R E V I E W S & A N A LY S E S Falls Reduction and Prevention Update: Pennsylvania Hospitals Increase Implementation of Best Practices Michelle Feil, MSN, RN INTRODUCTION* Senior Patient Safety Analyst In December 2011, the Pennsylvania Patient Safety Authority partnered with the Hos- Christina Hunt, MSN, MBA, HCM, RN Senior Patient Safety Liaison pital and Healthsystem Association of Pennsylvania to lead the Pennsylvania Hospital Engagement Network (PA-HEN) Falls Reduction and Prevention Collaboration. Begin- Pennsylvania Patient Safety Authority ning in January 2012, hospitals from across the commonwealth joined the collaboration ABSTRACT and enrolled in the Pennsylvania Patient Safety Reporting System (PA-PSRS) Falls Reporting Program. A group of 80 hospitals participated through December 2013. In 2012, the Pennsylvania Patient Safety Authority provided hospitals par- As part of the collaboration, the Authority developed two tools for the enrolled hos- ticipating in the Pennsylvania Hospital pitals to use in evaluating their falls prevention programs: an annual self-assessment Engagement Network Falls Reduction survey and a quarterly process measures audit (available at http://patientsafetyauthority. and Prevention Collaboration with two org/EducationalTools/PatientSafetyTools/falls/Pages/home.aspx). Analysis of results tools to evaluate their falls prevention from the initial use of these tools in 2012, as well as hospital rates of falls with harm, programs: an annual self-assessment was published in the December 2013 Pennsylvania Patient Safety Advisory article “Falls survey and a quarterly process mea- Prevention: Pennsylvania Hospitals Implementing Best Practices.”1 Highlighted find- sures audit. Hospitals that completed ings include the following: the survey in 2012 and 2013 reported —— Thirty-five individual falls prevention practices and/or specific program elements an increase in full implementation for were identified that correlated with lower rates of falls with harm. 16 of 17 categories of falls prevention —— Although the majority of hospitals reported full implementation for the majority best practices. Comparison of 2012 sur- of best practices in falls prevention, all hospitals reported practices that were miss- vey responses to audit results revealed ing or in need of improvement. a gap between levels of full implemen- tation of best practices reported on —— Medication review and sitters were identified as two categories of falls prevention the survey and compliance with falls practices that correlated with lower rates of falls with harm, but these practices prevention practices observed during were reported to have low levels of full implementation in most hospitals. the audit process. Analysis of 2013 —— A “policy-practice gap” was identified (i.e., interventions prescribed by policy were data shows a decrease in this gap and not implemented in practice) when comparing best practices reported as having improved compliance with falls preven- full implementation on the falls self-assessment survey with falls prevention prac- tion practices. Rates of falls with harm tices observed during the audit process. decreased for hospitals that completed Hospitals participating in the collaboration that have continued to use these tools have the self-assessment survey in 2012 been able to evaluate their current falls prevention programs and successfully identify and 2013 in addition to all quarterly and implement evidence-based practices missing or in need of improvement. They have audits. Hospitals participating in the also been able to monitor staff compliance with falls prevention practices and have collaboration and utilizing these tools seen increases in compliance, as well as reductions in rates of falls with harm. have been able to evaluate their current falls prevention programs, identify and METHODS implement evidence-based practices missing or in need of improvement, Falls SAT Survey monitor staff compliance with falls pre- The PA-HEN Falls Reduction and Prevention Collaboration Self-Assessment Tool vention practices, and decrease rates (SAT) survey was adapted from an existing questionnaire2 and was designed to evalu- of falls with harm. (Pa Patient Saf Advis ate the current structure and content of hospital falls prevention programs compared 2014 Jun;11[2]:69-77.) with evidence-based best-practice guidelines. The SAT survey was intended to serve Corresponding Author as a tool to assist hospitals in identifying best-practice elements that could be targeted Michelle Feil for improvement in their current falls prevention programs. For each falls prevention Scan this code practice listed in the SAT survey, respondents could report either full implementa- with your mobile tion, partial implementation, or no implementation. Hospitals participating in the device’s QR collaboration were asked to complete the