Falls Program Virtual Breakthrough Series 2: (BTS 2) Reducing Preventable Falls and Fall Related Injuries National Center for Patient Safety & VISN 8 Patient Safety Center of Inquiry Wednesdays, starting January 9, p

Julia Neily, RN., M.S., M.P.H. Julia Neily, RN, MS, MPH, has worked for the VA in various nursing roles for 26 years. She is currently the Associate Director of the NCPS Field Office. She joined the VHA National Center for Patient Safety in 2002 and has focused on fall and fall related injury prevention and evaluation of patient safety efforts such as cogni­tive aids, Ensuring Correct Surgery and Medical Team Training. Julia has a BS in Nursing from the University of New Hampshire, a Master of Science from New Hampshire College and a Masters of Public Health from Dartmouth Medical School.

Pat Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP Patricia Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP, Associate Director, VISN 8 Patient Safety Center of Inquiry, is both a Clinical Nurse Specialist and a Nurse Practitioner in Rehabilitation. As Associate Chief of Nursing for Research, she is also a funded researcher with the Research Center of Excellence: Maximizing Rehabilitation Outcomes, jointly funding by HSR&D and RR&D. Her contributions to patient safety, nursing and rehabilitation are evident at a national level – with emphasis on clinical practice innovations designed to promote elders’ independence and safety. She is nationally known for her program of research in patient safety, particularly in fall prevention. The falls program research agenda continues to drive research efforts across health services and rehabilitation researchers.

Acknowledgements National Center for Patient Safety VISN 8 Patient Safety Center or Inquiry Office of Nursing Services Home Based Primary Care Inpatient Evaluation Center Office of Mental Health Services and Operations. VAMCs Faculty You! 4

FBTS -2 Program Goals: Improve your organization’s infrastructure and capacity to reduce fall-related injures. Enhance environmental safety. Mitigate or eliminate modifiable fall risk factors. Assure reliable handoff communication about patients’ fall and injury risk. Integrate patient (family) as a partner in their fall prevention program. Reduce rate of repeat falls. Quantify impact of program changes. 5

Your Team Goals Each VAMC team will select the goals that you want to work on during this 6 month period. All teams do not need to work on all the goals, but rather are encouraged to select the goals that are congruent with you organization’s fall and injury prevention program needs. 6

Looking Ahead Ten Sessions of Learning and Sharing Jan 9 th : Improved Organizational Infrastructure and Capacity for Fall Prevention Programs Jan 23 rd : Ensuring a Safe Environment Feb 6 th : Mitigate or Eliminate Modifiable Fall Risk Factors, Part 1 Feb 20 th : Mitigate or Eliminate Modifiable Fall Risk Factors, Part 2 Mar 6 th : Reduce Moderate to Serious Injuries for Vulnerable Populations Mar 20 th : Clinically Relevant and Reliable Handoff Communication: Let’s Talk about Falls and Fall-related Injuries Apr 3 rd : Patients/Families as Full Partners in Fall Prevention Apr 17 th : Post Fall Management: Reducing Repeat Falls May 1 st : Fall Program Evaluation May 15 th : Sharing Program Successes June 5 th : Sharing Program Successes June 19 th : Extra Call if needed 7

8 Session Design Welcome and share innovations Work in Hospital Teams Facilitated Learning with Coaches Learn and Share Together Suggested assignments at end of each session Questions and answers Engage each other online

Session 1: Improved Organizational Infrastructure and Capacity for Fall Prevention Programs Objectives Overview of Falls Breakthrough Community (FBC) Alignment of FBC to National VA's Initiatives Link Aims to FBC Learning Sessions Use of Assessment Tools for Strategic Planning 9

Content This session is designed to introduce interdisciplinary teams to this National Falls Breakthrough Series 2 purpose, goals, structure and expectations. An overview of national VA and non-VA Initiatives in Patient Safety and Falls Injury prevention will confirm the direction of this curriculum. Interdisciplinary teams will increase their access and use of existing surveys and results to continue to improve programs, patient-centered individualize care, and interdisciplinary care practices. An overview of the state of science in fall prevention and injury protection will set the stage for new tests of change for clinical practice, patient education, and environmental safety.

