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Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans
Summary
Patient falls in hospitals are common and debilitating adverse events that persist despite decades of effort to minimize them. Improving communication across the assessing nurse, care team, patient, and patient’s most involved friends and family may strengthen fall prevention efforts. A team at Brigham and Women’s Hospital in Boston, Massachusetts, sought to develop a standardized fall prevention program that centered around improved communication and patient and family engagement. An early iteration of the model was associated with reduction in falls for older people.1 The team revised the program further to address the problem of younger patients’ misperceptions about their vulnerability to falls and lack of adherence fall prevention plans.2 To improve patient buy-in, the team increased the involvement of the patient in the assessment and prevention planning process. This engagement included working with the patient and their available friends and family to (a) identify their risk factors (e.g., forgetfulness or unwillingness to call for help) and (b) examine any history of falls and what precipitated the falls. After a process of revisions, the team created the Fall TIPS Program. A recent study in 14 medical units within three academic medical centers found that implementation of the Fall TIPS Program was associated with a 15% reduction in overall inpatient falls and a 34% reduction in injurious falls.3 Another recent study found that the benefits of the program in terms of savings associate with prevented falls far outweighed the costs.4 More recent research has helped the team to better understand and innovate implementation practices.5 The Fall TIPS Program is now used by hundreds of hospitals across the United States and internationally.
Fall TIPS Program resources include integrated risk assessment and care planning tools that help nurses produce a tailored plan of care with each patient. The program tools turn the information from the assessment into a customized fall prevention plan.6 Using the program toolkit, nurses work with the patient, the patient’s family, and the available support network to collect information and develop and execute a fall prevention plan. A central feature of the program is an illustrated visual aid that alerts the patient, family, and providers to the patient’s specific risk factors and the interventions most likely to prevent each patient from falling.
The innovation team emphasized that successful implementation depends on patient and staff buy-in, integration of the program into existing workflows, and fidelity to program processes. The team noted that they are grappling with how to ensure continuity in program implementation during periods of crisis. During the COVID-19 pandemic, for example, an increase in inpatient falls was associated with limitations in patient engagement along with restrictions on visitation.7
Innovation Patient Safety Focus
The innovation was developed to prevent patient falls in inpatient facilities. These incidents are typically considered avoidable.8
Resources Used and Skills Needed
To implement the intervention, organizations need the following:9
- Access to Fall TIPS resources
- Fall TIPS training and retraining for nursing and non-nursing staff, including new nurses
- Nursing workflows that allow for patient and family engagement to conduct the falls assessment, ensure use of the prevention plan, and conduct patient-level audits.
- Stakeholders (i.e., patients, families, care provider teams) willing and able to work together
- Support and buy-in from nursing staff and hospital and unit leadership
- Engaged nursing champions committed to the program
- Valid and reliable fall risk assessments conducted with every patient
- Ability to conduct audits and check for patient/family understanding of patient risk factors and the fall prevention plan
- Tailored fall prevention care planning for every patient
- Consistent implementation of the tailored care plan across the care team, including non-nursing staff
- A system for regularly collecting and reporting program compliance and falls data
Use By Other Organizations
The Fall TIPS Program has been used by more than 500 hospitals in the United States and internationally.
Date First Implemented
2009Problem Addressed
Patients are particularly vulnerable to falling while in the hospital due to a number of factors, including loss of mobility due to illness or treatment, the impact of medications, an unfamiliar environment, and obstruction from various tubes and catheters.1 As a result, for adult patients, hospitals report falls more frequently than any other adverse event .7 It is estimated that patients fall during approximately 1.9% to 3% of all hospitalizations.7 The results can be highly detrimental, often accelerating patient decline and causing longer hospital stays. One study estimated stays increased an additional 12 in-patient days after a patient fall.10
Description of the Innovative Activity
The Fall TIPS Program is based on engaging patients and their family/loved ones across three main processes: assessment, individualized preventative interventions, and auditing to ensure that patients are engaged in the three-step fall prevention process. The toolkit contains guides and aides that hospital personnel can use to conduct each of these processes.
The patient assessment is based on the Morse Fall Scale,11 which is a validated fall risk assessment tool for in-patient hospital settings. The scale includes the six most common reasons patients in hospitals fall: the patient fall history, high-risk conditions (including polypharmacy), use of IVs and other external devices, mental status, gait, and mobility. Under the program, nurses complete the assessment with the input of the patient and the patient’s family or other available support.
Each risk factor links with one or more actionable evidence-based interventions. The nurse creates a plan that incorporates the interventions and is visible to the care team, patient, and family on a laminated poster or printed visual aid. Nurses develop the plan while meeting with the patient and the patient’s family. The visual materials were tested and designed to be accessible to people with a range of health literacy and language backgrounds. The poster serves as a communication tool with other members of the patient’s care team.
