The Center for Research & Innovation in Patient Care

CalNOC Partners for Quality TRIP to Reduce Hospital Falls

Supported by AHRQ Grant #1U18HS1370401
Nancy E. Donaldson RN, DNSc., Principal Investigator

Introduction

Trip Team at the Retreat on January 31, 2003

The primary aim of the CalNOC Partners for Quality TRIP To Reduce Patient Falls Project, a four-year quality improvement demonstration Project, is to use evidence from the reported literature and the California Nursing Outcomes Coalition statewide repository to reduce the incidence of patient falls and severity of fall-related injury in California Hospitals. The Project builds on the established infrastructure and capacity of the California Nursing Outcomes Coalition (CalNOC). CalNOC engages California acute care hospitals in voluntarily reporting standardized nurse staffing, patient falls, and fall-related injuries, as well as other quality indicators, in a collaborative repository development and benchmarking Project using American Nurses Association’s quality indicators. CalNOC, described in publications that are presented in Appendix A (Donaldson, Brown, Aydin & Burnes Bolton, 2001; Brown, Donaldson, Aydin, & Carlson, 2001), is the largest of the American Nurse’s Association (ANA) nursing quality measurement research and development Projects and a major contributor of data to the ANA’s National Database for Nursing Quality Indicators (NDNQI). The CalNOC Partners TRIP to Reduce Falls demonstration Project expands and advances CalNOC’s efforts to use its quality benchmarking infrastructure as a vibrant network to expedite the transfer of evidence-based knowledge into practice as the basis for improving patient care quality and safety.

Reducing patient falls in acute care hospitals in California may be viewed as a first step in reducing patient falls nationally. Analysis of 13 quarters of CalNOC prospective hospital-generated patient falls risk assessment, incidence, and injury data reveals wide variation in fall rates, ranging from less than 1.0 to 13.0+ per 1000 patient days and nearly 50% of patients with unknown or undocumented risk assessment status. A majority of CalNOC sites (76%) report using “home grown” fall risk assessment tools with unknown predictive validity. We believe these findings may be representative of processes of care nationwide and present a clear professional mandate to reduce patient falls in acute care hospitals by translating evidence-based knowledge of falls risk assessment and the efficacy of fall prevention interventions into nursing practice.

Background Context of the Project

The CalNOC Partners TRIP to Reduce Falls Project logically evolves from 6 1/2 years of work by the California Nursing Outcomes Coalition (CalNOC) to build both the measurement capacity and the data repository on nursing assessment practices, staffing and patient care outcomes, CalNOC has demonstrated its ability to utilize a collaborative and strategic infrastructure to evaluate the impact of structural and process variables on patient outcomes. In undertaking this project, we acknowledge the converging forces that challenge the integrity of the American health care delivery system and drive our aims:

• Evolving over nearly two decades, prospective payment and adoption of managed care funding mechanisms have resulted in major restructuring of health care delivery systems in an effort to strategically align utilization of services, costs and reimbursement incentives (Aiken, Clarke & Sloane, 2000; Aiken Havens & Sloane, 2000; Aiken, Sochalski & Lake, 1997; President’s Advisory Commission, 1998; Curran & Mazzie; 1995; Walston, Burns, & Kimberly, 2000; Wiener, 2000). Resulting reductions in RN hours of care and skill mix have been associated with increased patient falls (Eck, 1999; Human, 2002; Sovie, 2000).
• New technologies and health care delivery practice patterns have shifted acute care services to home-based, community and ambulatory settings, delaying hospitalization and significantly reducing lengths of stay associated with episodes of acute care (President’s Advisory Commission, 1998; IOM, 1996; Kohn, Corrigan, & Donaldson, 1999). Overall patient acuity has increased during acute care episodes and patient turnover has increased. Risk of falls during hospitalization increases with co morbid conditions, acuity and age (Stevenson et al., 1998).
• Changing demographics-at-large, growth in America’s aging population, as well as improved disease management in chronic illness populations, have resulted in a markedly more complex and severely ill hospitalized patient population as evidenced by the Medicare Acuity Index (Aiken, Clarke & Sloane, 2000; IOM, 1999). Risk of falls during hospitalization increases with co morbid conditions. Further, elderly patients experience more falls, more severe fall-related injuries and sequelae ranging from loss of functional capacity to death (Stevenson et al., 1998). Changing demographics may contribute to rising fall rates and add urgency to the professional mandate to systematically reduce falls.
• Hospitals have reconfigured and redeployed their staffs and set new productivity standards, in an effort to do more with less (ANA, 2000; Foley, 1999; The Advisory Board, 2000). As a result, fewer nurses care for more patients within any given 24 hour period of time (Tillman, Salyer, Corley, & Mark, 1997). The resulting increase in nurses’ workload may be associated with fall incidence. Effective fall risk assessment and prevention is based on systematic proactive assessment of patient risk within 8 hours of hospital admission and periodic reassessment by the RN, as well as, reliable implementation of individualized prevention strategies linked to risk factors (Mosley, 1998; Sullivan & Badros, 1999).
• Patient falls are sensitive to nursing intervention and their reduction is within the purview of the profession, creating a mandate to expedite the transfer of knowledge to practice expected to reduce patient falls and fall-related injuries (ANA, 1995; 1996).

