LWW/JNCQ
JNCQ-D-13-00022
November 7, 2013
21:58
J Nurs Care Qual Vol. 29, No. 1, pp. 51–59 c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
Reducing Falls and Fall-Related Injuries in Mental Health A 1-Year Multihospital Falls Collaborative Patricia A. Quigley, PhD, ARNP, CRRN, FAAN, FAANP; Scott D. Barnett, PhD; Tatjana Bulat, MD; Yvonne Friedman, MS, OTR Despite much research on falls occurring on medical-surgical units and in long-term care settings, falls on inpatient psychiatry units are understudied. On the basis of fall injury program characteristics across multiple inpatient psychiatry units, we developed and implemented an operational strategic plan to address each falls prevention program element and enhance program infrastructure and capacity. Expert faculty provided lectures, coaching, and mentoring through biweekly conference calls and collaborative e-mail exchange. Findings support continued efforts to integrate measures to reduce serious fall-related injuries. Key words: fall prevention, fall-related injuries, falls, injury prevention, psychiatry, veterans
A
CONSIDERABLE body of research on falls and falls prevention in hospitals demonstrates that falling is a complex event Author Affiliations: VISN 8 Patient Safety Center of Inquiry (Drs Quigley and Bulat and Ms Friedman) and HSR&D/RR&D Research Center of Excellence (Dr Barnett), James A. Haley Veterans’ Hospital, Tampa, Florida. This material is based upon work supported by the Office of Research and Development, Department of Veterans Affairs, Health Services Research and Development Service award #IIR-03-003-1, and the Patient Safety Center of Inquiry, James A. Haley Veterans Affairs Medical Center. The views expressed in this article are those of the authors and do not necessarily represent the views of the Veterans Healthcare Administration or Department of Veterans Affairs. The authors declare no conflict of interest. Correspondence: Patricia A. Quigley, PhD, ARNP, CRRN, FAAN, FAANP, VISN 8 Patient Safety Center of Inquiry, James A. Haley VA Medical Center, 8900 Grand Oaks Circle, Tampa, FL 33637 (patricia.quigley@va .gov). Accepted for publication: July 8, 2013. Published online before print: October 21, 2013 DOI: 10.1097/01.NCQ.0000437033.67042.63
that typically involves multiple risk factors.1,2 These risk factors involve person-specific intrinsic risk factors, the physical environment, and the riskiness of a person’s own behavior. Patient falls are the most frequent adverse event associated with subsequent injury within the Veterans Health Administration (VHA)3 and are the leading cause of injuryrelated deaths among people aged 65 years and older.4 The 2 most serious fall-related injuries are hip fractures and intracranial hemorrhages.5,6 Although falls on medical-surgical units and in long-term care settings were the focus of extensive research over the years, falls on inpatient psychiatry units are understudied. Based on a 2005 summary report completed by the National Center for Patient Safety (NCPS) National Falls Toolkit Impact Evaluation,7 psychiatry units experienced a lower rate of overall falls but a higher rate of injurious falls than nursing homes or medicalsurgical units. Within the Department of Veterans Affairs, the NCPS reported rates 51
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
52
JNCQ-D-13-00022
November 7, 2013
21:58
JOURNAL OF NURSING CARE QUALITY/JANUARY–MARCH 2014
for major fall-related injuries as part of the National Falls Toolkit Impact Evaluation. The NCPS reported major injury rates for falls in mental health as 0.022 per 1000 bed days of care for 2006 quarter 1 and 0.031 for quarter 2. In addition, the NCPS reported that the percentage of falls with major injury in mental health was 5% in 2004 and it reduced to 3.5% in 2005. This level of injury is of greatest concern, as serious fall-related injuries result in loss of function, loss of life, and financial burden. While not all falls can be prevented, serious fall-related injuries can be eliminated with the use of protective equipment and environmental changes that decrease fall-related trauma. Serious injuries are rare occurrences. This report is the only available one in the VA that separates falls for inpatient psychiatry compared with other settings of care and was used as a basis of comparison for our study. In Veterans Integrated Service Network (VISN) 8 (South Georgia, Florida, and Puerto Rico), the incidence rates in inpatient psychiatry units are second only to those of long-term care (B. Ballot, MD, written communication, July 2009). Further research suggests that inpatients aged 75 years and older and those on geropsychiatry units were more likely to sustain serious fall-related injury (adjusted odds ratio, 2.8; 95% confidence interval, 1.3-6.0).8 Older adults with select mental health and substance abuse problems fall between 1.5 and 4.5 times more than the general elderly population. Psychiatric inpatients having recurrent falls have a significantly longer length of hospital stay than other inpatient populations.9 Furthermore, the odds of a fall-related injury among patients with cognitive disorders such as Alzheimer disease and other dementias were at least 3 times greater than those among the general elderly population and the differential increases with age.10 Increases in total costs resulting from a fall injury were greater among both elderly men and women with mental health conditions or dementia. The substantial burden of fall injuries among elderly with either mental health or substance
abuse conditions suggests the need to direct fall prevention and protection strategies specifically toward this vulnerable population. Fall risk factors among inpatient psychiatry populations are similar to those in longterm care and medical-surgical units.11 These risk factors include history of falls, generalized weakness, confusion or disorientation, difficulty with mobility or walking, elimination problems, and temperature elevation.12 Prior analysis of conditions involving falls suggests that the majority of falls occur when patients are attempting to get out of bed, walk to the bathroom, or change from a sitting to a standing position.12 Prescribed medication in psychiatry presents a unique fall risk. A number of psychotropic drugs including antidepressants, antipsychotic, and sedatives or hypnotics have been associated with increased risk for falls.13 The mechanisms involved include medication-induced orthostatic hypotension, ataxia, psychomotor slowing, and extrapyramidal symptoms.14 RESEARCH EVIDENCE READY FOR TRANSLATION According to a recent Cochrane review, the rate of injurious falls decreased after the introduction of population-based programs focusing on age, diagnosis of osteoporosis or history of hip fracture, and use of anticoagulation therapy.15 During this project, we initiated a number of translational projects in both acute and long-term care settings specifically addressing fall prevention and protection. Over the years, we have received numerous inquiries from psychiatry providers on how best to implement programs in that setting. Because of the risk for harm to self and others introduced by routine technology use in other health care settings (eg, height adjustable low beds with electrical cords), psychiatry staff have difficulty in making decisions about the safe use of technology. In 2009, we hosted an expert panel meeting with identified experts in geriatric psychiatry, psychology, geriatric medicine, nursing,
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00022
November 7, 2013
21:58
Reducing Falls and Fall-Related Injuries in Mental Health ergonomics, patient safety, and physical therapy, and a representative from each of the VHA’s NCPS, VISN 8, and Veterans Health Administration Central Offices to identify needed tools for translating evidence-based fall prevention and safe patient handling to inpatient psychiatry units. While the evidence supporting interventions in inpatient psychiatry is limited, the panel recommended that we customize existing evidence-based interventions from long-term care and medical-surgical units to inpatient psychiatry. Our subsequent strategic plan included developing, testing, and evaluating several best practices in inpatient psychiatry settings. METHODS Participating hospitals All institutions were located in similar metropolitan cities (eg, size, socioeconomic factors) with more than 100 000 veterans serving in their respective catchment areas. Five hospitals participated in this project. Table 1 provides a summary of total beds and inpatient psychiatry beds. Project kickoff In 2010, the VISN 8 project began with all inpatient psychiatry nurse executives and nurse managers invited to participate in the
53
project. For the participating Veteran Affairs Medical Centers, peer leaders and participating staff were identified for each inpatient psychiatry unit. Three projects were implemented simultaneously with concurrent goals of both expanding the program and empowering innovation. Project 1: Fall prevention program customized for inpatient psychiatry The evidence is strong to support multifactorial fall prevention programs for injurious falls in long-term care and acute care.16,17 An Institute for Healthcare Improvement collaborative on the prevention of injurious falls in acute care across 9 hospitals identified the lack of an organizational assessment to examine readiness at the organizational level to prevent serious injurious falls for inpatients as an apparent gap. To fill this gap, members of the Institute for Healthcare Improvement Falls Collaborative developed and pilot tested an organizational assessment tool that quantified the extent of fall and injury program implementation at organizational, unit, and patient levels. Project 1 required validation that the injurious fall prevention organizational selfassessment tool was clear and relevant for use in psychiatry. The original tool was modified for inpatient psychiatry on the basis of content expert
Table 1. Description and Number of Beds by Hospital Unitsa
Hospitals 1. Hospital, long-term care facility, residential treatment program 2. Hospital, tertiary care center 3. Hospital, tertiary care center 4. Hospital, tertiary care center, long-term care facility 5. Hospital and community living facility a Hospitals
Total Inpatient Beds
Total General Psychiatry Beds
Total Geropsychiatry Beds
397
1a: 23
1b: 10
191 348 415
32 50 4a: 40
0 0 4b: 12
390
24
0
1 and 4 contain 2 units each designated as “a” and “b.”
