H e a l t h C a r e Po l i c y a n d Q u a l i t y • O r i g i n a l R e s e a r c h Abujudeh et al. Outcome of an Outpatient Falls Prevention Program
Downloaded from www.ajronline.org by UCSF LIB & CKM/RSCS MGMT on 12/12/14 from IP address 169.230.243.252. Copyright ARRS. For personal use only; all rights reserved
Health Care Policy and Quality Original Research
Outpatient Falls Prevention Program Outcome: An Increase, a Plateau, and a Decrease in Incident Reports Hani H. Abujudeh1 Shima Aran Laleh Daftari Besheli Karen Miguel Elkan Halpern James H. Thrall Abujudeh HH, Aran S, Daftari Besheli L, Miguel K, Halpern E, Thrall JH
Keywords: falls, incident reports, process quality improvement, quality, quality improvement program, risk reduction DOI:10.2214/AJR.13.11982 Received September 24, 2013; accepted after revision December 9, 2013. 1
All authors: Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Founders Bldg, Rm 210, Boston, MA 02114. Address correspondence to H. H. Abujudeh ([email protected]).
AJR 2014; 203:620–626 0361–803X/14/2033–620 © American Roentgen Ray Society
620
OBJECTIVE. We implemented an outpatient falls guideline in 2008 in the department of radiology. Here, we describe our multiyear experience. MATERIALS AND METHODS. This was a retrospective study conducted between April 2006 and September 2013 to investigate outpatient falls. The span of the study was divided into eight periods. The incident reporting system was searched for the falls and the fall-related variables. RESULTS. A total of 327 falls occurred during 5,080,512 radiology examinations (rate, 0.64/10,000 total examinations). The highest rate was in period 6 (0.83/10,000 examinations). The average for periods 1 and 2 is 0.39/10,000 examinations (37 falls/945,427 examinations), and the average for periods 3–6 is 0.77/10,000 examinations (204 falls/2,656,805 examinations). The average rate for periods 7 and 8 is 0.58/10,000 examinations (86 falls/1,478,280 examinations). There was a statistically significant increase in the total number of falls reported between period 2 and period 3 (p = 0.02). There was a statistically significant decrease in outpatient falls between period 6 and period 7 (p = 0.01). The number of falls among patients 60 years old or older was 177 falls/2,180,093 examinations (rate, 0.81/10,000 examinations), and that among patients younger than 60 years was 150 falls/2,900,419 examinations (rate, 0.52/10,000 examinations), with a statistically significant difference (p = 0.007). Although the rate of falls was higher among female patients, there was no statistically significant difference between the sexes (p = 0.18). CONCLUSION. The outcome of the outpatient falls guideline was characterized by an increase, a plateau, and a decrease in incident reports. The initial increase may be due to the Hawthorne effect. The plateau may represent the value closest to the true incidence. The decrease may represent the effect of the program.
F
alls and fall-related injuries are preventable medical care–related harmful events. Falls may be devastating to patients and families and are costly for hospitals, the health care system, and society. Fall-related injuries can occur in up to 33% of in-hospital falls [1, 2], may result in serious injuries in up to 10% of cases [3], and may even result in death. Morbidity associated with falls can lead to a decline in quality of life, as well as significant increases in costs for patients and in length of stay in hospitals, and it increases the liability risks of hospitals [4, 5]. Several factors have been associated with the risk of falls and fall-related injuries. Falls are more common among older adults and are reported to be the most common cause of nonfatal injuries and accidental death in people older than 65 years in the United States
[6]. It has been reported that women fall more frequently than men in this age group [6, 7]. Medications (including CNS and cardiovascular drugs) [8], underlying medical conditions (e.g., decline in visual acuity, altered sensory and depth perception, decline in visual capacity, unstable gait, and other disabling medical conditions) [9, 10], race (i.e., white race), and history of falls are other risk factors for falls. In addition, environmental hazards, such as poor lighting, loose carpets, slippery flooring, or lack of handrails, can also contribute to the risk of falls [8]. However, no definitive predictor profile has yet been introduced [6]. In 2005, the Joint Commission added the requirement for assessment and periodic reassessment of patients’ risk for falling in the acute care setting as a National Patient Safety Goal [11]. The aim of this requirement was to
AJR:203, September 2014
Downloaded from www.ajronline.org by UCSF LIB & CKM/RSCS MGMT on 12/12/14 from IP address 169.230.243.252. Copyright ARRS. For personal use only; all rights reserved
Outcome of an Outpatient Falls Prevention Program ensure that all patients are screened for their risk of falling and to reduce fall-related injuries. In 2006, there was an extension to the program requiring implementation of a falls reductions program and a periodic evaluation of the effectiveness of the program [1]. Exercise programs, multimodal interdisciplinary prevention programs, medication and underlying disease control programs, identification of recurrent fallers, staff and patient education, and environmental interventions are examples of the fall-prevention protocols and preventive measures introduced in the literature [6, 12–16]. Most studies have been performed in long-term-care environments, and there is less information about the acute-care setting [6]. Most of the studies have assessed falls among older adults and inpatient settings; data are scarce on outpatient falls that occur in a supplemental service, such as radiology [12–27]. In 2008, the department of radiology at our hospital made a commitment to develop a process for managing the diverse population of outpatients who were identified as at risk for falls, according to the published studies [28–30]. An outpatient falls guideline was developed with the aim of preventing outpatient falls or decreasing the number and severity of injuries. The goals of the program were to develop a patient assessment tool to help identify the at-risk population, to educate both clinical and nonclinical staffs on both intrinsic and extrinsic or environmental risk factors, to provide safety strategies to prevent falls or minimize the injury from falls, to determine which interventions should be taken when a patient is identified as a risk for falls, to develop specific interventions during and after clinical evaluation if a fall occurs, and to assess the program’s effectiveness by determining staff compliance and the percentage of population indicated at risk (Fig. 1). Radiology is a specialty that cares for a large number of outpatients. As providers of care for outpatients, we have the duty to examine how to prevent falls, to create and implement guidelines that reduce falls, and harm to patients in the outpatient setting. We aim to present our experience of studying falls between April 2006 to September 2013, before and after the creation and implementation of an outpatient falls guideline in the department of radiology. The hypothesis of our study was that the outpatient falls guideline would result in a reduction in the number of falls in the outpatient radiology population.
TABLE 1: General Characteristics of Patients Who Fell Characteristic Fall rate
Inpatient
Outpatient
Total
0.59a
0.66a
0.64a
Total Fall Rate
Age (y) 62.3 ± 18.5
58.3 ± 21.3
59.1 ± 20.8
< 60
Overall mean ± SD
26 (17.3)
124 (82.7)
150
0.52a
≥ 60
41 (23.2)
136 (76.8)
177
0.81a
Male
34 (26.0)
97 (74.0)
131
0.59a
Female
33 (16.8)
163 (83.2)
196
0.68a
No injury
14 (24.6)
43 (75.4)
57
17.43b
Minor
28 (16.9)
138 (83.1)
166
50.76b
Moderate
24 (23.8)
77 (76.2)
101
30.89b
Severe
1 (33.3)
2 (66.7)
3
0.92b
Ambulating without assistance
34 (17.3)
163 (82.7)
197
60.24b
Assisted
21 (19.3)
88 (80.7)
109
33.33b
Bed rest
12 (57.1)
9 (42.9)
21
6.42b
Sex
Severity of injury
Mobility status of the patient
Note—Except where noted otherwise, data are number (%) of patients. aFall rates per 10,000 total number of examinations in each category. bPercentage per total number of falls (327 falls).
Materials and Methods An institutional review board for human subject research approved our study. Our study was compliant with the HIPAA. Informed consent requirement was waived for this study. The electronic incident reporting system was searched for the falls and fall-related variables, which are summarized in Table 1. All patients were included regardless of age, sex, race, or underlying medical condition. Three hundred twenty-seven falls occurred from April 2006 to September 2013.
Falls Definitions In our study, a “fall” was defined as an inadvertent change in a person’s position from standing, sitting, or lying down to lying on the ground or other surface lower than their starting point. This definition included patients who slipped from a chair to the floor, patients found down on the floor, and “assisted falls.” We defined “assisted falls” as events in which the patient was caught in the act of falling (with or without loss of consciousness) and the patient was lowered to the ground.
Fall-Related Injury The severity of the injury was assessed in individuals who sustained injuries. The level of severity of the injuries was categorized into three levels of minor, moderate, and severe. Minor injuries included bruises, abrasions, contusions or hemato-
mas, headache, and pain. Moderate injuries were defined as lacerations. Fractures and dislocations were considered severe injuries.