In summary, reducing patient falls is responsive to the demands of consumers, policy makers and the media concerned that the health care system exposes patients to iatrogenic risks, errors, and injuries which lead to unnecessary suffering, complications, prolonged recovery, extraordinary costs, and 44,000 to 98,000 unnecessary deaths per year (Bates et al., 1997; IOM, 2000; Presidents Advisory Commission on Consumer Protection and Quality in the Health Care Industry, 1998; Quality Interagency Coordination Task Force, 2000).

The CalNOC Partners TRIP to Reduce Falls Project is shaped by these contextual factors. CalNOC is uniquely positioned to now engage hospitals in a major effort to reduce patient falls statewide and nationally. It is significant to note that CalNOC sites (over 100 hospitals) have expressed a strong interest in understanding and improving fall risk assessment and prevention through attendance at conference educational programs and participation in multisite conference calls that have drawn up to 23 hospitals on the topic of falls. During a recent conference call (June 21, 2002) attended by 18 CalNOC hospital sites, those present unanimously endorsed the aims of this project and indicated strong interest in participating in the Project, should it be funded. Clearly, this project is timely. If not now, when?

Significance of Reducing Patient Falls in Acute Care

Acute care patient falls account for the greatest number of non-fatal injuries in hospitals with a reported incidence of 2.2 to 8.0 falls per 1000 patient days. When patients fall, an estimated 5% suffer fractures and an additional 10% experience serious injury (Blegen & Vaughn, 1998; Halfon, 2001; Perell, 2001). A majority of patient falls in acute care hospitals are predictable and preventable. The true incidence and impact of patient falls in acute care is unknown, although it is Projected that 94% of hospitals monitor the incidence of unit-level falls (Mark & Burleson, 1995). Since 1996, the Joint Commission for the Accreditation of Hospitals and Health Systems (JCAHO) has encouraged accredited institutions to report “unexpected occurrences involving death or serious physical injury” or sentinel events, so that patient care quality and safety lessons can be collected and disseminated (JCAHO, March 2002). Falls constitute 5% of JCAHO sentinel event reports and have increased 0.6% over the past 2 years. The majority of all reported sentinel event falls occur in acute care (63%) and 75% of sentinel events involve patient death.

Falls during hospitalization occur most frequently on medical-surgical patient care units and nearly 70% happen in the patient’s room with an additional 15% of falls in the bathroom. Falls are reported more frequently with advancing age, thus the frail elderly are the most likely to fall and also most likely to suffer life threatening fall-related injuries and disability (Jones et al., 1991; Oliver et al, 1997; Stevenson, et al, 1998). Recent claims data reveals that falls constitute a majority of claims paid by hospitals for patient injuries (Bed-Check Corp., 2001).

While the vast majority of patient falls do not result in injury, consequences from injurious patient falls extend hospital length of stay, require costly diagnostic, participating and follow-up care, may increase functional and ambulatory dependence and impact patient perceptions of personal safety and efficacy. The deleterious lasting psychosocial impact of falls that do not result in obvious injury, is not known, but alluded to in recent literature (Adkin, Frank, Carpenter, & Peyser, 2002; Kressig, Wolf, Sattern, O’Grady, Greenspan, Curns et al., 2001; Legters, 2002; McKee, Orbell, Austin, Bettridge, Liddle, Morgan et al., 2002).

Quality of care has been defined as the “degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional practice“ (IOM, 1994, p.3). There appears to be consensus in the literature that predictable and thus potentially preventable patient falls in acute care are adverse events and an indicator of system failure to ensure patient safety. Clearly, patient injuries due to falls threaten the likelihood of attaining desired health outcomes and may also reflect a failure of the health care system to effectively implement current professional knowledge that could reduce falls.

