The Texas Medical Center
Council of Nurse Executives
Collaborative Patient Fall Prevention Protocol
Terry Throckmorton, PhD, RN
The Methodist Hospital
Heather Chung, PhD, RN
The Methodist Hospital
Terri Newsom, MS, RN
The Methodist Hospital
Pam Windle, MS, RN, FAAN
ST. Luke’s Episcopal Hospital
Angie Ozaeta, RN, MSN, CPHQ
Ben Taub General Hospital, Harris County Hospital District
Mindy Lawrence, RN, BSN, OCN, CHPN
Houston Hospice
Pam Greene, PhD, RN
The Menninger Clinic
Sandra Cesario, PhD, RN
Texas Woman’s University
Arslee, Mackey, RN, Med
Harris County Psychiatric Hospital
Nena Bonuel, MSN, RN, CCRN, CNS, ACNS-BC
Michael E. DeBakey VA Medical Center (MEDVAMC)
Rosie Pine, PhD, RN
The Methodist Hospital
Hope Moser, MSN, RN, ANP, BC, WHNP, BC, DNP
The University of Texas
Jaya Paranilam, PhD
Statistician
The Methodist Hospital
1
Table of Contents
Topic
I. Introduction
Page
3
II. Background and Significance
4
III. Objectives
6
IV. Inclusion Criteria
6
V.
Methodology
6
VI. Intervention Plan
6
VII. Sample
8
VIII. Interventions
9
IX. Measurement
13
X. Control of Extraneous Variables
13
XI. Data Analysis
14
XII. Power Analysis
14
XIII. Ethical Considerations
15
XIV. Dissemination of Findings
15
XV. References
16
XVI. Appendix A Pre-Fall Huddle
19
XVII. Appendix B Post-Fall Huddle
20
XVIII. Appendix C Patient Survey
24
XIX. Appendix D Guideline for Employee Focus Groups
25
XX. Budget
26
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TMC Collaborative Fall Prevention Research Protocol
Introduction
Although there is no comprehensive patient fall data base for the Texas Medical Center
inpatient institutions, an analysis of incident reports, anecdotal and observational information,
and the continuing emphasis on patient safety led nursing leadership in the major Texas Medical
Center (TMC) institutions to focus the attention of their organizations on the prevention of
patient falls. They appointed an ad hoc research task force in late spring 2009 to examine the
issue and develop a data-based research approach to the problem that would cut across the
organizational and physical characteristics of the several hospitals, the variations in patient
demographics and illness patterns, and the variations in clinical staff management and training.
The research project developed by the task force, and proposed here, will address fall prevention
through four types of interventions: patient education, nursing and other staff education, and
behavioral interventions. As will be shown in the following section, models exist for the
proposed interventions, but none have ever been applied across independent institutions with a
coordinated approach that includes the simultaneous introduction of multiple interventions. The
study design (Table 1) calls for each institution to participate in the interventions over a period of
6 months. The study includes a basic cluster of activities completed by the unit staff including
pre-shift and post-fall huddles, fall risk assessment at frequencies dictated by the admission
assessment of risk, hourly rounding, and patient and family education. Small equipment
additions such as, chair and bed alarms, and yellow indicators of patient fall risk (yellow socks,
yellow arm bands, and room and chart markers) will be used for each patient.
The local significance of this project is indicated by the fact that the Texas Medical
Center institutions involved have dedicated staff time to the study design and the development of
this proposal. In anticipation of approval and funding of the project, they also have committed in
kind contributions in the form of staff time for specific education and training in techniques of
fall prevention and staff time for implementation of the study protocol. The co-investigators
believe that this project will produce benefits for TMC patients and institutions and bring
national recognition to TMC, itself, as a leader in the promotion of concrete steps to improve
patient safety. This is potentially a seminal study, the results of which can be applied in multiinstitutional health care systems nationwide. The experience and dedication of the coinvestigators will ensure that this important study, if funded, will be successfully completed.
The participating institutions are institutions in the Texas Medical Center that provide
acute and long term care to adults with medical, surgical, and psychiatric diagnoses. They
include: Ben Taub County Hospital, Harris County Hospital District (Medical Unit), Harris
County Psychiatric Hospital (Psychiatric Unit), The Methodist Hospital (Medical and Psychiatry
Units), Michael E. DeBakey VA Medical Center (MEDVAMC) (Medical Unit), St Luke’s
Episcopal Hospital (Medical Unit), and the Menninger Clinic (Psychiatric Unit).
