Christina Soncrant, M.P.H.

1. Lessons Learned from the VHA and Recommendations for Fall Related Injury PreventionChristina Soncrant M.P.H. VA National Center for Patient Safety

2. Christina Soncrant, M.P.H. Christina Soncrant, MPH, has worked for the VA National Center for Patient Safety for 8 years. She is currently a Health Science Specialist at the NCPS Field Office in Vermont. She joined the VA in 2011 after graduating from Dartmouth College with her masters degree in public health with a focus in healthcare improvement, implementation science, and health science research. Over the last 8 years her focus has been on fall and fall related injury prevention, fall data collection and evaluation, and coaching and leading breakthrough series nationwide on the topics of implementation science, falls prevention, pressure injury prevention, CAUTI and sepsis. In addition she does extensive work with other program offices such as the VISN 8 falls PSCI, the VA National surgery office, and the National Anesthesia Office. Her work involves evaluation of patient safety efforts such as Ensuring Correct Surgery, development of surgical and anesthesiology adverse event lessons learned for the field and research on adverse event prevention and improvement on various topics areas as well as research on implementation science and improvement projects such as the lessons learned and virtual breakthrough series.

3. Learning Objectives: • Discuss the background of the current problem on preventing falls and fall related injuries. • Share the success stories from collaboration between the National Center for Patient Safety and State Veterans Homes in preventing fall and fall related injuries. • Describe the results and lessons learned from a year of reported root cause analyses on serious falls in the VHA. • Peer to peer sharing on the successes and barriers to fall prevention interventions on the front line. • Provide an overview of the concepts of Diffusion of Innovation and Leading Change. How do we make change happen on the front line?

4. Epidemiology: around the world • Over 80% of falls occur in those over the age of 65, with the age adjusted death rate from falls over 65 years increasing from 47.0 per 100,000 in 2007 to 61.6 per 100,000 in 2016 (Healey et al. 2012, CDC M&M 2018). • Nearly 25% of falls required MD or hospitalization (Healey et al, 2012) • More than three-fourths of all falls occur in rooms or bathrooms of residents • Sit-to-stand or stand-to-sit transfers were associated w/ higher percentage of falls (42%) than walking (35%) (McGibbon et al, 2019)

5. Long Term CareFalls prevention in Nursing Homes. C. Becker & K. Rapp. 2010, Nov. Clinics in Geriatric Medicine. • Falls in LTC result in more serious complications: 10-25% resulting in fractures or lacerations; most serious – hip fractures • Hip fractures- associated with a host of negative outcomes- increased mortality (mortality 36% within 6 months, worst prognosis in those over 90 years of age). Those that survive, most have decreased mobility and ability to function independently. • Other injuries (fx pelvis, UE, Spine or skull) result in considerable suffering • Reducing the risk of falling can positively affect residents’ quality of life to a considerable extent • Mean Fall rate 1.7 falls per person-year (range 0.6-3.6), considerably higher than community-based fall rate (mean 0.65; range, 0.3-1.6) • In a facility with 100 beds, a fall can be expected about every other day.

6. Falls are one of the top ten sentinel events reported to Joint Commission and the number one Root Cause Analysis event type reported to the National Center for Patient Safety

7. The Challenge of Falls • Goal is to promote mobility and independence without injury • Risk factors: All are high risk (unless immobile or in coma) • We work with a population that often meets several of the well established risk factors: • muscular weakness, balance and gait deficits, poor vision, delirium, cognitive and functional impairment, orthostatic hypotension, urinary urge incontinence, and nocturia. • Comorbidities (dementia, depression, stroke, PD) may lead to attention deficits, executive dysfunction, or visual field loss – result in higher propensity to fall. • Side effects and interactions of drugs • Not all falls are preventable • Anticipated physiological; due to fall risk factors • Accidental; due to environmental causes • Unanticipated physiological; physical events unable to predict

8. NCPS falls toolkit: https://www.patientsafety.va.gov/professionals/onthejob/falls.asp

9. Think, Pair and Share

10. Are falls and fall prevention an issue? • What are your facilities top concerns and priorities right now? • Is fall prevention a priority at your facility currently?

