1. Spotlight Falling Through the Crack (in the Bedrails)

2. Source and Credits This presentation is based on the May 2016 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm ○ CME credit is available Commentary by: Patricia C. Dykes, PhD, RN; Wai Yin Leung, MS; and Vincent Vacca, RN, MSN, of Brigham & Women's Hospital ○ Editor, AHRQ WebM&M: Robert Wachter, MD ○ Spotlight Editor: Bradley A. Sharpe, MD ○ Managing Editor: Erin Hartman, MS 2

3. Objectives At the conclusion of this educational activity, participants should be able to: Review the epidemiology of patient falls and associated injuries in the hospital setting Describe the three-step fall prevention process Identify fall prevention best practices for use in the hospital setting Discuss a strategy for communicating the tailored fall prevention plan to all care team members, including patients and families 3

4. Case: Falling Through the Crack A 65-year-old woman with cirrhosis presented to the hospital with septic shock and respiratory failure. She was placed on a mechanical ventilator and admitted to the ICU. In order to administer medications, a nasogastric tube was also inserted. Although receiving medications for sedation, the patient was disoriented, and restraints were placed on her wrists to prevent her from pulling out key lines or tubes. On examination, she was found to have ascites, and the team decided to perform paracentesis to rule out infection. 4

5. Case: Falling Through the Crack (2) The intern and resident on the team worked together to prepare the patient for the procedure. The bedrail on one side was lowered, and the wrist restraint on that side was removed to facilitate the procedure. The procedure went smoothly without any complications. The intern and resident cleaned up the materials from the procedure and left the room. Moments later, multiple alarms went off in the patient's room. Nurses ran into the room and found her confused and trying to get out of bed. 5

6. Case: Falling Through the Crack (3) The patient had pulled out the nasogastric and endotracheal (breathing) tubes. Her leg was stuck in the bedrail, and she had a large laceration on her foot. Her oxygen saturation fell rapidly, requiring urgent re-intubation, and she was safely placed back on the mechanical ventilator. The nasogastric tube was replaced, and her foot laceration was sutured. The patient slowly improved with antibiotics and supportive care. She was discharged to a nursing facility 10 days later. 6

7. Case: Falling Through the Crack (4) In a review of the incident, it became evident that, after the procedure, the patient's wrist restraint was not replaced and the bedrail had been left down. In addition, the team had not communicated with the bedside nurse about when they would be performing the procedure or when they had finished it. The institution wondered what steps could be taken to prevent a similar incident in the future, as well as what were best practices for preventing inpatient falls. 7

8. Background: Inpatient Falls Falls are a major health problem globally and hospitalization increases the risk for falls The National Database of Nursing Quality Indicators (NDNQI) defines patient falls as: –An unplanned descent to the floor with or without injury to the patient Patient falls occur in approximately 2% of hospital stays Up to 1 million hospitalized patients fall annually in the United States 8

9. Injuries From Falls in Hospital Approximately 30% of falls result in injury Common fall-related injuries associated with morbidity and mortality include fractures, subdural hematomas, and excessive bleeding Falls with injuries are estimated to add 6.3 days to the hospital stay The average cost for a fall-related injury is $14,000 9

10. Falls That Are Not Preventable Falls can be classified as preventable or not Falls that are not preventable are caused by a new or previously unrecognized medical condition – Such as myocardial infarction, syncope, or seizure – These account for up to 8% of all falls in the hospital 10

11. Preventable Falls in the Hospital Preventable falls include –Accidental falls (14%) –Anticipated physiological falls (78%) Accidental falls include slips and trips caused by environmental factors (e.g., food or liquid spills) Anticipated physiological falls are caused by known physical factors 11

12. Anticipated Physiologic Falls The Morse Fall Scale (MFS) can identify individual fall risk factors The MFS can predict the risk for anticipated physiologic falls The MFS can then guide personalized interventions to prevent falls 12

