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Journal of Nursing

Videos, Bells and Whistles; Fall Risk or Injury Prevention? 

by Michelle Myers Glower RN MSN LNC [email protected]


Every healthcare system should be safe, effective, patient-centered, timely, efficient, and equitable. Quality of care review is done in Hospitals and Health Care facilities across the nation, at least it should be. Accredited facilities are required to have systems in place they can measure to determine whether the quality of services provided meet professionally recognized standards of care, including whether appropriate healthcare services were not provided or were provided in appropriate settings. (The Institute for Healthcare Improvement {IHI}, 2008) report patient falls are among the most common occurrences reported in hospitals and are a leading cause of death in people ages 65 or older. Patient death or serious disability associated with a fall while being cared for in a healthcare facility is considered a “Never Event” and a costly risk. The term “Never Event” is not friendly.  Never events consist of 28 occurrences on a list of inexcusable outcomes in a healthcare setting. They are defined as "adverse events that are serious, largely preventable, and of concern to both the public and healthcare providers for the purpose of public accountability. The list was compiled by the National Quality Forum is available and free to copy at http://en.wikipedia.org/wiki/Never_events


Of those who fall, as many as half may suffer moderate to severe injuries that reduce mobility and independence, and increase the risk of premature death. About 50 percent of older adults hospitalized for hip fracture never regain their previous level of function.


The US population is aging, the problem of hip fractures will likely increase substantially over the next four decades. There is a considerable body of literature on falls assessments, identification of fall risk and fall prevention programs; little evidence exists for the absolute impact of any given intervention. Yet, health care professionals believe they can prevent falls in hospitals and undertake well thought out improvement programs, with falls still being reported, with and without injuries. The intent should be applauded, but the fact remains, falls happen.


Hip fractures are the most frequent type of fall-related fractures. The cost of hospitalization for hip fracture averaged about $18,000 and accounts for 44% of direct medical costs for hip fractures. About one out of five hip fracture patients dies within a year of their injury. Leibson, Toteson, Gabriel, Ransom and Melton. (2002). Preventing a hip fracture in the elderly can be cushioned through the use of hips protectors, carpeted or padded flooring and or a mattress on the floor. Depending on whose study you read, the use of hips protectors to reduce or prevent hip fractures is widely debated.


Tzeng HM, Yin CY (2007) report heights of occupied beds as a possible risk factor for falls concluded the average height of patient beds on fall precaution was significantly higher than of those not on fall precaution. In a recent purchase of new hospital beds, we later found a significant difference in the bed heights from previous versions, assumptions were made that upgrading our hospital beds all had the previous height.


Another observation noted, if you have a higher patient/nurse ratio on weekends than on weekdays, this may result in nurses being less conscientious about keeping beds in the low position after treatments. In an effort to prevent high-fall-risk patients from falling, nurses may have consciously or unconsciously kept their beds in higher positions. Tzeng & Yin (2008).


Patients who are assessed and defined as “high risk” for a fall are put on fall precautions in the hospital. There are several different tools used to assess for fall risk. Yet No single fall-risk assessment tool has been conclusively validated. Despite the lack of evidence for falls risk assessment tools, many hospitals continue to use them. However attractive the use of such tool might be, if they do not perform sufficiently well in that setting and population, their use may be ineffectual or provide false reassurance that ‘something is being done’ to target high-risk patients while still diverting attention away from more potentially effective interventions. Oliver, Papaioannou, Giangregorio,Thabane, Reizgy and Foster (2008).


The Morse Fall Scale, St Thomas Risk Assessment Tool and Hendrich II  were validated in an inter-rater reliability and validity study in 2003. They concluded the Heindrich II Fall Risk Model is potentially useful in identifying patients at high risk for falls in acute care facilities. Kim EA, Mordiffi SZ, Bee WH, Devi K, Evans D. (2007).


