injury. This study was conducted in a subacute setting and applica­ tion to acute care is questionable. Haines, Bennell, Osborne, and Hill

(2004) also reported a reduction in falls using a targeted multiple intervention program by means of a fall risk alert card, an exercise program, an education program, and use of hip protectors. Once again, the study was conducted in a subacute setting and generaliza­ tion to acute care is questionable. In addition, complete randomiza­ tion was not utilized in this study.

Fonda, Cook, Sandler, and Bailey (2006) reported a reduction in falls using a multi-strategy falls prevention program. The study was conducted between January 2001 and December 2003 and demonstrated a 19% reduction in falls per 1,000 patient days. Also noted was a 77% reduction in serious injuries per 1,000 patient days over the same period. Of par­ ticular interest, some of the patients were in an acute care set­ ting, and this is one of few studies that included the use of a bed alarm as an individual strategy to reduce falls. Fonda and co-authors (2006) expanded the definition of a fall to include “impacting against an adjacent surface (e.g., wall or furniture), slips, trips and lower- ing/assisting a patient who is in the act of falling” (p. 379). Because of this expanded definition, more fall events were included com­ pared to other studies. The pre and post measurement are 2 years apart, and many other variables may have impacted the results. The authors suggest the extended time period between measure­ ments to be a sign of strength; the impact of the intervention was sustained over a 2-year period. Of note, this is the only study to demonstrate an improvement post intervention in the fall rate with serious injury compared to Haines and colleagues (2004), Healey and co-authors (2004), and Vassallo, Amersey, Sharma, and Allen (2000). The authors partially attributed this outcome to the fact the intervention was initiated on day 1 of admission with evalua­ tions as needed, compared to day 3 and weekly evaluations for the

Vassallo and associates (2000) study. This study was considered a quality improvement project and cannot be considered a random­ ized control trial.

Cumming and co-authors (2008) conducted a cluster ran­ domized control trial in 12 Australian hospitals covering 24 elderly care wards (12 acute care and 12 rehabilitation wards). The study focused on the effect of a targeted multifactorial falls pre­ vention program that included a fall risk assessment, patient edu­ cation, environmental modifica­ tion (specialty lighting, side rails, etc.), medication management, exercise program, and a custom- designed alarm system. The out­ come failed to show any signifi­ cant difference between the inter­ vention and control groups where the mean fall rate for the interven­ tion group was 9.26 per 1,000 bed days compared to 9.20 per 1,000 bed days for the control group (t22=0.05, p=0.96). The interven­ tion was conducted post assess­ ment. Most assessments were con­ ducted within 24 hours; however, all weekend admissions were con­ ducted on the following Monday. This process caused a delay on the intervention and therefore intro­ duced a variable in the study, which the authors do not appear to have taken into consideration. There is no mention of controlling this variable in the analysis.

Vassallo and colleagues (2000) completed a prospective observa­ tional study involving three hospi­ tal departments. Department A and B were of nuclear design where 85% of the beds were visi­ ble from a nursing station while department C was of longitudinal design and approximately 20% of the beds were visible. The authors recorded 199 falls involving 167 individual patients. The majority of falls originating in department C occurred in the actual bed area and this was the unit with the highest number of falls per occu­ pied bed days. Performance of activities of daily living precipitat-

NURSING ECONOMIC$/May-June 2014/Vol. 32/No. 3 137

Figure 1. Total Number of Falls with Injuries

2009 2010 2011

ed many of the falls and the major­ ity was not witnessed. These find­ ings dramatically highlight the need for caregivers to be alerted when the patient is attempting to move from the bed independently, especially in units where beds are not visible from the nursing sta­ tion. The literature review sup­ ports the implementation of a standardized falls prevention pro­ gram. The outcomes of the aggre­ gate studies demonstrate multiple interventions are more effective at preventing falls compared to indi­ vidual interventions.

Methodology In 2009, an interdisciplinary

team was initiated with the intent to develop a standardized fall pre­ vention program for adult patients in a for-profit health care system based in the Midwest United States. The system owns and oper­ ates 50 hospitals in 11 states (Alabama, California, Florida, Georgia, Missouri, Nebraska, North Carolina, Pennsylvania, South Carolina, Tennessee, and Texas). The team developed the work product around one principal goal: to decrease the number of anticipated falls with injuries. The multidisciplinary team reviewed the literature, discussed the topic with national and international experts, and developed a stan­ dardized program based on evi­ dence. The program includes a policy and procedure with a mini­ mum set of standards (definitions, screening, patient identification, medication review, plan of care, elements of handoff communica­ tion, standard measurement, re­ porting, and performance-im­ provement metrics); identification safety tools; a sample post fall assessment; implementation of a “stop the line” concept when a fall occurs; hourly rounding educa­ tion tool and log; room observa­ tion form; decision-making algo­ rithm for sitter usage; educational material for the caregivers, pa­ tients, and significant others (in­ cluding home safety instructions);

commitment standard for all health care providers; bed safety instruc­ tions; physical therapy evaluation process; audit tools; and a sample handoff communication tool (see Figure 1).

Once a patient has been iden­ tified at risk for a fall, the health care team must develop an indi­ vidualized plan of care aimed at mitigating the risk factors and therefore decreasing the risk of a fall. For that reason, interventions are not the same for all patients.

