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Wiping out falls

Systemic interventions help reduce patient risk

By Karen Lusky

From the August ACP Hospitalist, copyright © 2008 by the American College of Physicians

Sidebars: Keep an eye on medications Another tool to assess fall risk

A risk assessment approach that targets patients most likely to have adverse events after a fall can help decrease the incidence of serious fall-related injuries that Medicare—and perhaps a growing number of private payers—soon will not cover.

That’s why, in part, some hospitals are focusing on patient risk when assessing patients for falls, to head off injuries before they happen.

“You may see a 47-year-old patient who is on a blood thinner [and] doesn’t appear to have reasons why he would fall,” said Gail A. Nielsen, clinical performance improvement education administrator for the Iowa Health System in Des Moines. “But you have to continue to monitor that person to make sure that he doesn’t suddenly develop risk for falling.”

For example, she said, the person’s fall risk might change quickly if he starts a new cardiac or antihypertensive medication that would make him lightheaded.

By taking a preventive approach and working with the Institute for Healthcare Improvement, two hospitals in the Iowa Health System reduced the rate of moderate-to-severe fall-related injuries by 27%, according to Ms. Nielsen.

“We are looking to achieve one or fewer moderate or greater injuries per 10,000 [patient] days,” said Ms. Nielsen. “And across the system, we have reached 1.0 and are continuing to decrease injuries.”

Preempting falls is “all about mitigating the risk up front,” said Mary Haik, RN, director of performance improvement at Rush North Shore Medical Center in Skokie, Ill. “If you put in processes after the patient has fallen, the ship has sailed.”

To quantify patients’ fall risk, many hospitals, including St. Vincent’s Hospital in Manhattan, use the Morse Fall Scale. The scale, which is designed for adults, assigns a risk score based on whether the patient has a history of falling, has more than one medical diagnosis on the chart (indicating the possibility of polypharmacy), requires ambulatory aid (including holding on to furniture), is receiving IV therapy, or has gait problems and mental status impairment.

A score of 45 is the recommended threshold for denoting high risk, but the actual score as well as level of risk should always be recorded, said Janice Morse, RN, PhD, professor and presidential research chair at the University of Utah’s College of Nursing in Salt Lake City, who led the research team that developed the scale.

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Systemic interventions target common risks

To help guide its fall-risk assessment and management efforts, Iowa Health System categorizes falls as accidental, anticipated physiological, or unanticipated physiological. Anticipated physiological falls include those caused by a patient’s mobility problems, medications, surgeries and medical conditions, among other factors.

“We can make the most difference in preventing anticipated physiological falls, which is what we are really targeting. If we can’t predict a fall, we haven’t figured out how to prevent it.” —Gail A. Nielsen

“We can make the most difference in preventing anticipated physiological falls, which is what we are really targeting. If we can’t predict a fall, we haven’t figured out how to prevent it,” said Iowa Health System’s Ms. Nielsen.

Facilities that launched their fall programs before Medicare’s “never events” program was on the near horizon have already accumulated numerous lessons about how to launch and fine-tune a fall program. Hospitals should consider the following tips:

Assist those who need it. At Iowa Health System, nurses assist patients who don’t walk very well or make sure they have assistive devices, such as a gait belt, to walk.

Keep floors clear. To prevent accidental falls, hospitals can light pathways and keep them clear of trip hazards, said Ms. Nielsen. A visually impaired patient may perceive a shiny floor as a puddle, which may cause her to trip as she steps over it, she noted.

Provide appropriate footwear. Patients need grippers on their stocking feet that are on both sides. If the grippers are only on one side of the footwear, they may roll around when the patient is in bed, Ms. Nielsen cautioned.

Make sure patients can and will ask for assistance to get up. At Iowa Health System, hospital staff uses a “teachback” approach to make sure a patient knows how and why to use the call light to ask for help getting up. To shorten the distance between the nursing unit and patient rooms, Rush North Shore Medical Center in Skokie, Ill., set up substations in the middle of some of its longer units. In addition, many hospitals are using hourly rounding by nurses to preempt patients’ requests, including a desire to get up.

Time medication administration to prevent falls at night. Rush North Shore Medical Center tries to avoid giving anything at nighttime that might disrupt a patient’s sleep, reported Ms. Haik.

Mary Haven Merkle, MD, chief of the section of hospital medicine at the University of Texas M.D. Anderson Cancer Center in Houston, avoids giving patients diuretics near bedtime if at all possible. If a patient is hypoxic due to pulmonary edema and requires a dose of Lasix at night, she may offer the patient a bedside commode or consider placing a temporary Foley catheter, she said. (For more on medications and falls, see sidebar.)

