The Knowledge-based Nursing Initiative: Case Study: Fall Prevention

Transcription

1 The Knowledge-based Nursing Initiative: Case Study: Fall Prevention Wednesday March 16 9:30-11:00 Mary Hook, PhD, RN, PHCNS-BC Research Scientist, Nursing Aurora Health Care, Milwaukee, Wisconsin, USA Adjunct Clinical Assistant Professor University of Wisconsin-Milwaukee, College of Nursing Slide 1

2 Participant Objectives: Briefly define the types of patient falls and why fall prevention is important (in USA) Demonstrate the process for evidence review using two example research papers Discuss the current evidence for fall prevention strategies and show how the evidence is synthesized into recommendations for embedding Slide 2

3 Everyone is At Risk for Falling (Morse, 1997) Types of Falls: Anticipated ( predictable ) Physiological Falls (78%) Falls in people who are fall prone patients based on known risk factors (based on use of a fall risk assessment tool) Unpredictable Physiological Falls (8%) Falls that occur because of physiologic causes (acute illness, drug reaction, seizure, fainting, etc.) May not be predicted before the first occurrence Accidental Falls (14%) Falling in persons who are not fall prone Slipping, tripping; Other mishap (error in judgment) Prevent by keeping environment free of hazards Slide 3

4 Nursing-Sensitive Quality Indicators Nursing Sensitive Indicators reflect the structure, process, and outcomes of nursing care (ANA): Structure = supply, skill, & education/certification of staff Process = assessment, interventions, RN job satisfaction Outcomes = patient outcomes that improve if there is a greater quantity and quality of nursing care Nurse Sensitive Metrics (NDNQI) Patient Falls Fall-related Injury (Restraints) Slide 4

5 Fall Prevention Research Issues Fall Prevention is a frequent topic in both practice & research Authors often mix evidence across venues 1 in 3 older adults over 65 yrs have fallen (community) Literature is focused on identifying at-risk patients Many tools with untested reliability and validity in clinical setting Assessments are based on staff applying the tool correctly Unable to estimate specificity/sensitivity in the presence of interventions A high percentage of hospitalized patients will be at risk Missing the link between risk assessment and intervention Limited usable intervention studies Primarily tested with older adults on extended stay units Studies are not designed to provide conclusive evidence (multi-factorial interventions, small sample size, appropriate controls for cluster effects, and assumption violations) (Coussement, et al, 2007) Slide 5

6 Sources of Evidence Research (systematic, new knowledge) Synthesized evidence reviews Published consensus guidelines Expert opinion Practice-based evidence (quality improvement projects) Note: All sources must be evaluated for relevance, currency, & methodological quality Slide 6

7 Evaluating the Evidence Sample (size, generalizability) Fall events are rare: sample sizes should exceed 6,200 patients/24,000 days to effectively evaluate treatment effect (Coussement et al., 2007) Design Change in fall rate over time (not number of falls) Control for cluster effects and the idea that fall risk is increased after the first fall (not a normal distribution) Evaluate the fidelity of the intervention Measures Evaluating fall risk Context Concerns regarding outcome reporting Slide 7

8 Evidence Rating Systems (Melnyk & Fineout-Overholt, 2005) Level I: Level II: Level III: Level IV: Level V: Level VI: Level VII: Systematic reviews or meta-analyses of randomized control trials (RCTs) or clinical guideline based on systematic review of RCTs Evidence from at least one well-designed RCT Evidence from well-designed controlled trials without randomization Evidence from well-designed case-control or cohort studies Evidence from systematic reviews of descriptive or qualitative studies Evidence from single descriptive or qualitative study Evidence from experts (individual or groups) Slide 8

