Prevention program cut patient falls by 10%

Help patients overcome their fears, complacency

In the past few years, falls have killed 7,000 to 12,000 people over age 65. Nearly one-third of older Americans fall, costing more than $20 billion in direct health care costs, according to the U.S. Department of Health and Human Services. Elderly people who have chronic or serious health problems, including conditions that require rehabilitation, are at even greater risk of falling and becoming injured.

"We recognize falling as a potentially serious problem for our patients, and it’s a common occurrence in rehab because what we’re trying to do is get patients as close to an independent level of functioning as possible," says Dorothy Doweiko, RN, director of quality management for Spaulding Rehabilitation Hospital in Boston. Spaulding has about 290 beds and an outpatient program and is affiliated with Massachusetts General Hospital and Brigham and Women’s Hospital, also in Boston.

Here’s an example of a common falling scenario: A physical therapist and occupational therapist work to maximize a patient’s functioning during therapeutic sessions. Eventually, the patient regains self-confidence and some independence. One day after therapy sessions, the patient is back in the room and decides to get up and move without assistance. Then the patient falls.

"We try to set limits for when patients are back in their rooms, but many times patients don’t take the advice of their therapist or nurse, and they try to get up to go to the bathroom independently, and that’s when they fall," Doweiko says.

Spaulding Rehabilitation Hospital has had a 10% decrease in the number of falls over the past three years, a result of the hospital’s comprehensive fall prevention program. The hospital made a number of changes in the way it dealt with falls and the way staff evaluated patients for the risk of falling. Here’s how the program works:

1. The hospital formed a fall prevention task force. First, hospital administrators decided to make fall prevention a priority. "It was our No. 1 problem on the incidence reports," Doweiko says. Then employees and managers formed a fall prevention task force, which worked with the quality management department to develop strategies related to reducing falls.

The task force first had to define the term "fall." "There are different definitions for falls, and when you read articles about patient falls, some institutions categorize a fall as when a patient hits the floor involuntarily, even when the patient is dizzy and assisted to the floor by a therapist," Doweiko explains. "That’s a situation where the patient is aware of what’s going on, and for the most part, the patient is not injured." The task force decided not to include that type of situation in its definition of a fall. Instead, it defined the term as an incident in which a patient hits the floor involuntarily and unassisted. Then task force members outlined strategies for reducing the number of falls and developed an interdisciplinary fall risk prevention policy.

2. Staff collected data on patient falls. The quality management department had been collecting fall data over several years, so the task force used the information as a baseline for measuring improvement.

Employees routinely fill out incident reports that include falls, and the task force and quality management department pulled all the reports relating to patient falls. Then they collected the information on a database and analyzed it for trends. "We tried to categorize different types of falls," Doweiko says. Those situations include falls that occur when a patient is trying to get to the bathroom or when a patient moves to or from a shower chair.

3. They gave staff a risk assessment tool. The task force researched risk assessment in current medical literature and then helped create a one-page risk assessment tool for identifying high-risk patient behaviors. The tool includes general data, such as the patient’s age and whether he or she has a history of falls. The tool has categories that describe the patient’s physical condition, ambulatory devices used, medications prescribed, and mental status.

Each item has a place for nurses to check if the item applies to a particular patient. Once the nurse has completed the risk assessment tool, the checkmarks are evaluated. When the tool has four or more checkmarks, the patient is labeled high risk for falling.

Assessment tool needed to be revised

The first version of the risk assessment tool placed patients in categories of low, moderate, and high risk. But the tool didn’t work as expected. The tool was good at identifying low-risk patients who didn’t require fall prevention education and extra assistance, and it could identify high-risk patients who were given extra education and interventions and therefore had fewer than predicted falls. The problem was that patients in the moderate category became part of a gray area. They didn’t receive as much attention as the high-risk patients, which led to an unacceptable fall rate.

"The patients who were assessed to be at moderate risk were the ones who were falling the most," Doweiko notes. "They were the ones who were really our most frequent fallers."

The task force revised risk assessment. Now the tool has only two categories: low risk and high risk. Patients who previously were considered at moderate risk now receive the same education and interventions as those who are at high risk.

The tool also lists the interventions clinicians may choose, and it has a place to record when each intervention began. Interventions vary according to the patient’s condition. The risk assessment tool for traumatic brain injury patients will be slightly different from the tool used for cardiac or respiratory patients, for instance.

Here are some examples of interventions:

• ensuring a nursing call light is within the patient’s reach at all times and that nurses answer it as soon as possible;

• encouraging families to provide sneakers or other types of nonskid footwear for patients;

• putting the bed in a low position;

• keeping the patient’s transfer status up to date on the communication board in the patient’s room;

• making sure the patient is not left unattended during transfers or when walking.

Clinicians complete the assessment tool for each patient each week, noting any changes in status, such as if the patient has had a fall or appears to be unstable.

"It’s because we take the tool so seriously that we have good outcomes," Doweiko says. "It takes everybody being cognizant of the potential problems if we’re not mindful of a safe environment for each patient."

4. The task force educated staff, patients, and families. First, the hospital started a large educational effort, sending representatives to each floor to talk about different types of fall prevention measures that could be used for specific patient populations. For example, patients who have had strokes will need different fall prevention interventions from patients who have had a spinal cord injury.

Task force members and quality managers even visited the night shift staff, bringing doughnuts to 2 a.m. and 3 a.m. educational sessions. The education included showing employees videos with realistic scenarios that displayed problems resulting in falls. "The videos provoked discussion," Doweiko says. "One video gave a case study of how an employee should handle a patient who is obviously not safe, and it discusses the interventions the staff could take."

Each month, the hospital posts 12 fall prevention posters in corridors where they can be seen easily by staff, patients, and patients’ families. Therapy and nursing clinical educators created the posters using computer graphics, and the hospital printed them. Then the posters were laminated and hung on the walls. Each poster highlights a different issue related to falls and fall prevention, and they’re changed monthly.

"We want families to participate in this need for safety awareness, so the posters have common-sense guidelines," she explains.

Staff education included brown-bag luncheon discussions about fall prevention. The task force gave each floor or program some data about their own fall trends. "It’s really critical for the staff to know how they are doing," Doweiko says.

The task force also showed employees a comparison of the hospital’s fall data with fall data from other area hospitals. Unfortunately, the only data Doweiko could find for comparison came from acute care hospitals, so the comparison isn’t a true benchmark. "But at least they can see where we fit in when compared to acute care hospitals," she adds.

The comprehensive educational campaign paid off. Employees began to contribute their ideas and observations, and this helped the task force create more specific and better interventions. For instance, some staff said their problem wasn’t so much that patients weren’t following directions. Instead, most patients were on diuretics, which caused them to urinate frequently. Because those patients often were getting out of bed alone during the night and risked falling, the task force took appropriate steps, like placing commodes at the patients’ bedsides.

For more information, contact Dorothy Doweiko, RN, Director of Quality Management, Spaulding Rehabilitation Hospital, 125 Nashua St., Boston, MA 02114. Telephone: (617) 573-2475. Web site: