Nursing Treatment Plans

hello, i am regina nailon, a clinical nurseresearcher at the nebraska medical center. i have served on the hospital’s fall reductionteam for five years and continue to assist staff with implementing best practices infall risk reduction. and i am deborah conley, gerontological clinicalnurse specialist. i champion the fall risk reduction team atnebraska methodist hospital and coordinate our nurses improving care for healthsytemelders and the agewise geropalliative care nurse residency programs.this learning module, fall risk assessment: best practices for nursing staff in the acutecare setting, is one component of the capture falls toolkit.the purpose of the capture falls project is

to decrease the risk of inpatient falls insmall rural hospitals. this project is supported by grant numberr18hs021429 from the agency for healthcare research and quality.the content is solely the responsibility of the authors and does not necessarily representthe official views of the agency for healthcare research and quality.a research study was done by the capture falls team with critical access hospitals acrossthe state of nebraska in 2011, in which the study team was examining the hospital’scurrent state with fall risk assessment processes. this webinar will focus on four learning objectives:first, we will review baseline data from 2011 hospital survey specific to fall risk assessmentand communication of fall risk status.

secondly, we will discuss published fall riskassessment tools. we will also describe how to conduct a fallrisk assessment in the adult hospitalized patient.and lastly, we’ll summarize main points of the presentation contentpart one will provide for you the introduction and background of this webinar.an introduction to best practices in fall risk assessment will now be presented.much of the content in this webinar is derived from what we know in the published literature.references for this presentation are available on slides forty seven through forty nine ofthe handout that accompanies this webinar. the webinar content handout is available asa pdf document on the capture falls website.

the last slide of this webinar provides youwith the website address. the literature reveals several key pointsabout fall risk reduction. first, fall risk has been reduced in studieswhere interprofessional team members were actively engaged in fall risk reduction efforts.and secondly, an interprofessional team versus a nursing only strategy and use of benchmarksare associated with sustained improvement we might ask ourselves, what is evidence basedpractice? well, evidence based practice has three major integrated components that canbe conceptualized as a puzzle with the pieces fitting together.evidence based practice is the integration of best research evidence with clinical expertiseand patient values.

when we think about assessing quality of care,we find it helpful to use donabedian’s framework in which quality is a component of healthcarethat occurs within the context of patient care. there are three main components of theframework structureprocess and outcomesstructure includes the infrastructure that’s in place that supports care provision humanresources policy and proceduresequipment and the environmentprocess includes the actions taken to reduce fall riskstaff following policies procedures for fall

risk reduction program, prevention interventions,or having staff and patient education is also considered a processoutcome is the unit or hospital fall rate per one thousand patient daysor the injury fall rate per one thousand patient daysthe capture falls research team used this framework as we surveyed nebraska hospitalsin 2011. we examined the extent to which hospitalshad in place structures and processes related to fall risk reduction and we looked at theirfall outcomes within this context. seventy hospitals in nebraska responded toour survey, out of the eighty three general community hospitals in the state.the sample included fifty six of nebraska’s

sixty five critical access hospitalsthose hospitals with twenty five or fewer bedsand fourteen of the state’s eighteen non critical access hospitals.we were very pleased with the overall response rate of eighty four percent of the state’sgeneral community hospitals that participated in our survey.for the purposes of our project, we use the definition of a fall that is also used bythe national database of nursing quality indicators. a patient fall is a sudden, unintentionaldescent, with or without injury to the patient, that results in the patient coming to reston the floor, on or against some other surface such as a counter, on another person, or onan object such as a trash can.

injury levels can range from minor bruisingto major fracture or death. fall risk assessments help us determine apatient’s risk of falling while hospitalized. in our baseline survey we asked hospitalswho was accountable for their fall risk reduction program and we found out that the hospitalsvaried with regard to having no one, or having one person, or having a team accountable forimplementing the fall risk reduction program. we found that hospitals with a fall risk reductionteam had the lowest fall and injury fall rates compared to hospitals where one person orno one was accountable for implementing a fall risk reduction program.thirty nine percent or twenty two of the critical access hospitals that responded to the surveyhad either one individual or no one accountable

