R E V I E W S & A N A LY S E S Standardizing Reporting of Patient Falls: A Survey of Pennsylvania Hospitals Lea Anne Gardner, PhD, RN INTRODUCTION Senior Patient Safety Analyst Pennsylvania Patient Safety Authority Beginning in the fourth quarter of 2008, the Pennsylvania Patient Safety Authority partnered with the Health Care Improvement Foundation (HCIF) and 29 hospitals in the southeast region of Pennsylvania to standardize reporting of patient falls. At the end of the fourth quarter of 2010, this initiative culminated in a patient falls confer- ABSTRACT ence for participating hospitals to share their experiences. Given the positive response The Pennsylvania Patient Safety Author- to the regional initiative, the Authority and the Hospital and Healthsystem Association ity set out to evaluate the interest of of Pennsylvania explored the opportunity to expand this initiative statewide. Input Pennsylvania hospitals to expand a from various hospitals led to the development of a survey to ascertain the potential to regional initiative to standardize falls expand this project. The purpose of this article is to summarize the results of this state- reporting to a statewide level. A survey wide survey. was distributed to Pennsylvania hospitals to determine the level of interest in this METHODS initiative. The results showed a general In August 2011, the Authority surveyed Pennsylvania hospitals to evaluate statewide consensus among 81respondent hospi- expansion of the initiative to standardize reporting of patient falls. The survey was tals on the standardized falls definitions sent to 167 general acute care hospitals, specialty hospitals, children’s hospitals, and and willingness to participate. Hospitals rehabilitation hospitals or centers. Invitations to 13 facilities were undeliverable, which indicated support for separate report- reduced the sample size to 154 facilities. The survey included 25 questions: 18 general ing of comparison data of falls rates questions, 5 follow-up questions, and 2 open-ended questions. When analyzing the for general acute care and specialty results, the analysts interpreted nonresponses in two ways. For questions of preference, hospitals and for inpatient and outpa- the analysts interpreted nonresponses as indications of no preference and included tient settings. Potential barriers include them in the analysis. For all of the other questions, the analysts removed nonresponses financial, resource, and data collection from the analysis and calculated percentages based on specific responses. The unit of burdens (e.g., collecting unit-level utili- analysis is the hospital. zation data). (Pa Patient Saf Advis 2012 Jun;9[2]:43-6.) RESULTS Demographics The survey response rate was 52.5% (n = 81 of 154). Among respondents, two ques- tions had a 100% response rate (n = 81 of 81), the remaining response rates ranged from 69% to 94%. General acute care hospitals made up the majority of respondents (80%). The Figure shows a breakdown of the respondents. Hospital Comparison Data Questions about falls comparison data focused on current involvement of hospital com- parison of falls rates with external data sources, participation in a Pennsylvania statewide standardized reporting of falls rates initiative using comparison data, and which outpa- tient services and departments to include in the reporting of comparison data. External data sources. Seventy-nine percent (n = 64 of 81) of responding hospitals com- pared their falls rates with an external data source; 21% (n = 17 of 81) did not. Eleven different types of external source comparison data were identified and used by this sam- ple of Pennsylvania hospitals. Some hospitals identified multiple external data sources; however, the National Database of Nursing Quality Indicators (NDNQI) was the biggest external source (59.4%). Table 1 provides a breakdown of the external data sources. Statewide comparison data. The majority of hospitals, 85.2% (n = 69 of 81), were interested in participating in a Pennsylvania statewide standardized reporting initiative that would compare falls rates and improve processes, while 8.6% (n = 7 of 81) were not interested and the remaining 6.2% (n = 5 of 81) indicated no preference. A similar Vol. 9, No. 2—June 2012 Pennsylvania Patient Safety Advisory Page 43 ©2012 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S level of support was indicated for the ways specialty hospitals and for separate reporting departments for falls rates comparison hospitals prefer to have comparison data of comparison data of falls rates for inpa- data would be desired. They identified presented. There was strong support for tient and outpatient settings. See Table 2. nine different areas, with five settings/ separate reporting of comparison data of Outpatient comparison data. Hospitals departments receiving 97% of the total falls rates for general acute care and were asked which outpatient settings/ responses. See Table 3. Figure. Falls Survey Hospital Distribution Falls Definition 3% The