The STRATIFY falls risk assessment, a prediction tool developed for use for hospital inpatients, using a 0–5 score to predict patients who will fall. It has been widely used as part of hospital fall prevention plan, but it is not clear how good its operational utility is in a variety of settings. was significantly related to incidence of accidental falls in this large cohort but was a poor predictor of falls and cannot be recommended for routine use in acute hospital settings.  Careful review of your tool is recommended. Oliver et al. (2008).


To the community, fall precautions suggest that we, as providers, have in place something that will prevent the fall from occurring. It is an expectation from the consumer’s point of view that hospitals provide staff and possible sitters to avoid any fall from occurring.  It is the consumer’s point of view if a patient falls, we are at fault. No fall is the expectation and so it should be. Nurses have more than one patient assignment, in fact, they may have up to 8 or more patients and may all be high risk for a fall. With that being said, this does not mean the nurse is not observing as he/she makes their rounds and with each encounter looks for solutions to manage the patients who may be at risk. The fact is, when the nurse leaves the room, patient falls are not an uncommon scenario played out day to day.


Falls typically occur either while the patient is getting into or out of bed or shortly after the patient has exited the bed.  Those patients that are identified as on fall precautions, or high risk for falls is the patient’s history, it is not a plan.  Where would one find the plan in the hospital? Is it in the care plan? A policy? Do all staff know the plan?  In the event of a fall, the absence of written policies can increase a facility’s liability for failure to establish patient safety policies. The goal of a fall evaluation and prevention strategy is to minimize the risk of falling without compromising mobility or functional independence. Given the inherent trade-offs between safety and independence, this goal may be difficult to achieve in some individuals. Perhaps a better goal would be to prevent relevant fall-related morbidities such as serious injury. As the ability to identify the subset of fallers at risk for these fall sequelae improves, evaluative and preventive efforts can be better targeted. A recent report done by an expert panel provides an evidence-based approach to the management and prevention of falls, (The Quality Indicators for Assessing Care of the Elderly {ACOVE, 2001} project). Family members should be a part of the care, asking a family member to stay with the patient because of a fall risk is acceptable for creating a culture of safety.  Just as important in part of a prevention program that would out line measures that are implemented to make an attempt to prevent a fall is the post fall diagnostics.


Hospitals and LTC facilities may use bed alarms for what they describe as “fall precautions” these are beds with built in alarms.  The purpose of the alarms is to alert staff that the patient is attempting to exit the bed. The alarms are activated by either pressure relieving through the mattress or motion sensors that will alarm when one goes through or over the rails. I call bed alarms a notification of patient on the floor and therefore, get lifting help. In my experience, I have not seen an alarm re-route a confused patient from exiting the bed. Unless you are within feet maybe inches, patients fall fast, not in slow motion. Bed-exit alarms do not themselves prevent falls, a fact that is not always clearly understood. To be effective, they need to be implemented with care and with a clear understanding of their limitations.


Other fall preventative techniques include the “Night Watch” (NOC WATCH). The NOC WATCH device consists of a credit-card size device contained within an adhesive "patch" and worn on the thigh continuously for many days. The patch is small, wireless, disposable, waterproof, shockproof, and unobtrusive. When a patient's leg becomes weight-bearing (such as when a patient gets out of bed or stands up unassisted), the receiver emits an audible signal which both alerts the patient to sit down and also summons a caregiver. Results from a clinical study conducted to measure the effectiveness and operational characteristics of this device intended to reduce the incidence of falls in elderly patients at high risk of falling, NOC.watch device appears to have a large impact on reducing fall risk in nursing home patients, further evaluation in the acute care setting in needed. However, due to the lack of an equivalent control group, these results should be confirmed with a larger, randomized, controlled study to better estimate the true magnitude of the effect of the NOC.watch device on fall rates. Kelly Phillips, Cain, Polissar (2002).