for implementing a fall risk reduction programin their hospital. in our survey, we asked about structures thatwere in place to support fall risk reduction strategies.we asked hospitals if they used a validated, unmodified tool to assess a patient’s fallrisk of the fifteen hospitals with no one accountablefor fall risk reduction, thirty three percent or five used a valid tool.of the sixteen hospitals with one individual accountable, fifty percent used a valid tool.of the thirty nine hospitals with a team accountable, fifty six percent or twenty two used a validtool. we also asked hospitals about the processesthey had in place to support fall risk reduction

strategies. specifically, we asked iftheir team provides fall risk reduction education to staff via annual competency training andnew employee education of the fifteen hospitals with no one accountablefor fall risk reduction, none provided education. of the sixteen hospitals with one individualaccountable, thirteen percent, or two hospitals, provided education.of the thirty nine hospitals with a team accountable, twenty eight percent provided education.another process we asked about was the extent that staff discussed fall risk as a part ofdaily patient care. we asked if patient care staff from multipledisciplines discussed the patients’ fall risk in the context of daily careof the fifteen hospitals with no one accountable

for fall risk reduction, fourteen percentdiscussed fall risk. of the sixteen hospitals with one individualaccountable for fall risk reduction, twenty five percent discussed fall risk.and, of the thirty nine hospitals with a team accountable for fall risk reduction, fifty percent discussed fallrisk. we also asked hospitals about the role thatcommunication plays in their fall risk reduction efforts.specifically, we asked if they communicated fall risk status to patients and families,and whether staff communicated with other staff members across shifts and across unitsand or departments. what the data revealed was that hospitalswith an individual or with teams tended to

communicate fall risk more frequently to patients,families and across units and departments than those hospitals that had no one accountablefor a fall reduction program. another process the survey examined was theextent that nurses were assessing a patient’s fall risk at various time pointson admission, every shift, after a fall, or when the patient’s status changes.of the fifteen hospitals with no one accountable for fall risk reduction, none performed riskassessments at these frequencies. of the sixteen hospitals with one person accountablefor fall risk reduction, only one which was six percent of the totalperformed risk assessments at these frequencies. of the thirty nine hospitals with a team accountablefor fall risk reduction, twenty three percent

performed risk assessments at these frequencies.i’ll now turn the webinar content to deb who will discuss best practices for assessingrisk in the hospitalized patient. the next section of this webinar is assessingfall risk what are the best practices for assessingfall risk in the hospitalized patient there are numerous fall risk assessment toolspublished in the literature to use for hospitalized patients.there are also tools that individual organizations develop which may or may not be valid andreliable fall risk assessment tools. some tools are selected based on the disciplineassessing the patient. for example, there are nursing focused risk assessment toolsand physical therapy focused risk assessment

tools that you may want to use in your hospital.both may be appropriate depending upon who is assessing the patient.you may be asking yourself questions such as how do i determine which is the best toolfor my hospital how often should i assess patients and where do you document in themedical record a patients fall risk status these are all great questions and we willbe reviewing them in this webinar. in addition we will review what is meant by sensitivityand specificity of a fall risk assessment tool.what components need to be included when assessing for fall risk?the literature describes various patient variables that increase a patient’s risk for falling.these include

age usually over the age of sixty fivementation or cognition does the patient have a cognitive dysfunctionexperiencing delirium or dementia mobilitydoes the patient experience weakness or have an impaired gaitdoes the patient need assistance with toileting needsmedications can predispose a patient to falls. does the patient have polypharmacyfour or more medications medications shown to contribute to falls areanticonvulsants antipsychoticsbenzodiazepines antidepressantsclass one a antiarrythmics such as amiodarone

or procainamideopiates sedativesand diuretics we know from clinical experienceand the evidence demonstrates that environmental variablescan increase and contribute to a patient’s risk for fallingmost patients are not used to having medical equipment such as an iv poleoxygen tubing or a urinary catheter when they ambulate.there are also physical hazards in the hospital room such asdecreased or poor lighting lack of handrails in the bathroomassisted devices not within reach so they

can use them when they get upor just unfamiliar location of furniture and maybe even improper height of the bedand or the chair to meet the patient’s needs and clutterjust the fact that the patient being in an unfamiliar environment all contribute to a patients’risk of falling. another component of identifying what to assessfor fall risk is to identify patients at risk for sustaining an injury if they were to fall.in the next fifteen seconds, an older adult will be treated in a hospital emergency departmentfor injuries related to a fall. in the next twenty nine minutes, an olderadult will die from injuries sustained in a fall.injurious falls are one of the most common

