Gates Fallslit R
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Slideshow from 2010 Dimensions in Geriatrics conference in May and November 2010, addressing current literature and evidence-bassed practice in preventing patient falls.
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Gates Fallslit R
- 1. The Elements of Patient Fall Prevention: A Literature Synthesis Damon Gates, BSN, RN, CCRN-CMC Evidence-Based Practice Fellow Staff Nurse, H4200 Medical Cardiac Intensive Care Heart Hospital Abbott Northwestern Hospital Minneapolis, MN
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Notas do Editor
- In my role as Evidence-Based Practice Fellow, I'm examining the extent to which Abbott Northwestern Hospital's Fall Prevention Program reflects the most current research. While my focus is on inpatient acute care, I believe there are principles that are applicable to any practice setting.
- That there is little consensus concerning optimum fall prevention strategies will become glaringly apparent when we start discussing the literature.
- My initial selection of documents yielded a stack more than 4 inches thick, with 168 separate references. I was able to narrow that to 67 references as I attempted to narrow the field based on the question, “What does this tell us we need to change about ANW's current fall prevention plan?” Even with that, it becomes very easy to conclude that “anything will work” or “nothing will work.” Most of the literature describes a program a facility put in place, and what kind of result they saw as a result. In most cases, the program is successful, at least initially. Few studies document the effectiveness of the program for longer than 12 months, and fewer still show sustained success over the course of years. The number of assessment tools available is truly legion! They range from the carefully, prospectively validated to the home-brewed “it just feels right.” There are also published arguments that none of the available tools are adequately tested to be of any use, so why bother? However, even within this morass of conflicting data, there are some themes common to successful programs. It is my belief that when programs address all of these issues, optimal patient fall prevention results. As we proceed, I invite to consider your facility's fall prevention program, and consider how well it stacks up.
- My initial selection of documents yielded a stack more than 4 inches thick, with 168 separate references. I was able to narrow that to 67 references as I attempted to narrow the field based on the question, “What does this tell us we need to change about ANW's current fall prevention plan?” Even with that, it becomes very easy to conclude that “anything will work” or “nothing will work.” Most of the literature describes a program a facility put in place, and what kind of result they saw as a result. In most cases, the program is successful, at least initially. Few studies document the effectiveness of the program for longer than 12 months, and fewer still show sustained success over the course of years. The number of assessment tools available is truly legion! They range from the carefully, prospectively validated to the home-brewed “it just feels right.” There are also published arguments that none of the available tools are adequately tested to be of any use, so why bother? However, even within this morass of conflicting data, there are some themes common to successful programs. It is my belief that when programs address all of these issues, optimal patient fall prevention results. As we proceed, I invite to consider your facility's fall prevention program, and consider how well it stacks up.
- My initial selection of documents yielded a stack more than 4 inches thick, with 168 separate references. I was able to narrow that to 67 references as I attempted to narrow the field based on the question, “What does this tell us we need to change about ANW's current fall prevention plan?” Even with that, it becomes very easy to conclude that “anything will work” or “nothing will work.” Most of the literature describes a program a facility put in place, and what kind of result they saw as a result. In most cases, the program is successful, at least initially. Few studies document the effectiveness of the program for longer than 12 months, and fewer still show sustained success over the course of years. The number of assessment tools available is truly legion! They range from the carefully, prospectively validated to the home-brewed “it just feels right.” There are also published arguments that none of the available tools are adequately tested to be of any use, so why bother? However, even within this morass of conflicting data, there are some themes common to successful programs. It is my belief that when programs address all of these issues, optimal patient fall prevention results. As we proceed, I invite to consider your facility's fall prevention program, and consider how well it stacks up.
- Many falls prevention programs address some of these elements. Very few address them all. However, only those that do address them all have a high level of sustained effectiveness.
- A number of studies have demonstrated that the judgment of the clinician is at least as accurate at identifying patients at risk for falls as any assessment tool. However, delving deeper into the data shows that this is true only for the experienced, expert nurse. The reason tools are needed is we can't guarantee expert assessment 24/7. A tool also helps focus attention on fall risk, and makes assessment for it systematic. However, it's important to use a tool that is appropriate to your patient population. Granted, this often starts with a “best guess,” but can't stop there. How can you make the best “best guess”? Pick a tool, and learn how to use it correctly. Then go around your facility, to a variety of areas, and see if it works on the broadest variety of patients. Do you get a result consistent with expert observation of reality? Once you select a tool, rigorous training is needed, with regular refreshers. Even the best tool is useless if it is used inconsistently or incorrectly. Remember, you're selecting a tool, not getting married to it. If you find a tool isn't working in your situation, find a better tool!
