ABCs of Fall Injury Prevention: A Holistic Approach to Reducing Harm

1. The ABCS of Fall Injury Prevention A new look at preventing harm from falls

2. Defining Falls with Injury All documented falls with an injury level of minor or greater • Minor indicates those injuries requiring a simple intervention.

3. Types of Falls

4. Where to focus? • All Falls? • Falls with Injury? • What falls can be prevented? • What injuries can be prevented?

5. Recommended Focus • Preventable Falls • Accidental Falls • Anticipated Physiological Falls • Prevent injury

6. Cost of an Injurious Fall • Human Cost • Pain • Injury • Fear of falling leading to decreased mobility • Loss of independence • Loss of life • Monetary Cost • Average $11,250 • $3,500-$27,000 • Law suits Cost reference: Wu, S., Keeler, E., Rubenstein, L., Maglione, M.A., & Shekelle, P.G. (2010). A cost-effectiveness analysis of a proposed national falls prevention program. Clinical Geriatric Medicine. 26. 751-766.

7. Did you know? Falls are the leading cause of death due to injury age 65 and older • Risk Factors: • Recent fall • muscle weakness • behavioral disturbance • agitation, confusion • urinary incontinence and frequency • prescription of “culprit drugs” • postural hypotension or syncope

8. Other things we know about falls…. • 3-20% of inpatients fall at least once • 30% to 51% result in injury • 6-44% of these result in serious injury that could lead to death • Fracture • Subdural hematoma • Excessive Bleeding Oliver D, Healey F, Haines T. Preventing falls and fall-related injuries in hospitals. Clinics in Geriatric Medicine. 2010;26(4):645-692.

9. Why is reducing harm from falls so difficult? • What are the challenges? • Why is it so difficult to achieve and sustain ZERO? Brainstorm your ideas around challenges in preventing falls

10. Fall Injury Prevention Failures • Typical failures associated with patient assessment include the following: • Failure to recognize the limitations of the falls risk screening tools • Lack of a standardized or reliable process for comprehensive fall risk assessment • Lack of identification of patients at increased risk for a fall-related injury • Lack of expertise in administering the assessment after positive risk screening • Late administration of multifactorial and interdisciplinary assessment • Lack of procedure for or time to consistently reassess change in patient condition • Lack of clarity in expectations regarding patient assessment • Failure to intervene quickly and link interventions to specific assessed risk factors • Failure to reassess risk during patients’ entire hospital stay

11. Risk for fall • Major focus for hospitals • Everyone is at risk – dilutes the significance • New approach: Who is at risk for INJURY?

12. Look at both

13. ABCs Of Fall Injury rISK

14. Identify Patients at Risk for Injury ABC’S: A = Age >85 B = Bone (fracture risk or history) C = anti Coagulation or bleeding disorder S = Surgery during current episode of care

15. Age: > 85 years old • Sensory Deficits • Visual • Hearing • Sensation / Neuropathy • Orthostatic Hypotension • Mental Status changes • Weakness due to immobility

16. Age: > 85 years old • Teach Back Strategies • Assistive Devices • Sensory – glasses / hearing aid • Mobility • Floor Mats • Hip protectors if fracture risk • Height Adjustable Beds (low when resting only, raise up bed for transfer) • Safe Exit Side if patient is independent • Medication Review • Remove Ambien from order sets • Pharmacist review for culprit medications Population Specific Interventions

17. Bones • Osteoporosis Diagnosis • History of Fracture • Osteoporosis Risk Factors • Smoking • Steroid use • Alcohol use • Chemo therapy

18. Bones • Hip Protectors • Low Beds • Floor Mats • Evaluation of Osteoporosis • Vitamin D / Calcium Population Specific Interventions

19. Coagulation/Bleeds • Patients on Anticoagulants • Platelet disorder • History of excessive bleeding

20. Coagulation/Bleeds • Evaluate Use of Anticoagulation • Patient Education / Teach back • Helmets – TBI and Anticoagulants • Wheelchair Users: Anti-tippers • Incorporate risk for internal bleeding in post fall assessment and interventions, i.e. CT scan Population Specific Interventions

21. Coagulation/Bleeds • Teach patients and families about the risk for bleeding with a fall • In the Hospital • In the Community http://www.patientsafety.va.gov/docs/fallsToolkit/EducationBrochure_Anticoagulants-102407.pdf

22. Surgical Patients • Surgical procedure during current episode of care • Lower extremity amputation • Thoracic / Abdominal surgery

23. Surgical Patients • Pre-op Education / Teach Back: • Call, Don’t Fall • Call Lights • Post-op Education / Teach Back • Pain Medication: • Offer elimination prior to pain medication • Increase Frequency of Rounds Population Specific Interventions

24. Injury Prevention Interventions • Hip Protectors • Floor Mats • Low Beds • Helmets • Vit D and Calcium • Osteoporosis • Close monitoring • Address sensory deficits • Glasses, hearing aids, lighting • Patient Family Engagement • Teach back • Pre op and post op Teaching • Bedside handoffs • Family monitoring

25. Best Practices in Preventing Falls • Patient Family Engagement • Pre op teaching • Whiteboards • Contracts • Teach back • Bedside Handoff • Toileting supervision • No one toilets alone • Safety Trumps Privacy • Scripting • Proactive Mobility Programs • Ambulation • PT/OT • Purposeful Rounding • Possessions • Pathway • Potty • Communication • Safety Huddles • Post Fall Huddles • Weekly Fall Debriefs • Medication Management • Remove Ambien from order sets • Pharmacist review for specific populations

26. Choosing Protective Equipment and Technology • Engage staff and patients in selecting equipment to test • Test equipment on a small scale • Keep equipment accessible, and stored safely when not in use • Avoid heavy reliance on bed and chair alarms to prevent alarm fatigue

27. Bedside Mats – Fall Cushions CARE Pad bedside fall cushion Posey Floor Cushion NOA Floor Mat Roll-on bedside mat Soft Fall bedside mat Tri-fold bedside mat

28. Hip Protectors – Examples Safehip KPH CuraMedica HipGuard HIPS

29. Assistive technology for safe mobility-Bed & Chair Monitors AirPro Alarm Locator Alarm Bed & Chair Alarm Chair Sentry Economy Pad Alarm Safe-T Mate Alarmed Seatbelt Floor Mat Monitor Keep Safe QualCare Alarm

30. Key Resources • HRET improvement guide http://hret-hen.org/injuries-from-falls-and-immobility • AHRQ Preventing Falls Toolkit http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtoolkit.pdf • VA National Center for Patient Safety: Fall Tool Kit http://www.patientsafety.va.gov/professionals/onthejob/falls.asp • IHI: How to Guide on Injuries from Falls http://www.ihi.org/resources/Pages/Tools/TCABHowToGuideReducingPatientInjuriesfromFalls.aspx

31. Contact Information Jackie Conrad RN, BSN, MBA Improvement Advisor Cynosure Health 708-420-1130 jconrad@cynosurehealth.org