R ESEARCH COR N ER
Do patients accurately perceive their fall risk? By Seema S. Sonnad, PhD; Susan Mascioli, MS, BSN, RN, CPHQ, NEA-BC; Janet Cunningham, MHA, RN, NEA-BC, CENP; and Jennifer Goldsack, MChem, MA, MS
Abstract Background: In U.S. hospitals, from 700,000 to 1 million inpatients fall each year. About a third of these falls could have been prevented. Objectives: This project’s purpose was to document patient perceptions of their inpatient fall risk and determine how these perceptions were associated with clinical indicators of fall risk. Methods: From six medicalsurgical units, 193 patients were randomly selected and surveyed about their perceived fall risk during their hospital stay. For 101 of them, the Schmid fall risk assessment score, age, and gender were recorded. A retrospective review of the Schmid scores of all patients who fell during a 6-month historical sample period was reviewed for comparison. Results: Most patients (88%) reported that they didn’t feel at risk for falling during their hospital stay. No correlation between their Schmid score and their perceived fall risk was found. Historical review of all inpatients who’d fallen in a prior period showed that the 358 patients with known Schmid scores had a full range of scores. These are normally distributed from 0 to 6, with over 40% of patients experiencing falls having Schmid scores of less than 3. Conclusions: Patient perceptions of falls match neither their clinical risk nor their actual likelihood of falling. When designing fall prevention strategies, it may be important to remind providers of this gap in patient knowledge, which includes overconfidence in the role of the care team in preventing falls. 58 l Nursing2014 l November
Background Between 700,000 and 1 million falls occur each year in U.S. hospitals, according to data presented by the Agency for Healthcare Research and Quality in “Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care.”1 About one-third of these patient falls could have been prevented.2 Several reviews indicate that no single approach can reduce falls. Instead, multidimensional strategies are needed to combine improved routine processes and personalized fall prevention. This finding forms the basis of the 2013 National Institute for Health and Care Excellence guidelines for fall prevention, which have been updated to include prevention of falls in the hospital.2-4 Not only do 25% of falls result in physical injuries, but organizations such as the National Quality Forum use falls as a quality indicator.5 Besides the high monetary cost of falls—over $19 billion per year in the United States alone—the human cost shouldn’t be overlooked.6 Falling may lead to a loss of selfconfidence and independence and reduce activity, further increasing the risk of falling.7 Many older patients fear a loss of independence requiring admission to long-term care more than they fear death itself.8 Programs to improve patient safety and quality by reducing other adverse events are beginning to incorporate models of patient engagement. Although the research is limited so far, patient participation in the care planning process may be associated with improved patient
satisfaction and a decreased risk of adverse events.9 A recent pilot study of 50 patients in Australia showed that education tailored for older patients led to increased participation in fall prevention activities after discharge.10 In general, patients’ interest in engaging in quality and safety efforts hinges on programs aimed at preventable incidents using actions that patients perceive as effective.11 Objectives This investigation evolved as part of a fall-reduction process improvement project. The researchers’ goal was to document patient perceptions of their inpatient fall risk and how these perceptions were associated with clinical indicators of fall risk. Methods This project began as part of a process evaluation in an improvement project to reduce inpatient falls in medical units in a large nonuniversity teaching hospital. In April 2013, the nurse manager in each of the three units selected to participate in this project asked 10 randomly selected patients whether they felt at risk for falling during their stay in the hospital, and why or why not. As the project developed, these data were revisited, and the researchers became interested in understanding if there was a need for patient education and patient involvement in future fall prevention efforts. At this point, the team recognized that the study was transitioning from a standard process improvement effort to a prospective, survey-based research www.Nursing2014.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
