Overview

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 hospital^iv; 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 University.

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, pharmacists).

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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 questions:

1. Are you ready for this change?
2. How will you manage change?
3. Which fall prevention practices do you want to use?
4. How do you implement best practices in your organization?
5. How do you measure fall rates and fall prevention practices?
6. 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 more detail.

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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.

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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].
ⁱⁱ This 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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