Preventive Methods and Self-Assessment Questionnaire A self-assessment questionnaire, which included five questions with yes-or-no answer choices (Fig. 2), was designed for patients 6 years old or older to help imaging staff identify patients at risk and to put safety measures in place to minimize falls incidence and the severity of injury as a result of a fall. Patients were asked to complete the questionnaire, which recorded the history of falls in the past 3 months and any medications taken to alleviate anxiety during the 24 hours before falling. Intrinsic factors, such as age, comorbidities, weak muscle strength, or impairment in balance, gait, vision, or cognition, cannot be changed; however, recognizing these factors alerted imaging staff to the potential risk. Extrinsic or environmental factors include the use of certain medicines or polypharmacy, as well as lighting, floor surfaces, clutter, distraction, and noise. These factors were highlighted and altered by staff when appropriate [8]. With an overall focus on mobility and balance as putative key predictors of risk and, to a lesser degree, medications that may impact mobility and balance, patient were asked to complete the falls risk questionnaire.
AJR:203, September 2014 621
Abujudeh et al.
Downloaded from www.ajronline.org by UCSF LIB & CKM/RSCS MGMT on 12/12/14 from IP address 169.230.243.252. Copyright ARRS. For personal use only; all rights reserved
Project Plan and Strategy, Audits, Educational Modules, and Timeline Discussion of the department initiatives to reduce falls and the appointment of a safety officer to expose staff to safety and compliance discussions occurred during the last months of 2007. The problem or need was identified according to the Joint Commission release on National Patient Safety Goal number 9 [1]. The departmental guidelines and a “frequently asked questions” sheet concerning the process were developed for staff by January 2008 with associated in-service training. In May 2008, the outpatient falls guideline was implemented, and administration of the questionnaires was started with the goal of preventing outpatient falls in our department. Two audits of the program were performed to capture patients’ compliance with form completion, staff compliance with handing the forms to the patients, recording appropriate information, and entering identified at-risk patients into the fall prevention protocol and safety reporting system.
The first audit was a 1-month basic assessment on the compliance with the outpatient falls guideline conducted in August 2008. The second outpatient falls audit, conducted in August 2009, was a continuation and an extension of the 2008 outpatient falls guideline compliance audit. This second month-long audit included direct observations to assess compliance with completion of the questionnaire, the method of completing the forms (patient fills in the form or answers the questions from staff), the questionnaire collection procedures, and compliance with filing fall safety reports. Live observation of form administration was performed in patient waiting areas during a 15-minute observation period, during which a total of three patient encounters were observed per area. Falls safety reports were reviewed for the observation month to correlate falls risk responses and possible fall preventions. From 2010 through 2011, additional regular meetings were held to identify improvement strategies and weaknesses such as staff educa-
Administration of the questionnaire
Positive (+) answer to any of the 5 questions
Patients with mental impairment or patients unable to answer the questions were automatically considered to be “at risk for fall”
Negative (−) answer to all 5 questions
To identify patients “at risk for fall” staff members should: • Place a yellow sticker on patient’s ID band • Provide patients with a pamphlet on reduction of the risk for falls • Verbally notify the other staff when necessary
Constantly supervise and support the patients by • Offering a wheelchair or assistance to ambulate • Offering assistance with changing or bathroom activities • Asking patients if they need help for ambulation during the exam • Encouraging patients to notify the staff if they feel weak or unsteady • Ensuring that the patients fully understand these requirements
If fall occurs: • Assess the patient for injury and take appropriate action if additional care is required • File a safety report • Save and attach the completed questionnaire to the safety report • Review preventability of the fall with the Patient Safety Officer and area managers
Fig. 1—Outpatient falls guideline.
622
tion. Between February and August 2010, the departmental Quality and Safety Council realized that there was a need to further educate staff on fall risks and what to do when patients fall; a learning module was developed to address this need. In February 2011, all staff completed a competency test in the form of an online learning module and posttest review; an annual review was introduced as a requirement for all staff. The module included methods to determine both intrinsic and extrinsic risks for falls, simulated photos to illustrate risky situations in a variety of areas across the department, and a test to gauge knowledge. All filed safety reports concerning patient falls were investigated with the intent to determine what the staff could have done, if anything, to prevent the fall. Staff members were interviewed and asked to explain the events leading up to the fall to determine whether prevention measures were used. To assess the effect of the outpatient falls guideline, the overall study time period was divided into eight periods: April 2006 through September 2006, period 1; October 2006 through September 2007, period 2; October 2007 through September 2008, period 3; October 2008 through September 2009, period 4; October 2009 through September 2010, period 5; October 2010 through September 2011, period 6; October 2011 through September 2012, period 7; and October 2012 through September 2013, period 8 (Fig. 3). All the periods except the first are 1-year periods. Before April 2006, data collection was not complete.
Statistical Analysis The data were entered into a spreadsheet (Excel 2010, Microsoft) and were analyzed using SAS (version 9.3, SAS Institute) and SPSS (version 21.0, IBM) statistical software. The Student t test, chi-square test, Wilcoxon signed-rank test, and Cochran-Mantel-Haenszel statistic were used.
Results The study revealed a total of 327 falls over the length of the study. During the same period, there were 5,080,512 radiology examinations, with a falls rate of 0.64/10,000 examinations (Table 1). Of the 327 patients who fell, 131 (40%; rate, 0.59/10,000 total examinations) were male and 196 (59.9%; rate, 0.68/10,000 total examinations) were female. The mean (± SD) age was 59.1 ± 20.8 years (range, 5–101 years). Two hundred sixty patients (79.5%; rate, 0.66/10,000 total examinations) were outpatients and the remaining 67 patients (20.4%; rate, 0.59/10,000 total examinations) were inpatients.
AJR:203, September 2014
Downloaded from www.ajronline.org by UCSF LIB & CKM/RSCS MGMT on 12/12/14 from IP address 169.230.243.252. Copyright ARRS. For personal use only; all rights reserved
Outcome of an Outpatient Falls Prevention Program Forms Completion First audit—Of the total number of forms collected, 99.6% were completed. Patient responses to all risk questions were 64% (1297) “No” and 36% (724) “Yes.” Second audit—Of the total number of forms collected, 99% were completed. Patients’ response to all risk questions were 76% (709) “No” and 23% (224) “Yes.” Of the 709 patients responding “No,” 17 patients were determined by staff to be “At risk” because of an obvious risk factor, such as use of an assistive device or gait disturbance. The fraction of outpatients determined to be at risk for falls was 25%. Staff Compliance With Form Administration Of 10 areas that were assessed for forms administration compliance, seven areas were 100% compliant, one area was 92% compliant, one area was 61% complaint, and one area had no patients checked in during all three observation periods and compliance could not be assessed. Overall, 80% of staff complied with form administration.
TABLE 2: Number of Injuries by Level of Severity and Patient Age Group Patient Age Category Severity Level
< 60 y
≥ 60 y
Total
No injury
26
31
57
Minor
87
79
166
Moderate
37
64
101
Severe
0
3
3
150
177
327
Total
Study Periods Figure 3 summarizes the results. A total of 327 falls during 5,080,512 radiology examinations (rate, 0.64/10,000 total examinations) were reported. The highest rate (0.83/10,000 examinations) was in period 6. The average for periods 1 and 2 was 0.39/10,000 examinations (37 falls/945,427 examinations), the average for periods 3–6 was 0.77/10,000 examinations (204 falls/2,656,805 examinations), and the average for periods 7 and 8 was 0.58/10,000 examinations (86 falls/1,478,280 examinations).
Patient ID sticker here
Outpatient Falls Questionnaire Please answer these questions carefully to help us better assist you 1. Right now, how are you feeling? Weak Dizzy Light headed Fine Other 2. Do you need assistance to walk? Crutches Walker Cane Wheelchair A companion to help you Other 3. Have you fallen in the past 3 months? Yes No 4. Do you need help to walk? Yes No 5. Do you have fear of falling? Yes No 6. Have you taken/will you take any anxiety medication to help with today’s exam? Yes No Staff use only: Comments:
— Assistive device — Gait disturbance
Fig. 2—Outpatient falls questionnaire.