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
54
JNCQ-D-13-00022
November 7, 2013
21:58
JOURNAL OF NURSING CARE QUALITY/JANUARY–MARCH 2014
review from advanced practice nurses, clinical nurse leaders, and mental health chief nurses. After expert revision, the questionnaire was examined for content validity by independent mental health experts and one of the hospitals that was a tertiary care center and had a long-term care facility. Seven staff nurses in psychiatry volunteered to critically examine the clarity and relevance of each question to their practice. Changes were made on the basis of their feedback and then reviewed with the advanced experts for final consensus. The original questionnaire was modified to remove select items, including grab bars, that are not allowed because of suicide risk. The final version was reviewed by VA Research and Development Committee, along with an invitational letter, for distribution to units. This organizational assessment was distributed to all inpatient psychiatry staff by their respective unit nurse managers. Results for each Veteran Affairs Medical Center inpatient psychiatry unit were then reviewed by the project director, with the associate chief nurses, nurse managers, peer leaders, and designated key nursing staff. In addition, common program elements to all units across all hospitals were identified. Common fall and injury prevention program elements that were identified as requiring further implementation across all participating sites were to 1. implement a unit peer leader program, 2. customize use of hip protectors to reduce risk of hip fractures, 3. customize use of floor mats to reduce trauma from bed-related falls, 4. expand patient assessment to include injury risk on admission, and 5. expand patient education to include protection from fall-related injury. Following the identification of program elements, a VISN-wide strategic plan was subsequently developed to address each element and enhance its program infrastructure and capacity. Over the next 6 months (June to December 2010), expert faculty provided monthly lectures on the basis of previously identified strategic needs, with additional
coaching and mentoring through biweekly conference calls and e-mail exchange. The project team consisted of clinical experts and researchers in fall and fall injury reduction program implementation and evaluation. Additional faculty invited to present were fall experts from other Veterans Affairs Medical Centers and patient safety centers and injury centers. These faculty included engineers and injury epidemiologists able to teach about equipment and technology for fall prevention, fall detection and surveillance systems, and fall injury protection, as well as how to use strategies to test change and to spread and sustain implementation. The faculty and topics are listed below: r Geriatrician: Hip protector toolkit. r Nurse scientist/nurse practitioner: Floor mats selection and use, patient education resources, men and osteoporosis, and nonskid flooring and footwear. r Geriatric clinical nurse specialist and falls consultant: Innovations in equipment alarms and wandering technology for fall prevention, detection, and protection. r Occupational therapist: Available raised toilet seats. r Nurse scientist and implementation specialist: Role of peer leaders. r Engineer and researcher: Nonskid footwear and flooring. r Injury epidemiologist and scientist, The National Institute for Occupational Safety and Health consultant: Nonskid footwear and flooring. All education sessions were Web-based, offered virtually by conference call and shared PowerPoint presentation via Web communication. Each program component was subsequently implemented using expert lecture, plans for small tests of change, report of results, coaching, and mentoring. In addition, a follow-up plan over 5- to 8-week intervals based on the principles of Plan, Do, Study, and Act was initiated. Emphasized throughout the program were strategies for patient engagement and improved health literacy. To enhance adoption and spread of program
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00022
November 7, 2013
21:58
Reducing Falls and Fall-Related Injuries in Mental Health
55
elements, we reported results to all participants and shared lessons learned across sites. Thus, the results of the survey from across sites were critical in designing a program that was relevant to all mental health units across our medical centers.
to be helpful to them, and each reported planning to use the peer leader criteria to further expand this role to other nursing shifts. The feedback from the unit peer leaders verified that the Manual was a successful resource for their use.
