Falls Prevention Toolkit Webinar Transcript
Dr. William Spector: Thank you. I'm very pleased to be here to talk about our new web-based Falls Prevention Toolkit. As you see on this slide, there is a web address, so it’s worth noting what that is. This would allow you to get into the toolkit to use it. It’s: http:/www.ahrq.gov/professionals/systems/long-term-care/fallpxtoolkit/ And that will give you access to it.
So what is new about this toolkit? Well, first of all, its web-based design makes it easy to use. It has approximately 35 tools that are aimed at guiding a multidisciplinary change team. The focus is challenges that you may have associated with developing, implementing, sustaining a falls prevention program.
We understand that hospitals are at different places with respect to fall prevention. And it allows hospitals to look at the toolkit, see what they’re interested in, and find tools that they can adapt for their own environment. But, also, it provides guidance for hospitals that are more interested in understanding the evidence base for the particular tools, etc.; there’s much more supplemental material that they can get into, to help them, if they’re interested in that. And it also provides guidance, depending on what your role is in the multidisciplinary team.
And we’re very lucky to be able to have a strong team to help develop this – the RAND Corporation, ECRI Institute, and Boston University. So we’re very proud of this, and we’re, of course, very interested in having as many hospitals find use for this, and to use it to help improve falls prevention.
So I will hand this over to David to continue the presentation. Thank you.
David Ganz: Thanks very much, Bill, for that introduction. I’m David Ganz. I'm a geriatrician, and I work at the VA Greater Los Angeles Healthcare System at UCLA and also at the RAND Corporation. In this particular project, RAND was the prime contractor for this project.
The purpose of the Falls Prevention Toolkit was to develop text and tools to guide implementation and maintenance of a hospital fall prevention program. And we thought long and hard about: who is the audience for this toolkit?
And primarily, we think the toolkit is targeted at midlevel managers and also clinicians. This was a conscious decision on our part, thinking about who might most likely adopt and find use for the tools.
In terms of what the tools cover, as Bill mentioned, it really covers all stages of organizational change, and it’s really the kind of thing that you don’t have to read from cover to cover. It’s meant to be a reference guide, so you can jump in at any point. You’ll see that when Kathy goes through the specific tools as examples.
We hope that by the toolkit’s design, the approaches will be adaptable to local circumstances. So we have created the tools in both Word and PDF format so that you can either put them into your hospital’s electronic health record, or if you use a paper system, you can adapt the tools to your needs. .
The toolkit has six sections. The first section is on hospital readiness for change. And if I had to summarize this section, I would say that it’s really about engaging your leaders. Most of the work and organizational research suggests that leadership is a key element in making any change sustainable.
So before proceeding on to the next parts of your changes you want to make to your program, you want to make sure that your leadership is onboard. So we have a whole section about that.
The second section is on managing change. And this is really about getting people involved in the right way, to make sure you have buy-in throughout the hospital. Because fall prevention is interdisciplinary, you really need to make sure you have a number of different disciplines on your fall prevention committee or team. So we go into that in quite a bit of detail in that second section on managing change.
The third section is on choosing fall prevention practices. And this is sort of the meat of the toolkit, in the sense that this is where we cover what we think are best practices, based on the evidence that we’ve collected. So this is the most clinical chapter or section in the toolkit.
The fourth section is on implementing best practices. So once you’ve decided which fall prevention practices you want to adopt at your hospital, the next question is how to implement those into routine care. And so the fourth section deals with that. And a lot of that is figuring out roles and responsibilities for the team, so we have a little bit on that as well.
The fifth section is on measuring fall rates and fall prevention practices. So one of the key things we find is that in order to know where you are in your program and how you’re doing, you have to measure. And you can’t just measure the fall rates, because that’s the outcome you’re trying to improve. You also have to measure the fall prevention practices, which are the care processes. Because we can’t reasonably expect the outcomes to improve unless we change the processes that we’re using. So we go into that in the fifth section.