falls SAT survey in 2012 and again in 2013. reader to access the Authority's * The analyses upon which this publication is based were in part funded and performed under toolkit on this contract number HHSM-500-2012-00022C, entitled “Hospital Engagement Contractor for Part- topic. nership for Patients Initiative.” Vol. 11, No. 2—June 2014 Pennsylvania Patient Safety Advisory Page 69 ©2014 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S The Authority analyzed and compared most complete data was available from More hospitals also reported full imple- survey responses between the two years PHC4, and (2) this time period immedi- mentation for each of the following best to identify changes in implementation ately preceded completion of the falls SAT practices in 2013: level for falls prevention practices over the survey, therefore controlling for the influ- —— Communicating clear and consistent course of the collaboration. Only hospi- ence survey completion may have had on guidelines for completing patient tals that completed the falls SAT survey rates. The second time period of January safety event reports and follow-up or for both time periods were included in through June 2013 was selected for these investigation forms for patients who the analysis. same reasons, as well as to allow for com- have fallen as part of mandatory in- parison between two similar time periods. service educational programs Falls Prevention Process (46 hospitals in 2012, 60 in 2013) Measures Audit Tool RESULTS —— Utilizing a follow-up or investigation The Falls Prevention Process Measures form, separate from the patient safety Audit Tool is a point prevalence data Falls SAT Survey—Overall event report form, for patients who collection tool used to assess compliance Of the 80 hospitals that completed the have fallen (48 hospitals in 2012, with falls prevention practices most com- falls SAT in 2012, 74 completed the falls 60 in 2013) monly included as part of hospital falls SAT in 2013. Most hospitals reported full —— Requiring staff to include a descrip- prevention programs. Hospitals were asked implementation for the majority of falls tion of any equipment in use at to complete quarterly audits on the unit prevention best practices both years. As a the time of the fall in patient safety or units where they were piloting small group, these 74 hospitals reported 68.2% event reports (65 hospitals in 2012, tests of change as part of collaboration. of all practices with full implementation 73 in 2013) This point prevalence audit consisted in 2012, ranging from 20.5% to 92.7% Postfall assessment. Hospitals reported of documentation review (e.g., “Was a for individual hospitals. In 2013, the an average of 80.2% of best practices fall prevention plan documented?”) and percentage of practices reported with full in the category of postfall assessment as observation of patients and the environ- implementation increased to 78.2% for fully implemented in 2012, increasing to ment (e.g., “Does the patient have risk the group, ranging from 52.3% to 98.6% 88.7% in 2013. The two practices with identifiers?”). The Authority analyzed the for individual hospitals. Figure 1 shows the largest increase in the number of results of audits conducted for the quar- the percentage of full implementation hospitals reporting full implementation ter beginning July 1, 2013, and ending reported by these 74 hospitals for each cat- were (1) postfall event interventions are September 30, 2013, to identify overall egory of falls prevention practices by year. reviewed and, if necessary, revised and compliance with falls prevention practices. documented in the individual’s chart A secondary analysis of audit results was Falls SAT Survey—High Levels of (49 hospitals in 2012, 64 in 2013) and completed to evaluate compliance with Full Implementation (2) following a fall, the patient is reas- specific practices in hospitals reporting full Event reporting, postfall assessment, and sessed for falls risk and assessment implementation of these practices on the fall alarms were the top three categories of findings are communicated to staff who falls SAT survey. falls prevention best practices reported with interact with the patient (58 hospitals in full implementation in 2012 and 2013. 