- One of the bigger bugaboos is using the tool correctly. Some of the problem is the user, some of it's the tool, and a lot of it is the system. At Abbott, we used the Hendrich 2 scale. Unfortunately, it is not set up in Excellian to assure correct use, especially in ICU. When we have a patient who is sedated and paralyzed, the “Get up and go” test should be scored as “0,” because it can't be assessed. Usually they are scored “4,” because they can't stand without assistance, and end up being identified as high fall risk. If the only way a patient will fall is if we drop them, they aren't a fall risk! Part of the problem is the system: “Unable to assess-0 points” isn't an option. Part of the problem is the tool, in that it didn't come with that option built-in, even though Ann Hendrich herself has written that's what should happen. Part of the problem is our unwillingness to work around these shortcomings to use the tool correctly. How do we know we are using the tool correctly? This requires ongoing monitoring. We need to monitor the tool's results to assure inter-rater reliability. If a patient's condition is unchanged, the results obtained by different caregivers should be consistent. We also need to make sure the results are consistent with expertly assessed reality. By “expertly assessed” think “clinical specialist.” While data collected after a patient fall often includes this information, how often to we actually look at the patient's fall risk score before the fall had occured? Statistical monitoring of this information allows us to evaluate the predictive power of the tool we use. Ideally, every patient who experiences a fall has been previously identified as being at high risk.
- So we've identified the patient at risk, now what? We select interventions that work. It's easier said than done, for a number of reasons. When we've identified a patient as being at high risk for falls, we don't start with one intervention, see if it works, add another, see if it works, and so on. We select several interventions that “seem to make sense” from a long, not well-organized list and start them all at once. Assuming we're using the tool correctly and the patient is indeed at high risk, and they don't fall, we can never really be sure which intervention worked. The exception is if we pilot a single intervention, in addition to the usual stew of interventions we select. One of our telemetry units saw a marked decrease in falls when they decided to activate the bed exit alarm for all patients identified as high falls risk. However, such clear results are rare. What is often lacking is consideration of “why might this patient fall?” What are the specific contributing factors? This would allow us to...
- All of our interventions fall into two categories: decrease the number and intensity of fall risk factors, and interrupt behaviors that increase the patient's risk of falling. This takes some careful, critical thinking. For example, “altered elimination” is often cited as a falls risk factor, but why? A unit treating ambulatory Alzheimer's patients recognizes that when a patient gets up to the bathroom, he voids en route, then slips and falls. While supervised regular toileting helps, non-slip footware proves optimally effective. A med-surg unit finds it's because a patient is willing to brave the risks in a desperate attempt to get to the toilet. Different interventions are called for, depending on the nature of the urgency. Five bucks says no one has tried this: “Here is your call light, please call for help if you need to get up to the toilet. Someone will come and help you as soon as possible. If no one comes soon enough, and you can't hold it any longer, can you promise me that you'll go in the bed?” Of course, that long list of interventions doesn't make things easier. Perhaps we can borrow a page from Infection Control, and have universal and risk-specific interventions, such as balance precautions or strength precautions.
- Do your housekeepers know what to do around patients who are at high fall risk? Your dietary personnel? Your respiratory therapists? Tranditionally, fall prevention has been “nursing's job,” to the extent that patient falls are a “nursing-sensitive outcome.” If part of your falls risk intervention is “frequent observation,” they need to be observed by everybody! The first step is to make sure everyone knows what a patient needs to stay safe, within seconds of encountering a patient. Clever, evasive symbols don't cut it, spell it out! This is no more a compromise of confidentiality than a “protective precautions” sign. Second, facility staff with even transient patient contact need to have role-specific training for patient falls prevention. Finally, empower families and other visitors by welcoming them to your Falls Prevention Team, and teach them their role in preventing falls not just for their loved one, but for all patients. I would love to place a big mirror in the front lobby, with a sign saying, “Welcome to the Abbott Northwestern Falls Prevention Team!”
- Finally, we must monitor our effectiveness.