Optimizing the Use of an Electronic Fall Prevention Toolkit To Prevent Falls in Hospitalized Patients
By Geetha Achanta, PhD
Patient falls are common in hospitals. Based on the number of older Americans discharged from hospitals in 20081 and published fall rates in this population,2 approximately 2.5 million older Americans fell while hospitalized in that year and approximately 200,000 sustained an injury. Inpatient falls result in decreased mobility and loss of independence for patients, loss of time required to complete incident reports for hospital staff, and additional costs for payers. The Joint Commission requires that a fall risk assessment be conducted on every patient when admitted to a hospital and that a fall-prevention care plan be put in place. Despite these measures, fall rates have failed to significantly improve. A likely explanation is the wide variability in care plans across hospitals and inadequate communication between the care teams and their patients.
Over the past several years, Dr. Patricia Dykes and her colleagues at the Brigham and Women’s Hospital Centers for Education and Research on Therapeutics (CERT) have been working to reduce the gaps in fall-prevention care. At the American Medical Informatics Association annual meeting in 2012, Dr. Dykes presented findings from her team’s case-control study3 that used data mining and modeling techniques to identify the factors associated with falls among inpatients during the 6-month period the team tested its fall-prevention toolkit Fall TIPS (Tailoring Interventions for Patient Safety; FTTK). The FTTK was developed by Dr. Dykes and her colleagues with input from end-users and informaticians with human factors experience. The FTTK relies on a Morse Fall Scale-based risk assessment performed by a nurse to produce a patient-specific care plan. This documented plan is then communicated to patients, caregivers, and staff in addition to hanging bedside posters and distributing educational handouts to patients.
In an earlier study, published in JAMA in 2010,4 the team found that fall rates were significantly lower, particularly in older patients, in hospital units that used the FTTK when compared with units that provided usual care. However, only 22 percent of falls were prevented during this study versus the estimated 78 percent that were to be prevented with the FTTK-recommended care plan, leading the authors to conduct their more recent case-control study.
The case-control study was conducted at four Partners HealthCare acute care hospitals where the FTTK had been tested from January 1 through June 30, 2009. Cases included inpatients who had fallen in randomly selected intervention units; controls were randomly selected from patients admitted to the units within the same 6-month period and did not fall. Clinical data including demographics, Morse Fall Scale score, length of stay before falling, and recommended nursing interventions were abstracted for each case and control from the FTTK database. Fall incident data were also collected. The study included 192 patients (48 cases and 144 matching controls). Of these, 88 patients were 64 years of age or younger and 104 were 65 years of age or older.
Univariate and multivariate regression analyses were conducted to identify factors associated with falls in the overall inpatient population and in younger and older inpatients.
- Overall, inpatients who fell (cases) were 5.7 times more likely than those who did not (matched controls) to have needed help getting out of bed before the fall (e.g., the FTTK recommended this intervention).
- Among older inpatients, those who fell, when compared with those who did not, were:
- Less likely to have used a cane as an ambulatory aid before the fall
- 10.1 times more likely to have needed help getting out of bed before the fall (e.g., the FTTK recommended this intervention)
- 14.26 times more likely to have needed two people to help them get out of bed or walk (e.g., the FTTK recommended this level of assistance)
- Among younger inpatients who fell, none of the factors assessed were significantly associated with fall risk in multivariate analyses.
A review of medical records and incident reports for all inpatients who fell while the FTTK was being tested showed that the care plan recommended by the FTTK was accurate, but it was not adhered to at the time the fall occurred. For example, the FTTK recommended that inpatients with a weak gait have a person assist them and that inpatients with an impaired gait have two people assist them. However, a review of incident reports showed that inpatients were consistently alone at the time of the fall (patient nonadherence) or that inpatients with an impaired gait were being helped by only one person instead of two when they fell (provider nonadherence).
"This study showed us that the main problem was not with the FTTK-generated recommendations but with adherence to the recommendations," explains Dr. Dykes. "We learned from focus groups that the main reasons for patient nonadherence to recommendations, particularly among younger patients, were that they did not believe that they were at risk for fall, or that the nurses seemed rushed when they were recommending assistance for the patient, or that they were embarrassed to get help. The most common reason for provider nonadherence to recommendations was that there was not enough staff on the floor to help."
Based on the study findings, Dr. Dykes identified several practice recommendations for health care professionals who care for patients at risk for falls. She notes, "Fall prevention is a three-step process: assessing the risk of a fall, creating a care plan that is personalized and based on the assessment, and executing the plan every time. To make sure that the interventions are always executed, we cannot depend on the clinical staff alone. We have to always perform a good fall risk assessment, make sure that the intervention plan we develop is based on areas of risk for the patients, and involve the patients in this process." She adds that involving the patients and their families in completing the fall risk assessment is likely to improve its accuracy. Similarly, partnering with patients and families in developing the care plan is likely to increase their acceptance and execution of the recommendations.
In the future, Dr. Dykes and her colleagues plan to investigate if adhering to the three-step process of fall prevention and involving patients and their families at each step will prevent falls among inpatients, particularly in those who are younger.
The Centers for Education and Research on Therapeutics (CERTs) are a nationwide network of six research centers and a coordinating center that receive core financial support from the Agency for Healthcare Research and Quality. The CERTs conduct research and provide education that will advance the optimal use of drugs, medical devices, and biological products; increase awareness of the benefits and risks of therapeutics; and improve quality while cutting the costs of health care.
- HCUP Statistical Briefs - Elderly. Healthcare Cost and Utilization Project (HCUP). Agency for Healthcare Research and Quality, 2011. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb103.jsp Accessed November 14, 2013.
- Schwendimann R, Buhler H, De Geest S, Milisen K. Characteristics of hospital inpatient falls across clinical departments. Gerontology. 2008;54:342–8. PMID: 18460867
- Dykes PC, I-Ching EH, Soukup JR, et al. A case control study to improve accuracy of an electronic fall prevention toolkit. AMIA Annu Symp Proc. 2012;2012:170-9. PMID: 23304286. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3540550/.
- Dykes PC, Carroll DL, Hurley A, et al. Fall prevention in acute care hospitals: a randomized controlled trial. JAMA. 2010;304(17):1912-8. PMID: 21045097. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3107709/.
- Agency for Healthcare Research and Quality. AHRQ Healthcare Innovations Exchange. Fall Prevention Toolkit Facilitates Customized Risk Assessment and Prevention Strategies, Reducing Inpatient Falls. https://innovations.ahrq.gov/profiles/fall-prevention-toolkit-facilitates-customized-risk-assessment-and-prevention-strategies?id=3094. Accessed February 24, 2015.