Project 2: Unit peer leader program for falls
Project 3: Customization of hip protectors and floor mats in psychiatry settings
Peer leadership at the hospital unit level offers the potential to reduce the occurrence of injurious falls by decreasing practice variations. Peer leadership has been successfully used in health contexts, mainly in health promotion for adolescent populations18 and persons with chronic illness.19 Our objectives were to (1) have each unit identify at least 1 volunteer staff member as a unit-based fall prevention peer leader, (2) provide the peer leaders with coaching and mentoring to develop their peer leader skills, and (3) develop and disseminate a toolkit that could be modified for their use at the unit level. Using an expert consensus model, we developed the Peer Unit Leader Program and Toolkit. Two nurses, considered fall experts, drafted this toolkit specific to fall and injury prevention. A draft revision of the toolkit was subsequently presented to additional fall experts and nurse fall prevention champions at the participating Veteran Affairs Medical Centers. Following additional revisions, the peer leader toolkit was disseminated to inpatient psychiatry unit peer leaders for review, comment, trial use, and revisions over a 2-month period. Based on peer leader feedback, final changes were made to this toolkit, and it was then distributed to each unit. We subsequently developed a functional statement for an Inpatient Psychiatry Unit Peer Leader for Fall Prevention and selection criteria. During the initial 3 months of the program, designated peer leaders from each hospital prepared an individualized Peer Unit Manual and Toolkit for their respective units and hospital leadership. For example, peer leaders added their own unit fall policies and procedures to the Manual. All peer leaders found the Manual
As medically fragile patients with multiple medical comorbidities are admitted to VA psychiatry units, staff is faced with the need to reduce injurious falls (fall protection). Two technologies are useful for fall protection: hip protectors and floor mats. Hip protectors
While the evidence of hip protector effectiveness has been mixed, the most recent conclusion is that hip protectors are protective when used in high-risk patient populations at risk for hip fracture.20,21 We educated all sites about hip protector products, implementation methods, and strategies to increase patient adherence, referring all staff to our Hip Protector Toolkit. This toolkit includes prescriptive guidelines, patient adherence interventions, laundering guidelines, and replacement protocols. Floor mats
Although hip fractures in the older adults can result from falls from a standing height, falls from bed account for the majority of falls and injurious falls in institutional22,23 and home settings.24 Height-adjustable beds have become a standard of care in long-term care to reduce the incidence of injuries from falling out of bed. However, the standard for psychiatry settings is a platform bed that cannot be height-adjusted. Psychiatry beds do not have cords and other features that could be used to inflict self-harm, yet they are required for making beds functional from a fall injury prevention standpoint. The demand for safe beds to prevent falls, fall-related injuries, and selfharm is high, yet safe beds are not readily available. Therefore, use of floor mats is critical to
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
56
JNCQ-D-13-00022
November 7, 2013
21:58
JOURNAL OF NURSING CARE QUALITY/JANUARY–MARCH 2014
reduce the trauma that results from a fall to the floor. Floor mats are considered an essential component of any comprehensive injury reduction program in which injurious falls are a concern.25,26 Our prior research attempted to quantify the relationship between bed height and injury risk and protectiveness of floor mats in a laboratory setting using a Hybrid III mannequin.27 Older psychiatry inpatients are at higher risk for fall-related injury than the general older adult population, but floor mats are not used consistently in inpatient psychiatry settings on the basis of the assessment results. We educated all sites about floor mat products, implementation methods, and strategies for acceptance, referring to our Floor Mat Selection Guide. This guide includes impact properties, stability properties, coefficient of friction, thickness, weight, and overall size; use of these is only for those patients at risk for injury if a fall occurs (eg, patients with osteoporosis and those taking anticoagulants). Mental health unit peer leaders of 3 hospitals in our project reported no barriers to use of the products, with 2 of them reporting success with the use of floor mats. At the end of the implementation project, a 2-day meeting was held to bring unit peer leaders together from each site and review results of the postimplementation survey. The meeting allowed each unit to report on its tests of change and progress in expanding use of protective equipment, patient education materials, increased communication, and handoff related to patient fall and injury risks. RESULTS Our program evaluation included both quantitative and qualitative methods. Quantitative methods analyzed changes in organizational fall injury program elements and analysis of fall and fall injury data over time. Qualitative data were extracted from unit reports during a face-to-face meeting from all sites to report lessons learned and interventions adopted.
Postimplementation data analysis was completed in 2011, 1 year after baseline. The final sample included 86 direct care staff responses, of which 77 were usable (89.5%). Because of the small number of responses (range: 1-3) from each unit for the leadership section of the survey, only staff responses were analyzed and compared pre and post implementation. For staff, 41.8% practice on the day shift (8- and 12-hour shifts) and 27.0% practice on the evening/night shift, with 36.2% missing shift information. Changes in level of implementation for each fall injury program component are reported in Table 2 and are based on survey responses. Data analysis revealed changes in pre- and postimplementation survey scores by subscale. Scores ranged from 0 (no activity) to 3 (fully implemented). Improvements were evident in fall injury risk assessment ( + 1.7%) and discharge education ( + 3.0%). The largest positive change was reported for environmental safety to reduce the severity of injury ( + 8.6%), which includes use of hip protectors and floor mats. Presurvey full implementation of hip protectors was reported as 55.8%, the same as after the intervention. Full implementation of floor mats, however, was 24.4% preintervention, and this increased to between 36.3% to 49.0% (P < .001). Falls and fall-related injuries in mental health units The primary objective of this program was to facilitate adoption and integration of fall and injury prevention practices and equipment into mental health units in participating hospitals. Fall rates reported by VA NCPS (4.3 falls per 1000 occupied bed days of care [OBDC]) served as our within-VA comparison reference.28 Falls Cumulative and unit quarterly fall rates (per 1000 OBDC) are reported in the Figure. Fortyfive percent (n = 29 quarters) of the quarterly fall rates were below the lower limit of the NCPS 2004-2006 fall rates (4.3 falls per 1000
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00022
November 7, 2013
21:58
57
Reducing Falls and Fall-Related Injuries in Mental Health Table 2. Average Changes in Staff Reponses per Survey Subscales, Pre and Posta
Items Fall Injury Risk Assessment and Identification Screening for Likelihood of Falling Environmental Safety to Reduce Severity of Injury Post Fall Assessment Discharge Patient/Family Education a Statistical
Range of Scores (No. of Questions)
Pre
Post
Delta (% Change)
P
0-15 (5)
14.0
14.2
0.2 (1.7)
.14
0-21 (7)
18.9
18.8
− 0.1 ( − 0.3)
.95
0-30 (10)
15.0
16.3
1.3 (8.6)
.48
0-12 (4) 0-15 (5)
11.3 10.0
10.9 10.3
− 0.4 ( − 3.6) 0.3 (3.0)
.12 .33
testing was accomplished via paired t tests.
OBDC); 33% (n = 22 quarters) were within this range (4.3-6.6 falls per 1000 OBDC); and 22% (n = 14 quarters) had fall rates reported over the higher rate limit (6.6 falls per 1000 OBDC). Only hospital 3’s mental health unit maintained fall rates between 2 and 4 falls per 1000 OBDC. The mental health unit in hospital 1 reported the highest fall rate for 1 quarter (17 falls per 1000 OBDC), which is still within the reported range for geropsychiatry units.
Fall-related injuries Of the 65 quarters of fall and injury data that were reported, 56 (86.2%) reported injury fall rates. During the survey period, 32 quarters (49.2%) reported fall injury rates between 0.08 and 2.00 or less OBDC, and 13 quarters (20.0%) reported fall injury rates between 2.00 and less than 3.00 OBDC. Fall injury rates of 3.00 or more OBDC were reported in 17% of the surveyed quarters (Figure).
Figure. Average quarterly inpatient mental health fall rates and fall-related injury rates and percentage of falls with serious injury in mental health.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00022
58
November 7, 2013
21:58
JOURNAL OF NURSING CARE QUALITY/JANUARY–MARCH 2014
The quarterly percentage of falls with serious injury is reported in the Figure. The data indicate that in 1 quarter, 70% of the falls that occurred resulted in major serious injury, 3 quarters reported that 50% of the falls resulted in major serious injury, and 50 quarters (76.9%) reported no serious injuries. This finding supports continued efforts to integrate measures to reduce serious fall-related injuries in our VISN 8 Mental Health Unit, with the goal to eliminate hip fractures. DISCUSSION It is important to examine trends in falls, fall-related injuries and percentage of fallers with injury over the most recent 2-year period. When evaluating the impact of the NCPS National Falls Toolkit 2004-2006, these program evaluation measures were key measures specified by the VA NCPS working with our institution. At that time, NCPS separated mental health units as Behavioral Health and provided the first large scale comparative rates for this clinical specialty area in the United States. According to Oliver et al,1 falls are rarely evenly distributed across units in hospitals. In mental health units, this uneven distribution may be particularly apparent, with overall fall rates in the range of 2 to 4 falls per 1000 OBDC. Rates of falls in some geropsychiatry units are even higher. In mental health units, most patients are ambulatory, with the majority of falls occurring while walking. Hospital administrators, clinicians, patient safety
officers, and researchers continually reassess and build on current fall and injury reduction strategies. However, falls and fall-related injuries occur and remain a significant cause of morbidity and mortality among seniors in mental health programs. Successful falls prevention programs typically use a combination of interventions with environmental adaptations, such as assessing patients before and after a fall to identify and address risk factors and underlying medical conditions, educating staff about fall and injury risk factors and prevention strategies, reviewing medications, enabling patients to move safely in their environment, and providing patients with hip protectors and floor mats that may prevent a hip fracture if a fall occurs.29 Given the aging veteran population, we encourage other programs to build on our work with implementation of effective falls prevention programs that focus on protection from injury. While progress is being made, we believe that the percentage of falls resulting in serious injuries can be decreased. Equipment use specifically designed to reduce trauma during a fall, such as hip protectors and floor mats, should be integrated into patient care. Although the risk of suicide among the psychiatry inpatient population is always a concern, a safe balance can be achieved between suicide prevention and protection from serious fall-related injuries by addressing the complex relationships among individual, organizational, and cultural factors, and patients’ diverse and age-specific needs.