The program was communi­ cated via multiple national webi­ nars, conference calls, and indi­ vidual site visits. Since falls pre­ vention is largely influenced by nursing care, the chief nursing officer of each hospital was identi­ fied as the executive sponsor. A falls champion was also identified at each hospital to ensure the pro­ gram was communicated to all caregivers and also acted as the liaison to the system fall preven­ tion team. Educational sessions were offered via national webinars with all the falls champions to ensure proper and standardized dissemination of knowledge and expectations. The “falls with injury” metric was also added as measurement outcome to the chief

nursing officer monthly balanced scorecard to ensure ongoing mon­ itoring of the progress and to iden­ tify areas of opportunities. There is no additional or specific cost associated with implementation of this program since it is imbed­ ded into the daily practice and interventions of all health care members.

Results The program was deployed

over a period of 4 months. Using raw data, after 12 months of im­ plementation, the authors identi­ fied a decrease in anticipated falls with injuries of 41% after the first year and an additional 31% com­ paring year 2 to baseline. The authors identified a total decrease in falls in an acute care setting of 58.3% over a 2-year period post implementation of a standardized fall prevention program (see Fig­ ure 2).

After normalizing the raw fall data with patient days, the authors still identified a decrease in antic­ ipated falls with injuries of 37.5% after the first year and an addition­ al 33.3% comparing year 2 to baseline. The authors identified a total decrease of 58.3% over a 2- year period post implementation

138 NURSING ECONOMIC$/May-June 2014/Vol. 32/No. 3

of a standardized fall prevention program (see Figure 3).

Discussion and Recommendations Falls and falls with injuries

are clearly major patient safety concerns. Many risk factors have been identified as well as multiple interventions aimed at decreasing

the number of falls and falls with injuries. In this study, an evi­ dence-based standardized fall pre­ vention program resulted in a decrease in anticipated falls with injuries per 1,000 patient days of 58.3% [N= 36). Since the authors established earlier that a mean cost of hospitalization related to a

fall was $17,483 per event, this intervention yielded a minimum of $629,388 in cost avoidance in 2004 dollars. According to the Oregon State University Inflation Conversion Calculator (2013], one 2004 dollar is equal to $0,811 in 2012. Therefore, total cost avoid­ ance is estimated to be $776,064 ($629,388 X 0.811). This amount does not take into consideration potential litigation and/or other potential complications that may have easily increased the cost of care for a fall while in the hospi­ tal.

The purpose of this study was to implement a standardized falls prevention program for adult patients by offering multiple inter­ ventions targeting patient-specific needs with an expected outcome of decreasing falls with injuries. A reduction in falls with injuries over time was demonstrated using this methodology. A decrease in falls using multiple interventions was demonstrated, confirming find­ ings reported by Agostini and col­ leagues (2001); Cumming and associates (2008); Fonda and co-

Figure 2. Falls with Injuries per 1,000 Patient Days

Figure 3. Critical Component of a Standardize Fall Prevention Program

Use of a Standardized Valid and Reliable Screening Tool

Include Fall Risk During Bedside Handoff Communication

________ _ _ _ _ _ ____

Include Medication Regimen as Part of the Screening/


Implement Hourly Rounding and Rounding During

Shift Change

Offer an Individualized Plan of Care

If a Patient Is At Risk for Falls and Has a History of a Fall j

within the Last 12 Months and Is Cognitively Impaired, Offer

Continuous Observation

Offer Educational Material for the Clinical Staff, Patients,

and Significant Others

NURSING ECONOMIC$/May-June 2014/Vol. 32/No. 3

authors (2006); Haines and col­ leagues (2004); Healey and co­ authors (2004); and Jensen and associates (2002).

During the development and implementation of this national standardized falls prevention pro­ gram, the content was developed using the latest literature and con­ versations with national experts. The organization of the final pro­ gram includes a step-by-step guide of implementation. The plan was communicated using multiple methods such as group conference calls, one-on-one calls, site visits, and webinars. In addition, all falls champions were contacted to ver­ ify the program was fully imple­ mented.

This quality improvement study demonstrates patients with a his­ tory of a fall and the inability to follow simple commands or direc­ tions benefit from one-on-one ob­ servation in order to decrease the risk of fall with injury. This sub­ group of patients remains a con­ siderable challenge for any health care organization. Further re­ search is required to identify the appropriate and most cost-effec­ tive interventions to reduce their risk of falling in the health care setting.

There are multiple limitations in this study. First, a convenient sample size was used, making it difficult to generalize the findings at this time. In addition, a reliable method to verify how completely each expected intervention was implemented at the hospital level was not identified. Although the results are promising, we are unable to demonstrate and identi­ fy which intervention(s) had the most impact on falls. Further analysis and research, especially randomized controlled trials, are required to answer this question and provide additional insights in this very complex issue.

This finding supports the sys­ tematic reviews conducted by Clyburn and Heydemann (2011) and Wu, Keeler, Rubenstein, Maglione, & Shekelle (2010) where

they identified a lack of strong empirical evidence in the research conducted on this subject to date. In essence, this multifactorial pre­ vention program appears to have impacted the rates of falls with injuries and it is our opinion the program had significant impact on the reduction in falls with injuries.

Conclusion Falls are a serious problem for

patients. Falls generate multiple complications and have an impact on the well-being of patients who fall. Multiple risk factors have been associated with the risk for falls where environmental factors are heavy contributors. Studies have demonstrated patients tend to fall next to their bed, especially in rooms that do not offer direct visi­ bility from the nurses’ station. In this study, the impact of a stan­ dardized fall prevention program across 50 acute care hospitals in 11 states was analyzed. The im­ plementation of a standardized multifactorial program for adult patients appears to have reduced falls with injuries by 58.3% over a 2-year period, allowing for a poten­ tial cost avoidance reduction of $776,064 in 2013 dollars. Study limitations make it difficult to gen­ eralize these findings across all acute care settings in the United States. Further research is required, in the form of randomized control trial, to better understand the effect of individual interventions. $

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