project, so we sought and were granted approval to proceed by our health system’s institutional review board. In July 2013, a research coordinator revisited the same three medical units to survey more patients, resulting in a total of 92 surveyed patients in the three units targeted for intervention. At this point, patients eligible for the study included all patients on the selected units other than patients with a cognitive impairment, patients in isolation, and patients who didn’t speak English. Similar to the preproject survey, each patient was asked, “Do you feel that you’re at risk for falling right now?” and then, “Could you please explain to me why?” Responses were recorded on paper at the bedside by the nurse manager or the research coordinator. Between October 29 and November 11, 2013, a second group of patients was surveyed about the patients’ perceived fall risk during their hospital stay. These patients were drawn from three medicalsurgical units not included in the earlier surveys and not involved in specific fall reduction interventions resulting from this project. Data collection continued until 101 unique patients had been surveyed. The risk question was changed slightly, from “right now” to “during this stay in the hospital.” During this phase of data collection, the research coordinator reviewed the patient’s medical record to retrieve a current Schmid score for each participating
A snapshot of patients studied Type of unit First survey Adult medical/surgery/stroke overflow unit
32 (35%)
Step-down unit for acute stroke
31 (34%)
Inpatient medical telemetry unit
29 (32%) Total: 92 (100%)
Second survey Adult and geriatric medical unit
Male: 20 (54%) Female: 17 (46%) Mean age: 60.42 years
Inpatient medical-surgical, cardiac telemetry, and observation unit
Male: 12 (39%) Female: 19 (61%) Mean age: 62.00 years
Inpatient surgical unit
Male: 16 (48%) Female: 17 (52%) Mean age: 59.36 years Total male: 48 (48%) Total female: 53 (52%) Mean age: 60.77 years
patient, as well as the patient’s age and gender, information not collected during the first survey period. (See Understanding the Schmid Fall Risk Assessment Tool.) To contextualize the Schmid scores gathered as part of the patient survey, we recorded and reviewed the Schmid scores of all inpatients who fell between July 1, 2012, and January 22, 2013, throughout the health system. This health system is a 1,100-bed, two-hospital tertiary care health system in Delaware. Results Most patients didn’t feel that they were at risk for falling. (See A
Understanding the Schmid Fall Risk Assessment Tool The Schmid Fall Risk Assessment Tool is used to categorize the risk of falling by assessing certain patient characteristics in five domains: mobility, mentation, elimination, fall history, and current medications.25 Assessment tools such as the Schmid score can help to identify patients at risk for falls.26 The tool scoring system ranges from 0 to 6, with 0 being no identified risk and scores of 3 or greater identifying a patient as at risk for falling.
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Number of respondents N (%)
snapshot of patients studied.) Only 15/92 (16%) of the first group of patients and 9/101 (9%) of the second group responded that they felt at risk for falling while in the hospital. Reasons patients believed their fall risk was low can be categorized into three general areas: • Many patients said the nursing care was helpful and the nurses were attentive. • Other patients stated that they were careful and able to walk easily. • A third group stated that because they weren’t walking or getting out of bed much, they weren’t at risk. Patients who felt at risk for falling mentioned specific balance, injury, or nausea issues, recent falls, or concerns about equipment to which they were connected. We found no correlation between Schmid score and patient risk perception. In the group of 101 patients for whom Schmid scores were collected, only 9 said they felt November l Nursing2014 l 59
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R ESEARCH COR N ER
they were at risk for falling. For these nine patients, the Schmid scores were normally distributed across the range of potential scores (see Schmid scores for patients who felt at risk for falling). Eleven percent of women (6/54) felt themselves at risk for falling, while six percent of men (3/47) said they were at risk. Interestingly, the three men who felt they were at risk for falling had Schmid scores of 1, 2, and 3, indicating lower risk, while the women’s scores ranged from 2 to 5. The historical review of all inpatients who’d fallen showed that the 358 patients whose Schmid scores were known had a full range of Schmid scores, and they were normally distributed from 0 to 6 with over 40% of patients experiencing falls having Schmid scores less than 3. (See Schmid scores of patients
Schmid scores of patients who fell systemwide These data were collected from July 2012 to January 2013. Schmid score
Patients who fell N (%)
0
38 (11%)
1
37 (10%)
2
73 (20%)
3
82 (23%)
4
67 (19%)
5
46 (13%)
6
15 (4%)
who fell systemwide and Schmid scores from an analysis of historical falls.) Discussion The overall rate of risk perception (12%) is higher than the expected rate of falls in general inpatient population (2% to 3%), but lower than those reported for hospitalized
Schmid scores for patients who felt at risk for falling This figure shows the distribution of Schmid scores.