REFERENCES 1. Oliver D, Healey F, Haines TP. Preventing falls and fall-related injuries in hospitals. Clin Geriatr Med. 2010;26(4):645-692. 2. Cameron ID, Murray GR, Gillespie LD, et al. Interventions for preventing falls in older people in residential care facilities and hospitals (Protocol). Cochrane Database Syst Rev. 2005;(3):CD005465. doi:10.1002/14651858.CD005465. 3. Office of the DAS for Program/Data Analysis. The Changing Veteran Population: 1990-2010. Washington, DC: DVA. Department of Veterans Affairs Web site. http://www.va.gov/vetdata/veteran_
population.asp. Updated 2000. Accessed December 1, 2012. 4. Centers for Disease Control and Prevention. NCIPC, Fact Book for the Year 2000: Falls Among Older Adults. Atlanta, GA: Centers for Disease Control Web site. http://www.cdc.gov/ncipc/olderadults.htm. Updated 2000. Accessed December 1, 2012. 5. Centers for Disease Control and Prevention. National Center for Injury Prevention and Control. Falls: Older adults. Centers for Disease Control Web site. http:// www.cdc.gov/ncipc/duip/preventadultfalls.htm. Updated 2009. Accessed November 12, 2009.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00022
November 7, 2013
21:58
Reducing Falls and Fall-Related Injuries in Mental Health 6. Wu S, Keeler EB, Rubenstein LZ, Maglione MA, Shekelle PG. A cost-effectiveness analysis of a proposed national fall prevention program. Clin Geriatr Med. 2010;26(4):751-766. 7. Landesman A. Falls Data Collection Project: Participant Newsletter. Ann Arbor, MI: National Center for Patient Safety, Department of Veterans Affairs; October 5, 2005. 8. Fischer ID, Krauss MJ, Dunagan WC, et al. Patterns and predictors of inpatient falls and fall-related injuries in a large academic hospital. Infect Control Hosp Epidemiol. 2005;26(10):822-827. 9. Greene E, Cunningham CJ, Eustace A, Kidd N, Clare AW, Lawlor BA. Recurrent falls are associated with increased length of stay in elderly psychiatric inpatients. Int J Geriatr Psychiatry. 2001;16(10):965-968. 10. Finkelstein E, Prabhu M, Chen H. Increased prevalence of falls among elderly individuals with mental health and substance abuse conditions. Am J Geriatr Psychiatry. 2007;15(7):611-619. 11. Rubenstein LZ, Josephson KR. Falls in nursing homes. Clin Geriatr Med. 2002;18(2):141-158. 12. Tsai YF, Witte N, Radunzel M, Keller ML. Falls in a psychiatric unit. Appl Nurs Res. 1998;11(3):115-121. 13. Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a systematic review and metaanalysis: I. Psychotropic drugs. J Am Geriatr Soc. 1999;47(1):30-39. 14. Bulat T, Castle S, Rutledge M, Quigley P. Clinical practice algorithms: medication management to reduce fall risk in the elderly-part 4, anticoagulants, anticonvulsants, anticholinergics/bladder relaxants and antipsychotics. J Am Acad Nurse Pract. 2008;20(3):181190. 15. McClure RJ, Turner C, Peel N, Spinks A, Eakin E, Hughes K. Population-based interventions for the prevention of fall-related injuries in older people. Cochrane Database Syst Rev. 2005;(1):CD004441. doi:10.1002/14651858.CD004441.pub2. 16. Jacoby S, Ackerson TH, Richmond TS. Outcome from serious injury in older adults. J Nurs Scholarsh. 2006;38(2):133-140. 17. McClure R, Turner C, Peel N, Spinks A, Eakin E, Hughes K. Falls and fall-related injuries. Cochrane Database Syst Rev. 2006;(1):CD004441. 18. Jemmott L, Jemmott J. Increasing condom-use intentions among sexually active black adolescent women. Nurs Res. 1992;41:273-279.
59
19. Lorig LR, Ritter P, Stewart AL, et al. Chronic disease self-management program: 2-year health status and health care utilization outcomes. Med Care. 2001; 39(11): 1,217-1,223. 20. Gillespie WJ, Gillespie LD, Parker MJ. Hip protectors for preventing hip fractures in older people. Cochrane Database Syst Rev. 2010;(10):CD001255. doi:10.1002/14651858.CD001255. pub4. 21. Sawka AM, Boulos P, Beattie K, et al. Do hip protectors reduce the risk of hip fracture: a systematic review and meta-analysis of randomized controlled trials. Osteoporos Int. 2005;116(1):461-474. 22. Sadigh S, Reimers A, Andersson R, Laflamme L. Falls and fall-related injuries among the elderly: a survey of residential-care facilities in a Swedish municipality. J Community Health. 2004;29(2):129-140. 23. Thapa PB, Brockman KG, Gideon P, Fought RL, Ray WA. Injurious falls in nonambulatory nursing home residents: a comparative study of circumstances, incidence, and risk factors. J Am Geriatr Soc. 1996;44(3):273-278. 24. Gill TM, Williams CS, Tinetti ME. Environmental hazards and the risk of nonsyncopal falls in the homes of community-living older persons. Med Care. 2000;38(12):1,174-1,183. 25. Feinsod FM, Moore M, Levenson SA. Eliminating fulllength bed side rails from long-term care facilities. Nurs Home Med. 1997;5(8):257-263. 26. Hoffman S, Powell-Cope G, Rathvon L, Bero K. BedSAFE: evaluating a program of bed safety alternatives for frail elders. J Gerontol Nurs. 2003;29(11): 34-42. 27. Bowers B, Lloyd J, Lee W, Powell-Cope G, Baptiste A. Biomechanical evaluation of injury severity associated with patient falls from bed. Rehabil Nurs. 2008;33(6):253-259. 28. Stalhandske E, Mills P, Quigley P, Neily J, Bagian J. VHA’s national falls collaborative and prevention programs. In: Henriksen K, Battles JB, Keyes MA, Grady ML, et al., eds. Advances in Patient Safety: New Directions and Alternative Approaches. Vol. 2. Culture and Redesign. AHRQ Publication. No. 08-0034-1. Rockville, MD: Agency for Healthcare Research and Quality; 2008:393-407. 29. Centers for Disease Control and Prevention. Falls in nursing homes. http://www.cdc.gov/ncipc/ factsheets/nursing.htm. Updated 2008. Accessed December 1, 2012.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JNCQ-D-13-00022
November 7, 2013
21:58
J Nurs Care Qual Vol. 29, No. 1, pp. 51–59 c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
Reducing Falls and Fall-Related Injuries in Mental Health A 1-Year Multihospital Falls Collaborative Patricia A. Quigley, PhD, ARNP, CRRN, FAAN, FAANP; Scott D. Barnett, PhD; Tatjana Bulat, MD; Yvonne Friedman, MS, OTR Despite much research on falls occurring on medical-surgical units and in long-term care settings, falls on inpatient psychiatry units are understudied. On the basis of fall injury program characteristics across multiple inpatient psychiatry units, we developed and implemented an operational strategic plan to address each falls prevention program element and enhance program infrastructure and capacity. Expert faculty provided lectures, coaching, and mentoring through biweekly conference calls and collaborative e-mail exchange. Findings support continued efforts to integrate measures to reduce serious fall-related injuries. Key words: fall prevention, fall-related injuries, falls, injury prevention, psychiatry, veterans
A
CONSIDERABLE body of research on falls and falls prevention in hospitals demonstrates that falling is a complex event Author Affiliations: VISN 8 Patient Safety Center of Inquiry (Drs Quigley and Bulat and Ms Friedman) and HSR&D/RR&D Research Center of Excellence (Dr Barnett), James A. Haley Veterans’ Hospital, Tampa, Florida. This material is based upon work supported by the Office of Research and Development, Department of Veterans Affairs, Health Services Research and Development Service award #IIR-03-003-1, and the Patient Safety Center of Inquiry, James A. Haley Veterans Affairs Medical Center. The views expressed in this article are those of the authors and do not necessarily represent the views of the Veterans Healthcare Administration or Department of Veterans Affairs. The authors declare no conflict of interest. Correspondence: Patricia A. Quigley, PhD, ARNP, CRRN, FAAN, FAANP, VISN 8 Patient Safety Center of Inquiry, James A. Haley VA Medical Center, 8900 Grand Oaks Circle, Tampa, FL 33637 (patricia.quigley@va .gov). Accepted for publication: July 8, 2013. Published online before print: October 21, 2013 DOI: 10.1097/01.NCQ.0000437033.67042.63