Houston Hospice has been an active participant in the development of this protocol and
will continue to participate as a member of the collaborative team. The team will use the results
of this study and other research to design a home-based approach to fall prevention that will be
tested by Houston Hospice. Sandra Cesario, PhD, RN, the College of Nursing at Texas Woman’s
University, is also an active member of the collaboration and has contributed data relative to the
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environmental component of the study. Hope Moser, MSN, RN, ANP, BC, WHNP, BC, DNP,
The University of Texas, has been a member of the planning team and will continue to
collaborate through the implementation of the project.
Background and Significance
According to the Centers for Disease Control (2007), falls are the leading cause of injuryrelated deaths among adults age sixty-five and older and are the most common adverse events
reported in hospitals. In the United States (CDC, 2007), one of every three adults in this age
range falls each year, and about half of those will fall more than once. Falls also threaten the life
span of this age group. Only 50% of those sixty-five or older who suffer a serious fall will be
alive one year later. The monetary cost per patient fall is also an issue. The Centers for Disease
Control reports that, on average, the health care cost of falls is $19,440, three times the $6,259
increment in hospital charges reported below for patients with recorded falls.
The prevalence of falls among inpatients has been reported between 2 to 13 falls per
1,000 patient days (Healey & Oliver, 2006). Fall-related injuries frequently result in a downward
spiral in the patient’s physical health and mental outlook that includes reduction in physical
activities, independence, and confidence (Aronovitch, 2006). Approximately 28% of falls result
in injury, and close to 2% to 4% result in moderate to serious injury, such as facture of the neck
or the femur, increased frailty, reduced mobility (Fischer, Krauss, Dunagan, Birge, & Hitcho,
2005; Krauss, Evanoff, Hitcho & Nguagi, 2005), risk of premature deaths, and premature
admission to nursing homes (Rubenstein & Josephson, 2002/2003). The consequences of falls
extend beyond the obvious physical injury and emotional responses and include increased health
care costs. Carroll, Delafuente, Cox & Narayanan (2008A), in a retrospective study, examined
the direct medical care expenditures related to older adults who sustain a fall injury. They found
that hospital charges were $6,259 more than comparable hospital bills for non-fallers.
Hospital falls affect patients of all ages and admitting diagnoses and many happen when
the patient is alone or trying to get to or from the bathroom or maneuver in the small area of the
bathroom (Hitcho, et al., 2004; Oliver, Daly, Martin: McMurdo, 2004; & Krauss, et al., 2007). In
most hospitals, patients are routinely assessed for the potential to fall as well as other important
clinical measures on admission and at intervals during their stays in the hospital. Based on these
assessments, extensive protocols are put into place to prevent patients from falling; however, in
spite of best efforts, patients continue to fall. Hence, it is clear that preventing patient falls
requires more than assessment and vigilance on the part of nurses (Oliver, 2008; Perell, Nelson,
Goldman, Luther, Prieto-Lewis, Rubenstein, 2001; Eagle, Salama, Whitman, Evans, Ho, Olde,
1999). Patients fall for different reasons, sometimes unrelated to the variables listed on fall risk
assessment forms. It is clear that prevention of falls and prevention of injury when patients do
fall require behavioral and environmental interventions as well as creative thinking to arrive at
new solutions that meet patient needs and also satisfy Joint Commission and Centers for
Medicare and Medicaid Services requirements for patient care.
Falls in hospitals are not limited to older adults. While the prevalence of falls in older
patients can be as high as 40-46% of older patients admitted (Selgado, Lord, Ehrlich, Janji, &
Rahman, 2004), falls in general patient populations across all age groups have been estimated to
be approximately 2-12% (Vlahov, Myers, & al-Ibrahim, 1990; Mahoney, 1998). Risk factors for
4
falls include age, gait or balance impairment, sensory or cognitive impairment, medication
effects, environmental hazards, and whether the patient has previously fallen.
Patients admitted with psychiatric disorders are also at risk for falls, but the causes of
their falls may be less predictable than for adult patients admitted with medical or surgical
conditions. The incidence of falls for psychiatric patients tends to be higher with rates estimated
at 13.1 to 25 per 1,000 inpatient days (Blair and Gruman, 2005). The increased incidence may be
attributed to high rates of cognitive disturbance, behavioral manifestations, including agitation
and wandering, and use of psychotropic drugs (Angalakuditi, 2007; Tideiksaar, 2005). Blair and
Gruman (2005), in their six month review of patients on a 28 bed psychiatric unit found that age,
level of activity, and high levels of anti-psychotic drugs were predictors of falls with the high
dose drugs presenting the strongest correlation. Diagnosis was not significantly related to the
incidence of falls. The relationship between medications (hypnotics, psychotropics,
antidepressants, cardiovascular agents, and diuretics) and falls was also supported in studies by
Joo, et al. (2002) and Tinetti (2003). The side effects of these types of drugs, such as unsteady
gait and hypotension, can also easily predispose patients to falls.