Number of Patients
3
2
1
0 0
1
2
3
Schmid Score
60 l Nursing2014 l November
4
5
6
older patients (10% to 30%).12-15 In our sample, patient risk perception often didn’t correlate with Schmid score. However, the distribution of Schmid scores for patients who considered themselves to be at risk for falling was similar to the distribution of Schmid scores of patients who’d actually fallen in the prior period. Schmid scores for patients reporting no perception of fall risk shifted toward the lower end of the scale when compared with the scores of those who perceive risk or actually fell. (See Schmid scores for patients who didn’t feel at risk for falling.) This suggests that perceived risk may be an important indicator for actually falling in the hospital, but this is contrary to data from some of our surveyed patients, indicating that further investigation is needed. Of the 19 patients with a Schmid score of 4 or 5, only 3 felt at risk for falling in the hospital. Of these three patients, one had fallen previously, one reported dizziness and vertigo from a migraine, and one was concerned about all the equipment that had to remain connected when the patient was ambulating. Interestingly, high-quality nursing care may instill a false feeling of security in the patients. Nearly 40% of patients who didn’t report feeling www.Nursing2014.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Schmid scores from an analysis of historical falls This figure shows the distribution of Schmid scores. 100
Number of Patients
80
60
40
20
0 0
1
2
3
4
5
6
Schmid Score
Schmid scores for patients who didn’t feel at risk for falling This figure shows the distribution of Schmid scores. 25
20
Number of Patients
at risk for falling said that this was due to excellent nursing support. For example, patients said: • “I worry at home, but I’m safer here with the nurses.” • “They’re always there when you need them.” • “Nurses keep very careful watch.” Falls are the most common hospital-acquired condition, the primary cause of nonfatal injury in patients older than 65, and the focus of public health concern.16,17 Nevertheless, falls don’t seem to be a primary concern for patients. For example, one patient, age 91, with a Schmid score of 5 said, “I’m anxious about everything, but not falling,” and another said, “I’m 86. I’m past worrying.” Given that Morse believes that many falls related to expected physiologic factors can be prevented by identifying patients at highest risk and using early intervention, the findings from this investigation suggest that helping patients understand fall risk may be a critical component of fall prevention efforts.18 Just as patient engagement in promoting patient safety through programs such as The Joint Commission’s universal protocol to prevent wrong-site, wrong-procedure, and wrongperson surgery has been successful,19,20 engaging patients as active participants in fall prevention programs may be an important strategy for reducing falls. Previous studies have found that education during inpatient stays about patients’ personal risk factors and fall prevention strategies increases the likelihood of these same patients engaging in fall prevention behaviors both during their hospitalization and postdischarge.21-23 This information combined with our data suggests that the inpatient
15
10
5
0 0
1
2
3
4
5
6
Schmid Score
November l Nursing2014 l 61
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R ESEARCH COR N ER
setting may provide a key opportunity for patient education that can positively impact public health beyond the hospital. Education may reduce not only falls for inpatients, but also falls for people in the community setting, where over onethird of adults older than 65 are estimated to fall. Without effective interventions, this number is anticipated to rise to as high as 50% due to the aging of the population.24 More research may also be required to better understand why patients don’t perceive that they’re at risk. While our study indicates that excellence in nursing and the sense of security this provides may have a significant influence, other factors such as patients’ optimism bias and possible lack of knowledge about consequences should also be considered. Recognizing the elements that influence patient perceptions about their risk may not only empower nurses in their fall prevention efforts, but also across the board in addressing patient safety issues. Conclusions Patient perceptions of falls match neither their clinical risk nor their actual likelihood of falling. The researchers believe that their data support the hypothesis that involving patients in fall prevention may significantly reduce risk, increase satisfaction, and improve patient self-efficacy. This outcome is likely to carry over into risk-mitigating behavior changes during and after the hospital stay. Nurses must also remember that attentiveness to falls may instill a false sense of security in their patients about their fall risk. We recommend that strategies to improve patients’ awareness of their fall risk be implemented and investigated. ■ 62 l Nursing2014 l November
REFERENCES 1. Currie LM. Fall and injury prevention. In Patient Safety and Quality—An Evidence-based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0043.
18. Morse JM. Enhancing the safety of hospitalization by reducing patient falls. Am J Infect Control. 2002;30(6):376-380.
2. Cameron ID, Murray GR, Gillespie LD, et al. Interventions for preventing falls in older people in nursing care facilities and hospitals. Cochrane Database Syst Rev. 2010;(1):CD005465.
19. Berger Z, Flickinger T, Dy S. Promoting engagement by patients and families to reduce adverse events. In Making Health Care Safer. II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Evidence Reports/Technology Assessments, No. 211. Rockville, MD: Agency for Healthcare Research and Quality (US); 2013.
3. Goldsack J, Cunningham J, Mascioli S. Patient falls: searching for the elusive “silver bullet.” Nursing. 2014;44(7):61-62.
20. The Joint Commission. Facts about the Universal Protocol. 2014. http://www.jointcommission. org/facts_about_the_universal_protocol.
4. National Institute for Health and Care Excellence. Falls: assessment and prevention of falls in older people. Clinical Guideline #161. 2013. http:// publications.nice.org.uk/falls-assessment-andprevention-of-falls-in-older-people-cg161.
21. Haines TP, Hill AM, Hill KD, et al. Patient education to prevent falls among older hospital inpatients: a randomized controlled trial. Arch Intern Med. 2011;171(6):516-524.
