Fall Prevention: No, Falls Are Not Inevitable
March/April 2013
Special Advertising Section
Fall Prevention: No, Falls Are Not Inevitable
Patients fall. It’s a fact of hospital life. Weakened by illness or surgery, confused by medication or aging, patients try to do more than they can and the result is often a fall. It might be a fall from bed, a fall while trying to walk unsupported, a fall when trying to get up from a chair. These things happen all too regularly. As caregivers, your job is to prevent those falls from happening.
Jim Hendrich, president of AHI of Indiana (www.ahiofindiana.com) has been working with hospitals related to the assessment of fall risk and fall prevention for over a decade. He notes, “We’re starting to see hospitals embrace fall prevention in a way that is fairly proactive. Hospitals are now starting to look at patients as individuals rather than clustering them into a fall group or a non-fall group; nursing is viewing fall risk in a person-centered approach by asking, ‘Can we identify true fall-risk factors present in the individual, and if so, we can incorporate interventions—matched against the identified risk factor(s)—into a specific care plan around that patient.’ If we know who is at risk, what risk factors are present, and when that risk is likely to occur, then there may be a way to eliminate preventable falls.”
Initial assessment to determine risk of falling is required at admission. AHI offers its Hendrich II Fall Risk Model (H2Model) to help in this critical evaluation. Hendrich explains, “We often learn from our partners that the lack of re-assessment during a patient stay when anticipated or documented changes in acuity related to fall risk can lead to a fall event. The ‘gap’ in re-assessment can put patients in jeopardy when fall risk has changed from the previous assessment, and the appropriate interventions are not in use. A proactive approach can help reduce harm to patients, facility liability, control costs, while helping to demonstrate adherence to national standards and regulatory guidelines to improve the quality of patient care.”
In a hospital setting, nursing is required to do a variety of assessments related to medication administration, pain management, pressure ulcers, mobility, and the patient environment that can be directly related to fall risk. “We encourage nurses to make assessment and re-assessment part of the overall nursing process every time you’re interacting with a patient,” acknowledges Hendrich. “The patient has a responsibility in the care that is delivered as well. Nurses have an opportunity to have a meaningful conversation with the patient about fall risk factors that may be unique to both the patient and the care setting. This dialog may help the patient and families have a better understanding about the care that is being provided by clinical staff to achieve the appropriate outcome while keeping patients safe.”
Many AHI customers requested that they develop a patient education delivery system that supports the fall program. “I think it’s just as important that we approach it not only from the clinical side but also on the patient side to raise awareness,” says Hendrich. “From our perspective, when a discussion can occur between providers and patients related to fall risk factors, there is a real possibility that the patient experience can be improved. We would encourage physician groups that utilize nurse practitioners in primary care practices to take advantage of the opportunity to engage patients who may be at risk. They can have a meaningful conversation with the patient about what their risk factors are, present strategies that can support a prevention and wellness program for the individual, and then develop a care plan to address those factors throughout various care settings.”
“Specifically related to falls, we encourage nurses to focus on the patient who presents with risk factors in three distinct areas: intrinsic or pathophysiological factors, medication review, and patient mobility based upon the research. Evaluating fall data in this way may help provide clinical staff with information that can help identify trends for further study.”
Hospitals are making strides to get their fall rates down. National averages continue to fall, but there is still work to be done. “We’ve have hospital systems that have reduced their fall rates by 80 percent since they first started with us,” claims Hendrich. That success occurs when organizations are provided with the right resources; establish goals and strategies that support a culture of safety, and the determination of the entire organization to make a difference.
As Anna Hagopian, MSN, RN, director of medical/surgical services at MetroWest Medical Center, Framingham, Mass. says, “There is always an opportunity for facilities to make their environment safer for staff and patients in regards to fall prevention. There is not always one solution; it is a combination of solutions that we have found that has been successful. We start by figuring out early on if a patient is at risk for a fall by using fall assessment tools, history of falls, changes in medication, by looking at the entire picture. We make sure all staff members are educated—teamwork is stressed, making sure the entire team knows that a potential fall is everyone’s responsibility. It is vital to make sure the family and patient are educated and on board with the plan.”
Everyone may not play the same role in prevention, but everyone definitely has a role to play. And so does technology. At MetroWest, one of the approaches is the use of technology from EarlySense, Waltham, Mass. (www.earlysense.com). Hagopian recalls, “EarlySense has been helpful in the fact that it has allowed us to give every one of our beds the capability to have a bed exit alarm function without the staff having to search out proper equipment. It also shows us increased movement by a patient—that could potentially identify increased agitation in someone who had not been agitated in the past so we can treat them sooner.”
She adds, “The other feature that is so helpful is when a bed exit alarm goes off, the staff are paged on their beepers as to where the alarm is by room number. Prior to EarlySense we had to waste precious seconds listening to determine what direction to go by the sound of the alarm. We can also set the sensitivity of the alarm from 1 to 6—with 1 being the patient is already out of the bed to 6 where the patient barely moves their arm and it sets off the alarm. That can be extremely helpful.”
Tim O’Malley, president of EarlySense, explains the system. “The sensing technology is built into the bed or into a chair, and it is not intrusive to the patient. There’s no cord on the patient, there’s no switch activation. There’s simply a sensor that’s monitoring body movement of the patient as well as heart rate and respiration. Our monitors are at the bedside, and once you set that monitor, it’s networked into a full-blown system with a central station device that will activate a mobile phone or a pager of an individual caregiver that’s assigned to the patient.”