2012, 68 in 2013). Falls-with-Harm Rates Event reporting. Hospitals reported an Fall alarms. The category of fall alarms Rates of falls with harm per 1,000 patient- average of 85.7% of practices in the consists of three best practices. Hospitals days were calculated for January through category of event reporting as fully imple- reported an average of 79.3% of these June 2012 and for January through June mented in 2012, increasing to 91.8% practices as fully implemented in 2012, 2013 using falls with harm as reported in 2013. Because most practices were increasing to 86.5% in 2013. The number through PA-PSRS (i.e., any fall reported as reported as fully implemented in 2012, of hospitals reporting full implementation a Serious Event, as defined by Pennsylvania there was not much change reported in for each practice increased as follows: reporting requirements) and total facility 2013, with a few exceptions. The largest patient-days as reported to the Pennsyl- —— Holding staff accountable for a increase was seen in the number of hos- vania Health Care Cost Containment timely response to fall alarms pitals requiring staff to establish a new Council (PHC4).3 At the time of the initial (48 hospitals in 2012, 56 in 2013) intervention plan to prevent repeat falls as analysis in 2012, the period of January part of a standardized patient safety event —— Adequately training staff to through June was selected for two reasons: report (45 hospitals in 2012, 60 in 2013). use fall alarms, such as bed-exit (1) this was the time period for which the alarms, including inspection and Page 70 Pennsylvania Patient Safety Advisory Vol. 11, No. 2—June 2014 ©2014 Pennsylvania Patient Safety Authority maintenance of the systems Figure 1. Reported Percentage of Falls Prevention Best Practices with Full Implemen- (57 hospitals in 2012, 64 in 2013) tation by Category for Hospital Engagement Network Facilities Completing the Falls —— Using other falls prevention inter- Self-Assessment Survey Tool in 2012 and 2013 (N = 74) ventions in conjunction with fall alarms (71 hospitals in 2012, CATEGORY 2012 2013 72 in 2013) 85.7 Event reporting 91.8 Falls SAT Survey—Low Levels of Full Implementation 80.2 Postfall assessment 88.7 Of the falls prevention best-practice cat- egories, medication review remained the 79.3 category with the lowest percentage of full Fall alarms 86.5 implementation, followed by sitters, with 75.8 less than 50% full implementation in Staff education 85.2 each category reported both years. 72.7 Medication review. Despite being reported Falls program 81.9 with the lowest level of full implementa- 72.0 tion both years, some hospitals reported Assessing risk 83.6 progress in implementing falls prevention 70.9 best practices in the category of medica- Restraints 77.0 tion review. More hospitals reported 70.7 including pharmacists on their falls Evaluating the environment 80.1 prevention team in 2013 (n = 59) than in 2012 (n = 46), and the average percent- 69.1 Patient monitoring 82.8 age of medication review best practices reported as fully implemented increased 68.9 from 21.6% in 2012 to 34.2% in 2013. Plan of care 80.3 The following medication review best 68.2 Patient and family education 84.5 practices had the largest increases in the number of hospitals reporting full 66.0 implementation: Benchmarking 77.0 —— Instituting periodic review of formu- 62.6 Communication 70.5 lary medications by the pharmacy and therapeutics committee to iden- 58.9 tify those that increase falls risk and Policies and protocols 73.6 make recommendations about those 54.1 medications (10 hospitals in 2012, Assistive devices 71.4 31 in 2013) 44.6 —— Providing nurses access to a list of Sitters 41.3 medications that increase an individ- 21.6 ual’s risk of falling that is used when Medication review 34.2 assessing patients for falls risks (28 hospitals in 2012, 43 in 2013) 0 20 40 60 80 100 MS14234 —— Having pharmacy recommend alter- PERCENTAGE native medications to reduce the patient’s risk of falling if the prescribed medications increase the risk of falling (8 hospitals in 2012, 17 in 2013) Vol. 11, No. 2—June 2014 Pennsylvania Patient Safety Advisory Page 71 ©2014 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Figure 2. Absolute Change in Percentage of Falls Prevention Best Practices with Full Implementation by Category for Hospital Engagement Network Facilities Completing the Falls Self-Assessment Survey Tool in 2012 and 2013 (N = 74) CHANGE IN PERCENTAGE 20 17.3 16.3 14.7 15 13.7 12.6 11.6 11.4 11.0 9.4 9.4 9.2 10 8.5 7.9 7.2 6.1 6.1 5 0 -3.3 -5 s es g w k re n g n t m t n s g ts rs en en ol rm ris io tio tio rin kin tin in vie te ra ca vic oc m m at tra Sit la or ca ica ito og g ar re de on ss of uc ot in la ep s du hm on pr un se Re n ss pr ed vir n l e tio tr Fa fe as tm Pla se tiv m ls nc en d en ily ica l As m af an sis Fa Be ll ien m Ev tfa Co e St ed As th es fa t s Pa M Po ici g nd in l Po ta t ua ien al Ev t Pa MS14235 CATEGORY Sitters. The only category of falls preven- in 2013 reported having either no sitter —— Conducting a training program tion best practices that decreased in program (n = 5) or only a partially imple- for sitters (32 hospitals in 2012, terms of full implementation was sitters. mented sitter program (n = 3) in 2012. 