Corrine Abraham DNP, RN
Clinical Assistant Professor, Emory NHWSN
Coordinator for EBP & Innovation, Atlanta VAMC
IMPROVE
VISION - ANALYSIS
Leadership &
will to transform
SUSTAIN
Map &
Measure
Team &
Aim
Leadership &
Alignment top
to Bottom
Change
Feb 2013
July 2013
Spread Change
Over Time,
Transformation
Aug 2014
National Incidence of Falls
 3% - 20% of inpatients fall at least once 1
 Falls are the 6th most commonly reported sentinel event. 2
Consequences of Falls
 20% - 30% suffer injuries that ↑ their risk of early death.3
 Leading cause of injury-related death for adults over 65 yo.4
 Fractures most common and costly injury.5
Cost of Falls

↑ Length of stay, ↑ rates of discharge to institutional care, ↑
resource use 3-4,6
National Imperative
 National Patient Safety Goal - TJC 7
Serious Reportable Event - NQF 8
No reimbursement – CMS 9
Local Priority
Atlanta VAMC: Vulnerable population - many fall
related risks
Solution
1,10-11
 Multifactorial assessment & management effective
 Success associated with multidisciplinary team
 Tailored interventions can prevent injury
 Local
Priority: Preventing falls and fall related injury will decrease
expenditures and enhance patient safety as well as the organization’s
accountability to provide quality care
 Problem
Statement: In FY2013 (through May) the hospital
reported more than twice the national rate of falls with serious injury.
Two units had rates that exceeded the hospital average as well as the
national average of VHA hospitals of comparable acuity and size
Team
Aim
Map
Measure
Change
Corrine Abraham, RN, DNP, VAQS
Kelly Fripps, RN, Health Promotion
Sandra Thomas, RN, QA, Acute Care
Penny Gunter, RN, Education
Laurie Moore, RN, GNP, Long Term Care Ken Murphy, RN, Informatics
Heather Batchelor, MD, Hospitalist
Abebe Abera, RN, CNL, Acute Care (AC)
Gara Coffey, Pharm D, Long Term Care
Casey Hill, RN, Assistant Manager, AC
Deshondra Green, Pharm D, Acute Care
Sandra Dukes, RN, DNP, CNS, AC
Renee Browning, PT, Long Term Care
William Greene, RN, Mental Health
Beth Allen, PT, Acute Care
Kim House, MD, Long Term & Home
Care
Sponsor: Sandy Leake, RN, MSN,
Associate Director, Nursing and Patient
Care Services and Chief Nursing Officer
The goal of the quality initiative was to decrease
the rate of falls/injury by mitigating modifiable
risk factors and enhancing inter-professional
collaboration.

To reduce rates of falls on 8 Palliative at
Atlanta VAMC by 50% from a rate of 4.47 to 2.33 by July
2014
◦ To have zero injurious falls on 8 Palliative at Atlanta VAMC

To reduce rates of falls on 9 Surgical at Atlanta VAMC by
50% from a rate of 1.28 to 0.64 by July 2014
◦ To have zero injurious falls on 9 Surgical at Atlanta VAMC
 Electronic data bases
 Chart audits & queries
 Patient interviews (VOC)
 Health team member
interviews (VOC)
 Direct observation of care
 Surveys
 Organizational
 Workflow
patterns
 Circumstances
 Pattern
 Current
capacity
of falls
of fall events
processes
18
100.0%
16
90.0%
14
12
10
8
6
4
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
Primary Reason
Cum
20.0%
2
10.0%
0
0.0%
ePER Data (Jan – Feb)
 Outcome
Measures
Fall rate
Injury rate
Priority Area
Interventions 12 - 17
Documentation of
Risk
Standardize Communication
Electronic documentation templates
Staff Education &
Accountability
Monthly Resident orientation
Annual Staff Education
Accountability
Patient Education
Standardize Patient Education process
Individual Risk
Factors-
Modify Fall Risk Assessment process
Modify Post-Fall note
Environmental/equipment modifications
7
6
Injurious fall
Sustain
Phase
9 Surgical
8 Palliative
Improvement
Phase
5
4
3
2
1
0
Q1 12 Q2 12 Q3 12 Q4 12 Q1 13 Q2 13 Q3 13 Q4 13 Q1 14 Q2 14 Q3 14 Q4 14 Q1 15 Q2 15
77%
Assess
lower
extremity
strength
Provider Ordered Interventions
N = 81
62 %
Initiate fall
prevention
in-patient
referrals
58 %
Evaluate
orthostatic
hypotension
0%
Evaluate for
osteoporosis
15 %
Initiate fall
prevention
community
referrals
19 %
Document
history of falls
35% Assess
vision
N = 26
Lessons Learned
Implications for Spread
Risk
Standardizing communication → ↑ collaboration
Communication: Electronic note template → tailored interventions
Accountability:
Audits with feedback → ↑ accountability
Involvement of leaders → accountability
Patient
Education:
Team involvement → ↑ patient education
Individual Risk
Factors:
Injury Risk stratification → Identifies vulnerability
Electronic version → ↑ consistency
Education pamphlet → standardizes & ↑ tailoring