5. Bouldin EL, Andresen EM, Dunton NE, et al. Falls among adult patients hospitalized in the United States: prevalence and trends. J Patient Saf. 2013;9(1):13-17.
22. Whitehead C, Wundke R, Crotty M, Finucane P. Evidence-based clinical practice in falls prevention: a randomised controlled trial of a falls prevention service. Aust Health Rev. 2003;26(3):88-97.
6. Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and non-fatal falls among older adults. Inj Prev. 2006;12(5):290-295.
23. Nikolaus T, Bach M. Preventing falls in community-dwelling frail older people using a home intervention team (HIT): results from the randomized Falls-HIT trial. J Am Geriatr Soc. 2003;51(3):300-305.
7. Scheffer AC, Schuurmans MJ, van Dijk N, van der Hooft T, De Rooij SE. Fear of falling: measurement strategy, prevalence, risk factors and consequences among older persons. Age Ageing. 2008;37(1):19-24.
24. Inouye SK, Brown CJ, Tinetti ME. Medicare nonpayment, hospital falls, and unintended consequences. N Engl J Med. 2009;360(23):2390-2393.
8. Ball MS. Aging in Place: A Toolkit for Local Governments. 2007. http://www.atlantaregional. com/File%20Library/Local%20Gov%20Services/ gs_cct_agingtool_1009.pdf. 9. Weingart SN, Zhu J, Chiappetta L, et al. Hospitalized patients’ participation and its impact on quality of care and patient safety. Int J Qual Health Care. 2011;23(3):269-277. 10. Hill AM, Hoffmann T, Beer C, et al. Falls after discharge from hospital: is there a gap between older peoples’ knowledge about falls prevention strategies and the research evidence? Gerontologist. 2011;51(5):653-662. 11. Schwappach DL. Review: engaging patients as vigilant partners in safety: a systematic review. Med Care Res Rev. 2010;67(2):119-148. 12. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324(6):377-384. 13. Mahoney JE. Immobility and falls. Clin Geriatr Med. 1998;14(4):699-726. 14. Morgan VR, Mathison JH, Rice JC, Clemmer DI. Hospital falls: a persistent problem. Am J Public Health. 1985;75(7):775-777. 15. Haines TP, Bennell KL, Osborne RH, Hill KD. Effectiveness of targeted falls prevention programme in subacute hospital setting: randomised controlled trial. BMJ. 2004;328(7441):676. 16. Krauss MJ, Evanoff B, Hitcho E, et al. A casecontrol study of patient, medication, and carerelated risk factors for inpatient falls. J Gen Intern Med. 2005;20(2):116-122. 17. McNair PD, Luft HS, Bindman AB. Medicare’s policy not to pay for treating hospital-acquired conditions: the impact. Health Aff (Millwood). 2009;28(5):1485-1493.
25. Schmid NA. 1989 Federal Nursing Service Award Winner. Reducing patient falls: a researchbased comprehensive fall prevention program. Mil Med. 1990;155(5):202-207. 26. Rauch K, Balascio J, Gilbert P. Excellence in action: developing and implementing a fall prevention program. J Healthc Qual. 2009;31(1):36-42. At Christiana Care Health System in Newark, Del., Seema S. Sonnad is director of health services research; Susan Mascioli is director of nursing quality and safety; Janet Cunningham is VP of professional excellence and associate CNO; and Jennifer Goldsack is a research associate at the Value Institute. The authors would like to acknowledge the work of the LeSS Falls Team, also at Christiana Care Health System: Christine DeRitter, RN; Constance Jordan, RN; Amy Harty, PCT; Kristi Lester, RN; Denise Lyons, RN; Barbara Marandola, RN; John Pierro; Carys Price, PT; James Ruther, MD; Eva Smith, RN; Scott Shoop, PharmD; Amy Spencer, RN; Janice Sullivan, MPT; Shelby Sydnor; and Teresa Zack, RN. Research Corner is coordinated by Cheryl Dumont, PhD, RN, CRNI, director of nursing research and the vascular access team at Winchester Medical Center in Winchester, Va. Dr. Dumont is also a member of the Nursing2014 editorial board. The content in this article has received appropriate institutional review board and/or administrative approval for publication. Seema S. Sonnad has disclosed that she’s a board member of Advisory Panel on Assessment of Prevention, Diagnosis and Treatment Options for the Patient Centered Outcomes Research Institute and was a consultant for HealthCore, Inc., when she was writing this article. The other authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NURSE.0000454966.87256.f7
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Do patients accurately perceive their fall risk? By Seema S. Sonnad, PhD; Susan Mascioli, MS, BSN, RN, CPHQ, NEA-BC; Janet Cunningham, MHA, RN, NEA-BC, CENP; and Jennifer Goldsack, MChem, MA, MS