The total reported fall rate in period 2 was 0.41/10,000 radiologic examinations. The total reported fall rate in period 3 was 0.73/10,000 radiologic examinations. The increase in reported falls between periods 2 and 3 was statistically significant (p = 0.02). The total number of reported falls in period 6 was 0.83/10,000 radiologic examinations, and the total fall rate for period 7 was 0.60/10,000 radiologic examinations, with no statistically significant difference (p > 0.05). The total outpatient fall rates were 0.91/10,000 radiologic examinations for period 6 and 0.47/10,000 radiologic examinations for period 7. This was a statistically significant difference (p = 0.01). The total number of reported fall and outpatient falls in period 8 were 0.57/10,000 and 0.59/10,000 radiologic examinations, respectively. No significant differences were found between total number of reported fall or outpatient falls between periods 7 and 8 (p > 0.05) (Fig. 1). The rates of inpatient falls were 0.13, 0.47, 0.55, 1.05, and 0.50 per 10,000 total examinations for periods 2, 3, 6, 7, and 8, respectively. No statistically significant differences were found between any of the two consecutive years regarding the inpatient falls (p > 0.05). Fall Risk Factors (Age, Sex, Time of Day, and Mobility) and Severity of Injury Patients were divided into two age groups: younger than 60 years and 60 years old or older. Of the total 327 falls, 150 falls (rate, 0.52/10,000 radiologic examinations) occurred among patients younger than 60 years, and 177 falls (rate, 0.81/10,000 radiologic examinations) occurred among patients 60 years old and older. This difference was statistically significant (p = 0.0074). There were 131 falls among male patients (rate, 0.59/10,000 radiologic examinations) and 196 falls among female patients (rate, 0.68/10,000 radiologic examination). Although the rate of fall was higher among fe-
AJR:203, September 2014 623
male patients, the difference between sexes was not statistically significant (p = 0.18). Most falls occurred during the day from 11:00 am to 3:00 pm (36.7%; 120/327) followed by 7:00 am to 11:00 am (30.8%; 101/327). Most of the patients (60.2%; 197/327) who fell were mobile and fell while they were ambulating without assistance; a smaller number (33.3%; 109/327) fell while receiving ambulatory assistance, and a few (6.4%; 21/327) patients were bed ridden (Table 1). Injury was documented in 82.6% (270/327) of patients who fell. Fall-related injuries were minor, moderate, and severe in 166, 101, and three patients, respectively. Patients who were 60 years old or older had 66 moderate injuries and three severe injuries, compared with patients younger than 60 years, who had 37 moderate and no severe injuries (Table 2). The difference between the two groups was statistically significant (p = 0.031). In addition, we divided the level of severity of injury into two categories of significant (moderate and severe) and nonsignificant (no injury and mild injury) injuries. We found a statistically significant difference (p = 0.012) between the two categories of severity of the injury, between the two age groups of younger than 60 years (11.3% [37/327] significant injuries and 34.5% [113/327] nonsignificant injuries) and 60 years old or older (20.5% [67/327] significant injuries and 33.6% [110/327] nonsignificant injuries). These results show that, with increased age, the level of severity of injury significantly increases. Discussion Fall rates vary in different hospital settings and services [31]. The overall risk of a fall in the acute-care setting has been reported to be in the range of 1.9–3% during all hospitalizations [19–21]. In general hospital settings, fall rates have been reported to be 3.0 and 3.6 falls/1000 patient-days [25, 32–35]. The overall fall rate of 0.64/10,000 radiologic examinations was identified by this study in the department of radiology at our institution, with the highest rate being 0.83/10,000 radiologic examinations. Outcome of Our Outpatient Falls Guideline: Increase, Plateau, and Decrease Curve On the basis of the results and the interventions timeline, we can divide the total study time period into three main categories, according to the outcome and effect of our outpatient falls guideline.
624
0.90 Rate of Falls/10,000 Examinations
Downloaded from www.ajronline.org by UCSF LIB & CKM/RSCS MGMT on 12/12/14 from IP address 169.230.243.252. Copyright ARRS. For personal use only; all rights reserved
Abujudeh et al.
0.81
0.80
0.73
0.70
0.83 Outpatient Inpatient
0.36 0.60
0.60 0.50 0.41
0.40
0.36
0.72 0.62
0.56
0.37 0.46
0.30 0.20
0.33
0.38 0.24
0.10 0.00
0.11
0.14
0.22 0.12
0.11 0.03 0.03 Apr 2006 − Oct 2006 − Oct 2007 − Oct 2008 − Oct 2009 − Oct 2010 − Oct 2011 − Oct 2012 − Sep 2006 Sep 2007 Sep 2008 Sep 2009 Sep 2010 Sep 2011 Sep 2012 Sep 2013
Inpatient Outpatient Total
0.57
0.57
Period 1 0.14 1/73,291 0.43 10/234,171 0.36 11/307,462
Period 2 0.13 2/149,418 0.49 24/488,547 0.41 26/637,965
Period 3 0.47 7/149,708 0.81 40/493,499 0.73 47/643,207
Period 4 Period 5 0.60 1.08 9/151,144 16/148,757 0.73 0.73 37/509,798 38/519,581 0.7 0.81 46/660,942 54/668,338
Period 6 Period 7 0.55 1.05 8/146,067 16/152,237 0.91 0.47 49/538,251 27/569,739 0.83 0.6 57/684,318 43/721,976
Period 8 0.50 8/159,682 0.59 35/596,622 0.57 43/756,304
Fig. 3—Overall study time divided into eight periods. Graphs show fall rates per 10,000 total examinations (top) and total numbers of falls per total numbers of radiology examinations (bottom) for each period, by inpatient and outpatient groups. (Inpatient rate: Inpatient fall × 10,000/number of inpatient examinations; Outpatient rate: Outpatient fall × 10,000/number of outpatient examinations). Rates presented on graph show fall rates calculated for purpose of drawing graph (Inpatient rate: Inpatient fall × 10,000/number of total examinations; Outpatient rate: Outpatient fall × 10,000/number of total examinations).
Increase—The first impact was seen in a statistically significant increase in falls reports between periods 2 and 3 (p = 0.02). This increase may be due to the Hawthorne effect, suggesting that we were underreporting falls in the past. Although that may be the case, our experience shows that an increase in education and awareness and increased discussions resulted in an increase in reporting of the total number of falls. To exclude the possibility of the interference of any confounding factors on the increase, plateau, and decrease curve, we performed a correlation analysis of several risk factors and the time periods with inflection points in the curve (the initial increase and the eventual decrease). We looked at patient sex (male vs female), type (inpatient vs outpatient), and age (< 60 and ≥ 60 years old). None of the risk factors was significantly correlated with the fraction of patients who fell. Plateau phase (periods 4–6) after the primary increase—The sustained falls reporting rate did not change for three periods after the initial increase. Although one would have liked to see an immediate decrease in the falls reporting after introduction of the falls guidelines (a cause and effect), that did not happen in our experience. It took 3 years
with continued education and emphasis on falls to see a statistically significant reduction in falls reporting. This plateau may be closest to the true number of falls. The highest rate in the plateau was 0.83/10,000 radiologic examinations. The plateau rate overall rate was 0.77/10,000 radiologic examinations. Decrease—A statistically significant (p = 0.01) decrease in outpatient falls occurred between period 6 (0.91/10,000 total examinations) and period 7 (0.47/10,000 total examinations). We think that continued emphasis and education about falls in radiology eventually led to this improvement and reduction in reported outpatient falls. There was no statistically significant change between total number of reported falls between period 6 (0.83/10,000 total examinations) and period 7 (0.60/10,000 total examinations) (p = 0.10). There was no statistically significant change in inpatient falls between period 6 (0.55/10,000 total examinations) and period 7 (1.05/10,000 total examinations) (p = 0.13). This shows the relationship of outpatient falls reduction program with the outcome, where outpatient falls reports specifically were reduced and not the overall radiology population or the inpatient radiology population. The reduction in outpatient falls stayed con-
AJR:203, September 2014
Downloaded from www.ajronline.org by UCSF LIB & CKM/RSCS MGMT on 12/12/14 from IP address 169.230.243.252. Copyright ARRS. For personal use only; all rights reserved
Outcome of an Outpatient Falls Prevention Program sistent during period 8 as well, without a statistically significant difference between period 7 regarding the total number of reported falls (0.57/10,000 radiologic examinations), outpatient falls (0.59/10,000 radiologic examinations), or inpatient falls (0.50/10.000 radiologic examinations) (p > 0.05). Fall Risk Factors (Age, Sex, Time of Day, and Mobility) and Severity of Injury Our study showed that there were more falls among female patients than among male patients; however the difference was not statically significant. This finding is similar to those of other studies in the literature, in which falls are more frequent among female patients; however, death as a result of falls has been reported to be more common among male patients [6, 7, 36–39]. Most falls occurred during the day from 11:00 am to 3:00 pm, which is similar to the results reported by Tutuarima et al. [40], who reported that the greatest number of falls (53.1%) occurred in the daytime when most nursing staff were present. In our study, most of the patients who fell were mobile and fell while they were ambulating without assistance, which is in agreement with the results of a previous study [27]. In our study, fall-related injuries were mostly minor, followed by moderate and severe, and none of the patients died as a result of a fall. According to our results, the total number of falls was statistically significantly higher among patients 60 years old or older than among patients younger than 60 years (p < 0.0001). In addition, the level of severity of fall-related injuries increased with age. These findings are in agreement with literature, where it is mentioned that fall rates increase with age and the severity of the fallrelated injury and mortality rates increase dramatically after the age of 85 years for both sexes and across all ethnicities [6, 7, 36– 39]. Unintentional falls are considered to be the most common cause of nonfatal injuries and are the most common cause of accidental death in people older than 65 years [6]. Up to 30% of all hospital falls and approximately 6–44% of acute inpatient falls are reported to result in injury [15, 16, 38, 41–43]. Limitations There are several limitations to our investigation. Data were retrospectively collected from reports in the adverse event reporting system and data in the electronic medical records. Not all the required variables were