Authority/HCIF southeastern regional falls reporting initiative defined a fall as “any unplanned descent to the 6% floor (or other horizontal surface such as a chair or table), with or without injury to 11% the patient.” General acute care hospitals This definition of falls includes assisted Specialty hospitals falls, in which a caregiver sees a patient about to fall and intervenes, lowering him Rehabilitation hospitals or her to a bed or floor, and therapeutic falls, in which a patient falls during a Children’s hospitals 80% physical therapy session with a caregiver present specifically to catch the patient in case of a fall. The definition excludes fail- MS12238 ures to rise, in which a patient attempts Table 1. Data Sources Used by Hospitals for Comparison of Falls Rates NUMBER OF HOSPITALS DATA SOURCE USING DATA SOURCE*,† PERCENTAGE National Database for Nursing Quality Indicators ‡ 38 59.4% Estimates in peer-reviewed literature 15 23.4 Veterans Health Administration§ 7 10.9 Corporate and other company hospitals 7 10.9 Pennsylvania Patient Safety Authority and Health Care Improvement 4 6.3 Foundation southeast region falls initiative** Pennsylvania Mountains Healthcare Alliance falls benchmarking 4 6.3 and development of falls-related injury program†† Massachusetts performance measures‡‡ 3 4.7 Shared data among local hospitals 2 3.1 Maryland Quality Indicator Project§§ 1 1.6 Agency for Healthcare Research and Quality 1 1.6 University HealthSystem Consortium 1 1.6 * Out of 64 Responding Hospitals. Some hospitals identified multiple external data sources. † Websites provided when data sources were not accessible. ‡ Available from: https://www.nursingquality.org. § Available from: http://www.patientsafety.gov. ** Available from: http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/Pages/Home.aspx. †† Available from: http://www.pmhalliance.org/extra/AboutUs/Initatives/tabid/63/Default.aspx. ‡‡ Available from: http://www.patientcarelink.org/hospital-data/performance-measures.aspx. §§ Available from: http://www.wha.org/marylandQIP .aspx. Page 44 Pennsylvania Patient Safety Advisory Vol. 9, No. 2—June 2012 ©2012 Pennsylvania Patient Safety Authority Table 2. Preferences for Separate Standardized Reporting of Comparison Data PREFER SEPARATE STAN- DO NOT PREFER SEPARATE NO PREFERENCE FOR TYPES OF SEPARATE STAN- DARDIZED REPORTING STANDARDIZED REPORT- STANDARDIZED REPORT- DARDIZED REPORTING OF COMPARISON DATA ING OF COMPARISON ING OF COMPARISON OF COMPARISON DATA OF FALLS RATES DATA OF FALLS RATES DATA OF FALLS RATES* Acute care general hospitals 68 (84%) 0 (0%) 13 (16%) versus specialty hospitals Inpatient versus outpatient 62 (76.5%) 5 (6.2%) 14 (17.3%) settings * No preference reflects nonresponses to these specific survey questions but fails to rise from a sitting or reclining or whether they use the write-in descrip- Three percent (n = 2 of 70) of hospitals position. tion subcategory labeled “Other” when recommended the removal of first aid and The majority of responding hospitals, reporting falls data. A majority of hospi- minor sutures from the current falls with 80.5% (n = 58 of 72), used the falls defini- tals, 74.6% (n = 53 of 71), responded that harm definition, and another 3% (n = 2 tion identified by the initiative, and 19.4% they use the PA-PSRS falls event sub- of 70) of hospitals inquired about how to (n = 14 of 72) of responding hospitals categories; however, 25.4% (n = 18 of 71) classify rib fractures that do not require did not. When asked if changes in the of hospitals responded that they report surgical intervention. definition should be made, 70.8% falls using the write-in falls subcategory (n = 51 of 72) of responding hospitals said “Other.” One-half (n = 9 of 18) of the Collection and Measurement no. The remaining 29.2% (n = 21 of 72) of hospitals that use the write-in subcategory Issues responding hospitals provided comments “Other” to report falls events did not pro- General data collection concerns. Data or recommended changes to the defini- vide a reason for using this subcategory. collection questions assessed potential tion. Two respondents recommending Twenty-seven percent (n = 5 of 18) of these reasons for nonparticipation and current changes indicated that they would change hospitals identified patient conditions data submission practices. More than their facilities’ falls definition to the falls (e.g., seizures, syncope) as a falls event half, 59.2% (n = 45 of 76), of the respond- definition identified by the initiative. subcategory, and the remaining 22% ing hospitals would participate in the The recommended changes were grouped (n = 4 of 18) of these hospitals identified standardized patient falls reporting initia- according to 10 similar themes and are other circumstances of the fall (e.g., found tive even if additional data collection were presented in Table 4. on floor, intentional falls). required. The remaining hospitals, 40.8% Hospitals were asked whether they use When hospitals were asked about the (n = 31 of 76), were