11. Results from a Virtual Breakthrough Series to Prevent Fall and Fall-Related Injuries "Caring for America's Heroes" Collaboration between State Veteran Homes (SVH) and the Veterans Health Administration (VHA), National Center for Patient Safety (NCPS), and the VA Office of Geriatrics and Extended Care Operations

12. Background • 2 completed breakthrough series on falls with State Veterans Homes and an ongoing relationship between VHA NCPS and State Veteran Homes. - 2015 - 2016/2017 • 2 Papers, one published • NCPS falls toolkit: https://www.patientsafety.va.gov/professionals/onthejob/falls.asp • AHRQ falls toolkit: https://www.ahrq.gov/sites/default/files/publications/files/fallpxtoolkit.pdf

13. Interventions • Most common interventions: • Post fall huddles- you cant fix it if you don’t know the cause of the problem • Other interventions (e.g., improved documentation, improved communication, delirium/cognitive assessment, etc. • Program evaluation (e.g., review post-fall huddle data, regular meetings review fall cases, etc.) • Staff education • Intentional rounding

14. Outcomes • Unparalleled commitment and dedication • Individual teams made significant gains in attaining their aims- both process and outcome • Reduction in falls with non major injury in both breakthrough series and major injuries in the first. • Peer to peer learning and sharing • Despite the barriers you made CHANGE HAPPEN.

15. 2015 State Veteran Homes VBTS- Outcomes

17. Lessons Learned from Root Cause Analyses in the VHA: A 1-Year Review of Falls with Injury and Recommendations Soncrant C, Neily J, Bulat T, Mills P. Recommendations for fall related injury prevention: a 1-year review of fall related root cause analyses in the Veterans Health Administration. J Nurs Car Qual. (in press)

18. Methodology • We completed a Retrospective analysis of RCA reports between August 1, 2016 and August 1, 2017. • Study included all VA facilities. Over 1243 health care facilities nationwide, including 172 VAMC and 1062 outpatient sites. • We looked at the types of falls, preventability, patient outcome (injury level), injury type (fracture, laceration, etc.), root cause of the event, and lessons learned.

19. Results- Patient Characteristics • 90% of falls classified as preventable • Majority of the falls (83%) resulted in a major injury • The most common injury types were hip fracture (43%), other fracture (25%), and head injuries (16%). • Most falls (75%) were unwitnessed. [Oliver et al. (80% - 90%)]

20. Reported Root Causes/Contributing Factors of Events • Equipment and environmental hazards (21%) • Communication issues such as handoffs or post fall huddles (14%) • Patient supervision (10%)

21. Accident Theory- All new admissions are considered a fall risk until proven otherwise Reason. , Human Error: models and management, 2000

22. Best Practice Approaches • Fall prevention requires multiple interventions that are multifactorial, crossing several disciplines to be effective in mitigating or eliminating patient-specific, modifiable, fall risk factors • It takes truly an interdisciplinary team effort to reduce the risk of falls and related injuries

23. Most effective, fall prevention interventions should be targeted at both point of care and strategic levels. • Best Practice Approach: • Implementation of safer environment of care – protect and pad the environment • ID those at risk for injury • Implementation of interventions targeting those at risk for falls • Interventions to reduce risk of injury to those who do fall

24. Identifying High Risk, Vulnerable Populations • Screen for history of falls, or falls as reason for admit • Consider elders high risk • Screen for risk of injury using a tool such as the A, B, C, S • A = Age (equal to or greater than 85) or frailty B = Bones (fracture risk or history) C = AntiCoagulation (bleeding disorder) S = Recent surgery (during current episode of care) Health Research & Educational Trust (June 2018). Falls with Injury Change Package: 2018 Update. http://www.hret-hiin.org/Resources/falls/18/falls-with-injury-change-package.pdf (see page 31)

25. The ABCS Tool • Tool offers insight into what interventions should be put in place to protect the patient from injury in the event of a fall. • Examples: patients at risk for hip fracture due to poor bone health might be offered hip protectors. • Assume your at risk patient WILL FALL.