adverse patient events in acute care.this slide shows a fall risk matrix. this matrix provides a framework for targetingand identifying patients at risk for falls and for sustaining an injury if they fall.there are four different segments to consider on this matrix.the first line identifies patients who have a positive risk for falling but no risk forinjury. the second line identifies those that are atboth risk for a fall and an injury. this is the key one to consider when usingthe matrix. the third line implies that some patientsare not at risk for a fall nor of sustaining an injury.the last line identifies that a patient is

not at risk for falling, but they are at riskof sustaining an injury if they were to fall. the challenging part of implementing a fallrisk matrix is that there are limited published risk for injury fall tools currently available.however, instead of using a risk for injury tool we need to reshape the way we think offall risk assessment. using what we call a population based approachshould be our focus. for example one way is to consider operationalizing a fall risk matrix is using what is called the abcs, first coined in 2009 by author patriciaquigley and referenced on the slide. ask the questiondoes the patient meet any of the abcs a equals ageis the patient age 85 or older

b is for brittle bonesdoes the patient have brittle bones such as osteoporosiseither a history of it or on medications for osteoporosisc is for coagulation meds is the patient on anticoagulation medicationss is for surgical post op is the patient a surgical post op patientif the patient experiences one or more of thesethey are at risk for sustaining an injury if they were to fall in the hospital or inany other settings how do you know what fall risk assessmenttool you should use at your hospital and if it’s the right toolseveral factors including patient and environmental

variables will need to be considered.in the study done in 2011, the twenty nine nebraska hospitals indicated they used a riskassessment tool. with the majority of them indicating they used the morse fall scale,with eleven percent indicating they used the morse, but they modified it.the list on the slide is not inclusive of all of the risk assessment tools that arepublished and available for use. one important consideration of a risk assessmenttool is its properties of sensitivity and specificity.sensitivity is the ability of a fall risk assessment tool to correctly identify a fallrisk patient it tells you how well the tool can correctlyidentify patients truly at risk for falling.

specificity is the ability of a fall riskassessment tool to screen out patients who are not at risk for falling.it tells you how well the tool correctly identifies patients not at risk for falling.several published tools have established sensitivity and specificity, but not all published toolsprovide this information in the literature. slides twenty seven through thirty displaya sample of published fall risk assessment tools with items contained as of 2013.we advise webinar attendees to consult the literature for any revisions to publishedfall risk assessment tools. since the webinar content handout includesthese slides we will not read them here. i will now turn the webinar content back toregina who will discuss how to determine the

most effective risk assessment tool for yourhospital use. now that we’ve introduced a few examplesof published fall risk assessment tools, let’s talk about the sensitivity and specificityof risk assessment tools and why these are important concepts to your selection and useof a tool. sensitivity is the ability of a fall riskassessment tool to correctly identify a fall risk patientsensitivity tells you how well the tool can correctly identify patients truly at riskfor falling. we want a tool that’s highly sensitive todetecting and identifying true fall risk status. are not at risk for falling.specificity tells you how well the tool correctly

identifies patients not at risk for falling.we need a tool that does not identify everyone as being at risk for falling.it needs to be able to accurately screen out patients who truly are not at risk for falling.in a little while we will describe how to measure a risk assessment tool’s sensitivityand specificity. let’s first talk about the predictive abilityof risk assessment tools. the concept of predictive ability is closelyrelated to sensitivity and specificity. the predictive value is the probability orlikelihood of a fall occurring after a fall risk assessment score is known.a positive predictive value is the proportion of patients with a positive result those thatare identified as a fall risk who experience

a fall.a negative predictive value is the proportion of patients with a negative result those identifiedas not being a fall risk who do not fall. however, we want to be clear that the occurrenceof whether a patient falls is not just influenced by their fall risk score alone.so we select a tool for use in our hospital. how do we know it will workwell, there are several questions we need to ask of the tool and of the patients whohave experienced falls. first, how many of your patients who fallwere identified as being a risk for falling two, how many who fell were identified asnot being at risk we need a tool that’s sensitive to detectingfall risk and specific enough so that it screens

