CAPTURE

Collaboration and Proactive Teamwork Used to Reduce Falls

Fall Risk Assessment: Best Practices for
Nursing Staff in the Acute Care Setting
December 11, 2012 10:00 – 11:00 a.m. CST

Regina Nailon RN, PhD, Clinical Nurse Researcher

The Nebraska Medical Center
Deborah Conley, MSN, APRN-CNS, GCNS-BC, FNGNA
Gerontological Clinical Nurse Specialist
Nebraska Methodist Hospital
 Acknowledgement

This project is supported by grant

number R18HS021429 from the Agency
for Healthcare Research and Quality.
The content is solely the responsibility
of the authors and does not necessarily
represent the official views of the
Agency for Healthcare Research and
Quality. 2
 Learning Objectives
• Review baseline data from 2011 hospital survey
specific to fall risk assessment/communication.

• Discuss published fall risk assessment tools.

• Conduct a fall risk assessment.

• Review main points and questions from

attendees.

3
 Part I: Introduction and Background

Introduction to Best Practices

in Fall Risk Assessment

4
 Fall Reduction
• Fall risk has been reduced in studies where
interprofessional team members were actively
engaged in fall risk reduction efforts. (Gowdy and
Godfrey, 2003; Szumlas et al, 2004; von Renteln-Kruse and Krause,
2007)
• An interprofessional team (vs. nursing only
strategy) and use of benchmarks are associated
with sustained improvement (Sulla and McMyler, 2007;
Krauss et al, 2008; Murphy et al, 2008)

5
 Evidence Based Practice...What is it?

“The integration of best research evidence with clinical

expertise and patient values”
-Sackett et al., 2000, p.1
 Donabedian’s Framework to Assess Quality
• Quality occurs within the context of patient care:
– Structure: infrastructure in place to support care
provision (human resources, policy/procedures,
equipment, environment)
– Process: actions taken to reduce fall risk (follow
policy/procedures for fall risk reduction program,
prevention interventions, staff/patient education)
– Outcome: fall rate/1000 patient days; injury fall
rate/1000 patient days

Structure Process Outcomes

(Donabedian, 1980)
 2011 Falls Survey in NE Hospitals
• Examined structures-processes-outcomes
related to fall risk reduction.

• 70 of 83 general community hospitals in NE

responded (84%)
– 47 of 65 CAHs (72%)
– 13 of 18 non-CAHs (72%)

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 Definition of Fall / Fall Risk
• A fall is any unplanned descent to the floor
with or without injury (NDNQI, 2012).
• Injury levels can range from minor (bruising)
to major (fracture, death).

• What is fall risk?

9
 Baseline Survey Findings 2011
• Hospitals with a fall risk reduction team had
the lowest fall and injury fall rates compared to
hospitals where one person or no one was
accountable for implementing a fall risk
reduction program.
• 39% (N=22) of critical access hospitals (CAHs)
(<25 beds) that responded to the survey had
either one individual or no one accountable for
implementing a fall risk reduction program in
their hospital.
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Fall Risk Reduction Strategies: Structures
Do you use a validated, unmodified
tool to assess fall risk?

• Of 15 hospitals with no one

accountable for Fall
Reduction, 33% (5) used a
valid tool.
• Of 16 hospitals with one
individual accountable, 50%
(8) used a valid tool.
• Of 39 hospitals with a team
accountable, 56% (22) used
a valid tool.

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 Fall Risk Reduction Strategies: Processes
Does your team provide fall risk reduction education to staff via
annual competency training and new employee education?

100 • Of 15 hospitals with no one

% of Hospitals by Team Structure

90 accountable for Fall

80 Reduction, 0% provided
70 education.
60 • Of 16 hospitals with one
Nobody (n=15)
50 individual accountable, 13%
40
Individual (n=16) (2) provided education.
28 Team (n=39)
30 • Of 39 hospitals with a team
20 13 accountable, 28% (11)
10
0
provided education.
0
Yes 12
 Discussing Fall Risk in Daily Care
Do patient care staff from multiple disciplines discuss patients’
fall risk in the context of daily care?

100 • Of 15 hospitals with no one

% of Hospitals by Team Structure

90 accountable for Fall

80 Reduction, 14% (2)
70 discussed fall risk.
60
50 Nobody (n=15) • Of 16 hospitals with one
50
40 Individual (n=16) individual accountable, 25%
30 25 Team (n=39) (4) discussed fall risk.
20 14 • Of 39 hospitals with a team
10 accountable, 50% (19)
0 discussed fall risk.
Always/Frequently
13
 Role of Communication
Do you communicate fall risk status……?

14
 Fall Risk Reduction Strategies: Processes

Do nurses assess a patient’s fall risk at the following time points?

1) On admission 3) After a fall

2) Every shift 4) When status changes

• Of the 15 hospitals with no one

accountable, 0 performed risk
assessments at these
frequencies.
• Of the 16 hospitals with one
person accountable, 6% (1)
performed risk assessments at
these frequencies.
• Of the 39 hospitals with a team
accountable, 23% (9) performed
risk assessments at these
frequencies.
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 Part 2: Assessing Fall Risk

Best Practices for Assessing Fall

Risk in the Hospitalized
Patient

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 Assessing Fall Risk
• Fall risk assessment tools
– Published or home grown?
– Team approach to risk assessment
• Nursing-focused risk assessment tools
• PT-focused risk assessment tools
• Determining best tool for your hospital
– Sensitivity
– Specificity
• Frequency of assessing patient fall risk
• Documenting patient’s fall risk status
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 What to assess for fall risk?
• Evidence demonstrates patient variables that
increase a patient’s risk for falling:
– Age (over age 65)
– Mentation
• Cognitive dysfunction, delirium, dementia
– Weak or Impaired mobility
– Assistance with toileting needs
– Medications
• Polypharmacy (4 or more drugs)
• Anticonvulsants, antipsychotics, benzodiazepines,
antidepressants, Class IA antiarrythmics, opiates, sedatives,
diuretics
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 What to assess for fall risk?
• Evidence demonstrates environmental variables
that increase a patient’s risk for falling:
– Equipment
• IV pole
• Urinary catheter
– Physical hazards in room
• Poor lighting
• Lack of handrails in bathroom
• Poorly anchored rugs
• Clutter

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 Injurious Falls

• In the next 15 seconds, an older adult

will be treated in a hospital emergency
department for injuries related to a
fall.
• In the next 29 minutes, an older adult
will die from injuries sustained in a fall.
• Injurious falls are one of the most
common adverse patient events in
acute care.
NCOA and CDC (2012)
 Fall Risk Matrix
Targeting Patients at
Risk for Falls and Injury

+ Risk for Fall -- No risk Injury

+ Risk for Fall + Risk for injury
-- No risk for Fall -- No risk for injury
-- No risk for Fall + Risk for Injury
 Risk for Injury-ABCs
Does the patient meet any of the ABCs?

Age 85+
Brittle bones (osteoporosis)
Coagulation meds
Surgical post-op
Quigley, (2009)
 Fall Risk Assessment Tool Selection

• Which tool should we choose?

• How will I know it is the right tool for our
hospital?
• What fall risk factors is the tool assessing?
– Patient variables
– Environmental variables

23
 Fall Risk Assessment Tools
Used by Participating Hospitals

Nursing-based Fall Risk Assessment # Hospitals % Hospitals

Tool

Morse Fall Scale 29 41.4%

Morse Fall Scale – Modified 8 11.4%
Hendrich Fall Risk Assessment 5 7.1%
Hendrich Fall Risk Assessment - Modified 2 2.9%

Briggs Fall Risk Assessment 2 2.9%

Conley Scale 1 1.4%
Schmid Fall Risk Assessment 1 1.4%
1 1.4%
Schmid Fall Risk Assessment - Modified
 Sensitivity & Specificity of Risk Assessment Tools

• Sensitivity is the ability of a fall risk

assessment tool to correctly identify a fall risk
patient
– Tells you how well the tool can correctly identify
patients truly at risk for falling.
• Specificity is the ability of a fall risk
assessment tool to screen out patients who
are NOT at risk for falling.
– Tells you how well the tool correctly identifies
patients NOT at risk for falling.

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 Sensitivity & Specificity of Selected Published
Fall Risk Assessment Tools
Tool Author Sample/Size/Setting Sensitivity Specificity
Hendrich II Fall Hendrich et 355 fallers inpatient 74.9% 73.9%
Risk Model al, 2003 and 780 controls 86% in elders 43% in elders
general hospital (12) (12)
population
Morse Fall Morse et al., 100, inpatient 78 83
Scale 1989 fallers/100 controls
med/surg/neruo/
ortho/geri
Schmid No data
available

Johns Hopkins Poe et al.. Academic medical None provided None provided
Fall Risk 2007 center, 179 medical
Assessment patients, 17
Tool psychiatric patients
 Hendrich II Fall Risk Model
©AHI of Indiana Inc. All Rights Reserved. Use prohibited except by written permission from AHI of Indiana, Inc.
Confusion 4
Disorientation
Impulsivity

