Preventing Falls in the hospital setting Emily Geesner, Cristy Rose, Renee Floresta, Kara Saba, Elizabet Iankova, and Stephen Christie

Proposed Change After reviewing fall statistics in several facilities in the Bay Area and the protocol for assessing a patient’s fall risk, a lack of follow through with the patient in understanding and evaluating their capabilities is evident. When looking at other models for patient safety, it was found that adding a self-awareness of falls risk measure (SAFRM) and a Patient Assistance Agreement helps to facilitate a safe environment for the patient. The proposed plan would help decrease falls and increase patient awareness of the risks of unassisted movement.

Challenges Protocol changes may be resisted by staff who are accustomed to the standard Morse Fall Risk assessment tool. Development of a new charting mechanism that incorporates the SAFRM tool. Implementing both the SAFRM tool and the Patient Assistance Agreement may initially take more time during the admission process.

Plan: Supportive Literature Mihaljcic et al. (2015), conducted a study to characterize self awareness and factors associated with reduced self awareness of falls risk in the older adult population. Ninety-one participants, aged 60 years or older, across three inpatient rehabilitation facilities were studied. Three aspects of self awareness: intellectual, emergent, and anticipatory, were measured using the Self-Awareness of Falls Risk Measure (SAFRM). Results of the study showed that 59% of the sample underestimated their risk for falls, 39% had good overall self awareness of falls risk, and only 3% overestimated their risk for falls. Based on the results of the study, the researchers concluded that a significant proportion of the older adult population underestimates their risk for falls, and that underestimation of risk for falls was relatively uncommon. Factors found to be associated with reduced self awareness of falls risk were: being a man, higher educational attainment, neurologic history, lower cognitive ability, and lower functional ability.

Plan: Supportive Literature Physiotherapists and occupational therapists and patients at risk for falls each completed a survey regarding the patient’s capabilities and used to create their SAFRM score. Higher numbers indicate the patient is overestimating their abilities or underestimating their fall risk and negative numbers indicate the opposite; that the patient is underestimating themselves and overestimating their fall risk. A score of zero indicates perfect agreement between clinician and patient. Discrepancies of SAFRM scores are consistent with clinician reported patient awareness. This provides validity for the study to be generalized to real-life settings. This tool can help give nurses a greater idea of who is more likely to fall compared to the standard clinician only fall risk assessment.

Plan: Supportive Literature Nurse manager Janiel Wright and her team at the University of Utah’s Orthopaedic Center first implemented the Patient Assistance Agreement in 2009. After implementation of the agreement, the Orthopaedic hospital went seven months without a single fall incident. The Patient Assistance Agreement document is a written understanding between providers and patients that formally acknowledges and agrees to call for help when they feel the need to get out of bed. The pilot project lasted two years, from 2009 to 2011 reporting only 2 falls during that time, one of which was an assisted fall. The Patient Assistance Agreement document was proven to have a larger impact on patients than just a simple verbal warning. The project was so successful that Patient Assistance Agreements are now being used on many units within the hospital.  

DO: Evaluate Determine how many falls occur annually in the facilities of the Bay area for the proposed change. Assess nursing satisfaction through the use of a survey that evaluates both the positive and negative feedbacks for using the self-awareness of falls risk measure (SAFRM) and a Patient Assistance Agreement before and during implementation. Create an evaluation tool to document falls during a 30 day period and compare results each month from the previous months to assess the level of success of the SAFRM and Patient Assistance Agreement. Nurses will be assessed on education provided and documented regarding the Patient Assistance Agreement after completion of the SAFRM.

Do: Educate Nursing staff should be required to take an educational class on the SAFRM, reinforcing the concepts of intellectual, emergent, and anticipatory awareness and how to accurately score a patient in these categories. EBP should be provided. This class can be put on by physical therapists and nurse educators. A nurse manager can present the Patient Assistance Agreement to nursing staff, providing education on it and instructing that it must be signed by every patient that is not independent and/or at risk for falls admitted to the floor. The nurse must be a witness to signature and teach back should be done by the patient before signature is completed.  

DO: Engage Do: Pilot Program Staff buy-in will be facilitated through physical therapists, nurse educators, nurse managers, chief nursing officer (CNO), and charge nurses by stressing the importance of the change, making the change, and enforcing it.   Do: Pilot Program Nursing staff on Med-Surg, ER,  ICU, and CCU units.

DO: Implement Nurses provide thorough education to patients of the SAFRM concepts. The patient and nurse will complete the SAFRM during admission, the computer system will generate the SAFRM score to get an accurate representation of awareness. Education will be made to the patient about overestimating or underestimating their abilities based on the score calculated. Nurses will provide the Patient Assistance Agreement to every fall risk patient after completion of the SAFRM. The patient must provide teachback on the agreement to the nurse, as well as provide a signature of understanding that will be witnessed by the nurse. A copy of the agreement will hang in the room, reminding the patient of their written agreement and another will be placed in the patient’s chart. Either completion or failure to agree should be mentioned in shift changes and in multidisciplinary rounds so that further plans of action to prevent falls can be discussed.

Study During the 30 day implementation period: Determine how many falls occurred in the past year. Implement the SAFRM and Assistance Agreement concepts. Compare the results from the month before the implementation period and during. Measure the reduction in falls by each week. Keep a graph to show visual aid of the progress. Any changes will be made in the plan if necessary to find the perfect solution based on the SAFRM results, and patient surveys.

Plan of Action Nurses will attend education classes for the SAFRM and Assistance Agreement implementation. Nurses must educate the patients about the SAFRM, along with teach back and must sign the separate Patient Assistance Agreement to acknowledge their risk for falls. Agreements will hang in the patient’s rooms as a reminder system to both patient and nurse. Any falls must be reported to the leaders in charge of the implementation i.e. the charge nurse and nurse manager. Falls that occur during shift will be mentioned during huddles so that the charge nurse can review the SAFRM with the nurse and evaluate effective use of the tool. Rewards for compliance could be given to motivate the nurses and to reduce burn out.

References Mihaljcic, T., Haines, T.P., Ponsford, J. L., & Stolwyk, R. J. (2014). Development of a new self- awareness of falls risk measure (SAFRM). Archives Of Gerontology And Geriatrics, 59 249- 256. doi:10.1016/j.archger.2014.06.001 Pearce, Chief Nursing Officer, University of Utah Healthcare, M., & Grob, K. (2011). Prevent Falls With Signed Patient Agreements (Rep. No. 25). Retrieved February 22, 2016, from The University of Utah Healthcare website:http://healthcare.utah.edu/nursinginnovation/2011/10ideas/eight.php Self-Awareness of Falls Risk Among Elderly Patients: Characterizing Awareness Deficits and Exploring Associated Factors. (2015). Archives of Physical Medicine & Rehabilitation,96(12), 2145-2152 8p. doi:10.1016/j.apmr.2015.08.414