that typically involves multiple risk factors.1,2 These risk factors involve person-specific intrinsic risk factors, the physical environment, and the riskiness of a person’s own behavior. Patient falls are the most frequent adverse event associated with subsequent injury within the Veterans Health Administration (VHA)3 and are the leading cause of injuryrelated deaths among people aged 65 years and older.4 The 2 most serious fall-related injuries are hip fractures and intracranial hemorrhages.5,6 Although falls on medical-surgical units and in long-term care settings were the focus of extensive research over the years, falls on inpatient psychiatry units are understudied. Based on a 2005 summary report completed by the National Center for Patient Safety (NCPS) National Falls Toolkit Impact Evaluation,7 psychiatry units experienced a lower rate of overall falls but a higher rate of injurious falls than nursing homes or medicalsurgical units. Within the Department of Veterans Affairs, the NCPS reported rates 51
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
52
JNCQ-D-13-00022
November 7, 2013
21:58
JOURNAL OF NURSING CARE QUALITY/JANUARY–MARCH 2014
for major fall-related injuries as part of the National Falls Toolkit Impact Evaluation. The NCPS reported major injury rates for falls in mental health as 0.022 per 1000 bed days of care for 2006 quarter 1 and 0.031 for quarter 2. In addition, the NCPS reported that the percentage of falls with major injury in mental health was 5% in 2004 and it reduced to 3.5% in 2005. This level of injury is of greatest concern, as serious fall-related injuries result in loss of function, loss of life, and financial burden. While not all falls can be prevented, serious fall-related injuries can be eliminated with the use of protective equipment and environmental changes that decrease fall-related trauma. Serious injuries are rare occurrences. This report is the only available one in the VA that separates falls for inpatient psychiatry compared with other settings of care and was used as a basis of comparison for our study. In Veterans Integrated Service Network (VISN) 8 (South Georgia, Florida, and Puerto Rico), the incidence rates in inpatient psychiatry units are second only to those of long-term care (B. Ballot, MD, written communication, July 2009). Further research suggests that inpatients aged 75 years and older and those on geropsychiatry units were more likely to sustain serious fall-related injury (adjusted odds ratio, 2.8; 95% confidence interval, 1.3-6.0).8 Older adults with select mental health and substance abuse problems fall between 1.5 and 4.5 times more than the general elderly population. Psychiatric inpatients having recurrent falls have a significantly longer length of hospital stay than other inpatient populations.9 Furthermore, the odds of a fall-related injury among patients with cognitive disorders such as Alzheimer disease and other dementias were at least 3 times greater than those among the general elderly population and the differential increases with age.10 Increases in total costs resulting from a fall injury were greater among both elderly men and women with mental health conditions or dementia. The substantial burden of fall injuries among elderly with either mental health or substance
abuse conditions suggests the need to direct fall prevention and protection strategies specifically toward this vulnerable population. Fall risk factors among inpatient psychiatry populations are similar to those in longterm care and medical-surgical units.11 These risk factors include history of falls, generalized weakness, confusion or disorientation, difficulty with mobility or walking, elimination problems, and temperature elevation.12 Prior analysis of conditions involving falls suggests that the majority of falls occur when patients are attempting to get out of bed, walk to the bathroom, or change from a sitting to a standing position.12 Prescribed medication in psychiatry presents a unique fall risk. A number of psychotropic drugs including antidepressants, antipsychotic, and sedatives or hypnotics have been associated with increased risk for falls.13 The mechanisms involved include medication-induced orthostatic hypotension, ataxia, psychomotor slowing, and extrapyramidal symptoms.14 RESEARCH EVIDENCE READY FOR TRANSLATION According to a recent Cochrane review, the rate of injurious falls decreased after the introduction of population-based programs focusing on age, diagnosis of osteoporosis or history of hip fracture, and use of anticoagulation therapy.15 During this project, we initiated a number of translational projects in both acute and long-term care settings specifically addressing fall prevention and protection. Over the years, we have received numerous inquiries from psychiatry providers on how best to implement programs in that setting. Because of the risk for harm to self and others introduced by routine technology use in other health care settings (eg, height adjustable low beds with electrical cords), psychiatry staff have difficulty in making decisions about the safe use of technology. In 2009, we hosted an expert panel meeting with identified experts in geriatric psychiatry, psychology, geriatric medicine, nursing,
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00022
November 7, 2013
21:58
Reducing Falls and Fall-Related Injuries in Mental Health ergonomics, patient safety, and physical therapy, and a representative from each of the VHA’s NCPS, VISN 8, and Veterans Health Administration Central Offices to identify needed tools for translating evidence-based fall prevention and safe patient handling to inpatient psychiatry units. While the evidence supporting interventions in inpatient psychiatry is limited, the panel recommended that we customize existing evidence-based interventions from long-term care and medical-surgical units to inpatient psychiatry. Our subsequent strategic plan included developing, testing, and evaluating several best practices in inpatient psychiatry settings. METHODS Participating hospitals All institutions were located in similar metropolitan cities (eg, size, socioeconomic factors) with more than 100 000 veterans serving in their respective catchment areas. Five hospitals participated in this project. Table 1 provides a summary of total beds and inpatient psychiatry beds. Project kickoff In 2010, the VISN 8 project began with all inpatient psychiatry nurse executives and nurse managers invited to participate in the
53
project. For the participating Veteran Affairs Medical Centers, peer leaders and participating staff were identified for each inpatient psychiatry unit. Three projects were implemented simultaneously with concurrent goals of both expanding the program and empowering innovation. Project 1: Fall prevention program customized for inpatient psychiatry The evidence is strong to support multifactorial fall prevention programs for injurious falls in long-term care and acute care.16,17 An Institute for Healthcare Improvement collaborative on the prevention of injurious falls in acute care across 9 hospitals identified the lack of an organizational assessment to examine readiness at the organizational level to prevent serious injurious falls for inpatients as an apparent gap. To fill this gap, members of the Institute for Healthcare Improvement Falls Collaborative developed and pilot tested an organizational assessment tool that quantified the extent of fall and injury program implementation at organizational, unit, and patient levels. Project 1 required validation that the injurious fall prevention organizational selfassessment tool was clear and relevant for use in psychiatry. The original tool was modified for inpatient psychiatry on the basis of content expert
Table 1. Description and Number of Beds by Hospital Unitsa
Hospitals 1. Hospital, long-term care facility, residential treatment program 2. Hospital, tertiary care center 3. Hospital, tertiary care center 4. Hospital, tertiary care center, long-term care facility 5. Hospital and community living facility a Hospitals
Total Inpatient Beds
Total General Psychiatry Beds
Total Geropsychiatry Beds
397
1a: 23
1b: 10
191 348 415
32 50 4a: 40
0 0 4b: 12
390
24
0
1 and 4 contain 2 units each designated as “a” and “b.”