Symptomatic Depression 2

Altered Elimination 1

Dizziness 1
Vertigo

Male Gender 1

Any Administered 2
Antiepileptics

Any Administered 1
Benzodiazepines

Get Up & Go Test

Able to rise in a single movement – No loss of balance with steps 0

Pushes up, successful in one attempt 1

Multiple attempts, but successful 3

Unable to rise without assistance during test 4

(OR if a medical order states the same and/or complete bed rest is ordered)
*If unable to assess, document this on the patient chart with the date and time

A Score of 5 of Greater = High Risk Total Score

 Morse Fall Risk Assessment
(From Morse, J. M. (1997). Preventing Patient Falls. Thousand Oaks: Sage.)
Risk Factor Scale Points Patient’s Score

History of Falls Yes 25

No 0

Secondary Diagnosis (Two or more Yes 15

medical Diagnoses)
No 0

Ambulatory Aid Furniture 30

Crutches/Walker/Cane 15

None/Bedrest/Wheelchair/Nurse 0

IV/Saline Lock Yes 20

No 0

Gait/Transferring Impaired 20

Weak 10

Normal/Bed Rest/ Immobile 0

Mental Status Forgets limitations 15

Oriented to own ability 0

High Risk = 45 and higher

Moderate Risk = 25-44 Total Score __________
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Low Risk = 0-24
 Johns Hopkins Fall Risk Assessment Tool
Complete the following and calculate fall risk score. Points

Age (Single select)

60-69 years (1 point)
70-79 years (2points)
> 80 years (3 points)

Fall History (Single select)

One fall within 67 months before admission (5 points)

Elimination, Bowel and Urine (Single select)

Incontinence (2 points)
Urgency or frequency (2 points)
Urgency/frequency and incontinence (4 points)

Medications: Includes PCA/opiates, anti-convulsants, anti-hypertensives, diuretics, hypnotics, laxatives, sedatives, and psychotropics (Single
select)
On 1 high fall risk drug (3 points)
On 2 or more high fall risk drugs (5 points)
Sedated procedure within past 24 hours (7 points)

Patient Care Equipment: Any equipment that tethers patient (e.g., IV infusion, chest tube, indwelling catheters, SCDs, etc) (Single select)
1 present (1 point)
2 present (2 points)
3 or more present (3 points)

Mobility (Multi-select, choose all that apply and add points together)
Requires assistance or supervision for mobility, transfer, or ambulation (2points)
Unsteady gait (2points)
Visual or auditory impairment affecting mobility (2 points)

Cognition (Multi-select, choose all that apply and add points together)
Altered awareness of immediate physical environment (1 point)
Impulsive (2 points)
Lack of understanding of one’s physical and cognitive limitations (4 points)

Total Points
(Moderate risk = 6-13 Total Points, High risk > 13 Total Points)
 Schmid Fall Risk Assessment Tool
*Select only one indicator for each category Score
Mobility
(0) Ambulates with no gait disturbance
(1) Ambulates or transfers with assistive devices
(1) Ambulates with unsteady gait and no assistance
(0) Unable to ambulate or transfer
Mentation
(0) Alert, oriented x 3
(1) Periodic confusion
(1) Confusion at all times
(0) Comatose / unresponsive
Elimination
(0) Independent in elimination
(1) Independent, with frequency or diarrhea
(1) Needs assistance with toileting
(1) Incontinence
Prior Fall History (within past 6 months)
(1) Yes – Before admission (Home or previous inpatient care)
(2) Yes – During this admission
(0) No
(0) Unknown
Current Medications
(1) A score of 1 is given if the patient is on 1 or more of the following medications: Anti-convulsants / sedatives or psychotropics / hypnotics
(consider all medication side effects and role in fall risk.)

Score of 3 or more: Patient is at risk for falls and fall prevention interventions should be implemented. Total Score:
 Sensitivity & Specificity of Risk Assessment Tools

• Sensitivity is the ability of a fall risk

assessment tool to correctly identify a fall risk
patient
– Tells you how well the tool can correctly identify
patients truly at risk for falling.
• Specificity is the ability of a fall risk
assessment tool to screen out patients who
are NOT at risk for falling.
– Tells you how well the tool correctly identifies
patients NOT at risk for falling.

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 Predictive Ability of Risk Assessment Tools

• Predictive Value is the probability of a fall

after a fall risk assessment score is known.
• Positive Predictive Value is the proportion of
patients with a positive result (identified as a
fall risk) who falls.
• Negative Predictive Value is the proportion of
patients with a negative result (identified as
NOT being a fall risk) who DO NOT fall.
– Influenced by other variables, not just risk score
alone.
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 So, Does the Tool Work Here?
• How many of your patients who fall were
identified as at risk for falling?
• How many who fell were identified as NOT at
risk?
• We need a tool that’s sensitive to detecting
fall risk AND specific enough so that it screens
out patients who are NOT at risk.
• No perfect tool exists! No tool is 100% specific
and 100% sensitive.