High technology is also used as a “fall prevention” strategy and it is not cheap. Patients are remotely video surveillance for falls. With this, from a remote station, the tech observes a patient attempting to get out of bed they will call the nurse, or nurse’s station and report it. Communication from the monitor room to the nurse needs to be quick, like all other alarm responses, however, not quick enough to prevent most falls.  By the time the nurse gets the message and stops what he/she is doing, chances are, calling for lift help is the response. There is no better intervention to reduce falls than observation, unfortunately the high cost associated with the use of sitters verse modern technology has been under scrutiny all over the U.S especially during the current economic crises. Research has been mixed about the effectiveness of other approaches, such as increased vigilance, use of patient sitters, frequent assistance for toileting and other functions, and bed exit monitors. However, Nursing Economics (2007) reported use of a patient vigilance system is cost-saving as compared with increased use of patient sitters, even if patient fall rates drop with increased sitter use.


Contributing factors why patients end up on the floor are intrinsic, such as physiological illness, lower extremity weakness, poor grip strength, balance disorders, visual defects, cognitive impairment, and polypharmacy, as well as extrinsic, such as lighting, faulty assistive devices, and wet or cluttered floor surfaces. Reasons that contribute to falls are essential and every nurse and caregiver ought to know them. More importantly, what does the hospital have in place that limits falls and what is done post fall go hand in hand?


Studies on “Interventions for Preventing Falls in Acute- and Chronic-Care Hospitals” found no conclusive evidence that hospital “fall prevention programs” reduce the number of falls or fallers, although more studies are needed to confirm the tendency observed in the analysis of individual studies that targeting a patient's most important risk factors for falls actively helps in reducing the number of falls. These interventions seem to be useful only on long-stay care units. Coussement, DePaepe, Schwendimann, Denhaerynck,  Dejaeger and Milisen, (2008).


There may not be a successful 100% fall free program; however, there are many fall prevention/injury program ideas that are worth investing.  One of Joint Commission goals focuses on reducing the risk of patient harm resulting from falls in health care settings. Reviewing your falls with injuries against current prevention programs that include injury protection is critical for eliminating injuries.  
 
 
LEGAL NURSE CONSULTANT PERSPECTIVE


Litigation for hospital falls is growing in frequency and settlement size. As a legal nurse consultant (LNC) I analyze records, evaluate the case, and render an informed opinion After reviewing 6 cases of fall related injuries in LTC and Acute Care facilities in 2008, 100% of the patients reviewed were on documented fall precautions and 100% had a fall risk assessment. However, 0 had a documented prevention noted. From the documentation, there was nothing that addressed if there was a bed alarm on, rounding, placement of patient closer to a nurses station or use of a sitter.  The lights are on but no one is home.


In the case of  Cifelli v. St. Vincent’s, 2008 WL 4093163 (Sup. Ct. Richmond Co., New York, July 17, 2008). Titled Psych: No Fall-Risk Assessment Done, 


Negligence Found. The day before she fell and fractured her right tibia and fibula the fifty-seven year-old patient was involuntarily admitted to the hospital’s psychiatric unit for suicidal ideation. She had been in the same hospital several times over the previous few months for the same reason. Her Psychiatric Admission revealed, No Fall-Risk Nursing Assessment The fall-risk portion of the admission nursing assessment form was crossed out with the letters “N.A.” signifying that the nurse believed that risk assessment and fall precautions are not included in psychiatric care. The same nurse’s admitting progress notes pointed to unsteady gait, muscle weakness, confused mental state and poor judgment. The patient reportedly awoke, rang for help to the restroom, got no response and got up on her own. The jury in the Supreme Court, Richmond County, New York awarded her $598,000. The progress notes admittedly acknowledge the patient was at risk, yet where were the interventions? When you document the symptoms, you had better make mention what you did about them.


