A decade ago, a three-step fall prevention process called Fall TIPS (Tailoring Interventions for Patient Safety) was implemented in four hospitals and reduced inpatient falls by 25%, according to a randomized trial published in JAMA in November 2010. The researchers who led the study were disappointed that it wasn't even more effective. “We wondered why we didn't do better, because we know that more than 90% of falls are preventable,” said Patricia C. Dykes, PhD, MA, RN, principal investigator for Fall TIPS. In a follow-up case-control study, the researchers found that the most common reason why some patients who received the intervention fell was that they did not follow their fall prevention plan.
The project also found that while the intervention was very successful in older people, younger patients had a harder time following the plan, said Dr. Dykes, who is a senior nurse scientist and program director for research at Brigham and Women's Center for Patient Safety Research and Practice. “What they said was that the nurse had told them that they were at risk, but frankly, they didn't believe it because at home, they're independent,” she said. “They didn't realize that there are certain things in the hospital that increase the risk for falls, so they thought rather than bother a nurse, they would just get up and go to the bathroom. That's the most common scenario.” To resolve that problem, she and her colleagues developed a plan to increase patients' engagement in fall prevention.
How it works
The three-step Fall TIPS process always entailed a nurse completing a fall risk assessment at the bedside and developing a personalized fall prevention plan for the patient. Then the care team would consistently follow that plan, as well as take universal fall precautions. But the researchers realized that nurses also needed to engage the patient and/or family in all three steps of that process, said Dr. Dykes, also an associate professor of medicine at Harvard Medical School in Boston.
To accomplish this, the team developed a color-coded poster that hangs at the patient's bedside and provides clinical decision support. The poster, which was originally in English on one side and Spanish on the other, has since been translated into many different languages, she said. Nurses work with patients and families to do the risk assessment and develop the plan, using the colors of the poster to focus on interventions recommended based on the patient's personal risk profile, said Dr. Dykes. “This way, all the time, the patients and the families become very familiar, first of all, that the patient's at risk, what those risk factors are, and what they need to be doing about it in the hospital,” she said.
To assess the impact of Fall TIPS on patient activation, the research team surveyed a random sample of 343 patients before and after implementation of the intervention at three health care systems. Patients' knowledge, skill, and confidence were measured with the short-form Patient Activation Measure, adapted for fall prevention.
Overall, activation scores increased from about 64 before the intervention to about 81 afterward, according to results published in the March Joint Commission Journal on Quality and Patient Safety. “These patients are significantly more activated, which means that . . . patients feel empowered and able to protect themselves and prevent falls while they're in the hospital,” said Dr. Dykes. Scores increased at all three health systems, although the difference wasn't significant at New York-Presbyterian, probably owing to its high baseline level of activation, she said. About 60% of patients at Montefiore have a first language other than English, Dr. Dykes said, so “We're particularly thrilled that this is a tool that not just works, but works in diverse populations.”
Even though the intervention is fairly simple, changing clinical practice is always a challenge, Dr. Dykes said. “There was a lot of pushback at first from nurses who felt that they really didn't have enough time in the hospital to involve the patient in the risk assessment and developing the plan,” she said. But involving nurses in developing bedside tools to integrate patient engagement into their workflow, as well as feedback and encouragement from clinical champions on each unit, helped nursing staff adjust to the new workflow, Dr. Dykes said.
A new study by the Fall TIPS team, which has not yet been published, will report the long-term effects of the intervention on fall and injury rates in a large sample of patients, she said, adding that the team also wants to look at how the intervention could work in other settings, such as long-term care facilities.
Words of wisdom
More than 150 hospitals have implemented Fall TIPS, and interested hospitals can visit the program website to download the free toolkit, said Dr. Dykes, adding that it works best in the context of interdisciplinary care. “Having the plan there at the bedside, it can be used and implemented by the whole team, not just the nursing staff,” she said. “And it's most effective if the whole team has bought in.”