13. Risk Factors for Inpatient Falls Physiologic risk factors for falls include: –Gait instability –Lower limb weakness –Urinary incontinence or frequency –Need for assisted toileting –Previous fall history –Agitation or confusion –Medication adverse effects 13

14. Optimal Fall Prevention A previous WebM&M commentary (2003) discussed patient falls Fall and related injury rates have not changed much since 2003, but there is new evidence regarding how to prevent falls Specifically, optimal fall prevention in the hospital involves a three-step process 14

15. Three Step Process to Prevent Falls 15

16. Risk Screening Ensuring an accurate fall risk screening occurs early in the hospitalization is essential The assessment of risk is usually performed by the nurse and integrated into the clinical documentation system Evidence suggests that one root cause of patient falls is poor communication of the fall prevention plan and failure to follow the plan 16

17. Universal Fall Precautions Evaluation of the condition of the patients' feet can identify anatomic abnormalities that can impair ability to walk securely and may also reveal need for corrective footwear Ensure a safe environment, with room free of clutter and a clear path to the door and bathroom Place all necessary items (such as call light, telephone, and water) within patient's reach Maintain bed in proper position with wheels locked 17

18. Interventions to Prevent Falls 18

19. Communication of the Fall Prevention Plan Hospitals should use strategies to communicate the plan to all care team members as well as patients and families Patients and families should be engaged during risk screening and during planning The Fall TIPS (Tailoring Intervention for Patient Safety) is a tool that uses the evidence, communicates the plan, and involves families 19

20. This Case The patient in this case was clearly at risk for falling due to her sedation and disorientation She experienced a "near fall" with associated injuries She is a good illustration of the complexity of caring for hospitalized patients –She has serious and complex medical problems and requires both a fall prevention plan and an overall safety plan 20

21. Medication-related Sedation in This Case Medication-related sedation is common in hospitalized patients and a risk factor for falls Multiple interventions can be used in the setting of disorientation or sedation: –Frequent or continuous observation –Medication review and adjustment –Bed (or chair) alarms –Family members can assist with observation and redirection of the patient –Locate the patient room near the nurses' station 21

22. This Case (2) No information provided about this patient's fall risk screening or other assessment –Unclear whether a fall prevention plan was in place Yet, there was a communication breakdown –Resident and intern did not communicate with bedside nurse after the procedure –They failed to replace the wrist restraints and raise the bedrails 22

23. Continuous Virtual Monitoring Continuous Virtual Monitoring (CVM) can be used to monitor disoriented patients CVM involves a single trained observer to monitor patients via video feed The observers can notify nursing staff while redirecting the patient via two-way audio This may prevent falls and other self-injury CVM may reduce costs as multiple patients can be monitored by one observer 23

24. Adequate Staff Training Adequate staff training is essential to prevent falls All hospital staff should receive fall prevention training to maintain universal fall precautions Clinical staff also require education related to the following: –Three-step fall prevention process –Importance of engaging patients and families –Value of communicating the fall prevention plan 24

25. Adequate Staff Training (2) In a qualitative study, physicians and other clinicians often did not know how to locate the results of the fall assessment or the prevention plan All clinicians should be educated about where to find this information Clinicians should be encouraged to routinely communicate with nurses about the fall risk and the prevention plan 25

26. Adequate Staff Training (3) Nurses must be competent in fall risk assessment Nurses must also understand how to tailor the fall prevention plan to address patient-specific risk factors A mandatory refresher course on how to perform fall risk assessment is encouraged 26

27. Take-Home Points Falls and related injuries are a serious problem globally Hospitalization increases the risk for falls Use of a validated falls risk screening tool can help identify risks and guide development of individualized or tailored fall prevention and education plan Fall prevention is a three-step process: (i) screening for fall risk, (ii) identifying interventions tailored to patient- specific areas of risk, and (iii) applying the plan consistently along with universal fall precautions Bedside tools to communicate the tailored fall prevention plan to all team members, including patients and families can effectively prevent patient falls 27