A frequent omission in nursing documentation is what has been provided to prevent a fall. In addition, there is an inadequate post fall assessment.  Nursing assessments tend to say no complaints voiced, awake alert and confused. What kind of assessment is that?  That is an observation, not an assessment. If you want to prevent litigation, then nurses need to document the actual strategies in place that prevent a fall and a post fall assessment. This is a critical element most forgotten. Following a patient's fall the nurse needs to document an assessment of vital signs, level of consciousness, neurological checks, and functional status pre and post fall. If significant changes in patient's condition occurs, consider further diagnostic tests such as plain film x-rays, CT scan of the head/spine/extremity, neurological consultation, and /or transfer to a higher level of care for further evaluation, that is the minimum standard of nursing care. If the patient is anti-coagulated, there should be a hospital wide standard algorithm for post falls that mandates CT. Due diligence speaks volumes and may avoid a litigiousness stream of cases.


An incident report, calling the doctor and family, along with scooping the patient back to bed are not to be considered fall prevention or post procedure assessment. To say you have a fall program in place, you will need a complete fall assessment, plan, intervention, evaluation and a post fall procedure algorithm for nurses.  A post fall procedure program will identify injuries and save lives.


Resources for LTC


Fall prevention in nursing homes continues to be among the most challenging aspects of geriatric nursing, not only because of the high frequency of falls but also because of the significant impact on residents, families, staff, and administration. Several programs specifically designed to reduce falls in nursing home residents are available on www.medqic.org these include comprehensive multidimensional programs, bed safety, and restraint reduction strategies. The resources on Medqic have been peer reviewed by national experts and are downloadable at no cost.


The use of hip protectors as a means of preventing hip fractures in adults who fall is being widely implemented as more and more health-care providers are becoming aware of the serious consequences associated with falls. Hip protectors are constructed and worn by an individual as an undergarment. Each garment has either sewn-in or removable hip shields. There are many different types of hip protectors (soft shelled and hard shelled), which are manufactured by different companies. Depending on the health-care insurance coverage that an individual has, the hip protector cost may be covered by their insurance. One of the biggest challenges in using hip protectors is to ensure that the individual feels comfortable when wearing them. Because they are not always comfortable or seem impractical to the user, wear compliance may be an issue.


Parker, Gillespie and Gillespie (2004) state that there is some evidence that “for those living in institutional care with a high background incidence of hip fracture, a programme of providing hip protectors appears to reduce the incidence of hip fractures.”


Parker, M., Gillespie, L., & Gillespie, W. (2005). Hip protectors for preventing hip fractures in the elderly. The Cochrane Database of Systematic Reviews, 
The VA National Center for Patient Safety (NCPS) worked with the Patient Safety Center of Inquiry in Tampa, Florida, and others to develop the NCPS Falls Toolkit. The toolkit is designed to aid facilities in developing a comprehensive falls prevention program. You may download the entire program free at http://www.va.gov/ncps/SafetyTopics/fallstoolkit/index.html#notebook.


5 Million Lives Campaign. Getting Started Kit: Governance Leadership “Boards on Board” How-to Guide. Cambridge, MA: Institute for Healthcare Improvement; 2008. Available at:http://www.ihi.org/IHI/Programs/Campaign/BoardsonBoard.htm


The National Guideline Clearinghouse (NGC) is a public resource for evidence-based clinical practice guidelines. NGC is sponsored by the Agency for Healthcare Research and Quality in partnership with the American Medical Association and the American Association of Health Plans. Use the Search NGC feature. Type in "falls" and Click the Submit button. Web site:http://www.guideline.gov/index.asp


Additional resources are listed below and links are provided on ECRI’s Web site for falls prevention resources at http://www.ecri.org/falls. Falls Prevention Strategies in Healthcare Settings. ECRI (610) 825-6000, ext. 5889, or [email protected]


Guideline for the Prevention of Falls in Older Persons 2001. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. (http://www.americangeriatrics.org products positionpapers/Falls.pdf.)
As a conclusion, in order to eliminate disparities in hospital systems in comparing hospital related falls with and without injuries, it is vital that fall definitions should be standardized, reporting practices and fall classification be consistent, so that fall rates can be calculated, and rates compared to share successful methods of decreasing hospital falls.
 