Assessment, evaluation, and prevention of patient falls are significant challenges for all
organizations and professionals that take responsibility for the care of patients. Lacking in most
preventive programs is consistency of implementation by the staff, having an appropriate bundle
of preventive interventions, and partnership with the patient and family.
While it is clear that preventing falls among patients requires a multifaceted approach,
previous studies have primarily been focused on one “facet” at a time (Bourgault, et al., 2008;
Giles, Bolch, Rouvray, et al., 2006; Haines, Bennell, Osborne, et al., 2001; Healey, Monro, &
Cockram, et al., 2004; Quigley, et al., 2009; Schwendimann, Milisen, Buhler, et al., 2006; Studer
Group, 2009; Tideiksaar, Feiner, & Maby, 1993) rather than a coordinated, approach with
multiple interventions in multiple patient care settings. Research supports the use of fall
prevention programs, clusters of caregiver activities, and alert systems for use across institutions
and across age groups and diagnoses. Successful fall prevention requires a major focus from all
caregivers and consistency in application of the interventions. The patient and family must be
aware of the risks and participate in the fall prevention program. The purpose of this study is to
evaluate the outcome of clusters of activities and education when they are implemented
consistently across multiple institutions and patient groups with collaboration among disciplines
and patients and families.
In our review of the literature, we found no published studies in which separate
institutions collaborated to design, implement, and evaluate a cluster of fall prevention activities
with varied groupings of patients. Representatives from each institution in this collaborative
research study have actively participated in the study design and have worked and negotiated
together to arrive at an evaluable cluster of fall prevention activities that reflects available
research and the collective experience in designing the interventions to be evaluated in this
seminal study. The design of the Studer Group study which involved hourly rounding in separate
institutions was the closest to the design of this project (Studer Group, 2009).
5
Objectives for this Study
Our study has three objectives as listed below. The time line and study design table
illustrate how they fit together to achieve the objectives. (Tables 1 and 2.)
1.
2.
3.
To evaluate a fall prevention program using a cluster of caregiver activities and alert
systems for use across institutions and across and diagnostic groups.
To determine if there is a difference in the fall rate prior to and after a fall prevention
program using a cluster of caregiver activities and alert systems for use across institutions
and across diagnostic groups.
To determine the predictive value of each of the core factors on the fall risk assessments.
Inclusion Criteria
All patients admitted to the designated units of the participating hospitals will be included
in the study. Patients will be admitted to four medical units, one general hospital psychiatric unit,
one psychiatric hospital unit, and one residential psychiatric unit.
Methodology
Design
This study will use a multi-group repeated measures design to determine the differences
in fall rates prior to, during, and after implementation of a cluster of fall prevention methods.
Focus groups will be used to assess staff perceptions of the protocol. Patient perspectives will be
assessed using a short questionnaire asking them to rate how well the steps of the fall prevention
program have been implemented.
Inter-Institutional Fall Prevention Study Intervention Plan (See Table 1)
Pre-Study (1 to 3 Months)
Assessment of room sizes, configuration
Submission of Fall Risk Assessment tools and modifications
Summary of all fall prevention practices currently in place
Summary of the 6-month pre-study fall rate for each unit
Purchase and installation of fall packets (socks, flyer, wrist band, chart, and door markers).
Video and booklet development (hard copy of video content for hospitals without
video capability)
Education of all appropriate staff
Training of institution coordinators
Presentation of the study on each unit in as many sessions as needed to cover all staff
Distribution of laminated pocket cards and unit flyers with an outline of study steps
Follow-up e-mail and unit staff meeting reminders and updates
Ongoing monitoring and reminders from the institutions’ designated coordinator
Purchasing of Alert Systems (Fall Prevention packs and Alarm Systems) and training on their
use
Day 1 (Beginning on day 1 for each admission)
Admitting Patient Fall Risk Assessment
Assignment of Risk Level
Installation of bed/chair alarm alert systems
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Implementation of Fall Prevention Cluster
All patients and families will view or read the educational information on fall prevention for
patients and families under direct observation
RNs will discuss the education using a standard format and evaluate the understanding of
patients and families by asking them to repeat the information in their own words
Pharmacists will review medications for effects and medication schedules that may
predispose patients to falls
Pre-shift fall huddles will be performed for all patients regardless of admission risk score
Patients at medium to high risk will wear yellow slip prevention socks and wrist bands and
have their rooms and charts marked to indicate fall risk
Hourly Rounding with attention to all patient needs and emphasis on the three Ps (pain,
position, potty) will be implemented
Assist patient to the bathroom
Address pain
Position the patient
Post-fall huddles will be implemented for all patients who fall
Shift Patient Fall Risk Assessment with reassignment of risk level will be implemented as
indicated
Daily (Daily for each patient for six months)
Pre-shift huddle for all patients whose shift assessments were at medium or high risk
Shift Reassessments for Fall Risk with reassignment as indicated
Hourly Rounding
Reinforcement of patient and family education
Reminders to all staff members of their roles in fall prevention
Post-fall huddles and assessment of compliance with the fall prevention interventions will be
implemented for all patients who fall
Upon Discharge
Patients or family members will be asked to complete a brief survey regarding the fall
precautions discussed with them on admission and applied by the staff.