available for all patients in the reporting system. It is not known how many falls were not reported and patients who experienced falls were not followed up for a long time. One may consider that, after years of using falls guidelines, the reports decreased because of dormancy, slackness, or laxness; however, we think that, although this factor can never be excluded, our effort continues to this day. The day-to-day emphasis on improving patient care is important to every individual in our department. We think that we have a more open reporting culture than we did several years ago. Another limitation is the incorrect appearance that this single quality improvement project resulted in a direct reduction of falls; although we think that this was a major influence on the reduction, it is not the only one. The steps needed to achieve such an improvement are multifactorial and start with the entire institution’s adoption of a culture of improvement of care, which includes such things as adoption of a “Just Culture”; a transparent, open, and nonpenalizing reporting culture; the willingness to learn from errors and improve; and providing the resources to improve care. Education, measurement, and continued emphasis will eventually result in the desired outcomes. Conclusion The implementation of the outpatient falls reduction program resulted in an increase, a plateau, and an eventual decrease in reported falls in radiology. The initial increase in reported falls is likely due to the Hawthorne effect, the plateau may be closest to the true value, and the decrease in reported outpatient falls was the goal of the outpatient falls reduction program. References 1. The Joint Commission. Critical access hospitals: 2006 national patient safety goals. The Joint Commission website. www.splashcap.com/ JCAHO_2006-NPSG-3D.pdf Published 2006. Accessed June 2014 2. Cooper CL, Nolt JD. Development of an evidence-based pediatric fall prevention program. J Nurs Care Qual 2007; 22:107–112 3. Dempsey J. Falls prevention revisited: a call for a new approach. J Clin Nurs 2004; 13:479–485 4. Cho SH, Ketefian S, Barkauskas VH, et al. The effects of nurse staffing on adverse events, morbidity, mortality, and medical costs. Nurs Res 2003; 52:71–79 5. Tinetti ME, Inouye SK, Gill TM, et al. Shared risk factors for falls, incontinence, and functional
dependence: unifying the approach to geriatric syndromes. JAMA 1995; 273:1348–1353 6. Currie L. Fall and injury prevention. In: Hughes RG, ed. Patient safety and quality: an evidencebased handbook for nurses. Rockville, MD: Agency for Healthcare Research & Quality, 2008 7. Centers for Disease Control and Prevention. WISQARS leading causes of death reports, 1999– 2007. CDC website. webappa.cdc.gov/sasweb/ ncipc/leadcaus10.html. Published June 1, 2010. Accessed January 2013 8. Hartikainen S, Lonnroos E, Louhivuori K. Medication as a risk factor for falls: critical systematic review. J Gerontol A Biol Sci Med Sci 2007; 62:1172–1181 9. Rubenstein LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing 2006; 35(suppl 2):ii37–ii41 10. Fuller GF. Falls in the elderly. Am Fam Physician 2000; 61:2159–2168, 2173–2174 11. Currie LM. Fall and injury prevention. www.ahrq.gov/professionals/clinicans-providers/ resources/nursing/resources/nurseshdbk/CurrieL_ FIP.pdf. Published 2005. Accessed June 2014 12. Vagnair A. Preventing falls of patients in the hospital: toward a comprehensive intervention program (in French). Krankenpfl Soins Infirm 2000; 93:68–71 13. Schwendimann R, Bühler H, De Geest S, et al. Falls and consequent injuries in hospitalized patients: effects of an interdisciplinary falls prevention program. BMC Health Serv Res 2006; 6:69 14. Lakatos BE, Capasso V, Mitchell MT, et al. Falls in the general hospital: association with delirium, advanced age, and specific surgical procedures. Psychosomatics 2009; 50:218–226 15. Evans D, Hodgkinson B, Lambert L, et al. Falls risk factors in the hospital setting: a systematic review. Int J Nurs Pract 2001; 7:38–45 16. Hitcho EB, Krauss MJ, Birge S, et al. Characteristics and circumstances of falls in a hospital setting: a prospective analysis. J Gen Intern Med 2004; 19:732–739 17. Cumming RG, Sherrington C, Lord SR, et al. Cluster randomised trial of a targeted multifactorial intervention to prevent falls among older people in hospital. BMJ 2008; 336:758–760 18. Oliver D, Connelly JB, Victor CR, et al. Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses. BMJ 2007; 334:82 19. Morgan VR, Mathison JH, Rice JC, et al. Hospital falls: a persistent problem. Am J Public Health 1985; 75:775–777 20. Mahoney JE. Immobility and falls. Clin Geriatr Med 1998; 14:699–726 21. 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
AJR:203, September 2014 625
Downloaded from www.ajronline.org by UCSF LIB & CKM/RSCS MGMT on 12/12/14 from IP address 169.230.243.252. Copyright ARRS. For personal use only; all rights reserved
Abujudeh et al. J Med 1991; 324:377–384 22. Mahoney JE, Palta M, Johnson J, et al. Temporal association between hospitalization and rate of falls after discharge. Arch Intern Med 2000; 160:2788–2795 23. Wong CA, Recktenwald AJ, Jones ML, Waterman BM, Bollini ML, Dunagan WC. The cost of serious fall-related injuries at three Midwestern hospitals. Jt Comm J Qual Patient Saf 2011; 37:81–87 24. Halfon P, Eggli Y, Van Melle G, Vagnair A. Risk of falls for hospitalized patients: a predictive model based on routinely available data. J Clin Epidemiol 2001; 54:1258–1266 25. Agostini JV, Baker DI, Bogardus ST. Prevention of falls in hospitalized and institutionalized older people. Rockville, MD: Agency for Healthcare Research & Quality, 2001 26. Hill AM, Hoffmann T, Hill K, et al. Measuring falls events in acute hospitals: a comparison of three reporting methods to identify missing data in the hospital reporting system. J Am Geriatr Soc 2010; 58:1347–1352 27. Abujudeh H, Kaewlai R, Shah B, Thrall J. Characteristics of falls in a large academic radiology department: occurrence, associated factors, outcomes, and quality improvement strategies. AJR 2011; 197:154–159 28. Walther LE, Kleeberg J, Rejmanowski G, et al. Falls and fall risk factors: are they relevant in ENT outpatient medical care? (in German). HNO
626
2012; 60:446, 448–456 29. Heung M, Adamowski T, Segal JH, Malani PN. A successful approach to fall prevention in an outpatient hemodialysis center. Clin J Am Soc Nephrol 2010; 5:1775–1779 30. Donaldson MG, Khan KM, Davis JC, et al. Emergency department fall-related presentations do not trigger fall risk assessment: a gap in care of high-risk outpatient fallers. Arch Gerontol Geriatr 2005; 41:311–317 31. Weinberg J, Proske D, Szerszen A, et al. An inpatient fall prevention initiative in a tertiary care hospital. Jt Comm J Qual Patient Saf 2011; 37:317–325 32. Shekelle P, Maglione M, Chang J, et al. Falls prevention interventions in the medicare population. RAND Corporation website. www.rand.org/content/dam/ rand/pubs/reprints/2007/RAND_RP1230.pdf. Published 2003. Accessed May 6, 2014 33. Chang JT, Morton SC, Rubenstein LZ, et al. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. BMJ 2004; 328:680 34. Cumming RG. Intervention strategies and riskfactor modification for falls prevention: a review of recent intervention studies. Clin Geriatr Med 2002; 18:175–189 35. Gillespie L. Preventing falls in elderly people. BMJ 2004; 328:653–654
36. Hausdorff JM, Rios DA, Edelberg HK. Gait variability and fall risk in community-living older adults: a 1-year prospective study. Arch Phys Med Rehabil 2001; 82:1050–1056 37. Hornbrook MC, Stevens VJ, Wingfield DJ, et al. Preventing falls among community-dwelling older persons: results from a randomized trial. Gerontologist 1994; 34:16–23 38. Lauritzen JB. Hip fractures: incidence, risk factors, energy absorption, and prevention. Bone 1996; 18(suppl):65S–75S 39. National Center for Injury Prevention and Control. WISQARS injury mortality reports, 1999–2007. Centers for Disease Control and Prevention website. webappa.cdc.gov/sasweb/ncipc/mortrate10_ sy.html. Published 2013. Accessed May 6, 2014 40. Tutuarima JA, de Haan RJ, Limburg M. Number of nursing staff and falls: a case-control study on falls by stroke patients in acute-care settings. J Adv Nurs 1993; 18:1101–1105 41. Morse JM. Preventing patient falls. Thousand Oaks, CA: Sage Publications, 1997 42. Resnick B. Preventing falls in acute care geriatric nursing protocols, vol. 2. New York, NY: Springer, 2003 43. Rohde JM, Myers AH, Vlahov D. Variation in risk for falls by clinical department: implications for prevention. Infect Control Hosp Epidemiol 1990; 11:521–524
AJR:203, September 2014
Downloaded from www.ajronline.org by UCSF LIB & CKM/RSCS MGMT on 12/12/14 from IP address 169.230.243.252. Copyright ARRS. For personal use only; all rights reserved
Health Care Policy and Quality Original Research
Outpatient Falls Prevention Program Outcome: An Increase, a Plateau, and a Decrease in Incident Reports Hani H. Abujudeh1 Shima Aran Laleh Daftari Besheli Karen Miguel Elkan Halpern James H. Thrall Abujudeh HH, Aran S, Daftari Besheli L, Miguel K, Halpern E, Thrall JH
Keywords: falls, incident reports, process quality improvement, quality, quality improvement program, risk reduction DOI:10.2214/AJR.13.11982 Received September 24, 2013; accepted after revision December 9, 2013. 1
All authors: Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Founders Bldg, Rm 210, Boston, MA 02114. Address correspondence to H. H. Abujudeh ([email protected]).