The audit component of the program includes assessing the patient’s knowledge of their risk factors and prevention plan at the unit and hospital levels. Nurse champions conduct at least five individual interviews a month with patients and their families to check for understanding of the fall prevention plan. Nurse champions can use these findings to provide peer-to-peer feedback and assess compliance. Safety and nursing leaders should report these data to other nurses, members of the care team, and hospital administrators to track progress and support buy-in and compliance.
Context of the Innovation
Patient falls during hospital stays are a common adverse event. Because falls are considered largely preventable, the Centers for Medicare & Medicaid Services (CMS) stopped reimbursing hospitals for fall-related injuries. Still, patients in hospitals fall up to 1 million times per year.7 An estimated 30% of these falls result in injuries, which can range in severity.12
Unlike other adverse events that require a standardized clinical response, fall prevention depends highly on the needs of the patient. Including the input of people who know the patient best allows for greater customization. This approach has proven to be more effective than fall prevention programs that are based primarily on the production of a risk score and/or are not customizable.4
Results
A recent published study of the Fall TIPS Program between November 1, 2015, and October 31, 2018, used a nonrandomized controlled trial with a stepped wedge design.3 The study included all adult patients in 14 medical units within three academic medical centers in Boston and New York City (n=37,231 patients). After implementing the program, the hospitals saw an overall adjusted 15% reduction in falls compared with before implementation of the program (2.92 vs. 2.49 falls per 1,000 patient days) and an adjusted 34% reduction in injurious falls (0.73 vs. 0.48 injurious falls per 1,000 patient days). Based on auditing results, one site had 86% compliance and two sites had over 95% compliance.
A cost-benefit analysis of the Fall TIPS program in eight hospitals estimated that the program cost $0.88 per patient to implement and resulted in savings of $8,500 per 1000 patient-days in direct costs related to the prevention of 567 falls over three years and eight months. Factoring in two minutes a day of nurses’ time resulted in savings of $3,715 in direct costs per 1000 patient-days.13
Planning and Development Process
According to the innovation team, organizations interested in implementing the program should conduct a readiness assessment and falls prevention gaps analysis.8 Additionally, organizations should ensure the necessary infrastructure and workflows for implementation and develop an implementation plan. If one exists, the organization’s Fall Prevention Task Force should be involved in planning.
An important first step for laying the foundation for this innovation is building internal support for the program. To secure buy-in from leadership and nurses, the innovation team recommends explaining why fall prevention is important. The team also recommends emphasizing that the program does not take additional time or effort for nurses if nurses are already engaged in fall prevention efforts. Outreach and education on the program should reach various hospital groups, including the Quality and Safety Committee, nurse managers/directors, and clinical nurse specialists. Resources on the Fall TIPS Program website can help to guide these conversations.
Resources Used and Skills Needed
To implement the intervention, organizations need the following:9
- Access to Fall TIPS resources
- Fall TIPS training and retraining for nursing and non-nursing staff, including new nurses
- Nursing workflows that allow for patient and family engagement to conduct the falls assessment, ensure use of the prevention plan, and conduct patient-level audits.
- Stakeholders (i.e., patients, families, care provider teams) willing and able to work together
- Support and buy-in from nursing staff and hospital and unit leadership
- Engaged nursing champions committed to the program
- Valid and reliable fall risk assessments conducted with every patient
- Ability to conduct audits and check for patient/family understanding of patient risk factors and the fall prevention plan
- Tailored fall prevention care planning for every patient
- Consistent implementation of the tailored care plan across the care team, including non-nursing staff
- A system for regularly collecting and reporting program compliance and falls data
Funding Sources
The innovation team developed the program under grant number R18HS025128 from the Agency for Healthcare Research and Quality (AHRQ).
Getting Started with This Innovation
To begin, organizations should ensure completion of training modules by nurses and nursing assistants. Hospital staff should assess, based on the needs of a hospital, whether to use an electronic health record printout or paper version of the fall prevention plan. Implementing teams should recruit and train nurse champions and establish processes for auditing and reporting on fall data.
Sustaining This Innovation
The innovation team reports that sustaining the innovation requires several essential elements, including the following:
- Nursing leadership support is essential to ensure compliance with the program.
- Staff need to be involved in the process of redesigning the workflow to engage patients and family in the assessment and prevention plan process.
- Systems should be in place so that units can understand why a fall occurred and remediate the cause. More specifically,nurses should have channels to provide ongoing feedback to both staff and unit leadership so they can adjust and improve fall prevention workflows and communicate systemic problems.