Table 1: Inter-Institutional Fall Prevention Study Flow Table
Pre-Study Admission
(1 to 3 Mos.)
 Assessment of room sizes, configuration
x
 Submission of Fall Risk assessment tools
x
 Summary of current fall prevention practices
x
 6-months of pre-study fall rates for each unit
x
 Purchase and installation of fall packets
x
 Purchase and installation of bed/chair alarms
x
 Video and booklet development
x
 Education of all appropriate staff
x
 Admitting Patient Fall Risk Assessment
 Pharmacy Medication Review
x
7
Daily
(1-6 Mos.)








Assignment of Risk Level
Implementation of Fall Prevention Cluster
Pre-shift huddle for all patients
Shift Reassessments for Fall Risk with reassignment
as indicated
Hourly Rounding
Reinforcement of patient and family education
Reminders to all staff members of their roles in
fall prevention
Post-fall huddles and assessment of compliance with
the fall prevention interventions will be implemented
for all patients who fall
Table 2 Inter-Institutional Fall Prevention Study Timeline
Months 1-3
Months 4-9
Staff Education
Implementation of Bundle
Video and Booklet Development
Monthly Fall Rates
Past six months fall rate
Analysis of Fall Reports
Room dimensions and equipment
Compliance Monitoring
Purchasing of bed/chair alarms
Monthly Staff Focus Groups
Discharge Patient Survey
Collections
Staff focus groups related to
perceptions of the process
and recommendations
x
x
x
x
x
x
x
x
Months 10-12
Data analysis
Sample
One unit from each institution has been selected based on the types of patients admitted
to the unit and the ability of staff to implement the cluster of activities. One additional unit from
The Methodist Hospital was selected to serve as a third psychiatric unit representing units within
general hospitals and to increase the number of psychiatric patients in comparison with the
number of medical patients. Each hospital has agreed to significant in-kind investments in this
study in terms of the time of the co-investigator/site coordinator, time of staff away from the unit
for training, time of the staff for additional incremental assessments, and additional time for
patient and family education. In addition, staff members from each of the institutions will
contribute to the development of the video and booklet for patient and family education.
Depending on the occupancy rates during the study period, each unit has the potential to
admit 40 to 60 or more patients per week to the selected unit. The estimated potential number of
patients assessed and participating in the fall prevention strategies for six units over a six-month
period is expected to range from 960 to 1440. Data collection will probably continue for nine
months to ensure that an adequate number of falls are recorded.
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Interventions
This section includes a description of the interventions and measurements of the study.
The study is based in the inpatient setting and involves a cluster of caregiver behaviors and fall
prevention alerts (yellow socks, arm bands, door alerts and bed alarms).
The staff for each unit will be educated on the implementation of the fall prevention
bundle and will be given a protocol to follow. The protocol will include all assessments
(admission, pre-shift, within shift, and post-fall). All disciplines that provide service to those
patients (pharmacists, lab technicians, transporters, physical therapists, occupational therapists,
dietitians, housekeepers, chaplains, etc.) will be educated about fall prevention and their roles in
the process. Flyers will be developed for posting in the rooms to remind patients and staff about
fall risk. Directors and nurse managers will be educated on the required supervision to ensure
that staff members consistently implement each tool in the bundle. A study coordinator for each
institution (co-investigator for this study) will serve as a facilitator for this process. In addition to
the tasks delegated to staff, patients and families, when possible, will be asked to review a
specially developed educational booklet or video outlining fall risks in the hospital and their
partnership with the staff in preventing falls. The intervention will last for six months. A central
study coordinator will interface with each institutional coordinator, collect, summarize, and
analyze the data.
Fall Prevention Cluster
Fall Risk Assessment
Fall Assessment will be completed on admission using each individual hospital assessment tool.
Each of these tools includes a common core of items specific to potential to fall plus a few
additional items specific to the institution. Patients at low risk will be reassessed each shift.