26. How do we prevent falls with injury while encouraging mobility and independence?

27. Hip Fractures and Hip Protectors • Our study showed that 43% of all injuries were hip fractures. • 21% of root causes cited a lack of use of protective equipment such as hip protectors, helmets, or floor mats. • Have been shown to reduce the force of impact below the fracture threshold, reducing the risk of fracture. • New goal focusing on fall injury protection

28. Hip protectors • Although the evidence is mixed, research generally supports the use of hip protectors to prevent hip fractures, in nursing home settings, when they are worn • Multiple trials have reported positive results, (up to 84% reduction of risk of hip fracture if the protector was worn at the time of fall [Korall et al. 2015, Santesso et al. 2014]) • Patient acceptance and low adherence has been cited as an explanation for the lack of effectiveness [Cameron et al. 2011] • No serious side effects, a low cost approach to prevent hip fractures. • the evidence for hip protectors exceeds the evidence for many other interventions in geriatrics

29. Tips for success • Staff buy in- staff must believe in them, and utilize them with patients more. Staff can even wear them around to show patients that they buy into their use too. • Build relationships with residents. Cameron et al found that although overall adherence to use is modest, it is higher in nursing homes (49%) as opposed to those in hospitals (36%).45 • Education and patient read back/teach back-The 3 main reasons fall prevention is important: 1. Falls for the most part are preventable 2. Falls can result in injury and adversely impact your life (mobility, fear of falling, living situation) 3. Falls can lead to hospital stays or increase length of a hospital stay • Purchase a variety of hip protectors, let residents choose their own. Different styles, textures, hard v. soft, incontinence hip protectors available. Integrate the resident and family in the purchase and use of these.

30. Hip Protectors – Examples

31. Hip Protector Toolkit https://www.patientsafety.va.gov/docs/fallstoolkit14/HipProtectorToolkit_rev100709VK.doc • This web-based toolkit includes: • selection of brands and models, • sizing guidelines, • protocol for replacement, • policy template, • laundering procedure, • stocking procedure, • monitoring tools, • patient education materials, • provider education materials.

32. Below are link to information that you should find helpful for hip protectors.  • Hip protectors in an inpatient setting https://www.patientsafety.va.gov/docs/fallsToolkit/Hip_Protectors_in_an_inpatient_setting.asx • Protecting your hips with hip protectors https://www.patientsafety.va.gov/docs/fallsToolkit/Protecting_your_hips_with_hip_protectors.asx • Hip protectors pamphlet https://www.patientsafety.va.gov/docs/fallsToolkit/hip_protectors.pdf • Hip protector toolkit https://www.patientsafety.va.gov/docs/fallstoolkit14/HipProtectorToolkit_rev100709VK.doc

33. Traumatic brain injury in older adults and the use of helmets • In our study 16% of patient sustained serious head injuries, but no patients were wearing head protection. There were no actions related to head protection for patients at risk for head injuries or bleeding. • Fallsare the leading cause of TBI for older adults (51%), followed by motor vehicle crashes (9%), and unknown/other causes (21%).

34. Evaluation of Protective Properties of Commercially Available Medical Helmets • Head protection can minimize fall related head impact and injury, especially for those who are anti-coagulated. (Harvey et al. 2017, Wu et al. 2010, Wong et al. 2011) • Companies are developing innovative products with the appearance of baseball caps, winter hats, and beanies, to encourage patient compliance and comfort in using the products.