- New nurses and those on short-term assignments (i.e., travel nurses) should receive training on nurses’ role in the program and how to perform the fall risk assessments and create and implement the fall prevention plans.
- Organizations should integrate the Fall TIPS Program into local quality plans.
- To maintain organization wide buy-in,organizations should have processes for consistent reporting on falls and fall data, including improvements made in the past.
- Organizations should evaluate real-time issues that may impact program implementation such as restrictions on patient and family engagement due to enhanced contact precautions and prohibitions on visitors.
- Finally, it is important to remember that environmental conditions and hazards play a role in patient falls. Any fall prevention efforts should be multifaceted and include evidence-based efforts to create a safe hospital environment.14
References/Related Articles
Agency for Healthcare Research and Quality. A patient-centered fall prevention toolkit: tailoring interventions for patient safety. Accessed April 6, 2023. https://www.falltips.org/
Carter EJ, Khasnabish S, Adelman J, et al. Adoption of a patient-tailored fall prevention program in academic health systems: a qualitative study of barriers and facilitators. OBM Geriatrics. 2020;4(2).
Dykes PC, Adelman JS, Alfieri L, et al. The fall TIPS (tailoring interventions for patient safety) program: a collaboration to end the persistent problem of patient falls. Nurse Leader. 2019;17(4):365-370.
Dykes PC, Burns Z, Adelman J, et al. Evaluation of a patient-centered fall-prevention tool kit to reduce falls and injuries: a nonrandomized controlled trial. JAMA Netw Open. 2020;3(11):e2025889.
Morse JM. Preventing Patient Falls. Springer Publishing Company; 2008.
Footnotes
- Dykes PC, Carroll DL, Hurley A, et al. Fall prevention in acute care hospitals: a randomized trial. JAMA. 2010;304(17):1912-1918.
- Dykes PC, I-Ching EH, Soukup JR, Chang F, Lipsitz S. A case control study to improve accuracy of an electronic fall prevention toolkit. In: AMIA Annual Symposium Proceedings (Vol. 2012). American Medical Informatics Association; 2012:170.
- Dykes PC, Burns Z, Adelman J, et al. Evaluation of a patient-centered fall-prevention tool kit to reduce falls and injuries: a nonrandomized controlled trial. JAMA Netw Open. 2020;3(11):e2025889.
- Dykes PC, Curtin-Bowen M, Lipsitz S, et al. Cost of Inpatient Falls and Cost-Benefit Analysis of Implementation of an Evidence-Based Fall Prevention Program. JAMA Health Forum. 2023;4(1):e225125. doi:10.1001/jamahealthforum.2022.5125
- Carter EJ, Khasnabish S, Adelman J, et al. Adoption of a patient-tailored fall prevention program in academic health systems: a qualitative study of barriers and facilitators. OBM Geriatrics. 2020;4(2).
- Dykes PC, Adelman JS, Alfieri L, et al. The fall TIPS (tailoring interventions for patient safety) program: a collaboration to end the persistent problem of patient falls. Nurse Leader. 2019;17(4):365-370.
- Silvera GA, Wolf JA, Stanowski A, Studer Q. The influence of COVID-19 visitation restrictions on patient experience and safety outcomes: a critical role for subjective advocates. Patient Exper J. 2021; 8(1):30-39.
- Currie L. Fall and injury prevention. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Agency for Healthcare Research and Quality; 2008:ch. 10.
- Agency for Healthcare Research and Quality. Implement fall TIPS: Step 1. Secure buy-in from hospital leadership. Accessed April 6, 2023. https://www.falltips.org/implement-fall-tips/step-1/
- Dunne TJ, Gaboury I, Ashe MC. Falls in hospital increase length of stay regardless of degree of harm. J Eval Clin Pract. 2014;20(4):396-400.
- Adapted from Morse JM, Morse RM, Tylko SJ. Development of a scale to identify the fall-prone patient. Can J Aging. 1989;8:366-367.
- Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin Geriat Med. 2002;18(2):141-158.
- Dykes PC, Curtin-Bowen M, Lipsitz S, et al. Cost of Inpatient Falls and Cost-Benefit Analysis of Implementation of an Evidence-Based Fall Prevention Program. JAMA Health Forum. 2023;4(1):e225125. doi:10.1001/jamahealthforum.2022.5125
- LeLaurin JH, Shorr RI. Preventing falls in hospitalized patients: state of the science. Clin Geriatr Med. 2019;35(2):273-283.
Contact the Innovator
Patricia Dykes PDYKES@BWH.HARVARD.EDU