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
54
JNCQ-D-13-00022
November 7, 2013
21:58
JOURNAL OF NURSING CARE QUALITY/JANUARY–MARCH 2014
review from advanced practice nurses, clinical nurse leaders, and mental health chief nurses. After expert revision, the questionnaire was examined for content validity by independent mental health experts and one of the hospitals that was a tertiary care center and had a long-term care facility. Seven staff nurses in psychiatry volunteered to critically examine the clarity and relevance of each question to their practice. Changes were made on the basis of their feedback and then reviewed with the advanced experts for final consensus. The original questionnaire was modified to remove select items, including grab bars, that are not allowed because of suicide risk. The final version was reviewed by VA Research and Development Committee, along with an invitational letter, for distribution to units. This organizational assessment was distributed to all inpatient psychiatry staff by their respective unit nurse managers. Results for each Veteran Affairs Medical Center inpatient psychiatry unit were then reviewed by the project director, with the associate chief nurses, nurse managers, peer leaders, and designated key nursing staff. In addition, common program elements to all units across all hospitals were identified. Common fall and injury prevention program elements that were identified as requiring further implementation across all participating sites were to 1. implement a unit peer leader program, 2. customize use of hip protectors to reduce risk of hip fractures, 3. customize use of floor mats to reduce trauma from bed-related falls, 4. expand patient assessment to include injury risk on admission, and 5. expand patient education to include protection from fall-related injury. Following the identification of program elements, a VISN-wide strategic plan was subsequently developed to address each element and enhance its program infrastructure and capacity. Over the next 6 months (June to December 2010), expert faculty provided monthly lectures on the basis of previously identified strategic needs, with additional
coaching and mentoring through biweekly conference calls and e-mail exchange. The project team consisted of clinical experts and researchers in fall and fall injury reduction program implementation and evaluation. Additional faculty invited to present were fall experts from other Veterans Affairs Medical Centers and patient safety centers and injury centers. These faculty included engineers and injury epidemiologists able to teach about equipment and technology for fall prevention, fall detection and surveillance systems, and fall injury protection, as well as how to use strategies to test change and to spread and sustain implementation. The faculty and topics are listed below: r Geriatrician: Hip protector toolkit. r Nurse scientist/nurse practitioner: Floor mats selection and use, patient education resources, men and osteoporosis, and nonskid flooring and footwear. r Geriatric clinical nurse specialist and falls consultant: Innovations in equipment alarms and wandering technology for fall prevention, detection, and protection. r Occupational therapist: Available raised toilet seats. r Nurse scientist and implementation specialist: Role of peer leaders. r Engineer and researcher: Nonskid footwear and flooring. r Injury epidemiologist and scientist, The National Institute for Occupational Safety and Health consultant: Nonskid footwear and flooring. All education sessions were Web-based, offered virtually by conference call and shared PowerPoint presentation via Web communication. Each program component was subsequently implemented using expert lecture, plans for small tests of change, report of results, coaching, and mentoring. In addition, a follow-up plan over 5- to 8-week intervals based on the principles of Plan, Do, Study, and Act was initiated. Emphasized throughout the program were strategies for patient engagement and improved health literacy. To enhance adoption and spread of program
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00022
November 7, 2013
21:58
Reducing Falls and Fall-Related Injuries in Mental Health
55
elements, we reported results to all participants and shared lessons learned across sites. Thus, the results of the survey from across sites were critical in designing a program that was relevant to all mental health units across our medical centers.
to be helpful to them, and each reported planning to use the peer leader criteria to further expand this role to other nursing shifts. The feedback from the unit peer leaders verified that the Manual was a successful resource for their use.