Patients at moderate risk will be reassessed twice each shift and patients at high risk will be
reassessed every two hours. Fall precautions will be re-defined based on the reassessments.
Pre-Shift Huddle
Pre-Shift Huddles (Chung, personal communication, April 21, 2009) will occur prior to each
shift to focus additional attention on patients who have the most potential to fall or patients who
have had a change in status. The predisposing issues to address will include:
History of Falling
Has fallen in the hospital
Weakness/Balance
Confused/Dementia/Delirium
Diuretics/Greater than 50cc/hr IV
Laxative
Narcotics/Hypnotics/Psychotropics/Antidepressants/Cardiovascular Agents
Patient Controlled Analgesia Pump
Sedative/Hypnotics
Low Hemoglobin&Hematocrit/Anemia
Low Sodium
Orthostatic Hypotension
Hypoglycemia
Dehydration/Malnourished
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Dizziness (Ask)
Age (All age groups)
Visual Impairment
Pain Level
(See Appendix A for form.)
Hourly Rounding
Hourly rounding involves a visit by the Hospital Aide or Registered Nurse to evaluate and
address any patient needs with an emphasis on pain management, toileting (potty), and
positioning (Three Ps). This strategy was developed and evaluated by the Studer Group (2009)
using data from 27 nursing units in 14 hospitals across the country. The results of consistently
checking on patient needs reduced patient falls by 50%, while satisfaction scores improved.
Critical to the success of the process is consistent application of the eight behaviors of hourly
rounding. The eight behaviors of hourly rounding are:
1. Use key words in the opening conversation to reduce anxiety.
2. Accomplish scheduled tasks.
3. Address the pain, potty, position (3Ps).
4. Address other comfort needs.
5. Conduct an environmental assessment. Place needed items within reach.
6. Ask whether there is anything else you can do. Indicate that you have time.
7. Indicate when you will be back.
8. Document the round.
Post-Fall Huddles
Post fall huddles (Quigley, et al., 2009) were developed at the James A. Haley Veterans’
Administration Hospital, Tampa, Florida. With funding from Robert Wood Johnson Foundation,
the Post-Fall Huddle was evaluated as a means to assess all aspects that may have led to a patient
fall while the information is still clear in the minds of staff and the patient who fell. The
procedure requires that staff and patient gather within 15-30 minutes to assess and discuss the
fall. Post-fall huddle information that is reviewed includes:
Location and time of fall
Staffing
Environmental hazards
Patient activity at time of fall
Fall risk factors
Medication recall of 12 hours prior to fall
Post fall assessment findings
Recommendations for future prevention (See Appendix B).
Pharmacy Medication Review
Patients at risk for falls because of the timing of medications will be reviewed by the RN and
pharmacist on admission to determine a schedule that will be less likely to result in falls. For
example, patients scheduled to receive a diuretic BID at 9AM and 9PM will be rescheduled to
receive the diuretic at 6AM and 6PM. The types of drugs and the potential for falling will also
be addressed so that all staff can be alerted (Pennsylvania Patient Safety Advisory, 2008).
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Patient/Family Education
Hospital falls often occur because the patient is unaware of the risk for falling, underestimates
the impact of treatment on function, or has a strong need to be independent. Family members
may also be unaware of the potential for falling and patients often fall with the family member
present. Incorporating patients and families into the team makes them more aware of the
potential for falls and how to prevent them (McGreevey, 2006). Demonstration of understanding
will be evaluated using teaching with return demonstration asking the patient and family to
repeat the information back to the RN in their own words (Weinrich, S.P., Weinrich, M.C.,
Boyd, M.D., Atwood, J., Cervenka, B., 1994). In the event that the patient is unable to
participate in this process and a family member is not available, the patient’s condition will be
documented. Data from these patients will be analyzed as a separate grouping. A small poster
from the tool kit will be posted on the wall alerting the patient and family of the potential for
falls.
Fall Tool kit: yellow wristband/socks/dots/signage
Visible systems to alert nurses and other staff that patients are at risk for falls have been accepted
practice in hospitals for a number of years. However, when staff members move from one
hospital to another, the colors associated with the various alerts differ. In an effort to avoid
confusion, Texas has joined the national trend toward standardized wristbands. Yellow was
selected as the color for fall risk because of its association with ‘caution.’ Patients in this study
who are at moderate to high risk for falling will have yellow socks and armbands and yellow
dots on the chart and door for fall risk (United States Department of Veterans Affairs, 2009).