Abstract Background: In U.S. hospitals, from 700,000 to 1 million inpatients fall each year. About a third of these falls could have been prevented. Objectives: This project’s purpose was to document patient perceptions of their inpatient fall risk and determine how these perceptions were associated with clinical indicators of fall risk. Methods: From six medicalsurgical units, 193 patients were randomly selected and surveyed about their perceived fall risk during their hospital stay. For 101 of them, the Schmid fall risk assessment score, age, and gender were recorded. A retrospective review of the Schmid scores of all patients who fell during a 6-month historical sample period was reviewed for comparison. Results: Most patients (88%) reported that they didn’t feel at risk for falling during their hospital stay. No correlation between their Schmid score and their perceived fall risk was found. Historical review of all inpatients who’d fallen in a prior period showed that the 358 patients with known Schmid scores had a full range of scores. These are normally distributed from 0 to 6, with over 40% of patients experiencing falls having Schmid scores of less than 3. Conclusions: Patient perceptions of falls match neither their clinical risk nor their actual likelihood of falling. When designing fall prevention strategies, it may be important to remind providers of this gap in patient knowledge, which includes overconfidence in the role of the care team in preventing falls. 58 l Nursing2014 l November
Background Between 700,000 and 1 million falls occur each year in U.S. hospitals, according to data presented by the Agency for Healthcare Research and Quality in “Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care.”1 About one-third of these patient falls could have been prevented.2 Several reviews indicate that no single approach can reduce falls. Instead, multidimensional strategies are needed to combine improved routine processes and personalized fall prevention. This finding forms the basis of the 2013 National Institute for Health and Care Excellence guidelines for fall prevention, which have been updated to include prevention of falls in the hospital.2-4 Not only do 25% of falls result in physical injuries, but organizations such as the National Quality Forum use falls as a quality indicator.5 Besides the high monetary cost of falls—over $19 billion per year in the United States alone—the human cost shouldn’t be overlooked.6 Falling may lead to a loss of selfconfidence and independence and reduce activity, further increasing the risk of falling.7 Many older patients fear a loss of independence requiring admission to long-term care more than they fear death itself.8 Programs to improve patient safety and quality by reducing other adverse events are beginning to incorporate models of patient engagement. Although the research is limited so far, patient participation in the care planning process may be associated with improved patient
satisfaction and a decreased risk of adverse events.9 A recent pilot study of 50 patients in Australia showed that education tailored for older patients led to increased participation in fall prevention activities after discharge.10 In general, patients’ interest in engaging in quality and safety efforts hinges on programs aimed at preventable incidents using actions that patients perceive as effective.11 Objectives This investigation evolved as part of a fall-reduction process improvement project. The researchers’ goal was to document patient perceptions of their inpatient fall risk and how these perceptions were associated with clinical indicators of fall risk. Methods This project began as part of a process evaluation in an improvement project to reduce inpatient falls in medical units in a large nonuniversity teaching hospital. In April 2013, the nurse manager in each of the three units selected to participate in this project asked 10 randomly selected patients whether they felt at risk for falling during their stay in the hospital, and why or why not. As the project developed, these data were revisited, and the researchers became interested in understanding if there was a need for patient education and patient involvement in future fall prevention efforts. At this point, the team recognized that the study was transitioning from a standard process improvement effort to a prospective, survey-based research www.Nursing2014.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
