Where: Four acute care hospitals in the Partners HealthCare System, in and around Boston.
The issue: Reducing inpatient falls.
The fall prevention task force at Partners had tried many strategies to reduce inpatient falls, according to task force co-leader Patricia D. Dykes, RN, DNSc. “We had implemented the Morse fall scale. We also standardized our measures—incidence of falls, fall-related injury. The next logical step was to standardize interventions” to reduce falls, said Dr. Dykes, who is now a senior nurse scientist and program director for research in the Center for Nursing Excellence at Brigham and Women's Hospital.
Figuring out which interventions might be appropriate to implement across the entire health system was difficult, however. “There weren't any randomized trials which showed a significant decrease in patient falls in acute short-stay hospitals...There wasn't any evidence that a certain protocol was what you should do,” Dr. Dykes said.
So Dr. Dykes and other researchers talked to physicians, nurses and other health care providers, as well as patients who had fallen and their families. They asked what was being done to prevent falls and how the prevention efforts might be enhanced. Some areas of potential improvement emerged.
“[Patients] were all being assessed the same way, but the [fall prevention] plans were very often too lengthy, were not tailored to individual patients' determinants of risk, and the information about the plan was not available at the bedside. Not all the team members knew where it was located. The paraprofessionals and the patients didn't have access,” said Dr. Dykes.
Even apparently promising interventions like fall-risk warning signs weren't functioning ideally. “When patients were found to be at high risk, they were hanging these ‘high risk for falls' signs in the patient's room. But what we learned was that the care team members didn't find those signs particularly helpful because most patients had one and the signs did not provide information about why the patient was at risk and what could be done to prevent a fall.
“We liked the idea of the sign because everyone had access to it, including the patients and their family members and the paraprofessionals, but we knew we had to make it more specific,” Dr. Dykes continued. “We could take this fall risk assessment, which was being done anyway, and we could use that to generate a tailored plan for the patient.”
How it works
The Partners team (which included software experts as well as clinicians) built a computer-based fall prevention toolkit. Nurses did the same fall risk assessment that they had done before. After they entered the data, the toolkit produced fall prevention resources that were tailored to the individual patient's risk factors.
The toolkit's output includes a plan of care (which suggests interventions such as a bed alarm or physical therapy consult), individualized educational materials for patients and their families about fall risk, and individualized bed posters. The posters have icons, so they're easily understood, and they list specific issues that affect the patient's fall risk (for example, if he or she is tethered to an IV).
While the toolkit's results are individualized, the system itself was built to work for anyone. Two of the Partners hospitals where it was implemented were academic centers with their own Web-based electronic records systems, but the other two had systems from outside vendors. “Both of those implementations were completely different. We selected hospitals with different systems on purpose. We wanted to make our software generalizable,” said Dr. Dykes.
The toolkit was piloted in two units at each hospital. In a study published in the Nov. 3, 2010 Journal of the American Medical Association, fall rates were compared in the intervention units and a matched set of controls. The toolkit units had only 67 falls compared with 87 in the controls (P=0.02).
The project also got good reviews from participating clinicians. “We were very happy that we hadn't implemented something that was perceived as just another thing that has to be done,” said Dr. Dykes.
When the effects of the program were broken down in greater detail, it turned out that patients over age 64 had reaped most of the benefits—about two fewer falls per 1,000 patient-days, with a P value of 0.003. Younger patients hadn't seen a change. “If you look at the P values, there's really no difference in younger patients [between the control and intervention groups],” said Dr. Dykes.
But the researchers aren't certain whether that means the toolkit didn't work for younger patients, or possibly that it was not used as often with them. “Maybe the nurses or other caregivers thought this person's younger, I'm not going to bother,” Dr. Dykes speculated. “Adherence was high. It was close to 90%. Was that 10% mostly younger people?”
Dr. Dykes hopes to delve into the issue of age, and others, through additional research. Even with 10,000 patients, the first trial was not large enough to determine whether the toolkit reduced the number of fall-related injuries in addition to overall falls. Dr. Dykes and colleagues have proposed a larger trial, which will look at falls with injury and patient-level adherence to the program.
In the meantime, they're also trying to get the toolkit implemented across the Partners system. Because it was funded only as a trial, the toolkit was removed from the piloting units after the six-month study. “[The nurses] were actually quite devastated when we told them we had to turn it off,” said Dr. Dykes. The health care system's safety committee is currently working to bring the toolkit back and roll it out in all units and hospitals.
Words of wisdom
“Hospitals should use a validated fall risk assessment tool and integrate the tool into the electronic documentation system,” said Dr. Dykes. The electronic system should be programmed to automatically link evidence-based interventions to patient-specific areas of risk and allow the nurse to further tailor based on his or her knowledge of the patient, she recommended.