AJR 2014; 203:620–626 0361–803X/14/2033–620 © American Roentgen Ray Society
620
OBJECTIVE. We implemented an outpatient falls guideline in 2008 in the department of radiology. Here, we describe our multiyear experience. MATERIALS AND METHODS. This was a retrospective study conducted between April 2006 and September 2013 to investigate outpatient falls. The span of the study was divided into eight periods. The incident reporting system was searched for the falls and the fall-related variables. RESULTS. A total of 327 falls occurred during 5,080,512 radiology examinations (rate, 0.64/10,000 total examinations). The highest rate was in period 6 (0.83/10,000 examinations). The average for periods 1 and 2 is 0.39/10,000 examinations (37 falls/945,427 examinations), and the average for periods 3–6 is 0.77/10,000 examinations (204 falls/2,656,805 examinations). The average rate for periods 7 and 8 is 0.58/10,000 examinations (86 falls/1,478,280 examinations). There was a statistically significant increase in the total number of falls reported between period 2 and period 3 (p = 0.02). There was a statistically significant decrease in outpatient falls between period 6 and period 7 (p = 0.01). The number of falls among patients 60 years old or older was 177 falls/2,180,093 examinations (rate, 0.81/10,000 examinations), and that among patients younger than 60 years was 150 falls/2,900,419 examinations (rate, 0.52/10,000 examinations), with a statistically significant difference (p = 0.007). Although the rate of falls was higher among female patients, there was no statistically significant difference between the sexes (p = 0.18). CONCLUSION. The outcome of the outpatient falls guideline was characterized by an increase, a plateau, and a decrease in incident reports. The initial increase may be due to the Hawthorne effect. The plateau may represent the value closest to the true incidence. The decrease may represent the effect of the program.
F
alls and fall-related injuries are preventable medical care–related harmful events. Falls may be devastating to patients and families and are costly for hospitals, the health care system, and society. Fall-related injuries can occur in up to 33% of in-hospital falls [1, 2], may result in serious injuries in up to 10% of cases [3], and may even result in death. Morbidity associated with falls can lead to a decline in quality of life, as well as significant increases in costs for patients and in length of stay in hospitals, and it increases the liability risks of hospitals [4, 5]. Several factors have been associated with the risk of falls and fall-related injuries. Falls are more common among older adults and are reported to be the most common cause of nonfatal injuries and accidental death in people older than 65 years in the United States
[6]. It has been reported that women fall more frequently than men in this age group [6, 7]. Medications (including CNS and cardiovascular drugs) [8], underlying medical conditions (e.g., decline in visual acuity, altered sensory and depth perception, decline in visual capacity, unstable gait, and other disabling medical conditions) [9, 10], race (i.e., white race), and history of falls are other risk factors for falls. In addition, environmental hazards, such as poor lighting, loose carpets, slippery flooring, or lack of handrails, can also contribute to the risk of falls [8]. However, no definitive predictor profile has yet been introduced [6]. In 2005, the Joint Commission added the requirement for assessment and periodic reassessment of patients’ risk for falling in the acute care setting as a National Patient Safety Goal [11]. The aim of this requirement was to
AJR:203, September 2014
Downloaded from www.ajronline.org by UCSF LIB & CKM/RSCS MGMT on 12/12/14 from IP address 169.230.243.252. Copyright ARRS. For personal use only; all rights reserved
Outcome of an Outpatient Falls Prevention Program ensure that all patients are screened for their risk of falling and to reduce fall-related injuries. In 2006, there was an extension to the program requiring implementation of a falls reductions program and a periodic evaluation of the effectiveness of the program [1]. Exercise programs, multimodal interdisciplinary prevention programs, medication and underlying disease control programs, identification of recurrent fallers, staff and patient education, and environmental interventions are examples of the fall-prevention protocols and preventive measures introduced in the literature [6, 12–16]. Most studies have been performed in long-term-care environments, and there is less information about the acute-care setting [6]. Most of the studies have assessed falls among older adults and inpatient settings; data are scarce on outpatient falls that occur in a supplemental service, such as radiology [12–27]. In 2008, the department of radiology at our hospital made a commitment to develop a process for managing the diverse population of outpatients who were identified as at risk for falls, according to the published studies [28–30]. An outpatient falls guideline was developed with the aim of preventing outpatient falls or decreasing the number and severity of injuries. The goals of the program were to develop a patient assessment tool to help identify the at-risk population, to educate both clinical and nonclinical staffs on both intrinsic and extrinsic or environmental risk factors, to provide safety strategies to prevent falls or minimize the injury from falls, to determine which interventions should be taken when a patient is identified as a risk for falls, to develop specific interventions during and after clinical evaluation if a fall occurs, and to assess the program’s effectiveness by determining staff compliance and the percentage of population indicated at risk (Fig. 1). Radiology is a specialty that cares for a large number of outpatients. As providers of care for outpatients, we have the duty to examine how to prevent falls, to create and implement guidelines that reduce falls, and harm to patients in the outpatient setting. We aim to present our experience of studying falls between April 2006 to September 2013, before and after the creation and implementation of an outpatient falls guideline in the department of radiology. The hypothesis of our study was that the outpatient falls guideline would result in a reduction in the number of falls in the outpatient radiology population.
TABLE 1: General Characteristics of Patients Who Fell Characteristic Fall rate
Inpatient
Outpatient
Total
0.59a
0.66a
0.64a
Total Fall Rate
Age (y) 62.3 ± 18.5
58.3 ± 21.3
59.1 ± 20.8
< 60
Overall mean ± SD
26 (17.3)
124 (82.7)
150
0.52a
≥ 60
41 (23.2)
136 (76.8)
177
0.81a
Male
34 (26.0)
97 (74.0)
131
0.59a
Female
33 (16.8)
163 (83.2)
196
0.68a
No injury
14 (24.6)
43 (75.4)
57
17.43b
Minor
28 (16.9)
138 (83.1)
166
50.76b
Moderate
24 (23.8)
77 (76.2)
101
30.89b
Severe
1 (33.3)
2 (66.7)
3
0.92b
Ambulating without assistance
34 (17.3)
163 (82.7)
197
60.24b
Assisted
21 (19.3)
88 (80.7)
109
33.33b
Bed rest
12 (57.1)
9 (42.9)
21
6.42b
Sex
Severity of injury
Mobility status of the patient
Note—Except where noted otherwise, data are number (%) of patients. aFall rates per 10,000 total number of examinations in each category. bPercentage per total number of falls (327 falls).
Materials and Methods An institutional review board for human subject research approved our study. Our study was compliant with the HIPAA. Informed consent requirement was waived for this study. The electronic incident reporting system was searched for the falls and fall-related variables, which are summarized in Table 1. All patients were included regardless of age, sex, race, or underlying medical condition. Three hundred twenty-seven falls occurred from April 2006 to September 2013.
Falls Definitions In our study, a “fall” was defined as an inadvertent change in a person’s position from standing, sitting, or lying down to lying on the ground or other surface lower than their starting point. This definition included patients who slipped from a chair to the floor, patients found down on the floor, and “assisted falls.” We defined “assisted falls” as events in which the patient was caught in the act of falling (with or without loss of consciousness) and the patient was lowered to the ground.
Fall-Related Injury The severity of the injury was assessed in individuals who sustained injuries. The level of severity of the injuries was categorized into three levels of minor, moderate, and severe. Minor injuries included bruises, abrasions, contusions or hemato-
mas, headache, and pain. Moderate injuries were defined as lacerations. Fractures and dislocations were considered severe injuries.