And then, finally, the last section is on program sustainability. Because we realize that it’s easy to start something, but it’s hard to follow through. So we give a few strategies on how to sustain your fall prevention program in the final section. .
So you might wonder: how did we decide what to put into the toolkit? We used a multipronged approach. We started with an evidence review. So this was a systematic review of the literature.
And we looked at not just peer-reviewed publications, but also what was available on the Web and in government documents, like guidelines and things like that.
So we tried to be pretty thorough about gathering as much information as we could, partly so we didn’t have to reinvent the wheel, but to make sure that we knew where we were situating ourselves, relative to the other work that was out there. Then we also convened an expert panel.
There was an in-person meeting last February, in 2012, and then we had a followup conference call about 6 months later. And the expert panel was absolutely critical in sort of guiding the content of the toolkit.
We had experts from different disciplines, including nursing and rehab and pharmacy. We had a former hospital CEO. We had a fair number of different people so that we could get a good perspective on what we needed to have in the toolkit.
And then I think most importantly, we convened, with the help of ECRI Institute, a hospital workgroup. And the hospital workgroup – we’ll tell you a little bit more about that in a moment. But there were multiple attempts to basically gather information from the hospitals about the toolkit.
And it started with a self-assessment. Each hospital filled out an organizational self-assessment of where they were with respect to fall prevention. There was a followup phone call that ECRI Institute did to go over the findings from the self-assessment.
The next thing we did was an in-person meeting in February of 2012, where all the hospitals met with each other and talked about what their issues were that they wanted to work on. And we followed up that in-person meeting with monthly teleconferences, where the hospitals could bring up issues that were of importance to them. And also, that was one of their chances to give us feedback on the tools.
So it was a bidirectional collaboration, in the sense that we gathered information from the hospitals about what their needs were. But we also had them tell us what they thought about the tools.
We had two cycles of review, where we gave them the draft tools. They could try them out and then give us feedback on how those were working. And then we revised the tools, and they had an opportunity to look at the revised tools.
Finally, there was one site visit made to each of the six hospitals to gather additional information about what their organizational culture was like, what their care processes were – again, to help inform development of the toolkit.
So as I mentioned, we had six hospitals. And these were deliberately chosen by ECRI Institute to vary on geography, safety net status, profit status, unionization, and use of an electronic health record.
Again, the idea was we wanted to make sure that whatever we did was reasonably generalizable to the kinds of hospitals in the United States. And the units that were selected for piloting were also various. So there was a medicine unit, a neurology/neurosurgery unit, progressive care unit, inpatient rehab, and geriatric psychiatry. So we just tried to get as much variety as we could, in terms of these different units having patients with different risk factors for falls so that they could test a variety of different tools.
Now I'm going to turn it over to Kathy Pelczarski from ECRI Institute, who’ll tell you more about the specific tools
Kathy Pelczarski: Good morning. ECRI Institute’s role in the development of this toolkit was to recruit and work with participating hospitals in piloting the tools.
The pilot hospitals’ input was invaluable in helping the project team to tailor the tools to be realistically implementable, easy to use, broadly applicable in acute care hospitals, and highly relevant.
We believe all hospitals will find the toolkit to be highly relevant in helping them to address fall prevention challenges, seize opportunities for improvement, and utilize tools that can really help. I’d like to share some examples of these challenges, opportunities, and tools that are available now.
The first challenge relates to the composition of the team that oversees the falls prevention program at the hospital. Ever hear of the Atlas Syndrome, where some well-intentioned person or group decides to go it alone and take the weight of the world on their shoulders?
Historically, nursing has taken the weight of the world on their shoulders to prevent falls. The falls prevention committee typically included only nursing representation, and the care plan was exclusive to nurses.
While nursing was very well intentioned, this approach often lacked input from physical and occupational therapy, review of medications by pharmacy. And environmental services was not enlisted in making sure the environment was safe. Nurses often felt overburdened and overwhelmed.
