How is your organization doing in addressing fall risks for your patients?
Patient falls are among the most reported patient safety incident. Recent data from the Agency for Healthcare Research and Quality (AHRQ) estimates that 700,000 to 1 million hospitalized patients fall each year with a third sustaining serious injury or even death. Approximately half of the 1.6 million U.S. nursing home residents fall each year with nearly 10% resulting in significant injury according to a 2014 report from the Office of the Inspector General.1 Fall prevention has become even more important given the increase in the aging population who often present with more co-morbidities putting them further at risk for falls.
In addition to the physical and emotional impact of patient falls, the costs that are placed on hospitals in addressing patient falls is staggering. In 2007, the direct and indirect costs associated with falls totaled over $19 billion, including $179 million for fatalities following a fall. By 2015, Medicare reported that the cost of falls had risen to over $31 billion. It is estimated that this figure will rise to around $54.9 billion by 2020.2 Since 2008, the Centers for Medicare & Medicaid Services (CMS) stopped reimbursing hospitals for costs related to patient falls. Therefore, these costs are placed on the facility, which combined with the extended patient days because of a fall, reduces the availability of patient care resources that affects all patients.
Assessing and Mitigating Fall Risk by the Standards
The premise for patient care standards is to ensure patients receive safe healthcare services in an environment that protects them from harm. This includes addressing the issues with patient falls. Regulatory standards explicitly require that facilities assess their patients for fall risk and enact measures to prevent them from falling. It is imperative that facilities implement a robust Falls Prevention Program to ensure that initiatives are established, monitored, and maintained. At survey time, expect survey teams to ask about your fall risk process – How you assess risk? When? What do you do to address patients with high risk? Are your assessments accurate? Are you monitoring for compliance with fall prevention initiatives? Are you determining reasons for patient falls and modifying your program accordingly? Are patient falls decreasing?
Fall Prevention is a Team Sport
Falls should not be considered true accidents as there is evidence that a coordinated multidisciplinary clinical team approach can reduce their occurrence. Identification of underlying risk factors combined with coordinated interventions to mitigate these risks has been shown to reduce the incidence of inpatient falls by 20–30%.3 The key to an effective organization’s Fall Prevention Program is that it is a multidisciplinary obligation rather than a nursing-centric responsibility for planning and intervention. Leadership support is essential to ensure that fall prevention is kept at the forefront of organizational goals. Allocation of resources, training support and accountability is vital to a robust program and can only be supported through engaged Leadership. Medical Staff are an indispensable part through their assessment of the patient’s history, systems, and medication regimen. Physicians can ensure that fall risk is identified and addressed in the patient’s interdisciplinary plan of care. Pharmacy can provide alerts to the Provider and Nursing staff on the increased risk of falls related to the patient’s medication therapy. Other members of the healthcare team such as Radiology, Physical Therapy, Dietary and even Environmental Services are instrumental in recognizing patients at risk for fall and alerting those providing direct patient care about concerns. Nursing, by virtue of its greater touch time with patients, is in a unique position to assess for fall risk on an ongoing basis and ensure prevention measures are effectively initiated.
Key Elements of an Effective Program
Leadership Support – establishing organizational goals and allocating the resources needed for implementation, monitoring, and goal achievement.
Staff Education and Engagement – staff must be aware of the program’s elements, their responsibilities, and the impact of patient falls on the organization. Staff must be engaged and support the program.
Patient Education – an organized approach in educating the patient and their families on the Fall Prevention Program and their part in support of safety is critical. Considerations must be made regarding patients experiencing memory loss, dementia, or delirium.
Individualized Plan of Care – The plan of care must be sensitive to individual patient’s risk factors, needs, and preferences to be truly effective.
Consistent and Repetitive Assessment of Patient Fall Risk – The cornerstone of patient fall risk prevention is conducting an initial risk screening and consistent re-assessment periodically for any changes that will affect care initiatives.
Proactive Fall Risk Initiatives – Once an individualized plan of care has been developed, the team must initiate proactive initiatives to reduce the risk of falls for the patient. This may include education, use of banding/signage to indicate high fall risk patients and mobility assistance.
Purposeful Rounding / Proactive Toileting – According to the American Nursing Association, “purposeful rounding is a proactive, systematic, nurse-driven, evidence-based intervention that helps us anticipate and address patient needs.” Not only does this practice help reduce falls, but it increases team communication and patient satisfaction. Data has also demonstrated that a significant percentage of patient falls can be associated with toileting with some sources indicating these comprise between 40-50% of patient falls. Proactive Toileting, a part of purposeful rounding, reduces risk of falls associated with elimination by encouraging the patient to toilet regularly during rounds rather than relying on the patient to call for assistance.
Evaluating Program Effectiveness – It is important to ensure you have an active monitoring program that reviews all aspects of your fall program for effectiveness. This should include tracing for program compliance as well as data gathering on documentation of assessments and interventions. Consider developing a reporting tool that communicates your program’s data to your Quality, Medical Executive and Leadership committees. Communicate your program metrics to bedside staff so they can understand how their efforts are aligning with the program and the benefit of lowering fall rates.
Utilize Resources in Developing and Advancing Your Falls Prevention Program
There are several Fall Prevention Program resources that can provide you with guidance on how to establish or reinforce your program.
The AHRQ Falls Prevention Toolkit provides a comprehensive resource to address patient falls. Their toolkit is available at this link and can also be downloaded in pdf format: https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html
The Joint Commission Targeted Solutions Tool (TST) addressing fall prevention, is another excellent resource to consider for your program. It can be located at this link: https://www.centerfortransforminghealthcare.org/products-and-services/targeted-solutions-tool/preventing-falls-tst/
Preventing falls presents a daunting challenge to healthcare organizations that not only affect your patients physically, mentally, and emotionally but can extract a financial cost that takes away from the resources needed to provide care. It is incumbent on facility leaders to take time to review their Fall Prevention Program and commit to reducing this patient safety issue. Is it effective? What does your data show? What do you need to do to move forward?
1Preventing Falls in Hospitals. Content last reviewed July 2018. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html
2Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web–based Injury Statistics Query and Reporting System (WISQARS)[online].
3Morris, R., & O’Riordan, S. (2017). Prevention of falls in hospital. Clinical medicine (London, England), 17(4), 360–362. https://doi.org/10.7861/clinmedicine. 17-4-360.