9 Fall Prevention Research: To Apply or Not Apply... To Practice Example #1: Hourly Rounding to Prevent Falls Slide 9

10 Fall Prevention Research: To Apply or Not Apply... To Practice Example Intervention: Hourly Rounding Citation: Meade, C. M., Bursell, A. L., & Ketelsen, L. (2006). Effects of nursing rounds on patients' call light use, satisfaction, and safety. American Journal of Nursing, 106(9), 58-70; quiz Note: Paper is being used demonstrate how to systematically evaluate research results for application to practice. Slide 10

11 An Overview of the Study AIM: To determine the frequency of and reasons for patients call light use, the effects of 1-hour & 2-hour nursing rounds on patients use of the call light, and the effects of rounding on patient satisfaction and patient safety DESIGN: Quasi-experimental SAMPLE: 27 nursing units in 14 hospitals with nonrandom assignment (19 units excluded) INTERVENTION: Rounding Protocol (over 24 o ) OUTCOMES: Call light frequency Patient satisfaction Patient safety ( rate of falls measured as number of falls ) Slide 11

12 To Apply or Not Apply... To Practice Comfort Rounds started in the United Kingdom (UK) in 2005 No previous research linking rounding with fall reduction, however, the rounding protocol included items (6/12) that have been recommended by experts as strategies to prevent falls in patients at risk for falls (not for everyone) No patient-level information was collected (no sample or details about fall risk assessment) Safety outcome measure: No description regarding how fall events were gathered Outcome = Number of falls in 4 weeks prior to study vs. number during 4 weeks of study, by rounding group Slide 12

13 Gathering Referential Knowledge into Evidence Table Citation Question / Topic, Sample, Setting Type of Evidence Findings re: Patient Assessment Key Findings related to Practice Findings re: Problem Identification Nursing / Diagnosis Nsg. Diag. Findings re: Findings re: Nursing Nurse-Sensitive Intervention Sensitive Outcome Outcome Evidence Decision Mead, CM et al AIM: to determine frequency of and reasons for call light use and the effects of Q1 & Q2 hr rounding on satisfaction & pt safety. 46 units started w/ 19 excluded Quasiexperime ntal, nonrandom, non-equi valent groups (baseline for 2 wks and then either 1 or 2 hr rounding x 4 wks) Study conducted at the unit level (medical, surgical & combined care units). Not designed to study or describe patient level data (no fall risk assessments). Unable to determine if units evaluated in the study had patient populations who had a diagnosis of Risk for Falls/Injury Rounding protocol by RN/CNA included multiple 12 items (pain assessment, toileting, positioning & environmental mgmt-6/12 = fall prev. strategies) Fall outcomes were evaluated (post-hoc) based on fall counts over 6 week study period. Falls decreased w/ 1 hr rounding. (Short time for rare event; Not blinded; No accounting for # patient days) Study not designed to study patient falls. Can t be used to support rounding to prevent falling in acute care. Slide 13

14 Conclusion: To Apply or Not Apply...? Meade, et al. (2006) was a quasi-experimental study testing the effect of a 12-item rounding protocol on call light use and patient satisfaction Not designed to evaluate fall outcomes What does the study tell us? No evidence to support use of rounding to reduce falls 12-item rounding protocol was not always maintained during study (fidelities issues reported by researchers No replication of this protocol or any others to date Rounding strategy has been adopted widely (in the absence of evidence of effectiveness for fall prevention) Slide 14

15 Fall Prevention Research: To Apply or Not Apply... To Practice Example #2: Fall Prevention Toolkit Slide 15

16 Fall Prevention Research: To Apply or Not Apply... To Practice Example Intervention: Fall Prevention Toolkit Citation: Dykes, P. C., Carroll, D. L., Hurley, A., Lipsitz, S., Benoit, A., Chang, F., et al. (2010). Fall prevention in acute care hospitals: a randomized trial. JAMA, 304(17), Note: Paper is being used demonstrate how to systematically evaluate research results for application to practice. Slide 16