project, so we sought and were granted approval to proceed by our health system’s institutional review board. In July 2013, a research coordinator revisited the same three medical units to survey more patients, resulting in a total of 92 surveyed patients in the three units targeted for intervention. At this point, patients eligible for the study included all patients on the selected units other than patients with a cognitive impairment, patients in isolation, and patients who didn’t speak English. Similar to the preproject survey, each patient was asked, “Do you feel that you’re at risk for falling right now?” and then, “Could you please explain to me why?” Responses were recorded on paper at the bedside by the nurse manager or the research coordinator. Between October 29 and November 11, 2013, a second group of patients was surveyed about the patients’ perceived fall risk during their hospital stay. These patients were drawn from three medicalsurgical units not included in the earlier surveys and not involved in specific fall reduction interventions resulting from this project. Data collection continued until 101 unique patients had been surveyed. The risk question was changed slightly, from “right now” to “during this stay in the hospital.” During this phase of data collection, the research coordinator reviewed the patient’s medical record to retrieve a current Schmid score for each participating
A snapshot of patients studied Type of unit First survey Adult medical/surgery/stroke overflow unit
32 (35%)
Step-down unit for acute stroke
31 (34%)
Inpatient medical telemetry unit
29 (32%) Total: 92 (100%)
Second survey Adult and geriatric medical unit
Male: 20 (54%) Female: 17 (46%) Mean age: 60.42 years
Inpatient medical-surgical, cardiac telemetry, and observation unit
Male: 12 (39%) Female: 19 (61%) Mean age: 62.00 years
Inpatient surgical unit
Male: 16 (48%) Female: 17 (52%) Mean age: 59.36 years Total male: 48 (48%) Total female: 53 (52%) Mean age: 60.77 years
patient, as well as the patient’s age and gender, information not collected during the first survey period. (See Understanding the Schmid Fall Risk Assessment Tool.) To contextualize the Schmid scores gathered as part of the patient survey, we recorded and reviewed the Schmid scores of all inpatients who fell between July 1, 2012, and January 22, 2013, throughout the health system. This health system is a 1,100-bed, two-hospital tertiary care health system in Delaware. Results Most patients didn’t feel that they were at risk for falling. (See A
Understanding the Schmid Fall Risk Assessment Tool The Schmid Fall Risk Assessment Tool is used to categorize the risk of falling by assessing certain patient characteristics in five domains: mobility, mentation, elimination, fall history, and current medications.25 Assessment tools such as the Schmid score can help to identify patients at risk for falls.26 The tool scoring system ranges from 0 to 6, with 0 being no identified risk and scores of 3 or greater identifying a patient as at risk for falling.
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Number of respondents N (%)
snapshot of patients studied.) Only 15/92 (16%) of the first group of patients and 9/101 (9%) of the second group responded that they felt at risk for falling while in the hospital. Reasons patients believed their fall risk was low can be categorized into three general areas: • Many patients said the nursing care was helpful and the nurses were attentive. • Other patients stated that they were careful and able to walk easily. • A third group stated that because they weren’t walking or getting out of bed much, they weren’t at risk. Patients who felt at risk for falling mentioned specific balance, injury, or nausea issues, recent falls, or concerns about equipment to which they were connected. We found no correlation between Schmid score and patient risk perception. In the group of 101 patients for whom Schmid scores were collected, only 9 said they felt November l Nursing2014 l 59
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
R ESEARCH COR N ER
they were at risk for falling. For these nine patients, the Schmid scores were normally distributed across the range of potential scores (see Schmid scores for patients who felt at risk for falling). Eleven percent of women (6/54) felt themselves at risk for falling, while six percent of men (3/47) said they were at risk. Interestingly, the three men who felt they were at risk for falling had Schmid scores of 1, 2, and 3, indicating lower risk, while the women’s scores ranged from 2 to 5. The historical review of all inpatients who’d fallen showed that the 358 patients whose Schmid scores were known had a full range of Schmid scores, and they were normally distributed from 0 to 6 with over 40% of patients experiencing falls having Schmid scores less than 3. (See Schmid scores of patients
Schmid scores of patients who fell systemwide These data were collected from July 2012 to January 2013. Schmid score
Patients who fell N (%)
0
38 (11%)
1
37 (10%)
2
73 (20%)
3
82 (23%)
4
67 (19%)
5
46 (13%)
6
15 (4%)
who fell systemwide and Schmid scores from an analysis of historical falls.) Discussion The overall rate of risk perception (12%) is higher than the expected rate of falls in general inpatient population (2% to 3%), but lower than those reported for hospitalized
Schmid scores for patients who felt at risk for falling This figure shows the distribution of Schmid scores.