Hagopian adds, “Initial training and ongoing training is crucial and the biggest part is making sure you are creating a culture of safety within your facility. The EarlySense system has a feature where it produces reports to our managers on how quickly bed exit alarms are answered, who was actually put on an alarm, and the day and time. That is very helpful for auditing how the staff are doing. The reporting is not meant to be punitive; it helps to show where your potential weakness could be, where more training can be helpful.”
The EarlySense system offers more than just bed-exit information. It also can monitor respiration and heart rate. O’Malley comments, “It allows the staff to capture heart rate and respiration so they can not only monitor and be alerted for potential falls, but they can also be alerted for any kind of vital sign deterioration that may be occurring as well. We have a sensor plate, which is about the size of a pad of paper, that goes underneath the mattress and that sensor will be able to monitor, display, and transmit the patient’s heart rate, respiration, and motion, all individualized for the patient.”
Many facilities have tried using CNAs or even volunteers to act as “sitters” to monitor a patient at high risk for falls. According to Hagopian, “Sitters are definitely not the best way to help prevent falls, and I think the literature helps support that. It has been shown that falls occur even with a sitter right there with a patient. Again it is all about education, and compliance of the staff. I have said many times that it takes a culture of safety, and that starts by getting staff onboard throughout the hospital and making safety a priority from the top down.”
Agreeing with Hagopian is Laura Vento, assistant manager of quality, medical-surgical division of the University of California-San Diego Medical Center-Hillcrest. “First of all, we’re concerned with patient safety and we kept seeing that, even though we had sitters on patients, they were still falling, they were still pulling out lines and tubes. We could see this approach wasn’t working. And when we looked at our sitter usage against sitter usage in other UC hospitals, we are overwhelmingly number one. Our sitters are CCPs, Clinical Care Partners, but essentially nursing assistants. We use more than 65 full-time equivalents, basically 65 people with the full-time job of being sitters, which didn’t seem to be working very well to begin with.”
Vento began a search for a different way. “I was particularly interested in video monitoring with two-way audio,” she recalls. “That way a person could watch multiple patients and have the option to talk to them and try to redirect them. If you’re watching a screen and something is happening with the patient, you can’t yourself do anything but you can call the nurse right away, call the desk, call a nursing assistant who is nearby, to help them.”
But watching a monitor remotely isn’t an end in itself. “We still need to do everything we always do to try to keep our patients safe from falls or from pulling things out,” Vento admits. “So we make sure we have the bed alarm on, make sure we’re doing purposeful hourly rounding where you check to see if the patient is in pain, needs to use the bathroom, needs to be repositioned, has everything they need in their reach, things like that. The video is a supplemental resource for patients who are at risk for falling or at risk for pulling lines and tubes.”
UC-San Diego Medical Center embarked on a pilot program with Avasure, Belmont, Mich. (www.avasure.com), using their AvaSys mobile video carts. All units feature a pan, tilt and zoom camera; digital two-way audio speaker; microphone; LED lights; chime; and infrared light for low-light viewing. The camera can take in a full room view, and the monitor can pan and zoom on details, even readings on bedside monitors.
The hospital created a process whereby Vento and others review patients and determine whether they would be good candidates for video monitoring. “Patients we have found to be good candidates for video monitoring are those who are confused but redirectable, and dementia patients are a great population for that,” states Vento. “Those who really benefit from human sitters are extremely impulsive, with critical tubes and lines, and are not redirectable.”
The Hillcrest facility has six portable video monitors. Vento laughingly says, “Basically they look like IV poles with cameras and two-way audio boxes on them.” The six carts are deployed across nine units on six floors encompassing about 120 beds.
The observation station is on the sixth floor. Both the units on that floor no long use CCPs or nurse assistants, so the CCPs were trained as monitor techs. All are CNAs who have been sitters so they have a better idea of what to look for, and what behavior might not be appropriate.
“At first I was skeptical but thanks to great support from AvaSure we have implemented processes and trained our observers and we’re 100 percent confident AvaSys will reduce falls and save us money,” notes Vento. “Everyone at AvaSure has been really great about helping us with different resources and trying to connect us with people who have been doing the same projects.”
But no system should work alone to prevent patient injury. At Hillcrest, they take a larger view of the problem. According to Vento, “We have an evidence-based practice focused on things that have been proven in the research, in the literature, to help reduce patient falls and then adding our own clinical expertise on what works well on our units. We have guidelines and assessment tools; if we assess a patient is at risk for fall, we look at the individualized risk factors and educate the patient about it. It’s about being able to have that really honest, caring conversation with the patient.”
Could we move faster? “Absolutely because we are still having people getting hurt,” admits Jim Hendrich. “But I think we can say we now know why patients are at risk and how we can start to apply true interventions, true precautions, true communication tools to the process of how we identify fall risks and how we help provide a safe environment. More important, how to talk to patients about managing risk in a way that is meaningful and has the ability to mitigate or eliminate some of those risk factors to keep them safe.”
Tom Inglesby is an author based in southern California who writes frequently about medical technologies and improvement strategies.