implementing an evidencebased falls prevention program

1、1 1 Experienced Pioneering Independent Evidence-based Implementing an Evidence- Based Falls Prevention Program Michelle Feil MSN, RN Senior Patient Safety Analyst March 5, 2013 Objectives List components of an evidence-based falls prevention program Distinguish between components of a falls preventi

2、on program which have stronger and weaker levels of evidence to support them Identify strategies that are accepted as best practices Describe innovative approaches to falls and falls injury prevention “Sometimes I wish for falling Wish for the release Wish for falling through the air To give me some

3、 relief Because fallings not the problem When Im falling Im in peace Its only when I hit the ground It causes all the grief” Florence Welch (lead singer, Florence and the Machine) Gravity is a contributing factor in nearly 73 percent of all accidents involving falling objects. -Dave Barry (comedian)

4、 Grading Levels of Evidence Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews) Level II: Single experimental study (randomized controlled trials RCTs) Level III: Quasi-experimental studies Level IV: Non-experimental studies Level V: Care

5、report/program evaluation/narrative literature reviews Level VI: Opinions of respected authorities/Consensus panels (Capezuti, et al., 2008) Key Components Organizational support and leadership Multidisciplinary falls prevention team Risk assessment Multifactorial interventions Communication Reasses

6、sment Data collection we either overstate it or understate it.” Hillary Clinton Risk Assessment Pennsylvania Patient Safety Advisory “Falls Risk Assessment: A Foundational Element of Falls Prevention Programs” September 6, 2012 ://ADVISORI ES/AdvisoryLibrary/2012/Sep;9(3)/P

7、age s/73.aspx Joint Commission 2005 National Patient Safety Goal “reduce the risk of patient harm resulting from falls” initial assessment of falls risk periodic reassessments 2010 incorporated as a standard with two elements of performance assess and manage the patients risks for falls implement in

8、terventions to reduce falls based on the patients assessed risk Joint Commission, contd. Risk Assessment Level of Evidence: II Patients should be assessed for their falls risk: On admission Upon transfer from one unit to another With any status change Following a fall At regular intervals Guidelines

9、: ICSI, HCANJ, HIGN, NCPS, NICE, PSF, RNAO, TCAB Risk Assessment Tools Risk assessment tools by themselves do not prevent patient falls - they predict them Risk Assessment Tools Whats the Evidence? Sensitivity and specificity can vary greatly between tools (Perell 2001) Risk assessment tools with hi

10、gh sensitivity and specificity assess: gait instability agitated confusion urinary incontinence/frequency falls history prescription of culprit drugs (especially sedative/hypnotics) (Oliver 2004) Risk Assessment Tools Whats Out There? Morse Hendrich I 18:141-158. Individual Falls Risk Factors Profil

11、e of the Hospitalized Patient at Risk to Fall Cognitive impairment (including depression) History of previous falls Impaired mobility Special toileting needs Other contributors Advanced age Medications Cognitive Impairment Delirium Hypoactive Hyperactive Dementia Slower cognitive processing Depressi

12、on Depression and Falls Patients with depression are twice as likely to fall as those without depression (Perell 2001) Observe for any of the following signs: prolonged feelings of helplessness, hopelessness, or being overwhelmed tearfulness flat affect or lack of interest loss of interest in life e

13、vents melancholic mood withdrawal the patients statement of depression (Hendrich 2007) History of Falls Prior falls predict future falls History of falling within previous 12-month period can triple the risk of future falls Different studies have used different cut- off points Impaired Mobility Musc

14、le weakness Decreased gait speed Decreased stride length Use of assistive devices Arthritis Impairment in activities of daily living Special Toileting Needs Incontinence Urinary frequency Diarrhea Toileting - related falls increase the risk of fall-related injuries by an odds ratio of 2.4 Advanced A

15、ge 1 in 3 adults over age 65 fall each year Falls are the leading cause of injury death in adults over 65 Adults 75 and older are four times as likely to suffer an injurious fall than adults ages 65 to 74 ://homeandrecreationalsafety /falls/adultfalls.html 4 or more medications Benzodiazepine

16、s Anticonvulsants Sedative hypnotics Antidepressants Antipsychotics Opiates Antiarrhythmics Antihypertensives Diuretics Antihistamines Medications and Falls Risk The Challenge “Unlike other hospital-acquired conditions that were selected by the CMS, falls are often the result not of medical errors b

17、ut of diseases, impairments, and appropriate uses of medications and other treatments. Falls and injuries can occur even when hospitals provide the best possible care.” (Inouye, Brown then do whats possible; and suddenly you are doing the impossible. -Saint Francis of Assisi How do you eat an elepha

18、nt? One bite at a time. -Origin Unknown Fall Prevention Guidelines Agency for Healthcare Research and Quality (AHRQ) Agency for Healthcare Research and Quality. Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care online. 2013 Jan cited 2013 Feb 25. Available from Internet: :/ahrq.