Bathroom Supervision
Data from the participating hospitals and the literature (Agency for Healthcare Research and
Quality, 2004) support the high incidence of falls when patients are trying to move to or from the
bathroom or around in the bathroom. Part of the hourly rounding process is to assist patients to
the bathroom and stay with them until they are returned to bed. All staff will be educated to
remain with patients any time that they are in the bathroom and assist them back to bed. Staff
will be advised of approaches to protecting the patient’s privacy without jeopardizing safety.
Ancillary staff and family will also be trained to alert nurses or hospital aids when patients who
are at risk for falls are witnessed walking to the bathroom or other areas unattended.
Equipment
Bed/Chair Alarms/Alarm Pads
Bed/chair alarms serve as alerts to staff when they are not in the room with the patient that the
patient is getting out of the bed. They alarm at the nurses’ station so that anyone who is free can
immediately attend to the patient. The alarm and pad are used together as one unit.
Educational Program
All nursing staff on each unit will be educated on the fall prevention bundle, and the
purpose and use of the cluster, the alert systems, and the patient education materials (See Table 3
for a complete list of the education modules for staff members). All interdisciplinary staff
members who interface with the patient will be educated on their roles in preventing falls. This
group will constitute the unit fall prevention team in collaboration with the patient and
family/friends.
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Table 3: Staff Educational Modules
1. Purpose of the Study
2. Known Fall Risks
3. Role of each care provider in the study
Explain how each discipline will participate in the study
4. Data to be collected
Fall incidents
Patient fall risk assessment
Fall Huddle Data
Pre-Shift and Inter-Shift Huddles
Hourly rounding records
5. Interventions
Fall risk assessment tools
Fall packets
Purpose
Contents
How are they used
Where to get additional packets
Use of alarms and monitors
When they will be used
How to use them
Alarm and Pad placement and activation
Pre-shift huddles
What are they
Importance to study
Hourly rounding
What is done
What is recorded
Importance to fall prevention
Post-Fall huddles
What is accomplished during huddle
What is recorded as data
Shift fall reassessments
Purpose
When
What data are recorded
6. Data storage protocol
The educational program for the patient and family will incorporate the Joint
Commission Patients as Partners (Joint Commission Resources, 2006) concepts in the prevention
of falls. The videotape and booklet used with the patients and families will be the result of
collaboration among the hospitals to develop the best patient video/booklet. The final version
will include the best of all of the submissions as judged by the co-investigators and the media
advisors. Criteria will include: incorporation of the Patients and Families as Partners concept,
12
culturally sensitive or neutral, discussion of the enhanced potential to fall in the hospital, and
description of the fall prevention program. Reviewers will also consider language level,
presentation, and flow of the content. Staff will be advised to focus on a product that is
culturally sensitive. The patient population in The Texas Medical Center is diverse in culture and
religious preference. The video and booklet should be as neutral as possible. A multicultural
panel will review the video prior to production. This project development is designed to engage
staff in the fall prevention process. Covered content will include the role of patients and families
as partners in care and safety, the unfamiliar environment, treatment side effects, unfamiliar bed
and railings, differences in flooring and lighting, design of the bathroom, and the interventions
included in the study. (See Table 4)
Table 4: Patient/Family Information
1. Present and explain
The importance of fall prevention in the hospital
Implications of falls
Why falls may be more likely to occur in the hospital
Unfamiliar environment
Treatment side effects
Unfamiliar bed and railings
Difference in flooring and lighting
Design of the bathroom
How falls can be prevented (CDC Information)
Principles to follow in the hospital and at home
2. Role of patient and family members in preventing falls
Measurement
A baseline of fall rates will be completed using the National Database of Nursing Quality
Indicators (NDNQI) definition of a fall. NDNQI defines a fall as: “An unplanned descent to the
floor, either with or without injury to the patient/resident/client” (ANCC, 2008). Fall rates are
calculated by the total number of patient falls times 1,000 divided by the total number of patient
days. Fall rates will be measured monthly for six months prior to the study, at baseline, each
month for six months, and at the end of the implementation period. Each institutional coordinator
will monitor compliance with the fall prevention cluster. Incident reports generated after falls
have occurred will include a checklist of the prescribed items in the fall prevention cluster as
well as the standard information required by the institution. Compliance with the fall prevention
cluster will be assessed at each of the respective institutions. Focus groups will be used to assess
staff perceptions of the fall prevention program. A short Likert-type scale will be used to assess
patient perceptions of their experience of the fall prevention cluster activities.