Give everyone a “heads up” about a patient’s fall risk status. At Rush North Shore Medical Center, “we let all staff, transporters, physicians, dietary, family members, etc., know the patient is at risk and they need to follow certain guidelines to help ensure the patient doesn’t fall,” said Ms. Haik. One hospital in the Iowa Health System uses protruding signage in the hallways to flag patients at risk of falling.

Facilitate and monitor staff compliance with the program. To help ensure compliance and save nursing time, Iowa Health System provides nurses with a ready-made packet of fall-prevention interventions, including wall markers, special-colored armbands and blankets to identify high-risk patients, and bed safety alarms. Central supply puts the packets together, and housekeeping places them in high-risk patients’ rooms. Managers also monitor and troubleshoot the fall program and the reliability of interventions.

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Preventing future falls

While prevention is always the best medicine, experts said root-cause analysis of falls that do occur can stop a patient from taking a second tumble.

While prevention is always the best medicine, experts said root-cause analysis of falls that do occur can stop a patient from taking a second tumble—and identify systemic problems that simple remedies can fix.

The University of Texas M.D. Anderson Cancer Center discovered that one unit had a high rate of falls among patients who had undergone major gastrointestinal surgeries. But patients were falling around 72 hours after surgery rather than in the first 24 hours, as might be expected, said Beverly Nelson, RN, PhD, director of nursing practice programs. In response, the staff tested a combination of interventions such as hourly safety checks, mandatory use of bedside commodes for 72 hours, and mandatory staff assistance for patients getting out of bed. Once the interventions were implemented, the unit went 143 days between falls.

At Rush North Shore Medical Center, some patients on a psychiatric unit were falling because of behavioral reasons, such as a bid for attention or to delay discharge, said Sonia Lee, a clinical nurse specialist in gerontology. The hospital staff further discovered that falls were occurring during shift report. “So we divided up report into two separate groups so that one group of nurses was always with the patients. That made a huge difference,” Ms. Lee said.

Not every fall can be prevented, of course. Sometimes patients fall even when health care staff are present, said M.D. Anderson’s Dr. Merkle. “Those are the falls that break all our hearts.”

Michael D. Wang, MD, a hospitalist at the University of California at Irvine, agrees that hospitals will never reduce falls to zero. But if the hospital has “an optimized system and everyone is in tune to best practices to [prevent] falls, then we can significantly reduce falls and fall-related injuries,” he said.

Karen Lusky is a registered nurse and a freelance writer in Brentwood, Tenn.

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Keep an eye on medications

Medications are a key area for hospitalists to watch when evaluating patients for fall risk, said Michael D. Wang, ACP Member, a hospitalist at the University of California at Irvine. He recommends reducing fall risk for older or even middle-aged adults by assessing for and addressing such factors as delirium, polypharmacy and deconditioning. Physicians minimize the risk for delirium by controlling pain well and avoiding unnecessary medications, he said.

Along with benzodiazepines, other drugs, such as antiarrhythmics, diuretics and digoxin, can increase a patient’s fall risk, according to Dr. Wang.

“Meperidine, an opioid analgesic, probably doubles the risk compared to other opioids of contributing to delirium in older patients,” he cautioned. Delirium can cause patients to fall, and anticholinergic medications can in turn cause delirium. Dr. Wang believes physicians probably overprescribe diphenhydramine (Benadryl), which has anticholinergic properties, as a sleep aid. “The drug can contribute to confusion and can cause orthostatic hypotension,” he said.

Hospitalists can also help by providing a round-the-clock perspective to raise awareness about falls in older patients, said Brian C. Scanlan, ACP Member, a geriatric hospitalist at St. Vincent’s Hospital. “I’ll hear residents say, ‘Here comes Dr. Scanlan. He’s going to say ‘Stop the benzos and get a physical therapy assessment on this patient’,” he said.

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Another tool to assess fall risk

The University of Texas M.D. Anderson Cancer Center in Houston uses a fall risk assessment for adult patients that includes the following parameters, said Beverly Nelson, RN, PhD, director of nursing practice programs:

• Gait and mobility problems;
• Urinary frequency/urgency and how often the patient typically goes to the bathroom;
• Cognitive status;
• Medications (how many and what kind);
• How recently the patient had surgery;
• Whether the patient has tubes, drains, or IVs that could be trip hazards;
• A history of recent falls; and
• Use of assistive devices, such as a walker or cane.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated