School of Public Health and Preventive Medicine
Falls prevention in acute hospitals:
An overview of and update on the
6-PACK project
Anna Barker
6-PACK Chief Investigator
Leader of the Falls and Bone Health Team
Health Services Research Unit
Division of Health Services and Global Health Research
Department of Epidemiology & Preventive Medicine
Overview
The Australian Hospital system
The problem of in-hospital falls
What is the 6-PACK program?
6-PACK project overview
Findings from the 6-PACK project to date:
– Assessing nurse and senior management perceived barriers
and enablers to effective falls prevention in acute hospitals
– Reporting of fall events in hospitals
– Implementation learning from the 6-PACK project
 Where to from here
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THE AUSTRALIAN HOSPITAL
SYSTEM
The Australian Healthcare system
The Australian Hospital system
 Health care in Australia is provided by government
and private organisations
 1 hospital bed per 244 people
 Acute care
 Sub acute / rehabilitation care
 Community based care
– Hospital in the home
– Rehabilitation in the home
THE PROBLEM OF IN-HOSPITAL
FALLS
Question 1.
What proportion of all patient incidents in hospitals are falls?
A. 38%
B. 10%
C. 33%
D. 74%
Question 1.
What proportion of all patient incidents in hospitals are falls?
A.
B.
C.
D.
38%
10%
33%
74%
 In-hospital falls constitute 38% of all patient incidents
» Briggs and Steel 2007
Question 2.
 How many falls are estimated to occur in Australian acute
hospitals each year?
A. 10,000
B. 50,000
C. 100,000
D. 500,000
Question 2.
 How many falls are estimated to occur in Australian acute
hospitals each year?
A. 10,000
B. 50,000
C. 100,000
D. 500,000
 UK falls audit: over 250,000 falls reported each year from hospitals
in England
Falls in the acute hospitals setting
 Between 2 and 12% of inpatients fall
» Coussement J, et al 2008
– 5% of in-patients in 6-PACK trial
»
Barker 2013
 40% of fallers experience harm as a result of the fall
» Krauss et al. 2007
» Fischer ID, et al 2005
 25% of falls result in injury in 6-PACK trial
» Barker 2013
Why are in-hospital falls important?
 Costly to both the individual and the healthcare system:
– ↑ in hospital LOS
»
Bates et al., 1999, Vassallo et al., 2002 , Hill et al. 2006
– ↑ nurse and health professional workloads
»
Corso et al., 2006
– ↑ diagnostic and therapeutic procedures
»
Nurmi et al., 2002
– ↓ patient independence
»
Tinetti et al., 1993
– ↑ need for institutionalisation, rehabilitation and home care
»
Tinetti et al., 1997, Rizzo et al., 1998
Problem solved?
 A recent Victorian study found there was no reduction in the
rates of fall-related fractures in Victorian public hospitals over the
last decade
»
Brand et al., 2010
 Demographics of ageing and rising hospitalisation costs suggest
that the fall burden will escalate in coming decades
The demand for effective fall prevention
programs has never been greater!
WHAT IS THE 6-PACK
PROGRAM?
Investigator meeting
September
1
6-PACK
6-PACK
TNH fall injury rates
Fall injuries ↓ 50%
Falls risk
assessment
9 item tool
TNH-STRATIFY
Risk
management
Risk
reduction
6 nurse
delivered
strategies
Reduction in
fall related
injuries
Care plan
6-PACK
First thing in the
morning
Before all meals
Before going to
sleep
WHAT IS THE 6-PACK PROJECT?
Chief Investigators
Dr Anna Barker
Centre for Research
Excellence in Patient Safety
Associate Investigators
Prof Bob Cumming
A/Prof Caroline Brand
Centre for Research
Excellence in Patient Safety
A/Prof Cathie Sherrington
A/Prof Terrence Haines
Dr Trish Livingston
A/Prof Damien Jolley
Centre for Research
Excellence in Patient Safety
Dr Silva Zavarsek
Centre for Health Economics
Prof Keith Hill
Head School of Physiotherapy
Other Project Staff
Ms Jeannette Kamar
6-PACK Program Facilitator
A/Prof Sandy Brauer
Ms Renata Morello
6- PACK Project Manager
Prof Mari Botti
Ms Fiona Landgren
6- PACK Project Change
Management facilitator
What is the 6-PACK project?
 NHMRC funded $1.2 million cluster RCT
 Aims:
1. Map current falls prevention practice.
2. To investigate the impact of the 6-PACK program on fallrelated injuries.
3. To determine the cost-effectiveness of the 6-PACK
program.
4. To assess effectiveness of the program implementation
including identification of barriers, enablers and
sustainability.
Inclusion criteria
 Acute medical and surgical wards
 Average patient LOS <10 days
 Low-low beds
– ≤1 to each six standard beds on medical wards
– ≤1 each 29 standard beds on surgical wards
 No falls prevention checklist on the DAILY patient care plan
3 year project
2011
6 months baseline data
collection
Fall and fall injury data →
Matching and
randomisation
Barriers and enablers,
Safety culture →
Tailoring of
implementation
2012
12 months RCT data
collection
Falls and falls injuries
Costs
Implementation
Barriers and enablers
Safety culture
2013
12 months sustainability
data collection
Falls and falls injuries
6-PACK FINDINGS TO DATE
Data collection
 Nurse beliefs (N=546)
– Seven hospitals across Australia
• 12 focus group sessions (N=94)
• 44 item survey (N=428)
• Key informant interviews (N=24)
The problem of falls in acute hospitals
remains unresolved
 Many nurses raised falls as the number 1 patient safety
issue on their wards
 Survey results (N=428):
– Only 57% of nurses believe their current falls prevention program is
effective at reducing falls
– Almost 30% think falls are inevitable in older patients and cannot
be prevented
Risk assessment
 Nurses believe risk assessment tools are useful
“When they first get admitted you do go through some of the stuff
that you wouldn’t have known if you didn’t ask those questions.”
Falls risk assessment tools are a useful way of identifying
patients at risk of falling (N=428)
70
60
50
40
30
20
10
0
Strongly disagree
Hospital 1
Disagree
Hospital 2
Hospital 3
Neutral
Hospital 4
Agree
Hospital 5
Hospital 6
Strongly agree
Hospital 7
3
4
Barriers: risk assessment
“Half a day is filling out the paperwork.”
“The issue it raises is complacency, where staff just tick
the same boxes that were done yesterday without really
assessing.”
No clear time when paperwork should be completed
Long tools that were perceived to be inaccurate by
staff
3
5
Facilitators: risk assessment
 Nurses indicated a preference for tools that:
– Were quick and easy to complete
– Used only a two-level ‘high’ or ‘low’ risk
classification
– That were integrated into the documentation that
they viewed and used each shift such as the care
plan
3
6
Facilitators: risk assessment
“We’re often given a sheet of paper and told this has to
be done, but to get people more engaged with doing
it you have to explain to them why and how it would
benefit you as a caregiver.”
Education, audit, reminders and feedback are essential!
3
7
Individual surveillance and observation
for high risk patients
 Nurses voted this as the number 1 strategy to prevent
falls
– Position in high visibility area
“For patients that just constantly get up, if they are sitting
directly in front of the nurses’ desk, they’ll be stopped
a lot more than if they’re in bed way down the
corridor, and by having that high visibility, everyone
sees them and everyone helps.”
3
8
Nurse perceptions …
 Surveillance is an effective strategy
 But…
 Nurses stated that they were uncomfortable
staying in the bathroom with some patients as
they felt it compromised their privacy.
 Nurses also indicated that they believed a
constant patient observer was the most effective
strategy for preventing falls.
 Despite several discussions around falls that had
occurred even when a constant patient observer was
present.
Positioning high falls risk patients in high visibility areas is
an effective way to prevent them from falling (N=428)
70
60
50
40
30
20
10
0
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
4
0
Managing patients with delirium and confusion
was consistently identified by nurses as the
biggest challenge they face with falls
prevention
Targeted management programs for patients with delirium
and confusion are used on my ward (N=428)
70
60
50
40
30
20
10
0
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
Managing patients with delirium and
confusion
“It can be quite challenging; it’s not easy nursing. If
you’ve got people that are really quite delirious it’s
really hard. And it can be quite intensive work.”
4
3
Managing patients with delirium and
confusion
“...you get a lot of elderly patients now that are
confused ... they’re not happy being in a foreign
environment, they don’t want to stay in bed. We have
to get them out of bed but then they are at risk. If they
want to get up they will. That’s what happened to me
just the other week: one patient known falls risk, done
everything you possibly can. I had to take a patient to Xray, I walked out the room; 10 seconds later the patient
was on the floor.”
4
4
Managing patients with delirium and
confusion
 Barriers
– Knowledge and skills
– Access to geriatricians
 Facilitators
– Education
– Access to people with skills and knowledge
– More strategies for managing these patients, eg. diversion
therapy style activities similar to that offered in residential
aged care settings were highlighted as being potentially
useful.
4
5
REPORTING OF FALL EVENTS IN
HOSPITALS
Why is reporting of fall events important?
 Provide feedback to ward staff about:
– Impacts of their falls prevention efforts
– Benchmarking with other wards/hospitals
• Promoting healthy competition
 Identification of patterns, high-risk patients or activities
on your ward

Inform and target falls prevention strategies
–

Identify areas of need
Enhance knowledge translation and practice change
Question 3.
What proportion of fall events are captured in your
incident reporting system?
A. <25%
B. 25-50%
C. 51-75%
D. >75%
Question 4.
What proportion of fall INJURY events are captured in
your incident reporting system?
A. <25%
B. 25-50%
C. 51-75%
D. >75%
Capture-recapture study: Aims
 The aim of this study was to estimate the incidence of
falls in 26 acute wards from seven hospitals using data
from three sources:
– Spontaneous reporting to nurse unit managers
(NUMs)
– Documentation in medical records
– Incident reporting databases
Data collection
 Fall and fall injury data:
– Prospectively collected as part of 6-PACK
– Data sources for capturing fall events
1. Daily medical record audit of all admitted
patients
2. Daily verbal report from the NUM
3. Hospital incident reporting database
Data analysis
 A three-source capture-recapture analysis was
performed to estimate the real number of falls
occurring during the observation period.
 The model was flexible enough to allow dependencies
between sources
– E.g. NUM verbal report and incident reporting
Results
 12,834 patients
 449 unique falls were recorded during the
observation period
 6% (95% CI: 2-14%) of all falls were not reported
via any source
Capture-recapture study: Results
100%
90%
80%
79%
70%
60%
50%
40%
30%
20%
10%
0%
Medical record
Capture-recapture study: Results
100%
90%
80%
79%
70%
58%
60%
50%
40%
30%
20%
10%
0%
Medical record
NUM verbal report
Capture-recapture study: Results
100%
90%
80%
79%
70%
60%
58%
56%
NUM verbal report
Incident report
50%
40%
30%
20%
10%
0%
Medical record
Capture-recapture study: Conclusions
 Falls reporting in acute hospitals is incomplete
 The most commonly used source of fall
events—the incident reporting database—was
the most incomplete
So what?
Incident
reports
Medical
records
NUM
verbal
reports
IMPLEMENTATION LEARNING FROM THE
6-PACK PROJECT
Audience poll
 Does the carrot or the stick drive practice change?
– A. Carrot
– B. Stick
Do you get more flies with honey than vinegar?
Supported implementation strategy
 Assessment of barriers and enablers to successful falls
prevention
– Staff survey
– Focus groups
– Key informant interview
Tailoring of 6-PACK implementation
Change management
 Executive sponsorship
 Local champions
– 2 ward nurses as local champions
– Site clinical leader
 6-PACK change management facilitator
– Train and support the site clinical leader
 Ward walk rounds
– Weekly → fortnightly → monthly
 Audit, reminders, feedback
Risk assessment completed on
admission and updates each shift
100%
90%
Surgical 1
80%
Medical 1
Medical 2
70%
Surgical 2
60%
Medical 3
Medical 5
50%
Surgical 3
40%
Medical 6
Surgical 4
30%
Medical 7
20%
Medical 8
10%
Medical 9
0%
March
April
May
June
July
August
Sept
Oct
Nov
High risk patients have an alert sign and
receive at least one other strategy
100%
90%
Surgical 1
80%
Medical 1
Medical 2
70%
Surgical 2
60%
Medical 3
Medical 5
50%
Surgical 3
40%
Medical 6
Surgical 4
30%
Medical 7
20%
Medical 8
Medical 9
10%
0%
March
April
May
June
July
August
Sept
Oct
Nov
DEC
How to use the carrot most effectively...
 Celebrate the wins
 Highlight the challenge is now to sustain practice
change and positive outcomes
 Identify what is required to sustain change
– Create systems to ensure practice change
continues
 Pick the next goal
 Use some individual case studies to flag areas for
improvement
 We will be back to measure again...
Experience with the stick
 The data is wrong
 Our hospital is different, we have different resources,
we have different patients...
How to use the stick most effectively...
 Feedback must come from a clinician
 Ask questions first
– Why do you think we are seeing what we are?
 Encourage staff to self check ward data via audit
 Cherry pick focus areas
 Time on the floor to identify local problems and local solutions
 Need to keep data simple
 Case studies are very powerful
 Get clinicians to ask questions of the data
 Create a small (no more than 3) non-negotiables
Build capacity
For negative feedback to lead to improvement,
recipients need to believe that they can influence their
performance and control the outcome
» Ilgen & Davis 2000
Diagnose the cause of poor performance
– Knowledge
– Equipment
– Systems
– Resources
– Reminders
– Beliefs
High risk patients have an alert sign and
receive at least one other strategy
Medical 8
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
March
April
May
June
July
August
Sept
Oct
Nov
DEC
Engagement is essential...
“...in trials of audit and feedback health
professionals appeared to be mostly
passive recipients of feedback. They
argue that the effect may be greater if
the health professionals are actively
involved with specific responsibilities and
accountabilities for the change process.”
» Jamtvedt et al. 2006
Caution with the stick
 Take care when morale is low
– Don't ignore bad data...but...
• Partner to help improve things
• Set achievable targets
• Acknowledge differences and tough
circumstances
• Use local examples and create small group
‘huddles’ to workshop ideas for improvements
Key points: Our approach…
 Start with the carrot
– Innocent until proven guilty
– Set new goals
– Reassess
• More carrots or does there need to be some
stick?
Key points: Our approach…
 Engage when presenting data
– Face-to-face delivery
– Ask for perceptions of performance prior to presentation of
results
– Ask for why staff think results are what they are
– Compliment process data with real-life case studies
– Encourage ‘self-checks’/audits
• Experience the problem first hand
• Get all levels of staff involved
– Create milestones
– Review!
So what’s the answer: carrots or sticks?
If you don’t find what motivates
people, i.e. what their carrot is, you
might as well be feeding them sticks.
» Racquel Goddard
Many people believe that getting clinicians to
update their practice is a simple matter of using
carrots (incentives), sticks (punishments) and
sermons (education), yet the evidence
overwhelmingly suggests the process is much
more complex.
Understanding the variables influencing
interventions such as feedback will assist us to
measure the real effect on clinicians’ behaviour
and subsequent patient outcomes.
» Tracey Bucknall 2007
WHERE TO FROM HERE?
Where to from here?
 Implementation challenges
– Changing practice is hard
 The changing demographic of hospital patients
– The ageing tsunami
 Competing demands
 Staffing and resources
 Delirium…the missing link…unmet need