35. Helmets – Examples

36. High Risk Injury Interventions Low Beds Low profile beds are beds for frequent fallers. Low beds help prevent injuries because they are so low to the ground, often as low as 14 inches. If the patient did fall out of bed, the potential for injuries would be significantly reduced. Fall Protection Mats Bedside floor mats protect patients from injuries associated with bed-related falls. Mats can be placed on one side or both sides of the patient’s bed. May not be for every patient but for those with specific needs and history of falling from bed.Eliminate Sharp Edges

37. Think, Pair and Share

38. What fall and fall related injury preventions interventions have you implemented recently? • Do you find these interventions successful? • What helped with the successful implementation of these interventions? • What were some barriers you had to overcome?

39. Patient Observation • In our study, 75% of falls were unwitnessed by staff. • Purposeful rounding and 1:1 observation has been shown to decrease falls by nearly 60% (Quigley et al. 2009). • Non-purposeful rounding does not seem to have a marketed impact on patient care and fall reduction, but patients on purposeful rounding are less likely to get up without calling for help, as their needs are addressed preemptively (Mitchell et al, 2015). • Pennsylvania study- found that sitter use was associated with decreased rates of falls with injury due to the increase in number of assisted falls, although no decrease in fall rate (Feil et al., 2014). • Remember- ultimate goal is to eliminate INJURY

40. Take Home Points • Develop individualized intervention plans tailored to individual patients needs, and be consistent on ensuring these interventions are in place. • Consider using a model such as the TIPS program by Patricia Dykes

41. Pilot Testing Fall TIPS (Tailoring Interventions for PatientSafety): a Patient-Centered Fall Prevention ToolkitPatricia C. Dykes et al. The Joint Commission Journal on Quality and Patient Safety 2017.

42. The Fall TIPS Toolkit Requirements

43. Requirement: Simplify, add decision support, add Spanish version Fall Interventions (Circle selection based on color) Patient Name: Fall Risks (Check all that apply) Date: Use Ambulatory Aid Communicate Recent Falls History of Falls Walking Aid Cane Crutches Walker IV Assistance When Walking Toileting Schedule: Every __ hours IV Pole or Equipment Medication Side Effects Commode Bed Pan Bathroom May Forget or Choose Not to Call Assistance Out of Bed Bed Alarm On Unsteady Walk None

44. Fall Prevention Lessons Learned • Fall prevention is a 3-step process: • Conducting fall risk assessment using a prospectively validated tool. • Developing a plan of care that is tailored to patient-specific areas of risk. • Implementing the plan CONSISTENTLY.

45. Leading Change- John Kotter’s 8 Steps for Leading Change • This is where you all come in! • Establish a sense of urgency- Appeal to the heart • Form a powerful guiding coalition • Create a vision • Communicate the vision • Empower others to act • Plan for and create short term wins • Consolidate improvements • Institutionalize new approaches Kotter, “Leading Change”

46. A Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? ACT PLAN STUDY DO Langley et al. , The Improvement Guide, 1996

47. The PDSA Cycle Act Plan • Objective • Questions and predictions (why) • Plan to carry out the cycle (who, what, where, when) • What changes are to be made? • Next cycle? Study Do • Complete the analysis of the data • Compare data to predictions • Summarize what was learned • Carry out the plan • Document problems and unexpected observations • Begin analysis of the data Langley et al. , The Improvement Guide, 1996

48. A Conceptual Model of Change: Elements of Spread Diffusion is the process by which an innovationis communicated through channels over time among the members of a social system. Channel of Communication? Who is receiving the information? What are you selling? Context of Communication Everett Rogers (1995), “Diffusion of Innovations”

49. Spread Options • Completeness - implement changes that others have done, but you have not. Learn from what others have done. • Coverage - take what you have already done in one situation and spread it to other areas (e.g. other residents, units).

50. Characteristics of the innovation: • Relative Advantage - How much better is the new compared to the old? • Compatibility - How consistent is this new idea with values, past experience, and needs? • Complexity - How difficult is this new idea to understand and use? • Trialability - how easy is it to test the new idea? • Observability - How visible are the results of this new idea?