The Problem of Falls
Each year, somewhere between 700,000 and 1,000,000 people in
the United States fall in the hospital.i A patient fall is defined
as an unplanned descent to the floor with or without injury to the patient.ii
A fall may result in fractures, lacerations, or internal bleeding, leading to
increased health care utilization. Research shows that close to one-third of
falls can be prevented.iii As of 2008, the Centers
for Medicare & Medicaid Services (CMS) does not reimburse hospitals for certain
types of traumatic injuries that occur while a patient is in the hospitaliv;
many of these injuries could occur after a fall.
Staff in acute care hospitals have a complex and potentially
conflicting set of goals when treating patients. Hospital personnel need to treat
the problem that prompted the patient's admission, keep the patient safe, and help
the patient to maintain or recover physical and mental function. Thus, fall
prevention must be balanced against other priorities. Fall prevention involves
managing a patient's underlying fall risk factors (e.g., problems with walking
and transfers, medication side effects, confusion, frequent toileting needs) and
optimizing the hospital's physical design and environment. A number of practices
have been shown to reduce the occurrence of falls, but these practices are not
used systematically in all hospitals.
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The Challenges of Fall Prevention
Fall prevention requires an interdisciplinary approach to
care. Some parts of fall prevention care are highly routinized; other aspects
must be tailored to each patient's specific risk profile. No clinician working
alone, regardless of how talented, can prevent all falls. Rather, fall
prevention requires the active engagement of many individuals, including the
multiple disciplines and teams involved in caring for the patient. To
accomplish this coordination, high-quality prevention requires an
organizational culture and operational practices that promote teamwork and
communication, as well as individual expertise.
Fall prevention activities also need to be balanced with
other considerations, such as minimizing restraints and maintaining patients'
mobility, to provide the best possible care to the patient. Therefore,
improvement in fall prevention requires a system focus to make needed changes.
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Toolkit Designed for Multiple Audiences
This toolkit focuses on overcoming the challenges associated
with developing, implementing, and sustaining a fall prevention program. Therefore,
you will find that a good deal of the toolkit is focused on successfully
negotiating a change process at your hospital. This is what we feel makes the
toolkit unique. The toolkit was developed under a contract with the Agency for
Healthcare Research and Quality through the ACTION II program (Accelerating
Change and Transformation in Organizations and Networks). It was created by a
core team with expertise in fall prevention and organizational change. The team
included staff from the RAND Corporation, ECRI Institute, and Boston
This toolkit focuses specifically on reducing falls that occur during a patient's hospital stay. For more information on how to prevent falls outside the hospital, we recommend the American Geriatrics Society guidelines (available at http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2010/ ) and the Centers for Disease Control and Prevention STEADI Toolkit (available at http://www.cdc.gov/homeandrecreationalsafety/Falls/steadi/index.html). Efforts to prevent falls outside the hospital will help reduce the number of patients admitted to the hospital for fall-related injuries.
The toolkit's content draws on a systematic review of the literature.v
We also drew heavily on expert opinion regarding best practices in fall
prevention.vi We used the literature
wherever possible to support our recommendations. Throughout the toolkit you
will find citations to relevant literature where it exists.
In many cases, the literature was unclear or silent about
key aspects of care, or implementation strategies were not reported in adequate
detail. Therefore, we sought guidance from an expert panel and additional
experts in the field. We merged this input with our own experience both as
clinicians working in acute care hospitals and as quality improvement
specialists who work with hospitals to improve their fall prevention programs. In
addition, six hospitals volunteered to test the toolkit as part of this project.
Their feedback influenced this final version and many of the resource boxes
throughout the toolkit reflect their experiences.
The toolkit is designed for multiple uses. The core document
is an implementation guide organized under six major questions
intended to be used primarily by the Implementation Team charged with leading
the effort to put the new prevention strategies into practice.vii
The full guide also includes links to tools and resources found in the
Tools and Resources section of the toolkit, on the Web, or in the literature.
The tools and resources are designed to be used by different audiences and for
different purposes, as indicated in the guide.
Because it is important to have your facility's leadership
engaged, the toolkit includes a letter to introduce the program to other key
players, such as hospital senior management and unit nurse managers. This
letter may be found at the beginning of section 7 (Tool ØA, "Introduction and Overview for
Stakeholders"). The toolkit also contains an "Action Plan" (Tool 2F), which provides a quick overview of the steps
needed to implement and sustain a fall prevention program. In addition, it
contains an "Interdisciplinary Team" tool (Tool 2A), which has a matrix of all the
tools in this toolkit organized by the types of hospital personnel who would
most likely use them (e.g., tools for nursing staff, rehab personnel,
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Implementation Guide Organized To Direct Hospitals Through
the Change Process
To implement a successful initiative to improve fall
prevention on a sustained basis, your organization will need to address six
- Are you ready for this change?
- How will you manage change?