Number of Patients
3
2
1
0 0
1
2
3
Schmid Score
60 l Nursing2014 l November
4
5
6
older patients (10% to 30%).12-15 In our sample, patient risk perception often didn’t correlate with Schmid score. However, the distribution of Schmid scores for patients who considered themselves to be at risk for falling was similar to the distribution of Schmid scores of patients who’d actually fallen in the prior period. Schmid scores for patients reporting no perception of fall risk shifted toward the lower end of the scale when compared with the scores of those who perceive risk or actually fell. (See Schmid scores for patients who didn’t feel at risk for falling.) This suggests that perceived risk may be an important indicator for actually falling in the hospital, but this is contrary to data from some of our surveyed patients, indicating that further investigation is needed. Of the 19 patients with a Schmid score of 4 or 5, only 3 felt at risk for falling in the hospital. Of these three patients, one had fallen previously, one reported dizziness and vertigo from a migraine, and one was concerned about all the equipment that had to remain connected when the patient was ambulating. Interestingly, high-quality nursing care may instill a false feeling of security in the patients. Nearly 40% of patients who didn’t report feeling www.Nursing2014.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.Nursing2014.com
Schmid scores from an analysis of historical falls This figure shows the distribution of Schmid scores. 100
Number of Patients
80
60
40
20
0 0
1
2
3
4
5
6
Schmid Score
Schmid scores for patients who didn’t feel at risk for falling This figure shows the distribution of Schmid scores. 25
20
Number of Patients
at risk for falling said that this was due to excellent nursing support. For example, patients said: • “I worry at home, but I’m safer here with the nurses.” • “They’re always there when you need them.” • “Nurses keep very careful watch.” Falls are the most common hospital-acquired condition, the primary cause of nonfatal injury in patients older than 65, and the focus of public health concern.16,17 Nevertheless, falls don’t seem to be a primary concern for patients. For example, one patient, age 91, with a Schmid score of 5 said, “I’m anxious about everything, but not falling,” and another said, “I’m 86. I’m past worrying.” Given that Morse believes that many falls related to expected physiologic factors can be prevented by identifying patients at highest risk and using early intervention, the findings from this investigation suggest that helping patients understand fall risk may be a critical component of fall prevention efforts.18 Just as patient engagement in promoting patient safety through programs such as The Joint Commission’s universal protocol to prevent wrong-site, wrong-procedure, and wrongperson surgery has been successful,19,20 engaging patients as active participants in fall prevention programs may be an important strategy for reducing falls. Previous studies have found that education during inpatient stays about patients’ personal risk factors and fall prevention strategies increases the likelihood of these same patients engaging in fall prevention behaviors both during their hospitalization and postdischarge.21-23 This information combined with our data suggests that the inpatient
15
10
5
0 0
1
2
3
4
5
6
Schmid Score
November l Nursing2014 l 61
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R ESEARCH COR N ER
setting may provide a key opportunity for patient education that can positively impact public health beyond the hospital. Education may reduce not only falls for inpatients, but also falls for people in the community setting, where over onethird of adults older than 65 are estimated to fall. Without effective interventions, this number is anticipated to rise to as high as 50% due to the aging of the population.24 More research may also be required to better understand why patients don’t perceive that they’re at risk. While our study indicates that excellence in nursing and the sense of security this provides may have a significant influence, other factors such as patients’ optimism bias and possible lack of knowledge about consequences should also be considered. Recognizing the elements that influence patient perceptions about their risk may not only empower nurses in their fall prevention efforts, but also across the board in addressing patient safety issues. Conclusions Patient perceptions of falls match neither their clinical risk nor their actual likelihood of falling. The researchers believe that their data support the hypothesis that involving patients in fall prevention may significantly reduce risk, increase satisfaction, and improve patient self-efficacy. This outcome is likely to carry over into risk-mitigating behavior changes during and after the hospital stay. Nurses must also remember that attentiveness to falls may instill a false sense of security in their patients about their fall risk. We recommend that strategies to improve patients’ awareness of their fall risk be implemented and investigated. ■ 62 l Nursing2014 l November
REFERENCES 1. Currie LM. Fall and injury prevention. In Patient Safety and Quality—An Evidence-based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0043.
18. Morse JM. Enhancing the safety of hospitalization by reducing patient falls. Am J Infect Control. 2002;30(6):376-380.
2. Cameron ID, Murray GR, Gillespie LD, et al. Interventions for preventing falls in older people in nursing care facilities and hospitals. Cochrane Database Syst Rev. 2010;(1):CD005465.
19. Berger Z, Flickinger T, Dy S. Promoting engagement by patients and families to reduce adverse events. In Making Health Care Safer. II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Evidence Reports/Technology Assessments, No. 211. Rockville, MD: Agency for Healthcare Research and Quality (US); 2013.
3. Goldsack J, Cunningham J, Mascioli S. Patient falls: searching for the elusive “silver bullet.” Nursing. 2014;44(7):61-62.
20. The Joint Commission. Facts about the Universal Protocol. 2014. http://www.jointcommission. org/facts_about_the_universal_protocol.
4. National Institute for Health and Care Excellence. Falls: assessment and prevention of falls in older people. Clinical Guideline #161. 2013. http:// publications.nice.org.uk/falls-assessment-andprevention-of-falls-in-older-people-cg161.
21. Haines TP, Hill AM, Hill KD, et al. Patient education to prevent falls among older hospital inpatients: a randomized controlled trial. Arch Intern Med. 2011;171(6):516-524.