Preventive Methods and Self-Assessment Questionnaire A self-assessment questionnaire, which included five questions with yes-or-no answer choices (Fig. 2), was designed for patients 6 years old or older to help imaging staff identify patients at risk and to put safety measures in place to minimize falls incidence and the severity of injury as a result of a fall. Patients were asked to complete the questionnaire, which recorded the history of falls in the past 3 months and any medications taken to alleviate anxiety during the 24 hours before falling. Intrinsic factors, such as age, comorbidities, weak muscle strength, or impairment in balance, gait, vision, or cognition, cannot be changed; however, recognizing these factors alerted imaging staff to the potential risk. Extrinsic or environmental factors include the use of certain medicines or polypharmacy, as well as lighting, floor surfaces, clutter, distraction, and noise. These factors were highlighted and altered by staff when appropriate [8]. With an overall focus on mobility and balance as putative key predictors of risk and, to a lesser degree, medications that may impact mobility and balance, patient were asked to complete the falls risk questionnaire.
AJR:203, September 2014 621
Abujudeh et al.
Downloaded from www.ajronline.org by UCSF LIB & CKM/RSCS MGMT on 12/12/14 from IP address 169.230.243.252. Copyright ARRS. For personal use only; all rights reserved
Project Plan and Strategy, Audits, Educational Modules, and Timeline Discussion of the department initiatives to reduce falls and the appointment of a safety officer to expose staff to safety and compliance discussions occurred during the last months of 2007. The problem or need was identified according to the Joint Commission release on National Patient Safety Goal number 9 [1]. The departmental guidelines and a “frequently asked questions” sheet concerning the process were developed for staff by January 2008 with associated in-service training. In May 2008, the outpatient falls guideline was implemented, and administration of the questionnaires was started with the goal of preventing outpatient falls in our department. Two audits of the program were performed to capture patients’ compliance with form completion, staff compliance with handing the forms to the patients, recording appropriate information, and entering identified at-risk patients into the fall prevention protocol and safety reporting system.
The first audit was a 1-month basic assessment on the compliance with the outpatient falls guideline conducted in August 2008. The second outpatient falls audit, conducted in August 2009, was a continuation and an extension of the 2008 outpatient falls guideline compliance audit. This second month-long audit included direct observations to assess compliance with completion of the questionnaire, the method of completing the forms (patient fills in the form or answers the questions from staff), the questionnaire collection procedures, and compliance with filing fall safety reports. Live observation of form administration was performed in patient waiting areas during a 15-minute observation period, during which a total of three patient encounters were observed per area. Falls safety reports were reviewed for the observation month to correlate falls risk responses and possible fall preventions. From 2010 through 2011, additional regular meetings were held to identify improvement strategies and weaknesses such as staff educa-
Administration of the questionnaire
Positive (+) answer to any of the 5 questions
Patients with mental impairment or patients unable to answer the questions were automatically considered to be “at risk for fall”
Negative (−) answer to all 5 questions
To identify patients “at risk for fall” staff members should: • Place a yellow sticker on patient’s ID band • Provide patients with a pamphlet on reduction of the risk for falls • Verbally notify the other staff when necessary
Constantly supervise and support the patients by • Offering a wheelchair or assistance to ambulate • Offering assistance with changing or bathroom activities • Asking patients if they need help for ambulation during the exam • Encouraging patients to notify the staff if they feel weak or unsteady • Ensuring that the patients fully understand these requirements
If fall occurs: • Assess the patient for injury and take appropriate action if additional care is required • File a safety report • Save and attach the completed questionnaire to the safety report • Review preventability of the fall with the Patient Safety Officer and area managers
Fig. 1—Outpatient falls guideline.
622
tion. Between February and August 2010, the departmental Quality and Safety Council realized that there was a need to further educate staff on fall risks and what to do when patients fall; a learning module was developed to address this need. In February 2011, all staff completed a competency test in the form of an online learning module and posttest review; an annual review was introduced as a requirement for all staff. The module included methods to determine both intrinsic and extrinsic risks for falls, simulated photos to illustrate risky situations in a variety of areas across the department, and a test to gauge knowledge. All filed safety reports concerning patient falls were investigated with the intent to determine what the staff could have done, if anything, to prevent the fall. Staff members were interviewed and asked to explain the events leading up to the fall to determine whether prevention measures were used. To assess the effect of the outpatient falls guideline, the overall study time period was divided into eight periods: April 2006 through September 2006, period 1; October 2006 through September 2007, period 2; October 2007 through September 2008, period 3; October 2008 through September 2009, period 4; October 2009 through September 2010, period 5; October 2010 through September 2011, period 6; October 2011 through September 2012, period 7; and October 2012 through September 2013, period 8 (Fig. 3). All the periods except the first are 1-year periods. Before April 2006, data collection was not complete.
Statistical Analysis The data were entered into a spreadsheet (Excel 2010, Microsoft) and were analyzed using SAS (version 9.3, SAS Institute) and SPSS (version 21.0, IBM) statistical software. The Student t test, chi-square test, Wilcoxon signed-rank test, and Cochran-Mantel-Haenszel statistic were used.
Results The study revealed a total of 327 falls over the length of the study. During the same period, there were 5,080,512 radiology examinations, with a falls rate of 0.64/10,000 examinations (Table 1). Of the 327 patients who fell, 131 (40%; rate, 0.59/10,000 total examinations) were male and 196 (59.9%; rate, 0.68/10,000 total examinations) were female. The mean (± SD) age was 59.1 ± 20.8 years (range, 5–101 years). Two hundred sixty patients (79.5%; rate, 0.66/10,000 total examinations) were outpatients and the remaining 67 patients (20.4%; rate, 0.59/10,000 total examinations) were inpatients.
AJR:203, September 2014
Downloaded from www.ajronline.org by UCSF LIB & CKM/RSCS MGMT on 12/12/14 from IP address 169.230.243.252. Copyright ARRS. For personal use only; all rights reserved
Outcome of an Outpatient Falls Prevention Program Forms Completion First audit—Of the total number of forms collected, 99.6% were completed. Patient responses to all risk questions were 64% (1297) “No” and 36% (724) “Yes.” Second audit—Of the total number of forms collected, 99% were completed. Patients’ response to all risk questions were 76% (709) “No” and 23% (224) “Yes.” Of the 709 patients responding “No,” 17 patients were determined by staff to be “At risk” because of an obvious risk factor, such as use of an assistive device or gait disturbance. The fraction of outpatients determined to be at risk for falls was 25%. Staff Compliance With Form Administration Of 10 areas that were assessed for forms administration compliance, seven areas were 100% compliant, one area was 92% compliant, one area was 61% complaint, and one area had no patients checked in during all three observation periods and compliance could not be assessed. Overall, 80% of staff complied with form administration.
TABLE 2: Number of Injuries by Level of Severity and Patient Age Group Patient Age Category Severity Level
< 60 y
≥ 60 y
Total
No injury
26
31
57
Minor
87
79
166
Moderate
37
64
101
Severe
0
3
3
150
177
327
Total
Study Periods Figure 3 summarizes the results. A total of 327 falls during 5,080,512 radiology examinations (rate, 0.64/10,000 total examinations) were reported. The highest rate (0.83/10,000 examinations) was in period 6. The average for periods 1 and 2 was 0.39/10,000 examinations (37 falls/945,427 examinations), the average for periods 3–6 was 0.77/10,000 examinations (204 falls/2,656,805 examinations), and the average for periods 7 and 8 was 0.58/10,000 examinations (86 falls/1,478,280 examinations).
Patient ID sticker here
Outpatient Falls Questionnaire Please answer these questions carefully to help us better assist you 1. Right now, how are you feeling? Weak Dizzy Light headed Fine Other 2. Do you need assistance to walk? Crutches Walker Cane Wheelchair A companion to help you Other 3. Have you fallen in the past 3 months? Yes No 4. Do you need help to walk? Yes No 5. Do you have fear of falling? Yes No 6. Have you taken/will you take any anxiety medication to help with today’s exam? Yes No Staff use only: Comments:
— Assistive device — Gait disturbance
Fig. 2—Outpatient falls questionnaire.
