Hospitals Collaborate to Prevent Falls
November / December 2008
Hospitals Collaborate to Prevent Falls
Philadelphia-area hospitals have charted a unique strategy in patient safety: Facilities that are normally competing for patients are collectively identifying effective measures to prevent patient falls. Harnessing their strength as a regional collaborative, the hospitals have shared stories of how to implement effective interventions for falls prevention and have participated in brainstorming workshops to identify a long list of additional strategies. The facilities can then choose from the list those interventions that zero in on their unique challenges.
The project to reduce patient falls is one of several patient safety initiatives undertaken jointly by hospitals in the greater Philadelphia region since January 2006 under the direction of the Partnership for Patient Care (PPC). The PPC is a collaborative involving four groups: the Health Care Improvement Foundation (HCIF), an independent, nonprofit organization supporting innovative efforts to improve patient care; hospitals in southeastern Pennsylvania; Independence Blue Cross; and ECRI Institute. The partnership’s goal is to accelerate the effective adoption of evidence-based clinical practices by pooling the resources, knowledge, and efforts of hospitals and other key stakeholders. ECRI Institute, a nonprofit organization researching best practices to improve patient care, provides expertise in patient safety to facilitate the collaborative’s shared approach.
The partnership has made a meaningful difference in improving patient safety in the greater Philadelphia area. Together, the workshop participants identified nearly 60 different mitigation strategies to prevent patients from falling or to reduce the severity of injuries caused by falls. After hearing about each other’s successes and failures in falls prevention, the workshop participants applied specific mitigation strategies that addressed their facilities’ concerns. In the area of falls prevention, the 15 participating healthcare providers saw improvement in their organizations’ approaches to reducing patient falls as measured by surveys conducted at the hospitals before and after the workshops. The suggested interventions for falls prevention are publicly available to hospitals throughout the United States (see the sidebar “Failure Mode and Effects Analysis: Falls Prevention” for more information).
Why Falls Prevention?
Patient falls are a high-risk, high-volume, high-cost challenge for healthcare facilities. Nearly one-third of U.S. adults ages 65 and older fall each year, according to the Centers for Disease Control and Prevention (2008). Injuries from falls can lead to significant morbidity and mortality. Of those individuals who sustain a hip fracture — the most feared complication from a fall — more than 24% die within a year of the fall, and 50% never return to their normal level of functioning (National Safety Council, 2005). The estimated cost to treat serious falls-related injuries ranges from $15,000 to $30,000 per fall (Landro, 2005).
In Pennsylvania, where hospitals must submit reports of adverse medical events to the Pennsylvania Patient Safety Reporting System, an estimated 17% of all reports submitted in 2006 were for in-hospital falls. Of the total 33,882 reports of falls in the state in 2006, 1,196 were characterized as harmful events and 23 indicated the patient died as a result of the fall.
With input from a regional advisory group, the PPC selected falls prevention as a topic for an area hospital collaborative because of its broad application to the region’s hospitals and because of the evidence supporting the effectiveness of falls prevention strategies. Additionally, the topic dovetailed with national initiatives to address falls in healthcare facilities. For example, since 2005, the Joint Commission has identified the reduction of patient harm resulting from falls as one of its National Patient Safety Goals for hospitals. More recently, after the 15 hospitals completed their project in falls prevention, the Centers for Medicare & Medicaid Services said it would no longer pay for preventable injuries from falls sustained by Medicare beneficiaries during their hospital stay (Centers for Medicare & Medicaid Services, 2008). The collaborative’s work on falls prevention strategies has prepared Philadelphia-area hospitals for initiatives such as the federal government’s plan to no longer pay for certain hospital-acquired conditions such as injuries from preventable falls.