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 Looking at Predictive Value
At Risk Not at Risk

Fall True Positive False positive

(Positive Predictive
Value)
No Fall False Negative True Negative
(Negative Predictive
Value)

• We want to have as many true positives as possible and as many true

negatives as possible.

We don’t want falls – but we want our risk assessment tool to accurately predict
fall risk!

34
 Determining Sensitivity of a Tool
• Retrospectively examine all falls that occurred
over the past 2-3 years (aim for sample size of
between 30 and 50 –the higher the better).
• Using the risk assessment tool(s) under
consideration, assess faller’s risk score to
determine sensitivity (positive predictive
value).
– Did they score as a fall risk patient?

35
 Determining Specificity
• Need random sample of same number of
patients in hospital at same time as fallers
who DID NOT fall, to serve as control to
determine specificity (negative predictive
value).

36
 Selecting the Right Risk Assessment Tool

• Whichever tool yields highest results from

sensitivity/specificity testing = best fit for your
hospital.
• Need to trial the selected tool prospectively
moving forward to examine its performance.
– Tracking whether fall risk patients are the ones
who fall and those not at risk do not fall.

37
 Fall Risk Tool and Cut-off Score
• Once a tool has been selected and the specificity
and sensitivity of the tool has been determined,
the next step is to identify the cut-off score for
your institution.
One example in acute care:
• The Morse Fall Scale (MFS) was selected for ease
of use, based on evidence, ability for developing
it within the electronic medical record and the
opportunity to determine the best cut-off score
for the institution.
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 Fall Risk Tool and Cut-off Score (cont.)
• A specificity and sensitivity study was conducted
(n=1000 patients on three separate medical surgical
and progressive care units in two hospitals).
• During the specificity and sensitivity study all
patients who had a MFS score of ≥ 60 fell.
• Therefore, an additional category to capture those at
“greatest” risk of falling was identified and called
Severe Risk.
• Patients with a MFS of ≥ 60 are classified at Severe
Risk for falls.
• Targeted Severe Risk interventions are then
developed and implemented for this category,
because they are at the ‘greatest” risk of falling.
 Risk Assessment – How Often is Enough?
• Best practice evidence recommends assessing
every patient’s risk for falling frequently
throughout the hospitalization – NOT just those
patients found to be at risk.
– Upon admission – consider 1st assessment in ED and
communicating fall risk status to receiving unit for
determining most appropriate room assignment
– Every shift
– After a fall
– After any change in patient condition

40
 Selecting Fall Risk Assessment Tool

• Sensitivity/specificity.
• Ease of use.
• Cost, training, nursing time required to
complete the assessment.
• Do nursing staff know what to do with the
results?

41
Part 3: Communicating Fall Risk

Best Practices for

Communicating Fall Risk
Status in the Hospitalized
Patient

42
 Communicating Fall Risk
• To patient/family
– Education
– Signage: socks, wristband, magnet
• To staff
– During shift
– Shift to shift report
– Documentation in patient record
• Within unit/across units
– Hand off communication tool to report patient’s
fall risk
• To receiving facility upon hospital discharge 43
 Summary
• Team structure – not hospital size – significantly
predicts rate of falls and injuries.
• Best practices in fall risk assessment include:
– Consistent use of valid risk assessment tool
• Assesses patient characteristics that increase likelihood
of patient fall
• Testing tool in your setting to see if it works for your
patients/staff
– COMMUNICATION of fall risk status to the
patient/family, all team members within unit, across
units/departments and across facilities
• And interventions in place to reduce the patient’s risk of
falling 44
Questions?

45
 Contact Information
Regina Nailon RN, PhD
[email protected]
402-552-6561

Deborah Conley, MSN, APRN-CNS, GCNS-BC, FNGNA

[email protected]
402-354-4661

Web site where tools are posted

www.unmc.edu/rural/patient-safety
46
 Fall Prevention Resources
• Institute for Healthcare Improvement: Falls Prevention
http://www.ihi.org/offerings/MembershipsNetworks/MentorHosp
italRegistry/Pages/FallsPrevention.aspx
• VA National Center for Patient Safety: Falls Toolkit:
www.patientsafety.gov
• Centers for Disease Control and Prevention: Falls-Older Adults
http://www.cdc.gov/HomeandRecreationalSafety/Falls/pubs.html
• The American Geriatrics Society (search Falls within website for
resources) www.americangeriatrics.org or igeriatrics app
• Institute for Clinical Systems Improvement: Prevention of Falls
(Acute Care)
http://www.icsi.org/falls__acute_care___prevention_of__protoco
l_/falls__acute_care___prevention_of__protocol__24255.html
 Fall Prevention Resources