The total reported fall rate in period 2 was 0.41/10,000 radiologic examinations. The total reported fall rate in period 3 was 0.73/10,000 radiologic examinations. The increase in reported falls between periods 2 and 3 was statistically significant (p = 0.02). The total number of reported falls in period 6 was 0.83/10,000 radiologic examinations, and the total fall rate for period 7 was 0.60/10,000 radiologic examinations, with no statistically significant difference (p > 0.05). The total outpatient fall rates were 0.91/10,000 radiologic examinations for period 6 and 0.47/10,000 radiologic examinations for period 7. This was a statistically significant difference (p = 0.01). The total number of reported fall and outpatient falls in period 8 were 0.57/10,000 and 0.59/10,000 radiologic examinations, respectively. No significant differences were found between total number of reported fall or outpatient falls between periods 7 and 8 (p > 0.05) (Fig. 1). The rates of inpatient falls were 0.13, 0.47, 0.55, 1.05, and 0.50 per 10,000 total examinations for periods 2, 3, 6, 7, and 8, respectively. No statistically significant differences were found between any of the two consecutive years regarding the inpatient falls (p > 0.05). Fall Risk Factors (Age, Sex, Time of Day, and Mobility) and Severity of Injury Patients were divided into two age groups: younger than 60 years and 60 years old or older. Of the total 327 falls, 150 falls (rate, 0.52/10,000 radiologic examinations) occurred among patients younger than 60 years, and 177 falls (rate, 0.81/10,000 radiologic examinations) occurred among patients 60 years old and older. This difference was statistically significant (p = 0.0074). There were 131 falls among male patients (rate, 0.59/10,000 radiologic examinations) and 196 falls among female patients (rate, 0.68/10,000 radiologic examination). Although the rate of fall was higher among fe-
AJR:203, September 2014 623
male patients, the difference between sexes was not statistically significant (p = 0.18). Most falls occurred during the day from 11:00 am to 3:00 pm (36.7%; 120/327) followed by 7:00 am to 11:00 am (30.8%; 101/327). Most of the patients (60.2%; 197/327) who fell were mobile and fell while they were ambulating without assistance; a smaller number (33.3%; 109/327) fell while receiving ambulatory assistance, and a few (6.4%; 21/327) patients were bed ridden (Table 1). Injury was documented in 82.6% (270/327) of patients who fell. Fall-related injuries were minor, moderate, and severe in 166, 101, and three patients, respectively. Patients who were 60 years old or older had 66 moderate injuries and three severe injuries, compared with patients younger than 60 years, who had 37 moderate and no severe injuries (Table 2). The difference between the two groups was statistically significant (p = 0.031). In addition, we divided the level of severity of injury into two categories of significant (moderate and severe) and nonsignificant (no injury and mild injury) injuries. We found a statistically significant difference (p = 0.012) between the two categories of severity of the injury, between the two age groups of younger than 60 years (11.3% [37/327] significant injuries and 34.5% [113/327] nonsignificant injuries) and 60 years old or older (20.5% [67/327] significant injuries and 33.6% [110/327] nonsignificant injuries). These results show that, with increased age, the level of severity of injury significantly increases. Discussion Fall rates vary in different hospital settings and services [31]. The overall risk of a fall in the acute-care setting has been reported to be in the range of 1.9–3% during all hospitalizations [19–21]. In general hospital settings, fall rates have been reported to be 3.0 and 3.6 falls/1000 patient-days [25, 32–35]. The overall fall rate of 0.64/10,000 radiologic examinations was identified by this study in the department of radiology at our institution, with the highest rate being 0.83/10,000 radiologic examinations. Outcome of Our Outpatient Falls Guideline: Increase, Plateau, and Decrease Curve On the basis of the results and the interventions timeline, we can divide the total study time period into three main categories, according to the outcome and effect of our outpatient falls guideline.
624
0.90 Rate of Falls/10,000 Examinations
Downloaded from www.ajronline.org by UCSF LIB & CKM/RSCS MGMT on 12/12/14 from IP address 169.230.243.252. Copyright ARRS. For personal use only; all rights reserved
Abujudeh et al.
0.81
0.80
0.73
0.70
0.83 Outpatient Inpatient
0.36 0.60
0.60 0.50 0.41
0.40
0.36
0.72 0.62
0.56
0.37 0.46
0.30 0.20
0.33
0.38 0.24
0.10 0.00
0.11
0.14
0.22 0.12
0.11 0.03 0.03 Apr 2006 − Oct 2006 − Oct 2007 − Oct 2008 − Oct 2009 − Oct 2010 − Oct 2011 − Oct 2012 − Sep 2006 Sep 2007 Sep 2008 Sep 2009 Sep 2010 Sep 2011 Sep 2012 Sep 2013
Inpatient Outpatient Total
0.57
0.57
Period 1 0.14 1/73,291 0.43 10/234,171 0.36 11/307,462
Period 2 0.13 2/149,418 0.49 24/488,547 0.41 26/637,965
Period 3 0.47 7/149,708 0.81 40/493,499 0.73 47/643,207
Period 4 Period 5 0.60 1.08 9/151,144 16/148,757 0.73 0.73 37/509,798 38/519,581 0.7 0.81 46/660,942 54/668,338
Period 6 Period 7 0.55 1.05 8/146,067 16/152,237 0.91 0.47 49/538,251 27/569,739 0.83 0.6 57/684,318 43/721,976
Period 8 0.50 8/159,682 0.59 35/596,622 0.57 43/756,304
Fig. 3—Overall study time divided into eight periods. Graphs show fall rates per 10,000 total examinations (top) and total numbers of falls per total numbers of radiology examinations (bottom) for each period, by inpatient and outpatient groups. (Inpatient rate: Inpatient fall × 10,000/number of inpatient examinations; Outpatient rate: Outpatient fall × 10,000/number of outpatient examinations). Rates presented on graph show fall rates calculated for purpose of drawing graph (Inpatient rate: Inpatient fall × 10,000/number of total examinations; Outpatient rate: Outpatient fall × 10,000/number of total examinations).
Increase—The first impact was seen in a statistically significant increase in falls reports between periods 2 and 3 (p = 0.02). This increase may be due to the Hawthorne effect, suggesting that we were underreporting falls in the past. Although that may be the case, our experience shows that an increase in education and awareness and increased discussions resulted in an increase in reporting of the total number of falls. To exclude the possibility of the interference of any confounding factors on the increase, plateau, and decrease curve, we performed a correlation analysis of several risk factors and the time periods with inflection points in the curve (the initial increase and the eventual decrease). We looked at patient sex (male vs female), type (inpatient vs outpatient), and age (< 60 and ≥ 60 years old). None of the risk factors was significantly correlated with the fraction of patients who fell. Plateau phase (periods 4–6) after the primary increase—The sustained falls reporting rate did not change for three periods after the initial increase. Although one would have liked to see an immediate decrease in the falls reporting after introduction of the falls guidelines (a cause and effect), that did not happen in our experience. It took 3 years
with continued education and emphasis on falls to see a statistically significant reduction in falls reporting. This plateau may be closest to the true number of falls. The highest rate in the plateau was 0.83/10,000 radiologic examinations. The plateau rate overall rate was 0.77/10,000 radiologic examinations. Decrease—A statistically significant (p = 0.01) decrease in outpatient falls occurred between period 6 (0.91/10,000 total examinations) and period 7 (0.47/10,000 total examinations). We think that continued emphasis and education about falls in radiology eventually led to this improvement and reduction in reported outpatient falls. There was no statistically significant change between total number of reported falls between period 6 (0.83/10,000 total examinations) and period 7 (0.60/10,000 total examinations) (p = 0.10). There was no statistically significant change in inpatient falls between period 6 (0.55/10,000 total examinations) and period 7 (1.05/10,000 total examinations) (p = 0.13). This shows the relationship of outpatient falls reduction program with the outcome, where outpatient falls reports specifically were reduced and not the overall radiology population or the inpatient radiology population. The reduction in outpatient falls stayed con-
AJR:203, September 2014
Downloaded from www.ajronline.org by UCSF LIB & CKM/RSCS MGMT on 12/12/14 from IP address 169.230.243.252. Copyright ARRS. For personal use only; all rights reserved