Although the literature does not label patient falls a classic error in patient care, failure to prevent a fall that could be reasonably predicted by a prudent person is consistent with the notion of error of omission in health care. Few adverse events trigger more litigation than restraints and falls (Avon, 1999). Reason’s (1990) principles of human performance and human error production support prima facie acceptance that the potential for latent error in a system far exceeds actual errors. This suggests patient risk of injury from falls is far greater than the actual observed events. Reported falls may be the “tip of the falls iceberg”. Clinical events that constitute errors that are captured in hospitals’ official adverse event data, incident reports and sentinel event documentation then, are evidence of a system intersecting with the inherent risks presented by the patient, the patient’s disease process, and an extraordinarily complex network of health care providers, technologies and materials (Leape et al., 1991) converging in the form of active, injurious error and patient injury. Patient falls are quintessential examples of this principle. The literature repeatedly notes that falls occur when the patient’s intrinsic risk factors converge with an active illness process and co-morbidities, complicated by the extrinsic risks posed by the environment, and system capacity for prevention inherent in care giving. It is widely espoused that reports of patient falls in acute care represent a fraction of the actual falls, perhaps disproportionately capturing falls with injury. The true impact of patient falls on acute care quality, costs and outcomes is unknown (IOM, 1999; Presidents Advisory Commission on Consumer Protection and Quality in the Health Care Industry, 1998; Quality Interagency Coordination Task Force, 2000).

Rationale for Focused Intervention to Reduce Falls Through Evidenced Based Nursing Practice

Nurses are the “quality and safety monitors in health care”, (Foley, 1999, p.5). By virtue of their universal proximity and continuous presence at the patient’s bedside, where a the vast majority of all falls take place, nurses may be uniquely positioned to anticipate and observe precursors to falls, to intervene to rescue patients in fall prone situations and to describe patterns of patient care and system performance that interact to endanger patients by falling (Benner, Hooper-Kyriakidis and Stannard 1999). Clearly, nurses are at the heart of patient falls prediction and intervention in hospitals, with the moral and professional authority to systematically engage the system of health care delivery in adopting practice that may reduce falls.

While the literature acknowledges that some patient falls, generally viewed as unanticipated physiologic falls (Morse, 1989) cannot be predicted or prevented, there are numerous reports of reliable, accurate patient risk assessment by nurses using systematic falls risk assessment tools (Hendrich et al., 1995; Morse, 1989, Oliver et al., 1997, Uden et al.1999, Schmid, 1990). Among the first ANA indicators of nursing care quality, patient fall rate per 1000 patient days is considered a “nurse sensitive” indicator of patient care quality (Rantz, 1995; ANA, 1995) and has been repeatedly inversely associated with reductions in hours of care per patient day or reduction in RN hours in the mix of direct care providers (Eck, 1999; Reed, Blegen & Goode, 1998; Sovie, 2000; Taunton, et al., 1994).

Use of sensitive and reliable clinical risk assessment tools in nursing practice is considered prerequisite to the selection of individualized interventions which link risk and prevention. The clinical goal is to target resources and interventions to selected patient-specific risk factors, and deploy them effectively to minimize falls, given “evidence” of known risk. While the literature suggests that no single published tool is a superior predictor of falls, there is strong support for systematic assessment of risk as the first step in fall prevention. Based on their early and continuing contact with patients in acute care settings, nurses have immediate access to knowledge of key risk factors for falls gleaned from patients history, for example history of a prior fall, as well as knowledge of patients current functional status, and the opportunity to observe patients mental status, behavior and response to treatment. When gathered systematically, documented and updated periodically, these data elements and responsive early interventions are crucial to preventing patient falls and reducing injuries.

In response to knowledge of patient risk of falling, nurses have a high degree of influence and discretion in managing patient care services on the unit, such as the proximity of patient bed placement related to the “nurses’ station”, the implementation of high risk patient identification strategies (for example signs or wrist bands) and the use of myriad other interventions generally within the domain of independent nursing practice and judgment. In addition, the nurse, as an advocate for patient safety, has the duty and opportunity to engage other members of the health care team in interdisciplinary and interdepartmental interventions that may be essential to ensuring patient safety, such as special precautions when the patient is taken to other departments for diagnostic tests or treatment procedures. Most of all, nurses have knowledge of the patient care environment—they know the “blind” spots, when or where falls may be more likely.

Changing nursing practice to improve fall risk assessment and prevention is at once exquisitely challenging and rewarding. Registered nurses (RNs) constitute 60% of professional health care providers. The majority of RNs practice in “nursing services organizations” (NSOs) within licensed hospitals. Unlike their physician colleagues, nurses typically practice as employees in hospitals under policies; procedures and protocols, which codify much of the “content” of practice, expressed through professional assessment and intervention actions. Physicians, for example, may choose individually to adopt a practice innovation, while RNs must negotiate innovation adoption within the boundaries of organizational policies. As a result, substantive practice change is organizationally sanctioned, not individually determined. However, there is evidence that administrative support of innovation, in the form of formalized policies and procedures, increases innovation adoption by individual members of the staff (Linde, 1989: Wilson, 1989). Thus, translating evidence-based innovation into practice “policy” at the organizational level potentially expedites diffusion of a standardized approach to change, speeding implementation of the innovation, reducing practice variation, and theoretically increasing the expected effectiveness of the effort.