19、gov/research /ltc/fallpxtoolkit/index.html Falls Prevention Guidelines Hartford Institute for Geriatric Nursing (HIGN) Gray-Micelli D. Preventing falls in acute care. In: Capezuti E, Zwicker D, Mezey M, Fulmer T, editor(s). Evidence-based geriatric nursing protocols for best practice. 3rd ed. New Yo

20、rk (NY): Springer Publishing Company; 2008. p. 161-98. cited 2012 May 15. Available from Internet: ://content.aspx?id=12265 Health Care Association of New Jersey (HCANJ) Health Care Association of New Jersey. Fall management guidelines online. 2007 Mar cited 2012 May 15. Available from

21、Internet: ://docs/hcanjbp_fallmgmt6.pdf Falls Prevention Guidelines Institute for Clinical Systems Improvement (ICSI) Institute for Clinical Systems Improvement . Health care protocol: prevention of falls (acute care) online. 2012 Apr cited 2012 May 15. Available from Internet: ://f

22、alls_acute_care_prevention_of_protocol_/fall s_acute_care_prevention_of_protocol_24255.html National Center for Patient Safety (NCPS) National Center for Patient Safety. Falls toolkit online. 2004 Jul cited 2012 May 15. Available from Internet: ://SafetyTopics/fallstoolkit/index.htm

23、l National Institute for Clinical Excellence (NICE) National Institute for Clinical Excellence. Clinical practice guideline for the assessment and prevention of falls in older people online. 2004 Nov cited 2012 May 15. Avaialble from Internet: :/.uk/nicemedia/pdf/CG021fullguideline.pdf Patie

24、nt Safety First (PSF) Patient Safety First. The how-to guide for reducing harm from falls online. 2009 Sep cited 2012 May 15. Available from Internet: :/patientsafetyfirst.nhs.uk/ashx/Asset.ashx?path=/Interve ntion-support/FALLSHowTo%20Guide%20v4.pdf Falls Prevention Guidelines Falls Prevention Guid

25、elines Registered Nurses Association of Ontario (RNAO) Registered Nurses Association of Ontario. Prevention of falls and fall injuries in the older adult online. 2011 cited 2012 May 15. Available from Internet: :/rnao.ca/sites/rnao- ca/files/Prevention_of_Falls_and_Fall_Injuries_in_the_Older_Adult.p

26、df Transforming Care at the Bedside (TCAB) Institute for Healthcare Improvement. Transforming Care at the Bedside How-to guide: reducing patient injuries from falls online. 2008 cited 2012 May 15. Available from Internet: ://knowledge/Pages/Tools/TCABHowToGuideReducin gPatientInjuriesfromFall

27、s.aspx Reference Articles Ang NKE, Mordiffi SZ, Wong HB, Det al. Evaluation of three fall-risk assessment tools in an acute care setting. Journal of Advanced Nursing 2007;60(4),427435 Anderson O, Boshier P, Hanna G. Interventions designed to prevent healthcare bed-related injuries in patients. Cochr

28、ane Database of Systematic Reviews 2011;11:1-30. Cameron ID, Murray GR, Gillespie LD, et al. Interventions for preventing falls in older adults in nursing care facilities and hospitals. Cochrane Database of Systematic Reviews 2010;1:1-117. Capezuti, E., Zwicker, D., Mezey, M. 35(4):227-231. Referenc

29、e Articles Halm M. Hourly rounds: what does the evidence indicate? American Journal of Critical Care 2009 Nov;18(6):581-584. Harding AD. Observation assistants: sitter effectiveness and industry measures. Nursing Economics 2010 Sep-Oct;28(5):330-336. Healey F, Scobie S. Slips trips and falls in hospitals. London (UK): National Patient Safety Agency; 2007. Hendrich A. Predicting patient falls: Using the Hendrich II Fall Risk M