Outcome of an Outpatient Falls Prevention Program sistent during period 8 as well, without a statistically significant difference between period 7 regarding the total number of reported falls (0.57/10,000 radiologic examinations), outpatient falls (0.59/10,000 radiologic examinations), or inpatient falls (0.50/10.000 radiologic examinations) (p > 0.05). Fall Risk Factors (Age, Sex, Time of Day, and Mobility) and Severity of Injury Our study showed that there were more falls among female patients than among male patients; however the difference was not statically significant. This finding is similar to those of other studies in the literature, in which falls are more frequent among female patients; however, death as a result of falls has been reported to be more common among male patients [6, 7, 36–39]. Most falls occurred during the day from 11:00 am to 3:00 pm, which is similar to the results reported by Tutuarima et al. [40], who reported that the greatest number of falls (53.1%) occurred in the daytime when most nursing staff were present. In our study, most of the patients who fell were mobile and fell while they were ambulating without assistance, which is in agreement with the results of a previous study [27]. In our study, fall-related injuries were mostly minor, followed by moderate and severe, and none of the patients died as a result of a fall. According to our results, the total number of falls was statistically significantly higher among patients 60 years old or older than among patients younger than 60 years (p < 0.0001). In addition, the level of severity of fall-related injuries increased with age. These findings are in agreement with literature, where it is mentioned that fall rates increase with age and the severity of the fallrelated injury and mortality rates increase dramatically after the age of 85 years for both sexes and across all ethnicities [6, 7, 36– 39]. Unintentional falls are considered to be the most common cause of nonfatal injuries and are the most common cause of accidental death in people older than 65 years [6]. Up to 30% of all hospital falls and approximately 6–44% of acute inpatient falls are reported to result in injury [15, 16, 38, 41–43]. Limitations There are several limitations to our investigation. Data were retrospectively collected from reports in the adverse event reporting system and data in the electronic medical records. Not all the required variables were
available for all patients in the reporting system. It is not known how many falls were not reported and patients who experienced falls were not followed up for a long time. One may consider that, after years of using falls guidelines, the reports decreased because of dormancy, slackness, or laxness; however, we think that, although this factor can never be excluded, our effort continues to this day. The day-to-day emphasis on improving patient care is important to every individual in our department. We think that we have a more open reporting culture than we did several years ago. Another limitation is the incorrect appearance that this single quality improvement project resulted in a direct reduction of falls; although we think that this was a major influence on the reduction, it is not the only one. The steps needed to achieve such an improvement are multifactorial and start with the entire institution’s adoption of a culture of improvement of care, which includes such things as adoption of a “Just Culture”; a transparent, open, and nonpenalizing reporting culture; the willingness to learn from errors and improve; and providing the resources to improve care. Education, measurement, and continued emphasis will eventually result in the desired outcomes. Conclusion The implementation of the outpatient falls reduction program resulted in an increase, a plateau, and an eventual decrease in reported falls in radiology. The initial increase in reported falls is likely due to the Hawthorne effect, the plateau may be closest to the true value, and the decrease in reported outpatient falls was the goal of the outpatient falls reduction program. References 1. The Joint Commission. Critical access hospitals: 2006 national patient safety goals. The Joint Commission website. www.splashcap.com/ JCAHO_2006-NPSG-3D.pdf Published 2006. Accessed June 2014 2. Cooper CL, Nolt JD. Development of an evidence-based pediatric fall prevention program. J Nurs Care Qual 2007; 22:107–112 3. Dempsey J. Falls prevention revisited: a call for a new approach. J Clin Nurs 2004; 13:479–485 4. Cho SH, Ketefian S, Barkauskas VH, et al. The effects of nurse staffing on adverse events, morbidity, mortality, and medical costs. Nurs Res 2003; 52:71–79 5. Tinetti ME, Inouye SK, Gill TM, et al. Shared risk factors for falls, incontinence, and functional
dependence: unifying the approach to geriatric syndromes. JAMA 1995; 273:1348–1353 6. Currie L. Fall and injury prevention. In: Hughes RG, ed. Patient safety and quality: an evidencebased handbook for nurses. Rockville, MD: Agency for Healthcare Research & Quality, 2008 7. Centers for Disease Control and Prevention. WISQARS leading causes of death reports, 1999– 2007. CDC website. webappa.cdc.gov/sasweb/ ncipc/leadcaus10.html. Published June 1, 2010. Accessed January 2013 8. Hartikainen S, Lonnroos E, Louhivuori K. Medication as a risk factor for falls: critical systematic review. J Gerontol A Biol Sci Med Sci 2007; 62:1172–1181 9. Rubenstein LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing 2006; 35(suppl 2):ii37–ii41 10. Fuller GF. Falls in the elderly. Am Fam Physician 2000; 61:2159–2168, 2173–2174 11. Currie LM. Fall and injury prevention. www.ahrq.gov/professionals/clinicans-providers/ resources/nursing/resources/nurseshdbk/CurrieL_ FIP.pdf. Published 2005. Accessed June 2014 12. Vagnair A. Preventing falls of patients in the hospital: toward a comprehensive intervention program (in French). Krankenpfl Soins Infirm 2000; 93:68–71 13. Schwendimann R, Bühler H, De Geest S, et al. Falls and consequent injuries in hospitalized patients: effects of an interdisciplinary falls prevention program. BMC Health Serv Res 2006; 6:69 14. Lakatos BE, Capasso V, Mitchell MT, et al. Falls in the general hospital: association with delirium, advanced age, and specific surgical procedures. Psychosomatics 2009; 50:218–226 15. Evans D, Hodgkinson B, Lambert L, et al. Falls risk factors in the hospital setting: a systematic review. Int J Nurs Pract 2001; 7:38–45 16. Hitcho EB, Krauss MJ, Birge S, et al. Characteristics and circumstances of falls in a hospital setting: a prospective analysis. J Gen Intern Med 2004; 19:732–739 17. Cumming RG, Sherrington C, Lord SR, et al. Cluster randomised trial of a targeted multifactorial intervention to prevent falls among older people in hospital. BMJ 2008; 336:758–760 18. Oliver D, Connelly JB, Victor CR, et al. Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses. BMJ 2007; 334:82 19. Morgan VR, Mathison JH, Rice JC, et al. Hospital falls: a persistent problem. Am J Public Health 1985; 75:775–777 20. Mahoney JE. Immobility and falls. Clin Geriatr Med 1998; 14:699–726 21. 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
AJR:203, September 2014 625
Downloaded from www.ajronline.org by UCSF LIB & CKM/RSCS MGMT on 12/12/14 from IP address 169.230.243.252. Copyright ARRS. For personal use only; all rights reserved
Abujudeh et al. J Med 1991; 324:377–384 22. Mahoney JE, Palta M, Johnson J, et al. Temporal association between hospitalization and rate of falls after discharge. Arch Intern Med 2000; 160:2788–2795 23. Wong CA, Recktenwald AJ, Jones ML, Waterman BM, Bollini ML, Dunagan WC. The cost of serious fall-related injuries at three Midwestern hospitals. Jt Comm J Qual Patient Saf 2011; 37:81–87 24. Halfon P, Eggli Y, Van Melle G, Vagnair A. Risk of falls for hospitalized patients: a predictive model based on routinely available data. J Clin Epidemiol 2001; 54:1258–1266 25. Agostini JV, Baker DI, Bogardus ST. Prevention of falls in hospitalized and institutionalized older people. Rockville, MD: Agency for Healthcare Research & Quality, 2001 26. Hill AM, Hoffmann T, Hill K, et al. Measuring falls events in acute hospitals: a comparison of three reporting methods to identify missing data in the hospital reporting system. J Am Geriatr Soc 2010; 58:1347–1352 27. Abujudeh H, Kaewlai R, Shah B, Thrall J. Characteristics of falls in a large academic radiology department: occurrence, associated factors, outcomes, and quality improvement strategies. AJR 2011; 197:154–159 28. Walther LE, Kleeberg J, Rejmanowski G, et al. Falls and fall risk factors: are they relevant in ENT outpatient medical care? (in German). HNO
626
2012; 60:446, 448–456 29. Heung M, Adamowski T, Segal JH, Malani PN. A successful approach to fall prevention in an outpatient hemodialysis center. Clin J Am Soc Nephrol 2010; 5:1775–1779 30. Donaldson MG, Khan KM, Davis JC, et al. Emergency department fall-related presentations do not trigger fall risk assessment: a gap in care of high-risk outpatient fallers. Arch Gerontol Geriatr 2005; 41:311–317 31. Weinberg J, Proske D, Szerszen A, et al. An inpatient fall prevention initiative in a tertiary care hospital. Jt Comm J Qual Patient Saf 2011; 37:317–325 32. Shekelle P, Maglione M, Chang J, et al. Falls prevention interventions in the medicare population. RAND Corporation website. www.rand.org/content/dam/ rand/pubs/reprints/2007/RAND_RP1230.pdf. Published 2003. Accessed May 6, 2014 33. Chang JT, Morton SC, Rubenstein LZ, et al. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. BMJ 2004; 328:680 34. Cumming RG. Intervention strategies and riskfactor modification for falls prevention: a review of recent intervention studies. Clin Geriatr Med 2002; 18:175–189 35. Gillespie L. Preventing falls in elderly people. BMJ 2004; 328:653–654
36. Hausdorff JM, Rios DA, Edelberg HK. Gait variability and fall risk in community-living older adults: a 1-year prospective study. Arch Phys Med Rehabil 2001; 82:1050–1056 37. Hornbrook MC, Stevens VJ, Wingfield DJ, et al. Preventing falls among community-dwelling older persons: results from a randomized trial. Gerontologist 1994; 34:16–23 38. Lauritzen JB. Hip fractures: incidence, risk factors, energy absorption, and prevention. Bone 1996; 18(suppl):65S–75S 39. National Center for Injury Prevention and Control. WISQARS injury mortality reports, 1999–2007. Centers for Disease Control and Prevention website. webappa.cdc.gov/sasweb/ncipc/mortrate10_ sy.html. Published 2013. Accessed May 6, 2014 40. Tutuarima JA, de Haan RJ, Limburg M. Number of nursing staff and falls: a case-control study on falls by stroke patients in acute-care settings. J Adv Nurs 1993; 18:1101–1105 41. Morse JM. Preventing patient falls. Thousand Oaks, CA: Sage Publications, 1997 42. Resnick B. Preventing falls in acute care geriatric nursing protocols, vol. 2. New York, NY: Springer, 2003 43. Rohde JM, Myers AH, Vlahov D. Variation in risk for falls by clinical department: implications for prevention. Infect Control Hosp Epidemiol 1990; 11:521–524
AJR:203, September 2014