Relative advantage

Compatibility

Complexity

Trialability

Observability

I would like to acknowledge team members who
partnered in this initiative
◦
◦
◦
◦

Sponsor: Ms. Sandy Leake, CNE
Fall Prevention Sub-committee
Medical Residents: H. Batchelor, V. Pragya, A. Allen
MPH Student: E. Bredenberg
and colleagues who provided guidance & support
◦ National Collaborative (NCPS): Virtual Breakthrough Series
◦ Patient Safety Committee, Atlanta VAMC
◦ VAQS: Site faculty
1.Clyburn T, & Heydemann J. Fall prevention in the elderly: Analysis and comprehensive review of methods used in the
hospital and the home. J Am Acad Orthop Surg. 2011;19(7): 402-409.
2.ECRI Institute. Healthcare risk control: Falls. March; 2009; ECRI Institute: Pymouth Meeting, PA. www.ecri.org
3.Centers for Disease Control. Costs of falls among older adults. 2013;Author: Atlanta, GA .
http://www.cdc.gov/homeandrecreationalsafety/falls/fallcost.html
4.Curry L. Fall and injury prevention. In Patient Safety and Quality: An Evidence-based Handbook for Nurses. April 2008;Agency
for Healthcare Research and Quality, Rockville, MD.
http://www.ahrq.gov/professionals/clinicians-providers/resources/nursing/resources/nurseshdbk/index.html
5.Stevens, J A, et al. The costs of fatal and non-fatal falls among older adults. Injury prevention. 2006;12(5):290-295.
6.Wu S, Keeler E B, Rubenstein L Z, Maglione M A, Shekelle P G. A cost-effectiveness analysis of a proposed national falls
prevention program. Clin in Geriatr Med. 2010;26(4):751-766.
7.The Joint Commission. Preventing patient falls. 2013; Joint Commission Resources: Oakbrook, IL
http://www.jcrinc.com/Preventing-Patient-Falls/
8.National Quality Forum. Serious Reportable Events in Healthcare–2006 Update. 2006; Author: Washington, DC.
www.qualityforum.org
9.Centers for Medicare & Medicaid Services. Hospital-Acquired conditions.2012;Author: Baltimore, MD.
http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HospitalAcqCond/index.html?redirect=/HospitalAcqCond
10.Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Inpatient fall prevention programs as a patient safety strategy: A
systematic review. Ann Intern Med. 2013;158:390-6.
11.Oliver D, Healey F, & Haines TP. Preventing falls and fall-related injuries in hospitals. Clin in Geriatr Med. 2010; 26:
645- 692.
12.Agency for Healthcare Research and Quality. Preventing Falls in Hospital Falls: A Toolkit for Improving Quality of Care.
2013;AHRQ: Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/fallpxtoolkit/index.html
13.Institute for Healthcare Improvement. Transforming Care at the Bedside How-to Guide: Reducing Patient Injuries from Falls.
2012;Author: Cambridge, MA
http://www.ihi.org/knowledge/Pages/Tools/TCABHowToGuideReducingPatientInjuriesfromFalls.aspx
14.Minnesota Hospital Association. Road Map to a Comprehensive Falls Prevention Program. In Patient safety: Call to
action. 2011. Author. http://www.mnhospitals.org/Portals/0/Documents/ptsafety/falls/falls-prevention-roadmap.pdf
15.National Quality Forum. Safe practice 33: Falls prevention. In: Safe Practices for Better Healthcare–2010 Update. 2010.;
Author: Washington, DC. www.qualityforum.org. Accessed November 15, 2013:381.
16.Neily J, Quigley P, & Essen K. Implementation Guide for Fall Injury Reduction: VA National Center for Patient Safety Virtual
Breakthrough Series: Reducing Preventable Falls and Fall-Related Injuries. 2013; VA National Center for Patient Safety:
Washington,DC. http://www.patientsafety.va.gov/
17.VA National Center for Patient Safety. Falls toolkit. 2004;Department of Veterans Affairs: Washington, DC.
http://www.patientsafety.va.gov/professionals/onthejob/falls.asp#fallsnotebook