5. Bouldin EL, Andresen EM, Dunton NE, et al. Falls among adult patients hospitalized in the United States: prevalence and trends. J Patient Saf. 2013;9(1):13-17.
22. Whitehead C, Wundke R, Crotty M, Finucane P. Evidence-based clinical practice in falls prevention: a randomised controlled trial of a falls prevention service. Aust Health Rev. 2003;26(3):88-97.
6. Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and non-fatal falls among older adults. Inj Prev. 2006;12(5):290-295.
23. Nikolaus T, Bach M. Preventing falls in community-dwelling frail older people using a home intervention team (HIT): results from the randomized Falls-HIT trial. J Am Geriatr Soc. 2003;51(3):300-305.
7. Scheffer AC, Schuurmans MJ, van Dijk N, van der Hooft T, De Rooij SE. Fear of falling: measurement strategy, prevalence, risk factors and consequences among older persons. Age Ageing. 2008;37(1):19-24.
24. Inouye SK, Brown CJ, Tinetti ME. Medicare nonpayment, hospital falls, and unintended consequences. N Engl J Med. 2009;360(23):2390-2393.
8. Ball MS. Aging in Place: A Toolkit for Local Governments. 2007. http://www.atlantaregional. com/File%20Library/Local%20Gov%20Services/ gs_cct_agingtool_1009.pdf. 9. Weingart SN, Zhu J, Chiappetta L, et al. Hospitalized patients’ participation and its impact on quality of care and patient safety. Int J Qual Health Care. 2011;23(3):269-277. 10. Hill AM, Hoffmann T, Beer C, et al. Falls after discharge from hospital: is there a gap between older peoples’ knowledge about falls prevention strategies and the research evidence? Gerontologist. 2011;51(5):653-662. 11. Schwappach DL. Review: engaging patients as vigilant partners in safety: a systematic review. Med Care Res Rev. 2010;67(2):119-148. 12. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324(6):377-384. 13. Mahoney JE. Immobility and falls. Clin Geriatr Med. 1998;14(4):699-726. 14. Morgan VR, Mathison JH, Rice JC, Clemmer DI. Hospital falls: a persistent problem. Am J Public Health. 1985;75(7):775-777. 15. Haines TP, Bennell KL, Osborne RH, Hill KD. Effectiveness of targeted falls prevention programme in subacute hospital setting: randomised controlled trial. BMJ. 2004;328(7441):676. 16. Krauss MJ, Evanoff B, Hitcho E, et al. A casecontrol study of patient, medication, and carerelated risk factors for inpatient falls. J Gen Intern Med. 2005;20(2):116-122. 17. McNair PD, Luft HS, Bindman AB. Medicare’s policy not to pay for treating hospital-acquired conditions: the impact. Health Aff (Millwood). 2009;28(5):1485-1493.
25. Schmid NA. 1989 Federal Nursing Service Award Winner. Reducing patient falls: a researchbased comprehensive fall prevention program. Mil Med. 1990;155(5):202-207. 26. Rauch K, Balascio J, Gilbert P. Excellence in action: developing and implementing a fall prevention program. J Healthc Qual. 2009;31(1):36-42. At Christiana Care Health System in Newark, Del., Seema S. Sonnad is director of health services research; Susan Mascioli is director of nursing quality and safety; Janet Cunningham is VP of professional excellence and associate CNO; and Jennifer Goldsack is a research associate at the Value Institute. The authors would like to acknowledge the work of the LeSS Falls Team, also at Christiana Care Health System: Christine DeRitter, RN; Constance Jordan, RN; Amy Harty, PCT; Kristi Lester, RN; Denise Lyons, RN; Barbara Marandola, RN; John Pierro; Carys Price, PT; James Ruther, MD; Eva Smith, RN; Scott Shoop, PharmD; Amy Spencer, RN; Janice Sullivan, MPT; Shelby Sydnor; and Teresa Zack, RN. Research Corner is coordinated by Cheryl Dumont, PhD, RN, CRNI, director of nursing research and the vascular access team at Winchester Medical Center in Winchester, Va. Dr. Dumont is also a member of the Nursing2014 editorial board. The content in this article has received appropriate institutional review board and/or administrative approval for publication. Seema S. Sonnad has disclosed that she’s a board member of Advisory Panel on Assessment of Prevention, Diagnosis and Treatment Options for the Patient Centered Outcomes Research Institute and was a consultant for HealthCore, Inc., when she was writing this article. The other authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NURSE.0000454966.87256.f7
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