Overview of the Falls Breakthrough Community Structure, Process, and Outcomes Change Package Curricula Hospital Teams Couches: Clinical and Improvement Assignments as Learning Opportunities Expectations

Overview: National VA and non-VA Initiatives in Patient Safety and Falls Injury prevention Fall and Fall Related Injury Prevention National fall and fall related injury rates Improve NCPS database; SPOT related to falls VANOD post fall note collaboration

Preventing Falls: Call for Action Transform healthcare for frailty associated with old age. Prevent falls identified as an effective strategy. BUT, major area for improvement in routine practice. – 2003: IOM: Priority areas for national action: transforming health care quality Multifaceted and individualized fall prevention programs used inside and outside hospital setting. Thorough review of the strategies revealed they lack strong empirical evidence. – Clyburn, T.A., & Heydemann, J.A. (2011). Fall prevention in the elderly: Analysis and comprehensive review of methods used in the hospital and the home. J. of Am. Academy of Orthopedic Surgeons. 19(7):

Compelling Need In the hospital setting, approximately 3%-20% of inpatients fall at least once during their stay This translates into 4-12 falls per 1000 bed days of care Clyburn, T.A., & Heydemann, J.A. (2011) In April, 2011, CMS reported that falls with harm were the top adverse event in hospitals In VA, Falls is the #1 RCA event VA now has a national repository for falls data IPEC: rates, ranges At present, the largest and only comparative database is ANA’s NDNQI

NQF’s Safe Practices (2010) Falls occur frequently in hospitalized patients and LTC residents and are the leading cause of injury- related death for individuals over 65 yoa (CDC, 2006) Patients in LTC and hospitals fall 3 times more than the community dwelling persons age 65 and older All ages of patients are admitted to oncology, critical care, and infectious disease units are at risk for falls In 2009, The Joint Commission reported falls at the 6 th most commonly reported sentinel event Death occurs in 15% of elderly who fall in the hospital and 33% do not survive beyond one year of fall

Patient Falls and Injuries State of the Science Overview of current body of knowledge about reducing falls and fall injuries in hospitals

Preventing Falls: Call for Action Transform healthcare for frailty associated with old age. Prevent falls identified as an effective strategy. BUT, major area for improvement in routine practice. ─ 2003: IOM: Priority areas for national action: transforming health care quality Multifaceted and individualized fall prevention programs used inside and outside hospital setting. Thorough review of the strategies revealed they lack strong empirical evidence. ─ Clyburn, T.A., & Heydemann, J.A. (2011). Fall prevention in the elderly: Analysis and comprehensive review of methods used in the hospital and the home. J. of Am. Academy of Orthopedic Surgeons. 19(7):

Must Reads: Clinics in Geriatric Medicine, Nov D. Oliver, et al. Falls and fall-related injuries in hospitals. (2010, Nov). Clinics in Geriatric Medicine Clinical Nursing Research, An International Journal. 21(1) Feb. 2012: Special Issue: Falls in the Older Adult. Spoelstra, S. L., Given, B.A., & Given, C.W. (2012). Fall prevention in hospitals: An integrative review. Clinical Nursing Research. 21(1) ) Clyburn, T.A., & Heydemann, J.A. (2011). Fall prevention in the elderly: Analysis and comprehensive review of methods used in the hospital and the home. J. of Am. Academy of Orthopedic Surgeons. 19(7):

Hospital Falls: D. Oliver, et al. Falls and fall-related injuries in hospitals. (2010, Nov). Clinics in Geriatric Medicine. 80% - 90% are unwitnessed 50%-70% occur from bed, bedside chair or transferring between the two; whereas in mental health units, falls occur while walking Falls result in Increased LOS, higher rates of DC to institutional care, and greater amounts of healthcare resource use 19

Falls Rates (Oliver, et al., 2010) Acute Hospitals: ─ Range falls per 1000 OBDs (single observational studies in hospitals) ─ Range 3-5 falls per 1000 OBDs (multihospital studies) Mental Health Units ─ Range 2 – 4 falls per 1000 OBDs ─ Psychogeriatric units falls per 1000 OBDs Rates are the best way of facilitating comparisons between hospitals of different sizes Represent well over 1000 falls each year in a large acute hospital Perhaps as many as 1 million falls in hospitals per year

Injuries from Falls 30% to 51% of falls result with some injury Proportion of falls resulting in any fracture range 1%-3% Hip Fractures are 1.1%- 2% Proximal femoral fractures due to falls in hospitals result in poorer health outcomes than those that occur in the community Even soft tissue injuries or minor fractures cause significant functional impairment, pain and distress Minor or no injuries from falls can mark beginning of negative cycle – FOF, Debility

