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  • Preventing hospital falls: balancing vigilance, autonomy,

    cost and gravity. Ronald I. Shorr, M.D., M.S.

    Geriatric Research Education and Clinical Center (GRECC), Malcom Randall VAMC

    University of Florida

  • Today’s talk

    • Comments on some new findings and upcoming U.S. studies relevant to falls among community dwelling older adults.

    • Falls in hospital • “Under the hood” of two of our groups projects

    • Bed alarms

    • Effect of “No Pay” regulation on falls and physical restraint use

    • Thoughts on future directions for fall prevention research

  • PCORI/NIA multi-center fall prevention trial

    • $30M/5 years

    • 80 group practices/6,000 subjects

    • Main outcome: Fall Injuries

    • Intervention: Risk assessment + nurse “fall care managers” to develop and deliver evidence-based prevention plans tailored to the specific risks of each individual and to monitor patients’ outcomes in consultation with their primary care providers.

    • Control: Risk Assessment + educational materials

  • Fall Prevention 2016

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    January February March April May June July August September October November December

    Monthly Falls

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    January February March April May June July August September October November December

    Monthly Falls

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    January February March April May June July August September October November December

    Monthly Falls

  • Action Plan 1

    • Purposeful Hourly Rounding bed huddle presentation (all staff) and PowerPoint presentation

    • Leadership purposeful rounding (Kim @8am, Denisha @10am, Katie @12pm and Ro @2 and 4pm) If you will not be present (AL, meeting, etc.)for your rounding hour we will ensure someone is doing the rounding in your place. During leadership rounding we will ask staff (RN and NA) any issues/concerns with patient care, is charting up to date, PRNs cleared, address missing meds, and offer support to assist them.

  • Evaluation

    ….Our Purposeful Hourly Rounding Pilot has already shown some positive results! Thank you all so much for your feedback and input. I can’t wait to see the lasting impact this is going to have. If everyone truly does hourly rounding and follows the guidelines discussed below and in the power point using the 4P’s you will DEFINITELY see a reduction in falls and an increase in staff patient interaction that will also reduce the number of call lights….

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    January February March April May June July August September October November December

    Monthly Falls

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    January February March April May June July August September October November December

    Monthly Falls

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    January February March April May June July August September October November December

    Monthly Falls

  • Action plan 2

    • Bed alarms in-service and check off (all staff)

    • Post fall huddles with staff directly involved and present at bed huddle the for all teams to review fall prevention measures.

    • Veteran Companion cards for sitters and the NAs

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    January February March April May June July August September October November December

    Monthly Falls

  • Fall Rate

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    January February March April May June July August September October November December

    Monthly Falls

  • Workload

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    January February March April May June July August September October November December

    Monthly Falls

  • Scope of the Problem of Falls in Acute Care

    • In US about 1,000,000 falls annually (2% of hospital inpatients fall)

    • 11,000 Deaths/year

    • Increased LOS

    • Bad publicity

    • Litigation

  • Special considerations in US

    • Acute care hospitals • Short LOS

    • Limited specialized geriatrics services

    • Few empty beds

    • CMS regulations

    • Litigious environment

  • Falls and injurious falls

  • Hospital Falls Conceptual “Box Model”

  • A less refined model

  • Distraction: Major Fall Risk Factor?

  • Fall Prevention: Major Fall Risk Factor?

  • Merging of Interests

    Geriatric

    Medicine

    Pharmacoepidemiology

    Quality of Care

  • Early work

    • Fall evaluation “service”

    • Case/Control study on restraint use and falls.

  • Trial of Proximity Alarms

    • Funded by NIH (National Institute on Aging)

    • Cluster RCT 16 Nursing Units-Single Hospital

    • Primary Aim: Determine whether proximity alarms reduce falls by 25%

    • Secondary endpoints • Injurious falls

    • restraints

  • Limitations of Previous Research

    • Incident reports

    • Difficulty controlling for patient as well as unit-specific factors

    • Inadequate sample size

    • Tracking adherence

    • Restriction to older populations

    • Definition of “acute-care”

  • Proximity Alarms

  • Intervention

    • Main point: Let CLINICAL JUDGEMENT prevail—but make alarms “easy to use.”

    • Implementation team rounds • Alarms on a cart delivered to nurses

    • Administration encouragement and buy-in

    • In services on alarm use all shifts and days with frequent refreshers

    • 24/7 trouble shoot

    • Not a falls intervention service

    • Round on control units as well to keep visibility of study high

  • Implementation Rounds

  • Fall Evaluators

    • Interview with patient and/or witness

    • Assessment • Orthostatic vitals

    • 10 orientation items on MMSE

    • CAM

    • Interview with nurse

    • Environmental assessment • Tubes/lines

    • Restraints

    • Alarm

  • Covariates (at unit level)

    • Demographic (age, gender, insurance)

    • Staffing (RN, NA, LPN)

    • Fall risk (from EMR)

    • Psychotropic Drug (from BILLING)

  • Intervention and Control Units

  • Findings

    • Intervention successfully increased the use of bed alarms.

    • Compared to control units, we found NO change in: • Falls

    • Injurious falls

    • Fallers

    • Restraint use

  • Why didn’t alarms prevent falls?

    • Alarm issues • False positives (ringing causes patients and staff to turn off)

    • False negatives (patient on floor before alarm goes off)

    • Staff issues • Alarm fatigue

    • False sense of reassurance

  • Health Care Acquired Complications (HACs)

    • On 10/1/08 Medicare stopped allowing hospitals to “upcode” for care related to 8 “preventable conditions”

    • Regulation changes have been successful in achieving desired goals (e.g., OBRA-87).

  • Rosenthal M. N Engl J Med 2007;357:1573-1575

    “Never Events”

    • Retained object in surgery

    • Air embolism

    • Blood transfusion incompatibility

    • CAUTI

    • Pressure Ulcers

    • CLABSI

    • Mediastinitis after CABG

    • Fall with injury

  • How to prevent falls?

    “… we believe these types of injuries and

    trauma should not occur in the hospital, and

    we look forward to …identifying research…

    that will assist hospitals in following the

    appropriate steps to prevent these conditions

    from occurring after admission…”

  • Non Payment inpatient claims ICD-9 Codes

    • comorbid condition (CC) or major comorbid condition (MCC)

    • fractures (ICD-9-CM code range 800 through 829)

    • dislocations (ICD-9-CM code range 830 through 839)

    • intracranial injury (ICD-9-CM code range 850 through 854)

    • crushing injury (ICD-9-CM code range 925 through 929)

    • other and unspecified effects of external causes (ICD-9-CM code range 991 through 994).

  • Did the intervention “work?”

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    Before After

    Bad Thing

  • Did the i

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