29 in 2013) As a group, hospitals reported an aver- Also, of those hospitals that reported —— Creating a job description with age of 44.6% of sitter best practices as having sitter programs, fewer hospitals expectations for sitter behavior and fully implemented in 2012, decreasing to reported full implementation for the fol- responsibilities (37 hospitals in 2012, 41.3% in 2013 (see Figure 1). The number lowing best practices in sitter program 31 in 2013) of hospitals reporting full implementation design in 2013 compared with 2012: —— Establishing a process for requesting of sitter programs increased from —— Having a pool of sitters (32 hospitals and discontinuing sitters (33 hospi- 37 to 38 between 2012 and 2013, but only in 2012, 30 in 2013) tals in 2012, 28 in 2013) 30 of those hospitals reported full imple- —— Defining criteria for sitter qualifica- mentation in both years. The other eight tions (34 hospitals in 2012, 30 in hospitals reporting full implementation 2013) Page 72 Pennsylvania Patient Safety Advisory Vol. 11, No. 2—June 2014 ©2014 Pennsylvania Patient Safety Authority Table 1. Hospital Engagement Network Facilities’ Compliance with Falls Prevention assistive devices. The following practices Practices* in Patients Identified as Being at Risk to Fall (N = 1,222) had the largest increases: FALLS PREVENTION PRACTICE FALLS RISK —— Having the falls team and/or physi- PATIENTS (%) cal therapy evaluate types of devices Falls prevention plan documented 92.3 and aids (e.g., canes, walkers, wheel- chairs, grab bars) used by the facility Call bell within reach 89.6 to prevent falls (48 hospitals in 2012, Patients have appropriate footwear: nonskid socks or slippers 79.0 61 in 2013) Patient and family education documented 77.7 —— Providing training to staff on their Special equipment is in use: two siderails up 76.8 use and maintenance (40 hospitals Patients have risk identifiers: wristband 65.5 in 2012, 53 in 2013) —— Ensuring the weight-bearing capaci- Hourly rounds documented 64.3 ties of these devices and aids are Patients have risk identifiers: sign outside room 46.9 known to staff (25 hospitals in 2012, Alarms are in use: bed alarm 39.3 41 in 2013) Patients have risk identifiers: colored socks 36.7 —— Having physical therapy evaluate Special equipment is in use: low bed 32.3 patients identified as being at risk to fall and recommend appropri- Patient have risk identifiers: sign inside room 26.2 ate assistive devices (41 hospitals in Patients have risk identifiers: other 12.9 2012, 52 in 2013) Alarms are in use: chair alarm 10.7 —— Providing face-to-face training in Patients have appropriate footwear: rubber-soled shoes 7.1 their use to patients and families (44 hospitals in 2012, 52 in 2013) Special equipment is in use: floor mat 4.7 Patient and family education. The next Patients have risk identifiers: colored blanket 3.8 greatest increase in the number of hospi- Sitter is in place 3.1 tals reporting full implementation of falls Special equipment is in use: other 2.5 prevention best practices was seen in the Alarms are in use: other 1.7 category of patient and family education. Increases were reported in staff provid- Special equipment is in use: hip protectors 0.7 ing all patients and their family members Patients have appropriate footwear: other 0.1 direct education regarding the causes of * Assessed through use of the Falls Prevention Process Measures Audit Tool, July through September 2013 falls and the interventions used to prevent falls (36 hospitals in 2012, 55 in 2013) Falls SAT Survey—Largest between 2012 and 2013 by category (i.e., and in documentation of education Increases in Full Implementation the percentage of practices reported with (41 hospitals in 2012, 54 in 2013). Overall, of 1,745 individual practices full implementation in 2013 minus the Increases were also reported for nurses reported to have no implementation percentage reported with full implementa- educating patients specifically about in 2012, hospitals reported moving tion in 2012). The greatest increases were the following: 767 (44.0%) to full implementation in reported in the categories of assistive —— Intrinsic risk factors for falling 2013. In addition, of 1,450 practices devices, patient and family education, (43 hospitals in 2012, 62 in 2013) reported to have partial implementa- and policies and protocols. Increases were —— How to walk and transfer in and out tion in 2012, hospitals reported moving reported in 16 of 17 categories, with sitters of bed safely (45 hospitals in 2012, 921 (63.5%) to full implementation in identified as the only category in which the percentage of best practices with full imple- 63 in 2013) 2013. Of 7,621 practices reported with full —— How to use assistive devices (44 hos- mentation decreased. implementation in 2012, 6,944 (91.1%) pitals in 2012, 57 in 2013) were reported to remain at full implementa- Assistive devices. The greatest increase in the number of hospitals reporting full —— What to do if he or she falls (30 hos- tion in 2013. Figure 2 shows the absolute implementation for falls prevention best pitals in 