But more recently, many hospitals are transitioning from historically nurse-driven falls prevention teams to interdisciplinary teams. However, some hospitals are still struggling with engaging various disciplines.
The opportunity here is an interdisciplinary approach that provides the benefits of essential input and buy-in from all key stakeholders, the strength of collaboration, and shared ownership in the solution. The toolkit provides guidance on how to set up the interdisciplinary team for success, and the toolkit has numerous tools that support this effort.
The interdisciplinary team tool has three parts. Part 1 provides a list of potential team members and requires the user to identify individuals and their expertise that match the job functions listed. Part 2 provides a list of all tools in the toolkit, along with who should use the tool. For example, the patient and family education tool should be used by staff educators and nurses.
Part 3 provides a matrix of various disciplines, such as nurses, physical therapists, pharmacists, facility engineers, risk managers, etc., and all the tools that are applicable to their roles. The pilot teams actually use this matrix to help them engage various disciplines. By sharing the applicable tools with the appropriate discipline, it opens the door for that discipline’s input and engagement in the falls prevention program. .
The Plan of Action tool enables the fall prevention team to define a specific goal and develop a list of interventions required to achieve that goal. They can specify all required tasks and tools to complete each intervention, and assign responsibility and a target date to each task. .
The Managing Change Checklist helps the team monitor its progress in completing the change management activities, such as assessment of current fall prevention practices and knowledge or starting the work of redesign.
A challenge that many hospitals experience is staff not employing critical thinking in assessing a patient’s fall risk. The opportunity is for effective risk assessments that employ critical thinking and clinical judgment.
The toolkit not only provides established assessment tools, such as the Morse Fall Scale and the STRATIFY Scale for Identifying Fall Risk Factors, but also deeper dive tools, such as the Medication Fall Risk Score and Evaluation Tools, the Orthostatic Vital Signs Measurement Tool, and the Delirium Evaluation Bundle. These deeper dive tools support staff in getting to the root cause of the patient’s elevated fall risk.
Another common challenge is staff not implementing effective interventions to prevent falls. In this particular example, the hospital uses the Morse Fall Risk Assessment, and the score of 70 here indicates a high fall risk. The hospital goes strictly by the risk score and does not consider individual risk factors in selecting interventions.
All high fall risk patients get the same interventions, which at this particular hospital include a colored magnet on the door and colored slippers to indicate high fall risk and the use of bed exit alarms. Nothing less, nothing more. Unfortunately, these interventions are oftentimes not particularly effective in preventing falls.
The opportunity is for optimizing the effectiveness of interventions by tailoring the interventions to a patient’s individual risk factors, assessing their effectiveness, and modifying interventions as needed.
The Sample Care Plan Tool gives specific examples of interventions that may be considered for specific risk factors. The goals and the care plan are aimed at reducing the likelihood of falls, while maintaining the patient’s dignity and independence.
The Algorithm for Mobilizing Patients Tool is meant for patients who’ve experienced deconditioning or are at risk for deconditioning. After the physician orders mobilization, the nurse uses the inclusion and exclusion criteria in the tool to determine if the mobility algorithm is appropriate for the individual patient. Then nursing assistants or other appropriate hospital staff can follow the mobility algorithm to initiate mobilization.
Many hospitals have implemented routine rounds to address a patient’s personal needs. This is really a great common sense strategy. However, for many hospitals, these rounds are inconsistent or ineffective because of poor staff compliance with rounding.
If a patient requires assistance to the bathroom, that patient is often left unattended while toileting. Essential elements, like checking the environment, are often omitted from the rounds. And, in many cases, the nurse’s hurried demeanor contributes to the patient’s reticence to ask for help.
The opportunity for hospitals is consistent and effective rounds employing the concept of purposeful rounding, in which the nurse’s relaxed demeanor makes it easier for patients to ask for help, and incorporating standard elements, such as asking the patient if they need to go to the bathroom and checking the environment during each visit.
The scheduled rounding protocol integrates fall prevention activities with the rest of a patient’s care. This protocol can be used by nurses, nursing assistants, and unit managers to ensure that universal fall precautions are in place.