• Agency for Healthcare Research & Quality National Guidelines

Clearinghouse: Preventing falls in acute care
www.guideline.gov
• Hill-Rom: Safe Patient Handling and Fall Prevention www.hill-
rom.com
• Registered Nurses Association of Ontario Clinical Practice
Guidelines http://rnao.ca/sites/rnao-
ca/files/Prevention_of_Falls_and_Fall_Injuries_in_the_Older_
Adult.pdf
 References
Donabedian, A. (1980). The definition of quality and approaches to its
assessment. Ann Arbor, Michigan: Health Administration Press.
Gowdy M, Godfrey S. Using tools to assess and prevent inpatient falls. Jt Comm J
Qual Saf. 2003;29(7):363-368.
Hendrich, A., Bender, P., & Nyhuis, A. (2003). Validation of the Hendrich II fall risk
model: A large concurrent case/control study of hospitalized patients. Applied
Nursing Research, 16(1), 9-21.
Currie, L. Fall and Injury Prevention (Chapter 10). In, Hughes RG (ed.). Patient
safety and quality: An evidence-based handbook for nurses. (Prepared with
support from the Robert Wood Johnson Foundation). AHRQ Publication No.
08-0043. Rockville, MD: Agency for Healthcare Research and Quality; March
2008. http://www.ncbi.nlm.nih.gov/books/NBK2653/pdf/ch10.pdf
ICSI (Institute for Clinical Systems Improvement). Health Care Protocol:
Prevention of Falls (Acute Care), 2nd ed. Health Care Protocol: Prevention of
Falls (Acute Care)
http://www.icsi.org/falls__acute_care___prevention_of__protocol_/falls__ac
ute_care___prevention_of__protocol__24255.html. Accessed April 22, 2011.
49
 References
Krauss MJ, Tutlam N, Costantinou E, Johnson S, Jackson D, Fraser VJ. Intervention
to prevent falls on the medical service in a teaching hospital. Infect Control
Hosp Epidemiol. 2008;29(6):539-545.
Morse, J. M., Morse, R. M., & Tylko, S. J. (1989). Development of a scale to identify
the fall-prone patient, Canadian Journal on Aging, 8, 366-377.
Murphy TH, Labonte P, Klock M, Houser L. Falls prevention for elders in acute care:
An evidence-based nursing practice initiative. Crit Care Nurs Q. 2008;31(1):33-
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National Database for Nursing Quality Indicators (NDNQI). (Feb, 2012). Guidelines
for data collection and submission on quarterly indicators (v. 9.4).
National Council on Aging http://www.ncoa.org/press-room/fact-sheets/falls-
prevention-fact-sheet.html accessed November 13, 2012
Oliver, D., Britton, M., Seed, P., Martin, F., & Hopper, A. (1997). Development and
evaluation of evidence based risk assessment tool (STRATIFY) to predict which
elderly inpatients will fall: Case-control and cohort studies. British Medical
Journal, 315; 1049-53.

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 References
Poe, S., Cvach, M., Dawson, P., Straus, H., & Hill, E. (2007). The Johns Hopkins fall
risk assessment tool: Post-implementation evaluation. Journal of Nursing Care
Quality, 22(4), 293-298.
Quigley, PA, Hahm, B, Collazo, S, et. al. Reducing serious injury from falls in two
veteran’s hospital medical-surgical units. J Nurs Care Qual. 2009:24:33-41.
Sulla SJ, McMyler E. Falls prevention at Mayo Clinic Rochester: A path to quality
care. J Nurs Care Qual. 2007;22(2):138-144.
Salas E, Dickinson TL, Converse SA. Toward an understanding of team performance
and training. In: Swezey RW, Salas E, eds. Teams: Their Training and
Performance. Norwood, NJ: Ablex; 1992:3-29.
Szumlas S, Groszek J, Kitt S, Payson C, Stack K. Take a second glance: A novel
approach to inpatient fall prevention. Jt Comm J Qual Saf. 2004;30(6):295-302.
von Renteln-Kruse W, Krause T. Incidence of in-hospital falls in geriatric patients
before and after the introduction of an interdisciplinary team-based fall-
prevention intervention. J Am Geriatr Soc. 2007;55(12):2068-2074.

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evaluation by clicking on the link
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 University of Nebraska Medical Center

CAPTURE
Collaboration and Proactive Teamwork Used to Reduce
Falls