2012, 52 in 2013) change in the average percentage of prac- tices reported with full implementation practices was seen in the category of Vol. 11, No. 2—June 2014 Pennsylvania Patient Safety Advisory Page 73 ©2014 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Policies and protocols. The category of Table 2. Change in Rates of Falls with Harm in Hospitals Completing the Falls Self- falls prevention practices with the third Assessment Tool Survey, January through June 2012 and January through June 2013 greatest increase in the number of hos- 2012: FALLS 2013: FALLS pitals reporting full implementation was WITH HARM WITH HARM % CHANGE policies and protocols. The practice in PER 1,000 PER 1,000 this category that increased the most in PATIENT-DAYS PATIENT-DAYS terms of full implementation was includ- Hospitals missing 0.156 0.221 +41.7 ing the composition, responsibilities, and quarterly audits (n = 27) goals of the falls team in the hospital’s Hospitals completing all 0.125 0.119 -4.8 falls prevention policy (17 hospitals in quarterly audits (n = 41) 2012, 38 in 2013). Large increases in the number of hospitals reporting full implementation were also reported for the reach (89.6%), nonskid socks or slippers responded to the falls SAT survey in 2012 following practices: (79.0%), documentation of patient and and 2013. Of the 68 hospitals that com- —— Establishing a frequency and pro- family education (77.7%), and two sid- pleted both falls SAT surveys, 41 hospitals cess for conducting environmental erails in the up position (76.8%). Falls completed all quarterly point prevalence rounds (29 hospitals in 2012, risk identifiers, specialty equipment, and audits from September 2012 through 46 in 2013) alarms were found to have lower levels September 2013. Table 2 shows the dif- —— Outlining requirements to collect of implementation. Table 1 details the ference in rates of falls with harm during and review data on patient falls, percentage of patients at risk to fall who these two time periods for hospitals com- including unit type, time of day, were found to have each falls prevention pleting all quarterly audits compared with staffing ratios, interventions in place, practice in place. those that did not. Rates were lower and equipment in use, toileting patterns, In hospitals that completed the 2013 falls decreased for hospitals that completed all and medication (32 hospitals in SAT, 56 were identified that completed quarterly point prevalence audits, while hos- 2012, 48 in 2013) point prevalence audits between July 1 pitals missing audits had a higher rate that —— Developing a process for revising and September 30, 2013. As in 2012, increased between the two time periods. assessment and intervention strate- comparison of falls SAT survey responses gies based on data (31 hospitals in with audit results revealed a gap between DISCUSSION 2012, 47 in 2013) levels of full implementation of best A major focus of the PA-HEN Falls —— Defining the appropriate responses practices reported on the falls SAT survey Reduction and Prevention Collabora- to falls, including protocols for and compliance with falls prevention prac- tion has been to ensure that hospitals are postfall investigation (49 hospitals in tices observed during the audit process. implementing evidence-based practices 2012, 63 in 2013) However, in comparing results from 2012 in falls prevention. Education provided with 2013, an increase in compliance to hospitals in the collaboration has —— Planning for initial and ongoing was observed. The category of falls risk included a review of what is currently falls prevention education for staff indicators has been used to illustrate this established as best practice based on indi- (29 hospitals in 2012, 43 in 2013) gap and the improvement (see Figure 3). vidual, high-quality research studies and For example, in 2012, in hospitals that systematic reviews, as well as evidence- Falls Prevention Process reported full implementation for posting based falls prevention guidelines.4-12 The Measures Audit Tool of signs communicating falls risk outside falls SAT survey was provided as a tool for Sixty-four hospitals submitted point patient rooms, only 52.7% of patients hospitals to complete an annual review of prevalence audits between July 1 and identified at risk to fall were found to their falls prevention programs, assessing September 30, 2013. A total of have the signs in place during audits. This for congruence with these evidence-based 1,758 patients were audited, of which percentage increased to 75.4% in 2013. best practices. Hospitals were also pro- 1,748 (99.4%) had completed falls risk vided with an audit tool to be completed assessments and 1,222 (69.5%) were Falls-with-Harm Rates quarterly, assessing for compliance with identified as being at risk to fall. Of the Complete data to calculate rates of falls use of falls prevention