out patients who are not at risk.we also want to be clear that you understand, there is no perfect tool that existsthere is no tool that has one hundred percent sensitivity or one hundred percent specificity.but we do want a tool that gives us the highest values.well, let’s recall from a previous slide, that predictive value is the probability ofa fall after a fall risk assessment score is known.this table on slide thirty four displays a four quadrant grid that shows along the topaxis the outcome of the fall risk assessment was the patient at risk or not at risk.the side axis displays the outcome did the patient experience a fall, or no fall.positive predictive value is the proportion

of patients with a positive fall risk assessmentin other words, they’ve been identified as a fall risk patient and they experiencea fall. so on this table on slide thirty four, wesee this value in the upper left quadrant labeled true positive.negative predictive value is the proportion of patients with a negative result they wereidentified as not being a fall risk who do not fall.in our table here on slide thirty four, we see negative predictive value in the lowerright quadrant the true negativesbut we also have patients that fall who are not identified as being at fall riskthese are the false positives

the upper right quadrant in the tableand we also have patients identified as a fall risk who do not fallfalse negative found in the lower left quadrant. recall that sensitivity is the ability ofa fall risk assessment tool to correctly identify a fall risk patientas we discuss how to determine the sensitivity of a tool, we want to refer you to the capturefalls website where you can go to the tools inventory to find and download a worksheetto calculate sensitivity, specificity and predictive value.in determining sensitivity of a fall risk assessment tool, you’ll want to retrospectivelyexamine all falls that occurred over the past two to three years depending on the size ofyour hospital

aim for a sample size of between thirty andfifty falls. the larger the sample size, the better.using the risk assessment tool or tools that you are usingor are considering using in your hospital, assess each faller’s risk score to determinesensitivity the tool’s positive predictive value.we already know the patients fell, did the patient meet the risk assessment toolcriteria for being at risk. did the faller score as a fall risk patienton the tool you are using or are considering usinglet’s recall that specificity is the ability of a fall risk assessment tool to screen outpatients who are not at risk for falling.

specificity tells you how well the tool correctlyidentifies patients not at risk for falling. in order to calculate specificity, we needa random sample of the same number of patients who were in the hospital at the same timeas the sample of fallers that was used to calculate sensitivity, that did not fall,to serve as the control group. specificity tells us the tool’s negativepredictive value. the patient was not a fall risk and the patient did not fall.once you calculate sensitivity and specificity for each fall risk assessment tool you areexamining, you will need to decide which tool will be used.this will be the tool that gives you the highest results from sensitivity and specificity testingand is a best fit for your hospital.

you may need to trial the selected tool inreal time, moving forward to examine its performance. while you’re trialing the tool, you’llbe tracking whether fall risk patients are the patients who experience falls, and thenot at risk patients are not experiencing falls.i’ll now turn to deb who will describe how to modify a risk assessment tool to determinehow best to fit it to your hospital’s patient population.the key is to identify those for which interventions and resources are targeted, and to stratifyor identify who is at greatest risk of falling so you are not focusing efforts on those thatmay not need targeted or resource intense interventions.here is an example from methodist hospital

where i workwho selected the morse fall scale as their fall risk assessment tooland how they determined the best cut-off score. they conducted a non-experimental descriptivestudy with an n a thousand patients to determine specificity and sensitivity of an alreadyvalid and reliable tool. the morse fall scale was selected for itsease of use it was evidence based and it could be incorporatedinto the hospitals’ electronic medical record. the specificity and sensitivity for this researchstudy validated previous research on the morse fall scale indicating a cutoff score of fortyfive or greater for patients considered at high risk.however during this study, all patients who

scored sixty or greater on the morse fallscale actually ended up falling. therefore, a separate risk level of severe risk for fallswas identified by this hospital to use as the cutoff score for identifying those atgreatest risk of falling. for this group of patients who score sixtyor greater on the morse fall scale it’s not if they are going to fallit’s when are they going to fall if they have a morse fall scale of sixty or greaterstaff have a high degree of suspicion and heightened awareness for patients who havea morse fall scale of sixty or greater and they implement a set of targeted interventionsbased on this risk level. while conducting the specificity and sensitivityof the tool you select, ask yourself