Getting Started
The Philadelphia-area collaborative in falls prevention spanned a 7-month effort in 2007. The 15 participating hospitals identified two or three representatives from their facilities who would attend four workshops on falls held at ECRI Institute’s headquarters in Plymouth Meeting, Pennsylvania. The representatives typically were from patient safety, quality improvement, and nursing staff with direct patient care responsibilities. During the workshops, ECRI Institute staff led discussions about breakdowns in important clinical processes that can increase patients’ risk of falling. Using the principles of failure mode and effects analysis, the participants zeroed in on processes such as conducting a falls risk assessment of patients and selecting falls risk reduction interventions for patients. Breakdowns in these processes such as delays in communicating a patient’s risk of falling to caregivers will undermine any effort to prevent patients from falling. The workshop participants shared their own experiences and ideas and worked together to develop mitigation strategies and interventions to prevent breakdowns in these high-risk processes. Their goal was straightforward: to eliminate or minimize the potential for failures, to stop failures before harm reaches the patient, or to minimize the consequences of failure.
After each workshop, the participants returned to their facilities to try to select and adapt the strategies discussed at the workshop best suited to their unique situations. Typically, the participants worked with a larger team from the hospital — with additional representation from risk managers, physicians, nurses, pharmacists, physical and occupational therapists, and other departments — to complete their assignments.
Themes Emerge
Over the course of the 7 months, several goals for falls prevention emerged as the hospitals shared their experiences. The participants agreed that the strategies to prevent and reduce falls should focus on the following goals:
- Improve falls risk assessment.
- Incorporate medication review to identify patients at a high risk for falling.
- Provide visual cues or identifiers of high-falls-risk patients.
- Incorporate a multidisciplinary approach to care planning related to falls prevention.
- Address patients’ personal needs
- Ensure that falls prevention equipment is readily available and working properly.
- Provide effective patient education.
- Raise staff awareness about falls prevention efforts and provide staff education.
The workshop participants said the greatest value of the collaborative was meeting with other hospital representatives and sharing stories of how they accomplished their falls prevention efforts. For example, a hospital that had disbanded its effort to track falls related to patients’ medications may have heard how another hospital successfully incorporated the initiative. Listening to the strategies for achieving success, the hospital representatives could go back to their organization with new suggestions to reinvigorate the effort. Hospital participants repeatedly said that sharing information across organizations was the biggest benefit of the falls prevention workshops.
Hospitals reported particular benefit from others’ expertise developing a list of medications likely to increased a patient’s risk of falling and sharing tips for using the list. Workshop participant Temple University Health System, Philadelphia, was instrumental in developing the list and providing its strategies to the other hospital participants (see the sidebar “Health System Tackles Medications that Contribute to Risk of Falling” for more information).
Effective Interventions
Hospitals involved in the falls prevention project had access to a password-protected web site where they could post their falls prevention policies and toolkits, share measures for monitoring the effectiveness of falls prevention strategies, and review the falls interventions identified by the workshop participants. ECRI Institute also provided a research summary on patient falls in healthcare facilities and a synthesis of evidence supporting various assessment and prevention measures. The report was also available on the collaborative’s shared web site.
Among the 60-plus falls prevention strategies identified as particularly effective by the participating hospitals are the following:
- Develop a formalized methodology for therapy services (for example, physical therapy, occupational therapy) and nursing to integrate a patient’s falls risk assessment.
- Develop and implement a list of medications likely to increase a patient’s risk of falling for nurses to use as a reference when assessing a patient’s falls risk.
- Enlist the pharmacy department to place stickers on medications indicating high falls risk.
- Retrospectively track falls related to medications to identify high-risk medications and add them to the high-falls-risk medication list.
- Utilize white boards at the nurse’s station to identify patients at high risk of falling.
- Clip a color-coded visual identifier for high falls risk to wheelchairs and stretchers during transport of high-falls-risk patients.
- Develop a laminated pocket guide with the organization’s falls prevention policy and procedures for physicians and nurses.
- Question family about patient behaviors related to time of day (for example, expected behaviors at morning and evening hours).
- Implement hourly rounds to assess or to address patient’s personal needs (for example, toileting needs).