practices for patients identified as being at risk to fall, with harm was available for January patients identified at risk to fall. most had documentation of a falls pre- through June 2012 and for January through vention plan (92.3%), a call bell within Analysis of falls SAT survey responses, June 2013 for 68 of the 74 hospitals that audit results, and rates of falls with Page 74 Pennsylvania Patient Safety Advisory Vol. 11, No. 2—June 2014 ©2014 Pennsylvania Patient Safety Authority Figure 3. Compliance with Use of Falls Risk Indicators in Hospitals Reporting Full need to implement these practices in their Implementation on the Falls Self-Assessment Tool Survey, July through September institutions.1 2012 and July through September 2013 While some collaboration members were able to add pharmacists to their PERCENTAGE teams and move medication review best 100 practices to full implementation in 2013, 2012 2013 75.4 this continues to be an area where hospi- 80 69.2 61.2 63.2 tals struggle. Likewise, even though the 60 52.7 number of hospitals reporting full imple- 46.8 45.8 mentation of sitter programs increased 40 37.3 by one between 2012 and 2013, six hos- 20 pitals eliminated their sitter programs in that time, and the number of hospitals 0 with sitter programs remains low. Of Wristbands Sign outside Colored socks Sign inside the hospitals with sitter programs, the room room number reporting full implementation MS14236 FALLS RISK INDICATORS of best practices in sitter program design decreased. (Additional information on the use of patient sitters to prevent falls harm has allowed the Authority to iden- Hospitals were advised to create action is available on the Authority’s website tify the following: (1) an increase in full plans targeted to best practices identified at http://patientsafetyauthority.org/ implementation for 16 of 17 categories through completion of the falls SAT sur- ADVISORIES/AdvisoryLibrary/2014/ of falls prevention best practices, vey as missing or in need of improvement. Mar;11(1)/Pages/08.aspx.) (2) categories of falls prevention best prac- It is therefore feasible that each hospital For both of these categories of falls preven- tices in which hospitals have reported the could have been targeting multiple and tion practices, cost may be the barrier to largest increases in full implementation, different falls prevention program ele- full implementation.13,14 In fact, cost can (3) a decreased gap between levels of full ments for improvement over the course serve as a barrier to implementation for implementation of best practices reported of the collaboration. Comparison of falls any number of falls prevention practices. on the survey and compliance with falls SAT survey responses from 2012 with The Authority has developed a falls-with- prevention practices observed during the 2013 suggests that this is true. As a group, harm calculator (available at http:// audit process, and (4) a lower rate of falls these hospitals have reported making the patientsafetyauthority.org/ADVISORIES/ with harm in hospitals completing the most progress in moving best practices in AdvisoryLibrary/2012/Jun;9(2)/Pages/ annual falls SAT and quarterly audits. the categories of assistive devices, patient calculator.aspx) that may help hospitals and family education, and policies and make the business case for investing in Increased Implementation of protocols to full implementation. practices that a falls prevention team seeks Falls Prevention Best Practices to implement. By tracking reductions in Overall, hospitals reported a 10% increase Falls Prevention Best Practices the rates of falls with harm that occur in the percentage of best practices with Low Levels of Full as a result of implementing new falls reported with full implementation— Implementation prevention practices, cost savings can be from 68.2% in 2012 to 78.2% in 2013. Medication review and sitters continue to estimated that could justify the expense. Variability in the average percentage of be the two categories of best practices in practices reported with full implementa- falls prevention reported with the lowest Policy-Practice Gap tion also narrowed from a range of 20.5% levels of full implementation. Because As in 2012, comparison of responses to 92.7% in 2012 to 52.3% to 98.6% in both categories of best practices were to the 2013 falls SAT survey with the 2013, meaning there were fewer hospitals found to correlate with lower rates of results of audits conducted on inpatient at the lower end of full implementation in falls with harm, and because low levels of units at hospitals participating in the 2013 (i.e., while some hospitals reported implementation for these practices were PA-HEN falls collaboration revealed a gap as few as 20.5% of all practices with full reported on the 2012 falls SAT survey, between levels of full implementation of implementation in 