A final challenge for hospitals is sustaining an effective falls prevention program. In this example, the hospital launched a fall prevention initiative toward the end of 2008 through late 2009. And they saw admirable results. But the initiative was not viewed as an ongoing program, and the hospital never provided the essential feedback to the staff on the effectiveness of the fall prevention strategies. So once the initiative ended, the fall rates began to increase again.
The opportunity is for continuous improvement and sustainability through an ongoing, programmatic quality improvement approach that incorporates essential feedback to staff on the effectiveness of fall prevention strategies, fosters learning from all falls, and promotes safety innovation and staff recognition.
Tools that support the sustainability of an effective falls prevention program include: assessing fall prevention chair processes, postfall assessment for root cause analysis, information to be included in the incident reports, measuring progress checklists, and the sustainability tool.
You can easily find these tools and others by selecting the roadmap that is provided at the beginning of the content on the AHRQ web site. The roadmap organizes tools by action steps, and it also provides an easy guide to who should use each tool.
At this time, I would like to turn the presentation over to Kendra Belkin from Charlton Memorial.
Kendra Belkin:Thank you, Kathy and hello. My name is Kendra Belkin, and I’m a physical therapist and clinical practice specialist. I work on an acute rehabilitation unit named Southeast Rehabilitation Center. This unit is located at Charlton Memorial Hospital in Fall River, Massachusetts.
Charlton is part of a not-for-profit organization called The Southcoast Hospital System. The tools for this project were piloted on this 20-bed rehabilitation unit. We treat patients with a variety of diagnoses. But the majority of our patients on this unit have a neurological diagnosis.
I am currently on the systemwide fall committee, and I also run the systemwide Falls Champions. I am one of three members that were involved in the piloting of this project. One member was the director of the unit, the other a staff nurse, and, of course, myself.
I was recently involved in the implementation of a new fall prevention program that will be up and running systemwide in our hospital group by the end of this month. We were very fortunate that the piloting of these tools coincided with the development of our new falls program.
We piloted seven out of the available tools, and I will be briefly talking about two of the tools that we piloted – the Fall Knowledge Test and Assessing Fall Prevention Care Processes.
The first tool that we piloted was the Fall Knowledge Test. The piloting of this tool assessed the knowledge of our staff at the Southeast Rehab Center regarding falls and falls prevention. The results of this tool helped us to identify specific areas of educational need.
The tool’s format consisted of multiple choice questions. The tool was administered to a majority of our staff on the unit. This included physical therapists, occupational therapists, speech therapists, therapy assistants, unit assistants, rehabilitation aides, nurses, and CNAs.
Based on the initial piloting of this tool, we were able to provide input concerning the test instructions and the format of some of the questions. When correcting the test, we were finding that the staff had answered some of the questions incorrectly because of the wording or the phrasing of some of the questions.
Feedback was provided, and subsequently, the tool was revised. The tool’s results identified gaps in our staff knowledge regarding medications and environmental safety in relation to falls and falls prevention.
We were somewhat surprised about the need for education in the area of environmental safety – less surprised about the need for education in the area of medications. But based on these results, we were able to target specific areas of educational need and provide the needed education.
We also piloted a tool assessing falls prevention care processes. And this tool was used to evaluate whether falls prevention care processes were occurring consistently for patients on this unit. The tool can be used to assess if steps in the fall prevention program are being followed.
When a new program is implemented, sometimes, over time, some of the steps may no longer be followed, or the processes may have been altered. We found that sustaining a new program is a real challenge. With this tool in place, we can help to ensure that the program is sustained over time.
The way this tool is laid out, there’s a column on the left-hand side that lists specific questions that the reviewer needs to address. Across the top is a row with the numbers 1 through 20 that represent a specific patient and room. The last column is an area where you can add up the totals.