Linking research-based innovation to organizational strategic priorities and attaining leadership support has been an historical barrier to practice change in nursing. Even with official sanctions, the processes of obtaining, reviewing, interpreting, translating, piloting, evaluating and diffusing evidence-based innovation is arduous (Horsley, Crane, Crabtree & Wood, 1983). While clinicians may find that literature is more available since the advent of PC-based search engines and publication of full-text documents on the World Wide Web, accessibility or the extent to which the literature is user friendly, easy to understand and clearly tied to practice, continues to haunt clinicians (Rog, 1998) Oft cited barriers to using research-based evidence in practice include lack of time, expertise and support systems to undertake complex organizational change. Not mentioned in the research use literature, but of concern is the potential for variation in interpreting the evidence—perhaps due to incomplete literature searching, or difficulty obtaining seminal works or differences in the rigor of synthesis and conclusions. Clearly, leveraging technology and making new knowledge more accessible through strategic collaboration have the potential to foster the process of innovation extraction and to reduce variation in core processes that are inherent in moving new knowledge into practice.

The CalNOC Partners TRIP to Reduce Falls Project builds on nursing’s legacy of knowledge utilization studies that have been thoroughly reviewed elsewhere by key members of the Project team (Donaldson & Rutledge, 1998, Expediting the harvest and transfer of knowledge for practice in nursing: Catalyst for a journal. Online Journal of Clinical Innovations (OJCI), 1 (Article 2). http://www.cinahl.com/). Donaldson & Rutledge (1998) conclude, “Nursing’s research utilization legacy is substantial. The challenge now is to: (1) to build nursing’s knowledge utilization infrastructure; (2) to expand the innovation use capacity of individual clinicians across the continuum of care; and (3) to foster synergies among participants in the nursing knowledge enterprise to reduce redundant literature searching and retrieval, and link upstream innovation adoption with the tactical insight of clinicians who have pioneering experience with the transfer and transformation of the innovation. Strategies must be developed to expedite the transmission of knowledge-based solutions that may improve practice, to leverage technology and literature synthesis expertise and amplify feedback from consumers of nursing research to drive future inquiry” (p.6). The CalNOC ParQ TRIP to Reduce Patient Falls Project integrates these recommendations into its design and methods as it responds CalNOC benchmarking NSO “user” demand for assistance in improving falls risk assessment and outcomes.

The CalNOC Partners TRIP to Reduce Falls Project leverages technology and strategic collaboration to build capacity for evidence-based practice change to reduce patient falls within the context of existing organizational commitment to monitoring patient care quality and safety through benchmarking patient falls, injuries and related risk assessment practice. This project recognizes and capitalizes on the tradition of nursing’s commitment to ensure patient safety and accountability for preventing falls through skilled use of systematic assessment and effective prevention interventions. This project aims to engage established networks of nurses and their NSOs -those participating in CalNOC and the NDNQI database Projects, currently measuring falls risk assessment and incidence/injuries, in a systematic intervention to reduce preventable patient falls and the severity of injury related to patient falls, with the goal of expediting improvements in patient care that directly benefit patient safety and outcomes.

Aims of the Proosed Project

To achieve its aims, this ambitious two-phase, 4 year Project will partner with and expand its established network of investigators, clinicians and stakeholders to plan, design, implement and evaluate the impact of an innovative multifaceted acute care unit-based intervention with the aim of translating research into practice (TRIP). Grounded in Havelock’s (1986) knowledge utilization linkage model and Rogers’ (1995) innovation diffusion theory, this unprecedented collaborative Project will break new ground planning, designing and delivering a multifaceted, organizationally focused, TRIP intervention that links unit level implementation and patient outcomes. Because CalNOC sites continuously submit unit-level nurse staffing data for aggregation and benchmarking, the CalNOC Partners TRIP to Reduce Falls Project has the unique opportunity to analytically explore the extent to which variation in nurse staffing variables may impact the effectiveness of the innovation adoption and subsequent clinical outcomes. Benefiting from CalNOC’s ongoing statewide nursing quality data collection and benchmarking related to falls risk assessment, falls incidence and injuries, this project will evaluate the impact of its intervention on changes in preventable patient falls in adult medical surgical units over a 12 month period following adoption of institutionally specific falls risk assessment and intervention strategies after exposure to the TRIP intervention. Finally, following testing of the intervention delivery model in California, this project will extend its impact and evaluation by disseminating a highly web-based version of the CalNOC TRIP intervention to reduce patient falls to all hospitals participating in the ANA National Database for Nursing Quality Indicator and evaluate the impact of the intervention on participating NDNQI sites through their falls-related NDNQI data.

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