2012, no hospital hospitals participating in the collaboration best practices reported on the survey and reported less than 52.3% of all practices were encouraged to carefully evaluate the compliance with falls prevention practices with full implementation in 2013). Vol. 11, No. 2—June 2014 Pennsylvania Patient Safety Advisory Page 75 ©2014 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S observed during the audit process. This falls-with-harm rates was collected for the CONCLUSION gap has narrowed, but compliance with period of January through June 2012. Hospitals participating in the PA-HEN implementation of the specific falls pre- It is therefore possible that hospitals Falls Reduction and Prevention Col- vention practices audited has failed to implemented falls prevention measures in laboration have been able to evaluate reach 100%, suggesting falls prevention July and August and indicated full imple- their current falls prevention programs practices are not being implemented reli- mentation on the falls SAT survey even and successfully identify and implement ably in patients identified as being at risk though the practices were not in place evidence-based best practices missing or in to fall. Of special note, this gap may be when the falls with harm were occurring. need of improvement using the Hospital expected depending on the patient popu- Engagement Network Falls Reduction and Information on the implementation level lation and the hospital’s fall prevention Prevention Collaboration SAT survey. for best practices in falls prevention was protocol (for example, spinal cord injury Hospitals completing the falls SAT survey gathered from self-reporting hospitals patients may score as being at risk to fall and monitoring staff compliance with completing the falls SAT survey. Designa- in a hospital that reported full imple- falls prevention practices through quar- tion of implementation level (i.e., full mentation of nonskid socks or shoes terly use of the Falls Prevention Process implementation, partial implementation, with rubber soles; however, for this select Measures Audit Tool have seen increases or no implementation) is subjective to patient population, this footwear would in compliance and have achieved reduc- the respondent. not be indicated). tions in rates of falls with harm. Compliance with implementation of best Ongoing audits and engagement of staff Use of a self-assessment tool, such as the practices in falls prevention practices was in the audit process is suggested. This falls SAT survey, is suggested to identify not able to be calculated for all hospitals provides an opportunity for the falls pre- participating in the PA-HEN falls collabo- gaps between current hospital programs vention team to implement missing falls ration. Of the hospitals that completed the and evidence-based guidelines. Conduct- prevention practices and provide “just- falls SAT survey in 2012 and 2013, only ing audits of falls prevention practices in-time training”15 to staff while in the 63 submitted audit data for July through being implemented at the bedside using a process of conducting audits, rather than September 2012 and only 56 submitted tool such as the Falls Prevention Process waiting for future meetings to discuss the audit data for July through September Measures Audit Tool is also suggested results of the audits. Education surround- 2013. It is possible that compliance with to monitor for compliance with hospital ing hospital falls prevention policies and falls prevention practices may have been falls prevention policies and protocols. protocols can be reinforced, and solutions higher or lower across the 80 participating Hospitals are encouraged to focus contin- can be designed for barriers identified hospitals. In addition, while performance ued attention on best practices missing when compliance is low. of all quarterly point prevalence audits of or in need of improvement, as identified falls prevention practices appears to cor- through use of a self-assessment tool, Falls-with-Harm Rates as well as practices with which staff are relate with lower rates of falls with harm, In comparing hospitals participating in cause and effect cannot be inferred. found to be noncompliant during audits. the PA-HEN falls collaboration that did Hospitals may choose to focus particular and did not perform quarterly point Data used in calculating falls-with-harm attention on best practices found to corre- prevalence audits, rates of falls with harm rates is dependent on accuracy and con- late with lower rates of falls with harm but were lower initially and decreased for hos- sistency in reporting falls and identifying reported to have low levels of implemen- pitals that completed all audits. Rates of injury level through PA-PSRS. Hospitals tation for hospitals participating in the falls with harm were higher initially and included