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Baseline assessments
Examples of interventions
Audit results
Standardize data reporting
Random Chart Audits

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
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

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Date of Audit
Age
Admitting Diagnosis
Morse Score on Admission
Fall Risks Identified Accurately
Injury Risk Stratification
Injury Risks
Communication of Risk - DAR
Documentation of Tailored
interventions
Documentation of Pt Teaching Individual Risk
Nursing Re-assessment Accurate
Provider Assessment
Standardize education process
Veteran Interviews

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Inter-professional Rounds

Accurately report fall risk

Top Reasons at Risk
3 main reasons fall prevention is
important
◦
Falls for most part are preventable
◦
Falls can result in injury
◦
Falls can make hospital stay longer
◦
Learn risk factors
◦
Call for help
◦
Wait for help
◦
Unfamiliar places increase fall risk
◦
BR are small & it is easy to lose balance or get dizzy
3 actions to stay safe:
Two reasons to ask for help when going
to bathroom
The main purpose to use call light is: to
ask the staff for help
Locate call light: At bedside & in
bathroom
The main reason to wear non-slip
footwear
Pharmacist has not identified at risk
Over emphasis on policy
Six Sigma Fishbone or medsCause-and-Effect
fordizziness
4P’s (Plant, People,
Policies
side effects that cause
leading
to burnout and
or confusion leading to fall
non-adherence
to best
and Procedure)
Physician not attuned to assess and
intervene to mitigate modifiable fall risk
factors leading to ↑ chance of fall &/or
injury
Patient behavior (confusion, impulsiveness,
Unrealistic estimation of abilities) leads to
unassisted ambulation
Injurious
Falls
Staff not able to respond quickly (e.,g due
to understaffing) leading to patient not
waiting for assistance
Policy cumbersome to read, no
method of assuring accountability,
and limited resources for
enforcement leading to sub-optimal
implementation of fall prevention
Team members not aware of policy
and not educated about the roles &
responsibilities for implementing
fall/injury prevention
Vulnerabilities & Opportunities
Overcrowded & cluttered room creates
obstacles causing unsteadiness or trips that
lead to falls and /or surfaces leading to injury
sixsigmatutorial.com
practices
Lack of proper equipment e.,g., bedside
commode, elevated toilet sear , prompts walk
to BR and/or bending reaching that ↑ chance
of falling
Limited resources ,sitters to adequately
supervise
patients leading to unassisted position
changes
increasing chance of falls
Lack of assistive PT equipment and
protective equipment requiring patients
to ambulate or transfer unassisted and
potentially falling and getting injuried
Pt identified as at risk for fall and not
stratified for injury risk decreasing
likelihood that medical team is consulted
about intervening to prevent injury
Patient not educated on their risk and
why it is important to comply with
prevention strategies leading to
decreased likelihood that preventive
steps taken
Fall precautions overused
decreasing sensitivity and
decreasing use of
individualized interventions
to prevent falls and/or
injuries
Point
Value (Risk American Hospital Formulary
Level)
Service Class
3 (High)
Analgesics,* antipsychotics,
anticonvulsants,
benzodiazepines†
2
(Medium)
Antihypertensives, cardiac
drugs, antiarrhythmics,
antidepressants
1 (Low)
Diuretics
* Includes opiates.
Score
≥6
†
Comments
Sedation, dizziness,
postural disturbances,
altered gait and balance,
impaired cognition
Induced orthostasis,
impaired cerebral
perfusion, poor health
status
Increased ambulation,
induced orthostasis
Higher risk for fall; evaluate
Although not included in the original scoring system, the falls toolkit team recommends that you include
patient
non-benzodiazepine sedative-hypnotic drugs (e.g., zolpidem) in this
category.
Beasley B, Patatanian E. Development and implementation of a pharmacy fall prevention program. Hosp
Pharm 2009;44(12):1095-1102.
Provider Fall Evaluation Note
Fall Risk Evaluation
• Pertinent Medical History
• Identification of Risk Factors
• Interventions linked to Fall & Injury risk
• PT consult
• OT consult
• PharmD consult
• Orthostatic VS
• Enhanced surveillance
• Toileting assistance
• Injury prevention
Post Fall Evaluation
• Date of last known fall
• Assessment for injury
• Identification of factors contributing to fall