uncertain or would the defined falls event subcategories (e.g., falls with harm definition requiring the find additional data collection prohibi- toileting, ambulating) in the Pennsylvania inclusion of any fall where more than first tive. The most common reasons for lack Patient Safety Reporting System (PA-PSRS) aid care is needed, 94% (n = 66 of 70) of of participation included resource limita- respondents agreed with the definition. tions (financial, time, and personnel) and data collection burden, especially being Table 3. Outpatient Settings/Departments for Which Falls Rates Comparison Data Is Desired required to collect new types of data in OUTPATIENT SETTINGS/DEPARTMENTS TOTAL RESPONSES* PERCENTAGE addition to current data. Emergency room 52 77.6% Measurement issues. Responding hospi- Physical/occupational therapy 51 76.1 tals almost unanimously (94.3% [n = 66 Radiology 50 74.6 of 70]) acknowledged that they collect and Laboratory 39 58.2 monitor falls at the unit level, yet only Outpatient/hospital-based clinics 38 56.7 77.9% (n = 53 of 68) of hospitals were willing to report patient-days separately for Cardiology 3 4.5 every unit. Potential methods or resources Ambulatory surgical procedural units 3 4.5 to consider should the initiative require Postanesthesia care unit 1 1.5 unit-level data include the following: Nonclinical buildings and grounds 1 1.5 — Use of NDNQI data methods and * Out of 67 responding hospitals. Facilities provided more than one response. definitions Vol. 9, No. 2—June 2012 Pennsylvania Patient Safety Advisory Page 45 ©2012 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Table 4. Recommended Changes to or Comments on the Initiative’s Falls Definition NUMBER OF PERCENTAGE OF RECOMMENDED CHANGES OR COMMENTS RESPONDENTS* RESPONDENTS Therapeutic and developmental falls are not falls. 6 28.5% Assisted falls are not true falls. 4 19.0 Definition is not appropriate for behavioral health and rehabilitation 3 14.3 facilities. No recommended changes. 3 14.3 Hospitals would change their definition to the falls definition in the survey. 2 9.5 Failure to rise is ambiguous and inconsistent to measure. 2 9.5 The use of Steri-Strips or glue should be considered first aid. 1 4.7 Add falls risk assessment, patient population, and presence of staff 1 4.7 to definition. Provide distinction for anticipated versus unanticipated falls. 1 4.7 There are discrepancies between the initiative’s definition and the 1 4.7 National Database of Nursing Quality Indicators’ definition, which includes the use of high or low beds. * From 21 responding hospitals. Some respondents provided more than one comment. — Use of PA-PSRS, specifically the influenced by respondents’ involvement desire to use establishewd systems (e.g., patient-days reporting component of in the recent Authority falls reporting PA-PSRS, NDNQI, Centers for Medicare the infection control system initiative or other negative or positive and Medicaid Services or Institute for — Use of 1,000 patient-days as the stan- reporting experiences. Healthcare Improvement reporting sys- dard denominator for reporting falls tems) to facilitate reporting of falls rates. — Use of a web source to report data CONCLUSION Incorporating the survey information into or excel spreadsheet to collect data a statewide standardized falls reporting ini- This sample of Pennsylvania hospitals for reporting tiative would expand and enhance hospital indicates a willingness to participate monitoring and may improve understand- in a statewide initiative to standardize LIMITATIONS ing of patient falls. reporting of falls rates as well as a general There are several limitations to this agreement on the falls definition. Overall, ACKNOWLEDGEMENTS survey. It was sent to a sample of Penn- the consensus indicates that Pennsylvania Theresa Arnold, DPM, Pennsylvania Patient Safety hospitals actively compare falls rates to a Authority; Denise Barger, BA, CPHRM, CPHQ, sylvania hospitals with a response bias CPPS, HEM, Pennsylvania Patient Safety Author- toward acute care general hospitals and variety of external data sources and want ity; and Pamela A. Braun, RN, MSN, Health Care possibly hospitals actively involved in more facility-level, unit-level, and inpa- Improvement Foundation, developed the hospital tient- and outpatient-specific information. statewide falls survey. reporting performance measures and adverse event data. Distributing the survey There are several common themes to the in late August for a period of two and a issues of data collection and measurement, half weeks may have influenced the num- namely the standardization of definitions ber of responses. Survey responses may be and data collection requirements and a Page 46 Pennsylvania Patient Safety Advisory Vol. 9, No. 2—June 2012 ©2012 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 9, No. 2—June 2012. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2012 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. 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