in this analysis have agreed to PA-HEN Falls Reduction and Prevention increased for hospitals that did not com- consensus definitions for falls and falls Collaboration, namely practices in the cat- plete all audits. While cause and effect with harm as a condition for participation egories of medication review and sitters. cannot be confirmed, this suggests that in the PA-HEN falls collaboration; there- hospitals that are engaged in an ongoing fore, this limitation should have been Acknowledgments audit process may achieve greater reduc- minimized. The consensus definitions Denise M. Barger, BA, CPHRM, CPHQ, CPPS, were introduced in March 2012, which HEM, patient safety liaison, Delaware Valley- tions in rates of falls with harm. South, and Richard M. Kundravi, BS, patient may have affected reporting in the base- safety liaison, Northwest Region, contributed to Limitations line period. This data is also dependent the design and administration of the falls SAT on accurate and complete reporting of survey and the Falls Prevention Process Measures The initial falls SAT survey was admin- Audit Tool as members of the PA-HEN Falls total facility patient-days to PHC4. Reduction and Prevention Collaboration project istered at hospitals in July and August leadership team. 2012, whereas the data used to calculate Page 76 Pennsylvania Patient Safety Advisory Vol. 11, No. 2—June 2014 ©2014 Pennsylvania Patient Safety Authority NOTES 1. Feil M. Falls prevention: Pennsylvania 7. Gray-Micelli D, Quigley PA. Fall pre- 12. Agency for Healthcare Research and hospitals implementing best practices. vention: assessment, diagnoses, and Quality. Preventing falls in hospitals: Pa Patient Saf Advis [online] 2013 Dec intervention strategies. In: Boltz M, a toolkit for improving quality of care [cited 2014 Feb 20]. http://patient Capezuti E, Fulmer T, eds. Evidence-based [online]. 2013 Jan [cited 2013 May 8]. safetyauthority.org/ADVISORIES/ geriatric nursing protocols for best practice. http://www.ahrq.gov/research/ltc/fall AdvisoryLibrary/2013/Dec;10(4)/ 3rd ed. New York: Springer Publishing pxtoolkit/index.html Pages/117.aspx Company; 2012:268-97. Also available 13. Harding AD. Observation assistants: 2. ECRI Institute. Falls [self-assessment at http://www.guideline.gov/content. sitter effectiveness and industry measures. questionnaire]. Healthc Risk Control 2012 aspx?id=43933 Nurs Econ 2010 Sep-Oct;28(5):330-6. May;1:Self-assessment questionnaires 1. 8. Boushon B, Nielsen G, Quigley P, et al. 14. Fick DM, Cooper JW, Wade WE, et al. 3. Pennsylvania Health Care Cost Contain- Transforming care at the bedside how-to Updating the Beers criteria for potentially ment Council (PHC4) [website]. [cited guide: reducing patient injuries from falls inappropriate medication use in older 2013 Aug 5]. Harrisburg (PA): PHC4. [online]. 2012 [cited 2013 May 8]. http:// adults: results of a US consensus panel http://www.phc4.org www.ihi.org/knowledge/Pages/Tools/ of experts. Arch Intern Med 2003 Dec TCABHowToGuideReducingPatient 8-22;163(22):2716-24. 4. Institute for Clinical Systems Improve- InjuriesfromFalls.aspx ment. Health care protocol: prevention 15 Babylon 10 dictionary. Just-in-time of falls (acute care) [online]. 2012 Apr 9. Health Care Association of New Jersey. training [online]. [cited 2014 Mar 12]. [cited 2012 May 15]. https://www.icsi. Fall management guideline [online]. http://dictionary.babylon.com/just-in- org/_asset/dcn15z/Falls.pdf 2012 [cited 2013 May 8]. http://www. time_training hcanj.org/files/2013/09/hcanjbp_ 5. Registered Nurses’ Association of fallmgmt13_050113_2.pdf Ontario. Prevention of falls and fall injuries in the older adult [online]. 2011 10. National Center for Patient Safety. Falls [cited 2012 May 15]. http://rnao.ca/sites/ toolkit [online]. 2004 Jul [cited 2013 rnao-ca/files/Prevention_of_Falls_and_ May 8]. http://www.patientsafety.va.gov/ Fall_Injuries_in_the_Older_Adult.pdf professionals/onthejob/falls.asp 6. Patient Safety First. The ‘how-to guide’ 11. National Institute for Clinical Excellence. for reducing harm from falls [online]. Clinical practice guideline for the 2009 Sep [cited 2012 May 15]. http:// assessment and prevention of falls in www.patientsafetyfirst.nhs.uk/ashx/ older people [online]. 2004 Nov [cited Asset.ashx?path=/Intervention-support/ 2013 May 8]. http://www.nice.org.uk/ FALLSHow-to%20Guide%20v4.pdf nicemedia/pdf/CG021fullguideline.pdf Vol. 11, No. 2—June 2014 Pennsylvania Patient Safety Advisory Page 77 ©2014 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 11, No. 2—June 2014. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2014 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. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (Mcare) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions. Scan this code with your mobile device’s QR reader to subscribe to receive the Advisory for free.