Project 2: Unit peer leader program for falls
Project 3: Customization of hip protectors and floor mats in psychiatry settings
Peer leadership at the hospital unit level offers the potential to reduce the occurrence of injurious falls by decreasing practice variations. Peer leadership has been successfully used in health contexts, mainly in health promotion for adolescent populations18 and persons with chronic illness.19 Our objectives were to (1) have each unit identify at least 1 volunteer staff member as a unit-based fall prevention peer leader, (2) provide the peer leaders with coaching and mentoring to develop their peer leader skills, and (3) develop and disseminate a toolkit that could be modified for their use at the unit level. Using an expert consensus model, we developed the Peer Unit Leader Program and Toolkit. Two nurses, considered fall experts, drafted this toolkit specific to fall and injury prevention. A draft revision of the toolkit was subsequently presented to additional fall experts and nurse fall prevention champions at the participating Veteran Affairs Medical Centers. Following additional revisions, the peer leader toolkit was disseminated to inpatient psychiatry unit peer leaders for review, comment, trial use, and revisions over a 2-month period. Based on peer leader feedback, final changes were made to this toolkit, and it was then distributed to each unit. We subsequently developed a functional statement for an Inpatient Psychiatry Unit Peer Leader for Fall Prevention and selection criteria. During the initial 3 months of the program, designated peer leaders from each hospital prepared an individualized Peer Unit Manual and Toolkit for their respective units and hospital leadership. For example, peer leaders added their own unit fall policies and procedures to the Manual. All peer leaders found the Manual
As medically fragile patients with multiple medical comorbidities are admitted to VA psychiatry units, staff is faced with the need to reduce injurious falls (fall protection). Two technologies are useful for fall protection: hip protectors and floor mats. Hip protectors
While the evidence of hip protector effectiveness has been mixed, the most recent conclusion is that hip protectors are protective when used in high-risk patient populations at risk for hip fracture.20,21 We educated all sites about hip protector products, implementation methods, and strategies to increase patient adherence, referring all staff to our Hip Protector Toolkit. This toolkit includes prescriptive guidelines, patient adherence interventions, laundering guidelines, and replacement protocols. Floor mats
Although hip fractures in the older adults can result from falls from a standing height, falls from bed account for the majority of falls and injurious falls in institutional22,23 and home settings.24 Height-adjustable beds have become a standard of care in long-term care to reduce the incidence of injuries from falling out of bed. However, the standard for psychiatry settings is a platform bed that cannot be height-adjusted. Psychiatry beds do not have cords and other features that could be used to inflict self-harm, yet they are required for making beds functional from a fall injury prevention standpoint. The demand for safe beds to prevent falls, fall-related injuries, and selfharm is high, yet safe beds are not readily available. Therefore, use of floor mats is critical to
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
56
JNCQ-D-13-00022
November 7, 2013
21:58
JOURNAL OF NURSING CARE QUALITY/JANUARY–MARCH 2014
reduce the trauma that results from a fall to the floor. Floor mats are considered an essential component of any comprehensive injury reduction program in which injurious falls are a concern.25,26 Our prior research attempted to quantify the relationship between bed height and injury risk and protectiveness of floor mats in a laboratory setting using a Hybrid III mannequin.27 Older psychiatry inpatients are at higher risk for fall-related injury than the general older adult population, but floor mats are not used consistently in inpatient psychiatry settings on the basis of the assessment results. We educated all sites about floor mat products, implementation methods, and strategies for acceptance, referring to our Floor Mat Selection Guide. This guide includes impact properties, stability properties, coefficient of friction, thickness, weight, and overall size; use of these is only for those patients at risk for injury if a fall occurs (eg, patients with osteoporosis and those taking anticoagulants). Mental health unit peer leaders of 3 hospitals in our project reported no barriers to use of the products, with 2 of them reporting success with the use of floor mats. At the end of the implementation project, a 2-day meeting was held to bring unit peer leaders together from each site and review results of the postimplementation survey. The meeting allowed each unit to report on its tests of change and progress in expanding use of protective equipment, patient education materials, increased communication, and handoff related to patient fall and injury risks. RESULTS Our program evaluation included both quantitative and qualitative methods. Quantitative methods analyzed changes in organizational fall injury program elements and analysis of fall and fall injury data over time. Qualitative data were extracted from unit reports during a face-to-face meeting from all sites to report lessons learned and interventions adopted.
Postimplementation data analysis was completed in 2011, 1 year after baseline. The final sample included 86 direct care staff responses, of which 77 were usable (89.5%). Because of the small number of responses (range: 1-3) from each unit for the leadership section of the survey, only staff responses were analyzed and compared pre and post implementation. For staff, 41.8% practice on the day shift (8- and 12-hour shifts) and 27.0% practice on the evening/night shift, with 36.2% missing shift information. Changes in level of implementation for each fall injury program component are reported in Table 2 and are based on survey responses. Data analysis revealed changes in pre- and postimplementation survey scores by subscale. Scores ranged from 0 (no activity) to 3 (fully implemented). Improvements were evident in fall injury risk assessment ( + 1.7%) and discharge education ( + 3.0%). The largest positive change was reported for environmental safety to reduce the severity of injury ( + 8.6%), which includes use of hip protectors and floor mats. Presurvey full implementation of hip protectors was reported as 55.8%, the same as after the intervention. Full implementation of floor mats, however, was 24.4% preintervention, and this increased to between 36.3% to 49.0% (P < .001). Falls and fall-related injuries in mental health units The primary objective of this program was to facilitate adoption and integration of fall and injury prevention practices and equipment into mental health units in participating hospitals. Fall rates reported by VA NCPS (4.3 falls per 1000 occupied bed days of care [OBDC]) served as our within-VA comparison reference.28 Falls Cumulative and unit quarterly fall rates (per 1000 OBDC) are reported in the Figure. Fortyfive percent (n = 29 quarters) of the quarterly fall rates were below the lower limit of the NCPS 2004-2006 fall rates (4.3 falls per 1000
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00022
November 7, 2013
21:58
57
Reducing Falls and Fall-Related Injuries in Mental Health Table 2. Average Changes in Staff Reponses per Survey Subscales, Pre and Posta
Items Fall Injury Risk Assessment and Identification Screening for Likelihood of Falling Environmental Safety to Reduce Severity of Injury Post Fall Assessment Discharge Patient/Family Education a Statistical
Range of Scores (No. of Questions)
Pre
Post
Delta (% Change)
P
0-15 (5)
14.0
14.2
0.2 (1.7)
.14
0-21 (7)
18.9
18.8
− 0.1 ( − 0.3)
.95
0-30 (10)
15.0
16.3
1.3 (8.6)
.48
0-12 (4) 0-15 (5)
11.3 10.0
10.9 10.3
− 0.4 ( − 3.6) 0.3 (3.0)
.12 .33
testing was accomplished via paired t tests.
OBDC); 33% (n = 22 quarters) were within this range (4.3-6.6 falls per 1000 OBDC); and 22% (n = 14 quarters) had fall rates reported over the higher rate limit (6.6 falls per 1000 OBDC). Only hospital 3’s mental health unit maintained fall rates between 2 and 4 falls per 1000 OBDC. The mental health unit in hospital 1 reported the highest fall rate for 1 quarter (17 falls per 1000 OBDC), which is still within the reported range for geropsychiatry units.
Fall-related injuries Of the 65 quarters of fall and injury data that were reported, 56 (86.2%) reported injury fall rates. During the survey period, 32 quarters (49.2%) reported fall injury rates between 0.08 and 2.00 or less OBDC, and 13 quarters (20.0%) reported fall injury rates between 2.00 and less than 3.00 OBDC. Fall injury rates of 3.00 or more OBDC were reported in 17% of the surveyed quarters (Figure).
Figure. Average quarterly inpatient mental health fall rates and fall-related injury rates and percentage of falls with serious injury in mental health.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00022
58
November 7, 2013
21:58
JOURNAL OF NURSING CARE QUALITY/JANUARY–MARCH 2014
The quarterly percentage of falls with serious injury is reported in the Figure. The data indicate that in 1 quarter, 70% of the falls that occurred resulted in major serious injury, 3 quarters reported that 50% of the falls resulted in major serious injury, and 50 quarters (76.9%) reported no serious injuries. This finding supports continued efforts to integrate measures to reduce serious fall-related injuries in our VISN 8 Mental Health Unit, with the goal to eliminate hip fractures. DISCUSSION It is important to examine trends in falls, fall-related injuries and percentage of fallers with injury over the most recent 2-year period. When evaluating the impact of the NCPS National Falls Toolkit 2004-2006, these program evaluation measures were key measures specified by the VA NCPS working with our institution. At that time, NCPS separated mental health units as Behavioral Health and provided the first large scale comparative rates for this clinical specialty area in the United States. According to Oliver et al,1 falls are rarely evenly distributed across units in hospitals. In mental health units, this uneven distribution may be particularly apparent, with overall fall rates in the range of 2 to 4 falls per 1000 OBDC. Rates of falls in some geropsychiatry units are even higher. In mental health units, most patients are ambulatory, with the majority of falls occurring while walking. Hospital administrators, clinicians, patient safety
officers, and researchers continually reassess and build on current fall and injury reduction strategies. However, falls and fall-related injuries occur and remain a significant cause of morbidity and mortality among seniors in mental health programs. Successful falls prevention programs typically use a combination of interventions with environmental adaptations, such as assessing patients before and after a fall to identify and address risk factors and underlying medical conditions, educating staff about fall and injury risk factors and prevention strategies, reviewing medications, enabling patients to move safely in their environment, and providing patients with hip protectors and floor mats that may prevent a hip fracture if a fall occurs.29 Given the aging veteran population, we encourage other programs to build on our work with implementation of effective falls prevention programs that focus on protection from injury. While progress is being made, we believe that the percentage of falls resulting in serious injuries can be decreased. Equipment use specifically designed to reduce trauma during a fall, such as hip protectors and floor mats, should be integrated into patient care. Although the risk of suicide among the psychiatry inpatient population is always a concern, a safe balance can be achieved between suicide prevention and protection from serious fall-related injuries by addressing the complex relationships among individual, organizational, and cultural factors, and patients’ diverse and age-specific needs.