- Implement a patient sitter program for patients at high risk of falling who do not adhere to falls prevention interventions.
- Require housekeeping staff to perform routine checks to ensure bed alarms are working properly.
- Develop a tool for family and staff to identify patient behaviors that may result in fall.
- Educate all staff regarding the use of visual identifiers for high-falls-risk patients.
- Implement an education campaign on the organization’s falls prevention program that includes new, existing, and per-diem staff.
- Provide follow-up education for staff members who do not adhere to falls prevention measures.
- Incorporate role-playing in staff education (for example, rub petroleum jelly on eyeglasses to demonstrate a patient’s visual impairment and risk of falling).
Measuring and Sustaining Success
The 15 participating hospitals conducted self-assessment surveys at the start of the workshops and after the 7-month initiative was completed to evaluate their progress in the areas of culture, infrastructure, and practices related to falls prevention. The surveys did not measure falls rates, although the participating hospitals are tracking this information on their own. The results of the self-assessment survey indicated significant progress in falls prevention awareness and identified an overall 8% improvement in the follow-up score compared with the baseline score.
The greatest improvements were in the organizations’ culture to support falls prevention. The surveys identified progress in areas such as caregivers receiving education and training to reduce patients’ risk of falling (13.8% improvement overall), hospitals employing effective strategies to promote falls awareness among staff (17.6% improvement), and caregivers receiving feedback about the effectiveness of their hospital’s strategies to reduce the risk of falls (9% improvement).
The self-assessment surveys also measured approaches in the general areas of the infrastructure to support falls prevention and practices used for falls prevention and found improvement in both areas. Some of the significant gains included providing caregivers with a list of medications likely to increase a patient’s risk of falling (43.9% improvement), enlisting the pharmacy staff to alert caregivers if a patient’s medication profile indicates a high falls risk (104.8% improvement), providing information to a patient and the patient’s family about the interventions used by caregivers to reduce that patient’s risk of falling (10.6% improvement), and seeking input from a physical therapist if the caregiver identifies a patient with mobility difficulties during a falls assessment (26.2% improvement).
The PPC continues its work in developing patient safety solutions to high-risk and error-prone processes. In 2008, the regional partnership turned its efforts to developing solutions for preventing wrong-site surgery and pressure ulcers. The hospitals in the Philadelphia region enthusiastically support the efforts that provide visible demonstration of hospitals’ commitment to patient safety within their communities while enhancing the region’s recognition as a patient safety leader.
Kathryn Pelczarski is director of ECRI Institute’s Applied Solutions Group and spearheads ECRI Institute’s efforts in the Partnership for Patient Care’s patient safety projects.
Cynthia Wallace is senior risk management analyst with ECRI Institute’s risk management services. ECRI Institute (formerly ECRI), a Plymouth Meeting, Pennsylvania-based nonprofit organization, dedicates itself to bringing the discipline of applied scientific research to healthcare to uncover the best approaches to improving patient care. For additional information on the Philadelphia region’s collaborative patient safety projects, contact Pelczarski at kpelczarski@ecri.org.
References
Centers for Disease Control and Prevention. (2008, April 25). Falls among older adults: an overview. Available at http://www.cdc.gov/ncipc/factsheets/adultfalls.htm
Centers for Medicare & Medicaid Services. (2008, August 19). Medicare program; changes to the hospital Inpatient Prospective Payment Systems and fiscal year 2009 rates [final rule]. 42 CFR §§ 411, 412, 413, 422, 489. Available at http://edocket.access.gpo.gov/2008/pdf/E8-17914.pdf.
Landro, L. (2005, March 3). Hospitals aim to curb injuries from falling; risk for young patients. Wall Street Journal, Sect. D, 1,7.
National Safety Council. (2005, February 14). National Safety Council joints U.S. Consumer Product Safety Commission to reduce elderly falls and injuries. Available at http://www.nsc.org/news/nr021405.aspx