The reviewer took this tool, went to each room on the unit, for the maximum of 20 rooms, to see if the nursing call light was within reach, if proper footwear was being used, and if the room was free of clutter. The reviewer then would go to the chart in the computer to look up more specific information regarding falls in each of the 20 patients.
When we were piloting the tool, we were finding that some of the challenges in gathering all the required information in a timely manner, because of the location of the information, were some items in patients’ rooms, and others in charge, or computers at the nurses station. The results of these audits have provided us valuable information on the processes of our falls prevention.
Since piloting the tool, we have tailored this tool to meet the needs of our time constraints by grouping related items together. We have also eliminated and added some more questions that were more specific to our particular falls prevention program.
We have included additional elements, such as whether the purposeful rounding logs were completed, if alarms are working and in place, the communication boards in the patient rooms are filled out, if the door signage is present, if the neon bracelet has been applied, and if the patient contract is at bedside.
We are just about to roll out a new falls prevention program in the next couple of weeks. As the leader of the Falls Champions for Southcoast Hospital Systems, we’ll be implementing this tool, with the changes we have made, in the next couple of months.
The Falls Champions tool will be responsible for the audits. There is one member from each unit at all three hospitals. We will be using this tool on every unit on a monthly basis. Thank you. And next will be Pat Benson speaking from Augusta Health.
Pat Benson:Thank you. This is Pat Benson. I am the nursing quality coordinator at Augusta Health. I have been the nursing leader on our fall prevention team that started approximately 18 months ago. Our 37-bed medical unit became our piloting unit for trialing the Fall Prevention Toolkit, as there were opportunities to decrease our fall rates.
One of the most helpful tools that we piloted was the Environmental Safety Inspection Checklist. This tool provides an inspection checklist to identify and resolve environmental safety issues in the patients’ rooms. The results from the inspection process are used to determine which items require attention by nursing staff, maintenance, or replacement by facility engineers.
The checklist includes different categories. One of the categories is pathways. It’s a reminder to remove unused equipment and rearrange anything in the room for a clear path for the patient to the bathroom, to the sink, and keeping the over-bed table across the bed and patient for safety.
The checklist also reminds to check furniture. Is it clean? Is it in need of repair or replacement? Are there broken bed wheel locks? Are all bed functions operational?
Also, what access does a patient have? Can they easily reach their personal items? Can they reach their cane and walker, so that if they do decide to get up unassisted, they at least have their safety aids to help them?
In piloting this tool, we decided to add a picture of a typical patient room, with an appropriate environment set up, corresponding to the items on the checklist. The checklist has been used to educate nursing and environmental services staff, so that we can keep the room set up safe.
Most departments conduct periodic audits to identify and address environmental issues and areas to improve patient safety. For example, during our initial audits, we identified and documented problems related to bed malfunctions, such as the bed exit system and call bell.
We were able to use the results of our audit to justify implementation of our bed replacement plan. And I'm happy to say that we now have new beds.
We selected this tool for piloting because of its multidisciplinary checklist. It includes nursing, maintenance, environmental services, and others. The architectural layout of some patients’ rooms is challenging from a fall prevention perspective. The patient needs to walk around the bed to reach the bathroom, then walk back around the other side of the bed to access a hand washing sink. The patient chair and other obstacles were frequently in the way because there was insufficient room for a clear path.
Our checklist and our picture helped to solve this so that staff were able to keep those items located in the correct location for patient safety. There are plans to begin renovating these rooms next year, but in the meantime, we wanted to keep the room as safe as possible.
We also selected to pilot the Postfalls Assessment for Root Cause Analysis to aid us in investigating and addressing causes for patient falls. This tool provides a standardized approach to postfall evaluation and is important for organizational learning about how to prevent future falls.
The nursing supervisor uses this tool to talk to staff and the patient after each fall. It’s been helpful to incorporate it into the Environmental Safety Inspection Checklist as part of the investigation of our postfall assessment.
It helps us to determine whether environmental safety issues contributed to the patient’s fall, thus preventing additional falls for the patient and other patients. Thank you.