Control of Extraneous Variables
Each institution will submit a description of the rooms on the participating unit (room
blueprint) including:
 size of the rooms and bathrooms
13
 distance from the bed to the bathroom
 setup of the room in terms of position of the bed in relation to the bathroom door
 position of the toilet in relation to the bathroom door
 position of the sink in relation to the toilet and bathroom door
 any fall prevention equipment already in place
 all fall precautions currently in place in the hospital
The fall assessment tool used by staff will also be recorded along with any changes made
to the tool for that institution. The patient population will be described in terms of diagnosis,
usual care, and identified issues related to falls. All fall assessments will be tabulated for each
patient. For all patients who fall, the last fall assessment prior to the fall will be reviewed to
determine whether the patient’s score indicated a high risk for falling. The pre-fall score will be
compared to the post-fall huddle information.
Data Analysis
Data on falls will be analyzed for the entire project and for each institution. Trend lines
will be developed for the overall study and for each institution. Differences in the extraneous
variables in relation to the trend lines will be descriptively reviewed. Logistic Regression will be
used to determine the combination of variables that best predicts why patients fall. Odds ratios
will be calculated for each variable in the admission fall risk assessment and pre-fall huddle.
Descriptive data on the implementation process and compliance with the algorithm will be
collected and analyzed in relation to each unit’s fall data. Focus groups with the staff will be
conducted to evaluate the process in terms of impact on workflow, time expended, and perceived
cost/benefit. These data will be reviewed by two independent reviewers for common words and
themes. The analysis from each of the two investigators will be reviewed for agreement and rereviewed until agreement is reached. Staff members will then be asked to review the results to
determine whether they are consistent with their thoughts about the process. At discharge,
patients will be asked to complete a short survey regarding their perceptions of the fall
prevention activities during their hospital stays. These data will be compared with the
compliance data and fall data. The statistician from The Methodist Hospital will oversee the data
analysis.
1. To determine if there is a difference in the fall rate prior to and during a fall prevention
program using a cluster of caregiver activities for use across institutions and across
diagnostic groups.
Trend lines will be used to visualize the trends before and during the intervention.
A Friedman 2-way ANOVA by ranks will be used to determine whether the differences
in fall rates before, during, and after the intervention are significant.
2. To determine the predictive value of each of the factors on the fall risk assessments.
Logistic regression will be used to determine which factors best predict fall occurrence.
3. To determine staff perceptions of the fall prevention activities.
4. To determine patient perceptions of degree to which they experienced each of the fall
prevention activities.
Power Analysis
Logistic Regression Power Analysis
A logistic regression of a binary response variable (Y) on a continuous, normally distributed
14
variable (X) with a sample size of 1000 observations achieves 91% power at a 0.05000
significance level to detect a change in Prob(Y=1) from the value of 0.070 at the mean of X to
0.101 when X is increased to one standard deviation above the mean. This change corresponds to an
odds ratio of 1.500. With a potential of 60 patients per unit per week and seven units, the potential to
accrue 1,000 patients is clear.
Odds
R
Power
N
P0
P1
Ratio Squared
Alpha
Beta
0.90516
1000
0.070
0.101
1.500
0.000 0.05000 0.09484
(Hsieh, Block, & Larsen, 1998).
The focus group data will be taped and entered into a secure data base. Common words, phrases,
and themes will be derived by two independent analysts. The themes will be reviewed until
there is agreement between the two analysts. The patient perception scale is based on the steps in
the prevention cluster. It was reviewed by a panel of five experts with 100% agreement on the
content and clarity of the items. The patient perception scale data will be entered into a secure
data base and frequencies and percents will be calculated for each item. Coefficient alpha will be
calculated to determine internal consistency.
Ethical Considerations
All fall rates collected in this study will be delinked from any patient identifiers. The
institutions will also be coded. Fall risk assessments and post fall huddle data collected during
the study will be coded to allow for matching of assessments per patient over time. Assessments
and fall huddles will be tracked along with hourly rounding documentation to evaluate
compliance. Post fall huddle data will be linked by code to the assessment data and delinked
from the caregivers involved with the fall. The code sheets and data will be kept in a locked file
cabinet in the primary investigator’s office. Upon completion of the study, the code sheet will be
destroyed. The only identifier that would link patients to the study once it is completed would be
a consent form. A waiver of consent will be requested from the Internal Review Board. This
protocol will be submitted for review by the Internal Review Board for Protection of Human
Subjects at each of the respective institutions as per the institutional policy. Data will be entered
on a secure, password protected computer for analysis.
Dissemination of Findings
Results of the study will first be presented to the Texas Medical Center Council of Nurse
Executives with the goal of sharing this information with the administration of all institutions in
the medical center. This group includes representatives from the health care institutions as well
as the universities. Therefore the findings could impact curriculum, creating an early awareness
of fall prevention, as well as direct care.
