Don't Let Your Cancer Patients Take the Fall!

Patient falls and falls with injury are serious preventable problems in hospitals and are among the measures employed as standard metrics of the quality of nursing care; they are included in both The National Quality Forum (NQF) National Voluntary Consensus Standards for Hospital Care: An Initial Performance Measure Set (http://tinyurl.com/nygwo5) and The Institute for Healthcare Improvement’s National Patient Safety Goals (http://tinyurl.com/m5gj7w). Injuries and death associated with patient falls while being cared for in a health care facility are classifi ed by the NQF as “serious reportable events” (http://tinyurl.com/n6kmcz). As of October 2008, costs associated with fall-related injuries in hospitals were no longer reimbursable under Medicare, and other insurers of healthcare will likely follow suit (http://tinyurl.com/nnft92).

In the state of Massachusetts, patient falls are publicly reported and disseminated through Patients First (www.patientsfi rstma.org), an initiative to establish transparency related to hospital-based care by voluntarily posting nurse-sensitive measures endorsed by the NQF. According to the Massachusetts Department of Public Health, patient falls constituted 77% of the 205 serious reportable events that occurred in hospitals in the first half of 2008 (http://blog.hcfama.org/?p=2010). These startling statistics make it clear that simply being hospitalized places a patient at risk for injury related to falls. The unfamiliar environment, acute illness, surgery, bed rest, medications, treatments, and the placement of various tubes and catheters are common challenges that place patients at risk. Patients with cancer are often particularly vulnerable to falls due to disease and treatment-induced deficits, polypharmacy, and excessive fatigue (http://tinyurl.com/mx8q67). Other risk factors identified for patients with cancer who fell while hospitalized when compared to non-fallers were older age; more physical dependency; being less alert and more confused; having problems with orientation to person, time, and place; weak arm muscle strength; and fatigue (http://tinyurl.com/mn2vh6).

Falls are devastating to patients, family members, and nurses, who often feel responsible when a patient falls while under their care and supervision. Even when no injury is apparent, a single fall may result in a fear of falling that can begin a downward spiral of reduced mobility, leading to loss of function and further risk for falls.¹ The majority of published studies are in the area of fall risk assessment. Therefore, the risk factors associated with patient falls are well established. Oncology nurses often complete a standardized fall risk assessment scale (such as the Morse Fall Scale, available at (www.janicemorse.com/fallscale.php) on all hospitalized patients and are well aware of the factors that place their patients at high risk for falls. However, the linkage between nursing assessment of fall risk status and interventions to prevent falls in hospitalized patients is yet to be established.²

Rethinking fall prevention in hospitals: Fall TIPS

Fall TIPS is a two-year, Robert Wood Johnson Foundation-funded study that aims to establish an evidence-based linkage between routine nursing fall risk assessment and structured communication with tailored interventions to prevent patient falls in hospitals. In the first phase of the Fall TIPS study, focus group interviews of professional and paraprofessional caregivers were conducted to explore existing barriers, facilitators, and interventions used to prevent falls in hospitals. Interviews were also conducted with patients who had fallen while in the hospital. A content analysis of the resulting transcripts revealed that while nurses routinely assess their patients’ risk for falls, communication related to fall risk status and communication of the plan to prevent falls was inconsistent.³

Variable communication was identified as a major barrier to the collaboration and teamwork that participants said was needed to prevent patient falls. “High risk for fall” signs were routinely hung in patients’ rooms to alert caregivers of a patient’s risk status. However, professional and paraprofessional caregivers reported that these signs were too common and too generic to be useful. The study team also learned that even when a fall prevention plan was included in the electronic or paper patient record, this information was not routinely available to caregivers at the patient’s bedside. Neither nursing assistants who typically provided care for several hours, nor family members who often spend a great deal of time with oncology patients, had access to the patient’s fall prevention plan, and thus did not know important information, such as how the patient got to the bathroom (patients had identified the loss of balance in the context of an urgent need to reach the bathroom as the most common reason for falling).³

Fall TIPS Toolkit: Bringing fall prevention guidelines to the bedside

Based on the requirements gathered in the interviews, the study team built Fall TIPS, a platform-independent fall prevention toolkit. Fall TIPS leverages existing practices and workflows (eg, routine nursing fall risk assessment, the use of signs to alert caregivers to fall risk status) and makes use of information technology to decrease barriers to fall prevention. Using the Fall TIPS toolkit, nurses complete the fall risk assessment using the online Morse Fall Scale. The toolkit automatically selects a core set of evidence-based interventions directly linked to patient-specific risk status. The nurse has the ability to further tailor the interventions based on his or her knowledge of the patient. The nursing assessment data and the associated tailored interventions are then processed by the Fall TIPS software to generate three patient-specific fall prevention tools: a bed poster, a plan of care, and an educational handout for patient and family. In hospitals where there is a paper patient record in place, all three forms automatically print when the nurse completes the initial patient fall risk assessment. In hospitals where an electronic patient record is in place, the bed poster and educational handout are printed, and the interdisciplinary plan of care is stored in the electronic record. The figure provides an example of a tailored bed poster for a patient who is at high risk for falls. Note that in addition to conveying risk status, the bed poster includes actionable alerts related to patient toileting status, assistance required to get the patient out of bed, and mental status (eg, bed alarm is needed).

Next steps for Fall TIPS

The effectiveness of the Fall TIPS toolkit is currently being studied as part of a randomized control trial in four hospitals (www.clinicaltrials.gov/ct2/show/NCT00675935). The Fall TIPS study will be completed in August 2009 and the study team will make the findings and toolkit available to assist other hospitals and health care systems with their fall prevention efforts.

Dr Dykes is Corporate Manager Nursing Informatics and Research at Partners Healthcare Systems and Instructor in Medicine at Brigham and Women’s Hospital, Harvard Medical School. She serves as nurse scholar and principal investigator of the Fall TIPS study. Dr Middleton is Corporate Director of Clinical Informatics Research & Development; Chairman of the Center for Information Technology Leadership at Partners Healthcare Systems; and Assistant Professor of Medicine at Brigham and Women’s Hospital, Harvard Medical School. He leads the development of enterprise clinical systems strategy, software product management for PHS, and serves as the physician scholar and co-investigator on the Fall TIPS study. Dr Carroll is the Yvonne L. Munn Nurse Researcher in the Munn Center for Nursing Research, Institute for Patient Care at Massachusetts General Hospital in Boston. She serves as nurse scholar and co-investigator of the Fall TIPS study. Dr Hurley is a Senior Nurse Scientist Emerita at Brigham and Women’s Center for Nursing Excellence, Brigham and Women’s Hospital in Boston. She serves as nurse scholar and co-investigator and brings her expertise in both patient safety research and in the qualitative methods used in the Fall TIPS project.

References

1. Tinetti ME, Richman D, Powell L. Falls efficacy as a measure of fear of falling. J Gerontol. 1990;45(6):239—243.

2. Morse J. Preventing Patient Falls. Thousand Oaks, CA: Sage Publications; 1997.

3. Dykes PC, Carroll DL, Hurley AC, et al. Why do patients in acute care hospitals fall? Can falls be prevented? J Nurs Adm. 2009;39(6):299-304.