17 An Overview of the Study AIM: To investigate whether a fall prevention tool kit (FPTK) using health information technology (HIT) decreases patient fall rates in hospitals. DESIGN: Clustered Randomized Clinical Trial SAMPLE: 4 Usual Care (n=5,104 Pts) vs. 4 Treatment Units (n=5,160) in Urban Hospital; 48,250 Pt Days INTERVENTION: Computer-generated fall intervention plan based on patient-specific falls risks with communication tools for patient and key stakeholders. OUTCOMES: Fall events/1,0000 Patient Days by unit (6 months) Fall-related injuries Slide 17

18 To Apply or Not Apply... To Practice Three preliminary phases to qualitatively evaluate problem and design a solution based on nursing process Study was designed with large sample (n=10,264 pts, 48, 250 Days), comparable patient populations (approx 50% under age 65 yrs) with statistical controls for clustering and an apriori analysis outcome evaluation plan using a Poisson regression for an outcome that is not independent (if fall occurs, increased likelihood of having another). Adherence dashboard (assessing fall risk with poster at bedside). Did not evaluate quality of communication with caregivers & patients. Significantly lower adjusted fall rate: 3.15 (95% CI, ) per 1000 patient-days vs. control units 4.18 (95% CI, ) per 1000 patient-days; Rate difference = 1.03 (95% CI, ) per 1000 patient-days (P=.04). Three pts had recurrent falls (1 tx, 2 control). No statistical difference in fall-related injury (7 vs. 9). Slide 18

19 Gathering Referential Knowledge into Evidence Table Citation Question / Topic, Sample, Setting Type of Evidence Key Findings related to Practice Findings re: Patient Assessment Findings re: Problem Identification Nursing/ Diagnosis Nsg. Diag. Findings re: Findings re: Nursing Nursing Nurse-Sensitive Intervention Outcome Sensitive Outcome Evidence Decision Dykes, P.C. et al AIM: To investigate whether a fall prevention tool kit (FPTK) using HIT can decrease fall rates on 8 inpatient medical units with increased fall risk pts Clustered Randomized Trial of usual care w/ education vs. FPTK interventi on;. 3 develop mental phases prior to RCT Nurses assessed fall risk using Morse Fall Scale to identify risks & drive interventio ns. Comparab le patient population Risk for falls with tailored intervent ions Computergenerated a patientspecific plan, a poster board and patient ed materials. Used to increase communicat ion and strength of intervention Adherence dashboard. Apriori plan for fall & injury outcome evaluation over 6 month study period. Not blinded (potential for bias) Well designed study with large sample (>10K). Falls reduced with noncognitive ly impaired pts Slide 19

20 Conclusion: To Apply or Not Apply...? Dykes, et al. (2010) was a clustered randomized control trial testing the effect of a fall prevention tool kit (FPTK) using health information technology (HIT) on patient fall and injury rates on high risk inpatient medical units. Well-designed study with significant outcome for other patients What does the study tell us? Generalizable Inadequate communication contributes to incomplete understanding of fall risk status and the fall prevention plan, consistent with results previously reported local management of fall risk Emphasized the need for intervention around transferring and toileting Did not influence fall outcomes with younger patients Slide 20

21 Fall Prevention Recommendations Slide 21

22 Assessment: Screen for Predictable Fall Risk Factors Risk Factors are most responsible for predictable falling: History of previous falls Altered mobility Altered mental status Altered elimination Many screening tools available that identify at risk patients Falls are rare events Inpatient Slide 22

23 Assessment: Screen for Fall-Related Injury Risks (Currie, 2008) Metastatic bone disease Osteoporosis Anti-platelet agents (except low dose ASA) Anticoagulant therapy Elevated coagulation laboratory results Decreased platelet count Coagulopathy Slide 23

24 Assessment: Screen for Unanticipated Special Conditions Fall Risk Tools typically do not assess for unanticipated special conditions or injury risk factors that increase risk for fall-related injury if an unanticipated condition or accidental fall occurs. Special conditions (Morse, 1997) includes: - Syncope - