Pat Quigley,PhD,MPH,ARNP,CRRN,FAAN,FAANP Associate Director, VISN 8 Patient Safety Center Associate Chief for Nursing Service/Research

E-Mail: patricia.quigley@med.va.gov

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Overview Formulate measurable fall-related

outcomes that build upon NDNQI data Differentiate types of falls as a basis for

analysis of program effectiveness at patient, unit and organizational levels

Compare Proactive vs Reactive Approaches to Fall and Injury Prevention

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IOM – Crossing the Quality Chasm. Care should meet these criteria:

S - safe T- timely E - efficient E - effective E - equitable P- patient-centered

www.iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx

Types of Measures

Processes Structures Outcomes Balancing Measures: Impact of change

on other parts of our system; i.e., as fall and injury rates decline, did other measures improve or decline

Types of Outcomes

Quality (QOL, Satisfaction, Function, M&M)

Financial (Cost Savings, ROI) Access (Access to Treatment) Timeliness (Care in timely manner) Nurse-Sensitive Outcomes

Core NDNQI Data

Age, Gender Fall Risk: ○ Assessment prior

to fall ; Scale score;

○ Time since last risk assessment;

○ At risk for Falls (y/n)

Fall Prevention Protocol in Place

Falls ○ Assisted Fall ○ Repeat Falls

Injury Physical Restraint Prior Fall this Month

Fall Prevention Program vs. Falls Outcomes

Fall Prevention Program Falls Fall-related Injuries Days without a fall Staff Involvement-

Unit-based Champions

Falls QI Committee Cost of Program

(ROI)

Falls Outcomes Actual Numbers of

Falls (event, rate, percent)

Fall Type Repeat Falls Fall-related Injury

Formulate Measurable Fall-Related Outcomes Structure, Process, Outcomes Reduce preventable falls by 20% in 1

year Requires data collection for type of fall What are the types of fall? Others

Eliminate serious fall-related injuries in 1 year

First Step: Types of Falls

Accidental Falls Anticipated Physiological Falls Unanticipated Physiological Falls

Morse, J. (1997). Preventing Patient Falls. Thousand Oaks, CA: Sage

Intentional Falls

Second Step: Link to Fall Risk Assessment Fall Risk Screening Tools

Validity, Reliability Sensitivity, Specificity Likelihood of which Type of fall?

Comprehensive Fall Risk Population-based Individualized

Morse Fall Scale Properties

Exposure/ Outcome

Fall + Fall – (no fall)

Sum

E+ Sensitivity TP

FP PPV a/a+b

E- FN Specificity TN

NPV d/c+d

a/a+c

d/b+d

Total

Sensitivity: 78% (a/a+c) (proportion of those who fall and identified at risk by test)

Specificity: 83% (d/b+d) (proportion of those who are free of fall and identified not at risk by test)

PPV 10.3% (proportion of those with risk who fall)

NPV 99.2% (proportion of those with no risk who are free of fall)

100 falls, 4,000 control (due to fall rate X 1,000 pt days of care); 82.9% of cases classified correctly

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Differentiate Screening from Assessment Screening

Disease Detection Who should undergo diagnostic testing for

confirmation- Cut off point to be negative or positive Over-reliance on screening tools What tool are you using?

Assessment Data for differential Diagnosis

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Interventions

Structures and Processes What interventions will you implement?

Universal Fall Precautions? Let’s look at the evidence

But first….. What is the evidence?

Best Practice Approach in Hospitals:

Most effective, fall prevention interventions should be targeted at both point of care and strategic levels

Implementation of safer environment of care for the whole patient cohort (flooring, lighting, observation, threats to mobilizing, signposting, personal aids and possessions, furniture, footwear)

Identification of specific modifiable fall risk factors Implementation of interventions targeting those risk

factors so as to prevent falls Interventions to reduce risk of injury to those people

who do fall (Oliver, et al., 2010, p. 685)

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Third Step: Expand Evaluations Methods Prevalence Studies Formative and Summative Evaluation

Methods Type of Falls Severity of Injury ○ How are you assessing for injury? Duration?

Extent of Injury? Repeat Falls Survival Analysis Annotated Run Charts

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Fourth Step: Prevent Repeat Falls: Safety Huddles? Post Fall Analysis

What was different this time? When? How? Why? Prevention: Protective Action Steps to

Redesign the Plan of Care

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Accident Theory

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Outcomes of Post Fall Huddles

Specify Type of Fall Specify Root Cause (proximal cause) Identify actions to prevent reoccurrence Changed Planned of Care Summative Outcome: Prevent Repeat Fall:

Same Root Cause and Same Type of Fall

Formative Outcomes

Structures: Who attends: Nursing and others – Count them Add actions to your run-chart: Annotated run

chart; Capture interventions

• Processes: ○ Timeliness of Post Fall Huddle (number of

minutes) ○ Timeliness of changing plan of care ○ Time to implemented changed plan of care

Program Effectiveness: Fall Prevention Organizational Level: Expert

interdisciplinary all team, program evaluation, leadership, environmental safety, safe patient equipment, anti-tippers on wheelchairs

Unit Level: education, communication-handoff, universal and population-based fall-prevention approaches

Patient Level: exercise, medication modification, orthostasis management, assistive mobility aides, others……

Program Effectiveness: Protection from Serious Injury Organizational Level: available helmets,

hip protectors, floor mats, height adjustable beds; elimination of sharp edges

Staff Level: education, adherence, communication-handoff includes risk for injury

Patient Level: adherence with hip protector use, helmet use, etc.

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Falls

per

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ays

2008 2009

Falls per 1000 Patient Days

Fall Rate UCL LCL National Mean

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Fall

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2008 2009

Fall Rate by Type of Fall per 1000 Patient Days Fall Rate Anticipated Falls Unanticipated Falls Accidental Falls Intentional Falls

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Jan 3 08 Feb 2 08 Mar 25 08 May 1 08 May 31 08 Jul 7 08 Aug 30 08 Sep 17 08 Nov 23 08

Day

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Inju

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Days Between Serious Injury Days Between Serious Injury Average

Annotated Run Chart

JAH VAMC Med-Surg Falls with Harm by Quarter per 1000 pt days(Includes all harm categories: Minimal, Moderate, Major & Death)

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Q12004

Q22004

Q32004

Q42004

Q12005

Q22005

Q32005

Q42005

Q12006

Q22006

Q32006

Q42006

Q12007

Q22007

Quarter

Fall

s w

/h

arm

per

10

00

pt

day

s

Computer Template for Morse Fall Scale

and embedded template into Adm and

Trsf notes (12/05)

Revised Post Fall Note (3-12/05)

Added Alert re-meds to Scale

(11-12/05)

Developed Education Brochure on meds

and fall risk (11/05)

Staff education on falls (1/05)

Staff education on falls (10/05)

Added handoff

form (4/06)

Red non skid socks (pilot 5S then to all

M-S 12/05)

Call-Don't Fall Signs (6-9/05)

Updated Falls HPM

(9/05)

Equipment purchased (alarms, mats, low beds 12/03-12/05)

Started AARs (safety

huddles) on test units 10-

12/06

Teachback w/pts 11/06

Put pts on high risk falls precautions w/hx of falls, osteoporosis, Morse score > 50, on anticoagulants, low

platelets 12/06Use yellow wrist bands

on high falls risk pts 1/07

Start comfort safety rounds on off-tours (evenings, nights,

weekend days) 2-3/07

Keep Thinking Out of the Box!

Leadership: Culture of Safety Fall Rounds Signage Frequency of Fall Risk Screening Measurements of Effectiveness

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Questions?