- Which fall prevention practices do you want to use?
- How do you implement best practices in your organization?
- How do you measure fall rates and fall prevention practices?
- How do you sustain an effective fall prevention program?
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Sections of the Guide
The six questions make up the major sections of the
implementation guide. Each major question is in turn organized by a series of
more detailed questions to guide the Implementation Team through the
improvement process, as summarized in the table of contents. Each section
begins with a brief explanation of why the question is relevant and important
to the change process or to fall prevention. Each section concludes with action
steps and specific resources to support the actions needed to address the
questions. Additional resources that may be helpful to implementers may be
found in the appendix "Bibliography of
Studies Implementing Fall Prevention Practices."
Each section also suggests specific tools and resources to
assist you. In addition, printer-friendly versions of all these referenced
tools and resources are compiled in section 7.
Some resources are intended for the Implementation Team to use during the
planning and system change process. Others are designed as educational
materials or clinical tools to be used by unit staff as they implement the new
strategies and use them on an ongoing basis. Sections also include references
or links to more detailed resources for those who want to explore an issue in
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Adaptation of the Guide to Your Organization
While the implementation guide is designed to cover the full
improvement process from deciding to make changes to monitoring sustainability,
some sections may be more relevant than others if your organization has already
begun the improvement process. Sections 1 and 2 are intended to guide you
through an assessment of your readiness to change and help you plan your
processes to change.
Hospitals may have their own approaches in tailoring the
toolkit to their needs. The guide can be used as a reference document with
sections consulted selectively as needed. To help you find the pieces you need,
the questions that guide the full process are listed in the table of contents
and the location of subjects can be found in the roadmap.
Because the changes needed are usually complex, most
organizations take at least a year to develop, incorporate, and consolidate the
new fall prevention practices. Some take longer as early accomplishments
uncover the need and opportunity for further improvements. It will be important
to balance the need to proceed thoughtfully with the need to move quickly
enough to show progress and maintain momentum.
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Improvement as Puzzle Pieces
The path through the guide is not a single sequence of
steps. Instead, the sections can be better viewed as interlocking pieces of a
puzzle, for two reasons. First, the components of improvement are not linear
and independent; one piece may depend on another and work will need to move
back and forth between them. Second, each hospital may choose to start with a
different section of the guide, depending on its local needs.
We present this view of the guide as a puzzle with the image
below. To orient readers using the guide, we repeat this image at the beginning
of each section with the content of the section highlighted. In addition,
throughout the guide, we explicitly cross-reference subsections where
assessments, decisions, or tools in one area will contribute to deliberations
or actions in another.
i Estimate from
Currie LM. Fall and injury prevention. In: Patient safety and quality. an evidence-based
handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality;
2008. AHRQ Publication No. 08-0043. Available at: www.ahrq.gov/qual/nurseshdbk/docs/CurrieL_FIP.pdf [Plugin Software Help].
definition comes from the National Database of Nursing Quality Indicators. For
the full definition, see resource box in section 5.1.2.
iii See Cameron
ID, Murray GR, Gillespie LD, et al. Interventions for preventing falls in older
people in nursing care facilities and hospitals. Cochrane Database of
Systematic Reviews 2010, Issue 1. Art. No.: CD005465.
iv As of October 2012, CMS'
list of codes for falls and trauma includes fractures, dislocations,
intracranial injuries, crushing injuries, burns, and other injuries (such as
hypothermia). The specific Comorbidity and Complication/Major Comorbidity and
Complication codes are 800-829; 830-839; 850-854; 925-929; 940-949; and
991-994. CMS may update these codes periodically, so check the CMS Web site at www.cms.gov for guidance.
v See Hempel S, Newberry S,
Wang Z, et al. Review of the evidence on falls prevention in hospitals. RAND
Working Paper. (Prepared for the Agency for Healthcare Research and Quality,
Contract No. HHSA2902010000171, PRISM no. HHSA2903200IT, Task Order #1).
Publication No. WR-907-AHRQ. Santa Monica, CA: RAND; 2012. Available at: www.rand.org/pubs/working_papers/WR907.html . Also go to Appendix, "Bibliography of Studies Implementing
Fall Prevention Practices," for details.
vi In the context of this
toolkit, "best practices" refers to both (1) a standard way of developing,
implementing, and sustaining a hospital fall prevention program; and (2) those
clinical care processes that, based on literature and expert opinion, represent
the best way of preventing falls in the hospital.
vii We conceive of the
Implementation Team as a standing committee charged with overseeing the
hospital's fall prevention program. Joint Commission standards require ongoing
efforts to assess risk for falls and to intervene to reduce fall risk; staff
education regarding fall prevention; and an evaluation of the effectiveness of
the hospital's fall prevention strategies, including fall risk assessment,
interventions, and education. Therefore, many hospitals already have in place a
fall committee that could become the Implementation Team.
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