how many of your patients who fall were identifiedas at risk for falling how many who fell were identified as not atrisk as noted earlier, we need a tool that’ssensitive to detecting fall risk and specific enough so that it screens out patients whoare not at risk. in this study just reviewed, every patientwho fell had a morse fall scale of greater than sixty. a new category was identifiedto capture these fallers which was called severe risk.staff resources and time are targeted at those at severe risk with those with a morse fallscale of sixty or greater. how often should staff perform a fall riskassessment of patients in the hospital

best practice recommends assessing every patient’srisk for falling frequently throughout the hospitalization and not just those patientsfound to be at risk. therefore using the following as guidelineswill help drive your practice for hospitalized patientsupon admission consider first assessment in the emergency department and communicatingfall risk status to receiving unit for determining most appropriate room assignment and interventions.include the assessments every shift after a fallafter any change in patient condition surgery, diagnostics requiring sedating medicationsor a transfer to another unit patients’ level of risk can change at anypoint along the continuum as suggested above.

we have just covered how to select a fallrisk assessment tool for your hospital and how to determine its sensitivity and specificityand its cutoff score. the tool should be easy and relativily quickto administer. some tools have a cost to use them, so considerthat in the selection as well as the time and resources necessary for educating staffon using it correctly. nursing staff should be taught how to interpretthe results of the fall risk assessment and what interventions to implement based on thepatients level of risk. so now that we’ve put into place a fallrisk assessment tool with appropriate levels of sensitivity and specificity, and have assesseda patient’s fall risk status, how do we

communicate to care providers and others thatpatient’s fall risk status the last section of this webinar will describebest practices in communicating fall risk status in hospitalized patients.the literature reveals that best practices in communicating fall risk includecommunicating the patient’s fall risk to the patient and to his family and their familymembers. not only is it important to inform the patient and family when the patient hasbeen identified as being at risk, but it’s also critical to educate the patient and familyabout why they are at risk and what their role is in helping to prevent the patientfrom falling. this likely will include educating the patientand family about the use of the call light

for assistance.educating them about the signage and the tools that will be used in the fall prevention effortsduring the patient’s hospital stay, such as special colored socks, or a specialcolored wristband, or signage such as magnets or other symbolsthat indicate a patient’s fall risk to all who enter the patient’s hospitalroom. best practice also includes communicatingfall risk to staff during the shift, at shift to shift report, and documenting the patient’sfall risk status in the patient’s medical record.it is also best practice to communicate the patient’s fall risk within the unit andacross units and departments when there is

a patient hand off. say for instance the patientis transported to the radiology department for a procedure.the staff handing the patient off to the radiology department staff needs to be sure the radiologystaff are aware of the patient’s fall risk status. the patient may be wearing a specialcolored wristband, but staff cannot assume the receiving staff will see the wristband.lastly, best practices include communicating the patient’s fall risk to the receivingfacility when the patient is discharged from the hospital and has to be provided care ina long term or other type of non-acute care facility.this webinar has provided best practices on fall risk assessment for nursing staff inthe hospital.

we reviewed the baseline data from the nebraska2011 hospital survey specific to fall risk assessment and communication in critical accesshospitals. various published fall risk assessment toolsand how to select a tool was presented. identifying not only fall risk but risk forinjury was covered using the simple abcs age eighty five plusb brittle bones c coagulation meds ands post surgical patient both specificity and sensitivity were coveredto provide a guidance as you determine the best fit of a tool and cutoff score for yourhospital. the importance of teamwork and team structurehave been highlighted as a key component which

significantly predicts rate of falls and injuries.lastly, we reviewed best practices in fall risk assessment.these include the consistent use of a valid risk assessment tool where you assess patientcharacteristics that increase the likelihood of a patient fall andtesting the tool at your setting to see if it works for your patients and staffcommunication of fall risk status to the patient and family, all team members within the unit,across units, departments, and across facilities in addition, interventions that have beenput in place to reduce the patient’s risk of falling need to be communicated every timewith every patient. fall reduction is a team effort and anyonehaving contact with the patient is a stakeholder

in the effectiveness of the hospital’s fallrisk reduction efforts. on slides forty five and forty six, we haveprovided you with a lot of additional fall prevention resources. again, this webinarcontent is available as a pdf document on the capture falls website for your use.and we have provided four slides of references which, again, are available on the handoutthat accompanies this webinar. please consult the capture falls project websitefor additional resources. type capture falls into an internet search engine or enter theurl the website address found on this last slide.