Abstracts will be submitted in response to calls for abstracts from nursing medical and
nursing psychiatric professional associations as well as to those from management and health
care quality organizations. Articles for publication will be written related to the process of
collaboration and the study. This seminal study may also serve as a basis for a future annual
Texas Medical Center Forum on the Status of Fall Prevention.
15
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18
Appendix A
Pre-Fall Huddle
Appendix B.
Post-Fall Huddle
19
Appendix B
Post-Fall Huddle
Situation
When and where
Time of day fall occurred:_________
During change of shift?
 Yes
 No
Staffing:
 Full staff
 Shift understaffed by (how many?)____
 Some staff unavailable due to __________________ (e.g., breaks,
emergency on unit)
Where did the fall occur?
 Pt/ resident room
 Pt / resident bathroom
 Hallway
 Other:___________________________
Environment
If in patient room, check items that were out of the person’s reach
 Call light
 Phone
 Kleenex box
 Food tray
 Waste basket  Assistive device (cane, walker, glasses,
hearing aid)
Other:_____________________________________
Hazardous foot wear:
 Yes:_____________________________________
 No
Trip hazards?
 Clothing
 Shoes: ill-fitting / untied laces
 Tubing / cord
 Obstructed path to bathroom
 Other:__________________________
 None
20
Evidence of slippery floor?
 Yes
 No
Was lighting in the room adequate?
 Yes
 No
Was there equipment malfunction?
 Tab alarm
 Bed rails
 Other:__________________
Activity
What do we think this person was doing at the time of the fall?
 Getting up on own
 Trying to get to the bathroom
 Trying to get (where)____________
 Reaching for something
Leaning on something
Other: _________________________
When did you last see this person?
What was the person doing when last seen?
Ask the person: “What happened this time that was different from all the
other times you have done this activity?
Background
Fall risk factors (check all that apply):
 Impaired mobility
 Impaired mentation
 Impaired / altered elimination patterns (nocturia, urgency, frequency,
diarrhea, incontinence, laxative, bowel prep)
 Dehydration
 Impaired communication / sensory (vision, hearing, neuropathy)
 Impaired vital signs (fever, slow or fast heart rate, low blood pressure)
 Prior fall history (at home, previous facility, or during this stay)
 Takes anticonvulsant
 Takes tranquilizer
 Takes psychotropic / hypnotic
21



Takes benzodiazepine
Medication changes within the past 2 days from what to what
Diagnosis-related
o Hypotension
o Hypoglycemia
o Parkinsons
o Other:___________________________________
Meds received in the 12 hours prior to the
fall:___________________________________________
(May print out med sheet, highlight meds received in previous 12 hours, and
attach)
Assessment
If diabetic, check glucose (glucometer). Result:_______________________
Injury:
 None
 Minor:___________________
 Moderate:___________________
 Severe:______________________
Why do you think this happened?
Recommendation
What can we do to prevent this from happening again? Care plan
recommendations:



Hourly
rounding
Oxygen tubing
mgmt
Toileting plan

Alarm


Improve w/c positioning


Remove equipment from
path to BR
Remove clutter from
room
Non-slip footwear

Hip protectors

Move to room closer to
nurses’ station
Identify items pt wants
close to them
Fall precaution indicators
In place

22


PT eval


OT eval

Use call system to listen
in room
Removable lap tray on
w/c



Other:
Patient education re: risk /
strategies
Family education re: risk /
strategies
Pharmacy review of meds
Post-fall checklist
 Perform post-fall monitoring, including neurologic checks if evidence /
suspicion of head injury
 Revise plan of care to include prevention strategies based on HUDDLE
findings
 Communicate fall and increased risk to physician, next shift, other
healthcare team members, family if applicable
 Copy this sheet and keep on unit
 Fill out pt safety report and attach original of this sheet to it
23
Appendix C
Patient Survey
Please read the following questions and circle the number below the word or phrase that
best describes your response.
Strongly Disagree Neutral
Disagree
Agree
Strongly
Agree
1. I was given information
2.
3.
4.
5.
about fall prevention when
I was admitted.
The staff visited my room
every hour to check on me.
The staff checked on my
bathroom needs as often as
I needed.
The staff placed my call
light, TV remote and other
needed items within easy
reach.
The staff responded in a
timely manner to my call
light.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
6. The staff made an adequate
effort to prevent me from
falling while I was in the
hospital.
24
Appendix D
Staff Focus Group Guide
1. How effective have you been in implementing the fall prevention cluster?
2. What effect is this process having on workflow?
3. How much time do you spend in implementing the cluster?
4. Do you think that the benefit of this program in preventing falls is valuable?
5. What changes would you make to this program for future use?
Questions will be added as they arise in the focus groups.
25