Ability to Predict Falls Risk screening vs. Risk assessment Type of Fall In-depth tool validity analysis by Oliver, et al., 2010, suggested need for Comprehensive Fall Risk Assessment to identify modifiable and nonmodifiable risk factors

Empiric Evidence for Fall and Injury Prevention in Hospitals Multifactorial components with multiprofessional input mostly seen in successful trials (note * no two trials bundle the same interventions) ─ Post fall review, patient education, staff education, footwear advice, toileting A couple of trials included medication review and prevention and detection of delirium Patients themselves favored multifactorial approach reviewed by a health professional

Multi-Professional Involvement is Essential No hospitals trials that focused solely on changing nursing practice succeeded in reducing falls or injuries, as is also the case in care home settings

Single Interventions in Hospitals Exercise or Additional PT (RCTs insufficiently powered to detect effect in reducing falls) Increased observation or assistance – intuitive sense but anectodal Patient Education – multi- media education with trained health professional follow-up has promise to be beneficial in preventing falls Specialist Support to Manage Dementia – only 1 trial, no difference Cal / Vit D: effect determined after discharge Hip Protectors (no trials in acute care; adherence issues in hospitals) Flooring to reduce impact: promising Medication Review and Adjustment: requires specialist pharmacist Prevention and Management of Delirium Reducing sedative and hypnotic medications

Single Interventions without Empiric Evidence Continence management or promotion Education and training for staff or relatives Correction of visual impairment Recognition or management of dizziness, syncope, pre-syncope, or postural hypotension Attention to footwear Environmental modifications (including flooring materials) to prevent falls or injuries

Where is the evidence for medical interventions? Multifaceted and individualized programs have been created to prevent falls in the elderly. Many of these interventions are based on expert opinion and statistical trends. ROL revealed that the risk of fall is only slightly greater in the hospital environment than in the home. There is no medical evidence that evidence-based guidelines are effective in fall prevention. Clyburn, T.A., & Heydemann, J.A. (2011). P. 402

Limits to Science Research methodology Issues: design and conduct of studies Lack of control for effectiveness analysis Over generalizing fall as the outcome (fall vs. non-fall) Interventions based on category of risk (not specific risk factors) Fall prevention is usually a complex intervention Falls are rare outcome (affects sample size and power)

2010 Cochrane Review Inconclusive Evidence Hospital fall prevention interventions: Inconclusive evidence Provided no recommendations regarding fall prevention interventions in the hospital setting Cameron, I., et al., Intervention for preventing falls in older people in nursing facilities and hospitals. Cochrane Database for Systematic Reviews 1, Art. No.: CD

Clinical Judgment Evidence-based Practice – Vs Results of Scientific Inquiry 30

New Tests of Change Clinical Practice Patient Education Environmental Safety 31

Interdisciplinary Teams Access and use of existing surveys and results to continue to improve programs, patient-centered individualize care, and interdisciplinary care practices. What are these surveys and results: IPEC Database/Proclarity Cube NDNQI Data: Program Analysis of Fall Occurrences (excel spreadsheet): Individualized Care, Interdisciplinary Care Practices Team Effectiveness Organizational Self Assessment Fall Data Analysis (IHI)

33 Results of Organizational Assessments: Preventing Falls with Injury VISN 8 PSCI: Organizational Self Assessment Tool – Infrastructure and Capacity IHI Injurious Fall Data Collection Tool LS Team Characteristics Tool Let’s review these tools!

Aggregated Results of Questionnaires To be added

Overview of Next Session: #2 Presentation: Ensure a Safe Environment Faculty: Levanne Hendrix, PhD, ARNP, Palo Alto VA Pat Quigley, PhD, ARNP, CRRN, Assoc. Director, VISN 8 PSCI Objectives: Differentiate environmental safety for preventing fall vs. reducing injuries from falls Link environmental assessment to type of fall: accidental falls Review strategies for environmental safety assessment 35

Homework Assignments from this Session to report and next session Declare aim for falls work organizational level and unit level program attributes. Determine the top 3 opportunities to enhance your program at the Unit and Organizational Level. (share in Session Develop a strategic plan for action for each of the 3 prioritized opportunities. Complete baseline Team Leadership Characteristics Assessment 36

Next Session January 23 rd, 2p-3:30p Eastern Ensure a Safe Environment 37