Patient safety is seen as a quality of care issue more and more lately, and one of the biggest threats to patient safety is the risk of falling. Healthcare organizations have sought to reduce the risk of falls for many years, with an assortment of policies, procedures, and devices, but one approach is showing success with its emphasis on changing how an entire culture addresses falls.
The experience of 17 hospitals using the approach suggests that the gadgets and devices so often used to reduce falls are not nearly as effective at improving patient safety as broader, systemic changes to the organization.
Some specific procedures and tools are necessary, but the overall attitude toward preventing falls is what makes the difference in this program.
A program developed at the University of Nebraska focuses on creating a culture of safety and teamwork, and making sense of the risks associated with falls. The program is called Collaboration And Proactive Teamwork Used to Reduce (CAPTURE) Falls, and it has been implemented in 17 Nebraska hospitals, 16 of which are critical access hospitals with 25 or fewer beds.
A team lead by Katherine J. Jones, PT, PhD, associate professor in the Division of Physical Therapy Education at the University of Nebraska Medical Center (UNMC) in Omaha, implemented a fall risk reduction that, according to UNMC’s website, addresses “inpatient falls at three levels: the patient, the microsystem (unit), and the organization.”
“We take the approach that falls are complex. There are three sources of risk: the patient, the environment the patient is in, and the system,” Jones says. “What does your system look like for your organization to mitigate fall risk? That’s what we’ve really focused on because that seemed to be the component that had not received enough attention in previous efforts.”
Coordination of Teams
The Nebraska experience demonstrates that when trying to address a complex problem (like falls) that involves many different aspects of the healthcare process, the most important factor is the coordination between teams, Jones says. CAPTURE Falls involves three different teams. The core team is made up of the clinicians at the bedside, including nurses and therapists. The coordinating team includes the professionals — such as quality improvement leaders — who are responsible for the structures, processes, and outcomes of the fall risk reduction program. The coordinating team also conducts audits to assess the efficacy of training and interventions.
The third is the contingency team that comes together for a short time, almost like a code team. They conduct the post-fall huddle to evaluate an incident and derive lessons.
The participating hospitals first look at how they use teamwork to manage fall risk, conducting a gap analysis in which they look at not just what is done at the bedside but at 21 specific processes that the program groups under the term “coordination.” That word has a specific meaning in industrial organizational psychology literature, referring to all of the activities done to plan, standardize, and adjust a process in real time.
“So we look at these 21 processes that plan, standardize, and adjust these processes in real time. The hospitals rate themselves as to whether they do or don’t do it, and if they do it, they rank themselves in effectiveness,” Jones explains. “What we found is that it was the extent of implementing these 21 coordinating processes that significantly predicted unassisted and injurious fall rates. What was done at the bedside — bed alarms, chair alarms, low beds, nonskid footwear, all those bedside interventions — the frequency of implementing those interventions did not affect unassisted and injurious fall rates.”
That may be a surprise to a lot of quality improvement leaders, Jones notes. That finding should not be taken to mean there is no value in those bedside assistive devices, she notes, but rather that the processes had more direct impact on preventing falls. The CAPTURE Falls program emphasizes the proper use of one device in particular — gait belts — to assist patients with mobility issues or risk factors for falling.
“Everyone falls for the same reason: their center mass is outside the limits of stability. If you ask a nurse why a patient fell, you get answers like they didn’t put their call light on,” Jones says. “Other patients don’t fall when they don’t put their call lights on, so that shows a lack of understanding of the biomechanical basis for falls.”
Jones is preparing to publish research showing those results, but the CAPTURE Falls program materials are available on the university’s website.
Compare Risk Assessment Tools
The 21 processes that do make a difference include things such as informing frontline staff about actions taken to improve systems as a result of reported falls.
The hospitals’ experiences showed the importance of being deliberate about the use of the fall assessment tool, Jones says, determining the positive predictive value of their current tool and then comparing it to at least two other tools.
“They pulled the records for 20-30 patients who had fallen and the same number for patients who had been in the hospital at the same time who had not fallen, looking at the fall assessment risk scores with the tool they were using and then with other tools,” Jones says.
“They could see which tools better identified the tools that better identified the risk of falling. The hospitals that did that generally opted to change their tool from one that is well known and in use for a long time to one that is newer but links interventions to fall risk factors.”
That step, investigating the effectiveness of their current tools and adopting a new one if necessary, set off the next series of events in which staff are trained to use the fall risk assessment tool.
“We find that over time there may be vast differences in how any given nurse scores a patient on a risk assessment tool. There was a very nice relationship between actually teaching nurses to use that fall risk assessment tool and lowered injurious fall rates,” she says.
Report All Falls
The program also emphasizes the importance of reporting all falls, both assisted and unassisted. Assisted falls are those in which a caregiver is assisting the patient’s mobility, perhaps by steadying him or her while walking or by transferring the patient from bed to wheelchair.
Fall programs can focus excessively on unassisted falls, seeing them as the “worst” example of what can happen and what might have been prevented with assistance, Jones says, while paying too little attention to assisted falls. Patients still fall when assisted and there are lessons to be learned from those experiences as well, she says.
Jones notes that unassisted falls are most commonly associated with patients 65 or older and cognitive impairments. Unassisted falls occur most often in the bathroom.
Hospitals are encouraged to mobilize patients as early as possible, but that can increase the risk of falls, Jones notes.
“It is important to remember that it is not all falls that hospitals are penalized for. They’re penalized for falls with serious injury,” Jones says.
“So if we are mobilizing patients at the earliest possible opportunity to prevent secondary deconditioning and pressure ulcers, patients will fall,” she adds. “But if we are with them and trained to appropriately assist ambulation and transfers with assistive devices and the use of a gait belt, then an assisted fall is much less likely to result in harm than an unassisted fall.”
Not all falls can be avoided with assistance, but when a facility reports assisted falls, that is feedback on their assistive training, Jones says.
The repeat fall rate also is a key factor to study, derived by dividing the number of falls by the number of patients who fell. If the rate is greater than one, that means some patients are falling more than once.
“We found that one of the things that primarily affected the repeat fall rate is training in how to conduct the post-fall huddle. This is a quick meeting of all the staff caring for the patient immediately after the fall to discuss what happened, how they are going to prevent it happening again, and what can be learned for the system,” Jones says. “Training in conducting post-fall huddles is associated with a lower repeat fall rate, as is the post-fall huddle rate. The more often a fall is followed by a post-fall huddle, the less likely the patient will fall again.”
- Katherine J. Jones, PT, PhD, Associate Professor, Division of Physical Therapy Education, University of Nebraska Medical Center, Omaha. Phone: (402) 559-8913. Email: [email protected].