 
 
REFERENCES


Boushon B., Nielsen G., Quigley P., Rutherford P., Taylor J., Shannon D. (2008). Transforming Care at the Bedside How-to Guide: Reducing Patient Injuries From Falls. Cambridge, MA: {Electronic Version}. Institute for Healthcare Improvement. Available at: http://www.IHI.org.
Retrieved from http://en.wikipedia.org/wiki/Never_events &http://www.cms.hhs.gov/ 2008.
Leibson CL., Toteson ANA., Gabriel SE., Ransom JE., Melton JL III. (2002). Mortality, disability, and nursing home use for persons with and without hip fracture: a population-based study. {Electronic Version}. Journal of the American Geriatrics Society, 50, 1644–50.
Tzeng HM,. & Yin, CY. (2007). Height of hospital beds and inpatient falls: a threat to patient safety. Journal of Nursing Administration. Dec;37(12):537-8
Tzeng HM., & Yin, CY. (2008). Heights of occupied patient beds: a possible risk factor for inpatient falls. {Electronic Version}. Journal Clinical Nursing. Jun; 17(11):1503-9
Oliver, D. Papaioannou, A.  Giangregorio, L. Thabane, L.  Reizgys, K and Foster, G. (2008). Should elderly patients be screened for their ‘falls risk’? Validity of the STRATIFY falls screening tool and predictors of falls in a large acute hospital. {Electronic Version}. Journal of the American Medical Directors Association, 37(6), 702-706.
Kim EA, Mordiffi SZ, Bee WH, Devi K, Evans D. (2007). Three fall-risk assessment tools in an acute care setting {Electronic Version}. Journal of Advanced Nursing, 60(4), 427-435.
Oliver et al. (2008).
Wenger, N. MD, MPH; Shekelle, P., MD, PhD. (2001). Assessing Care of Vulnerable Elders: ACOVE Project Overview. {Electronic Version}.135(8), 642-646.
Kelly KE, Phillips CL, Cain KC, Polissar NL, Kelly PB. 2002. {Electronic Version}.Evaluation of a nonintrusive monitor to reduce falls in nursing home patients. Journal of the American Medical Directors Association. 3(6), 377-82.
Spetz, J., Jacobs, J., Hatler, C. (2007). Cost effectiveness of a medical variance system to reduce patient falls. {Electronic Version}. Nursing Economics, Nov-Dec.
Coussement, J., De Paepe, L., Schwendimann, R., Denhaerynck, K., Dejaeger, E., and Milisen, K., (2008).  {Electronic Version}. Journal of the American Geriatrics Society 56.1 (Jan 2008): p.29. DOI:http://dx.doi.org/10.1111/j.1532-5415.2007.01508.x
Kelly et al. (2002).
Parker, M., Gillespie, L., & Gillespie, W. (2005). Hip protectors for preventing hip fractures in the elderly. The Cochrane Database of Systematic Reviews
http://www.nursinglaw.com (2009) Legal Eagle Eye Newsletter. July 2009. of  Cifelli v. St. Vincent’s.


Biography


Michelle Myers Glower RN MSN, LNC, from Chicago Il. with over 20 year experience in nursing. Graduated from Loyola University in Chicago and obtained my Graduate degree from Saint Xavier University in Nursing Education. Areas of specialty include emergency, pediatrics and acute care. Currently in practice at Saint Mary’s Hospital/Trinity Health System as Clinical Services Director for Heart,Vascular,Pulmonary & Orthopedics’, in Grand Rapids Mi., I have been a Legal Nurse Consultant for 5 years and review cases across the United States for deviations in the Standard of Care for Nursing.  Married to an emergency room physician who also practices here in Grand Rapids Mi as Medical Director for Urgent Care. I have 1 adult son who is currently pursuing his Doctorate at the University of Wi. We have 2 dogs Gabbi and Ty.

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