REFERENCES 1. Oliver D, Healey F, Haines TP. Preventing falls and fall-related injuries in hospitals. Clin Geriatr Med. 2010;26(4):645-692. 2. Cameron ID, Murray GR, Gillespie LD, et al. Interventions for preventing falls in older people in residential care facilities and hospitals (Protocol). Cochrane Database Syst Rev. 2005;(3):CD005465. doi:10.1002/14651858.CD005465. 3. Office of the DAS for Program/Data Analysis. The Changing Veteran Population: 1990-2010. Washington, DC: DVA. Department of Veterans Affairs Web site. http://www.va.gov/vetdata/veteran_
population.asp. Updated 2000. Accessed December 1, 2012. 4. Centers for Disease Control and Prevention. NCIPC, Fact Book for the Year 2000: Falls Among Older Adults. Atlanta, GA: Centers for Disease Control Web site. http://www.cdc.gov/ncipc/olderadults.htm. Updated 2000. Accessed December 1, 2012. 5. Centers for Disease Control and Prevention. National Center for Injury Prevention and Control. Falls: Older adults. Centers for Disease Control Web site. http:// www.cdc.gov/ncipc/duip/preventadultfalls.htm. Updated 2009. Accessed November 12, 2009.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00022
November 7, 2013
21:58
Reducing Falls and Fall-Related Injuries in Mental Health 6. Wu S, Keeler EB, Rubenstein LZ, Maglione MA, Shekelle PG. A cost-effectiveness analysis of a proposed national fall prevention program. Clin Geriatr Med. 2010;26(4):751-766. 7. Landesman A. Falls Data Collection Project: Participant Newsletter. Ann Arbor, MI: National Center for Patient Safety, Department of Veterans Affairs; October 5, 2005. 8. Fischer ID, Krauss MJ, Dunagan WC, et al. Patterns and predictors of inpatient falls and fall-related injuries in a large academic hospital. Infect Control Hosp Epidemiol. 2005;26(10):822-827. 9. Greene E, Cunningham CJ, Eustace A, Kidd N, Clare AW, Lawlor BA. Recurrent falls are associated with increased length of stay in elderly psychiatric inpatients. Int J Geriatr Psychiatry. 2001;16(10):965-968. 10. Finkelstein E, Prabhu M, Chen H. Increased prevalence of falls among elderly individuals with mental health and substance abuse conditions. Am J Geriatr Psychiatry. 2007;15(7):611-619. 11. Rubenstein LZ, Josephson KR. Falls in nursing homes. Clin Geriatr Med. 2002;18(2):141-158. 12. Tsai YF, Witte N, Radunzel M, Keller ML. Falls in a psychiatric unit. Appl Nurs Res. 1998;11(3):115-121. 13. Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a systematic review and metaanalysis: I. Psychotropic drugs. J Am Geriatr Soc. 1999;47(1):30-39. 14. Bulat T, Castle S, Rutledge M, Quigley P. Clinical practice algorithms: medication management to reduce fall risk in the elderly-part 4, anticoagulants, anticonvulsants, anticholinergics/bladder relaxants and antipsychotics. J Am Acad Nurse Pract. 2008;20(3):181190. 15. McClure RJ, Turner C, Peel N, Spinks A, Eakin E, Hughes K. Population-based interventions for the prevention of fall-related injuries in older people. Cochrane Database Syst Rev. 2005;(1):CD004441. doi:10.1002/14651858.CD004441.pub2. 16. Jacoby S, Ackerson TH, Richmond TS. Outcome from serious injury in older adults. J Nurs Scholarsh. 2006;38(2):133-140. 17. McClure R, Turner C, Peel N, Spinks A, Eakin E, Hughes K. Falls and fall-related injuries. Cochrane Database Syst Rev. 2006;(1):CD004441. 18. Jemmott L, Jemmott J. Increasing condom-use intentions among sexually active black adolescent women. Nurs Res. 1992;41:273-279.
59
19. Lorig LR, Ritter P, Stewart AL, et al. Chronic disease self-management program: 2-year health status and health care utilization outcomes. Med Care. 2001; 39(11): 1,217-1,223. 20. Gillespie WJ, Gillespie LD, Parker MJ. Hip protectors for preventing hip fractures in older people. Cochrane Database Syst Rev. 2010;(10):CD001255. doi:10.1002/14651858.CD001255. pub4. 21. Sawka AM, Boulos P, Beattie K, et al. Do hip protectors reduce the risk of hip fracture: a systematic review and meta-analysis of randomized controlled trials. Osteoporos Int. 2005;116(1):461-474. 22. Sadigh S, Reimers A, Andersson R, Laflamme L. Falls and fall-related injuries among the elderly: a survey of residential-care facilities in a Swedish municipality. J Community Health. 2004;29(2):129-140. 23. Thapa PB, Brockman KG, Gideon P, Fought RL, Ray WA. Injurious falls in nonambulatory nursing home residents: a comparative study of circumstances, incidence, and risk factors. J Am Geriatr Soc. 1996;44(3):273-278. 24. Gill TM, Williams CS, Tinetti ME. Environmental hazards and the risk of nonsyncopal falls in the homes of community-living older persons. Med Care. 2000;38(12):1,174-1,183. 25. Feinsod FM, Moore M, Levenson SA. Eliminating fulllength bed side rails from long-term care facilities. Nurs Home Med. 1997;5(8):257-263. 26. Hoffman S, Powell-Cope G, Rathvon L, Bero K. BedSAFE: evaluating a program of bed safety alternatives for frail elders. J Gerontol Nurs. 2003;29(11): 34-42. 27. Bowers B, Lloyd J, Lee W, Powell-Cope G, Baptiste A. Biomechanical evaluation of injury severity associated with patient falls from bed. Rehabil Nurs. 2008;33(6):253-259. 28. Stalhandske E, Mills P, Quigley P, Neily J, Bagian J. VHA’s national falls collaborative and prevention programs. In: Henriksen K, Battles JB, Keyes MA, Grady ML, et al., eds. Advances in Patient Safety: New Directions and Alternative Approaches. Vol. 2. Culture and Redesign. AHRQ Publication. No. 08-0034-1. Rockville, MD: Agency for Healthcare Research and Quality; 2008:393-407. 29. Centers for Disease Control and Prevention. Falls in nursing homes. http://www.cdc.gov/ncipc/ factsheets/nursing.htm. Updated 2008. Accessed December 1, 2012.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
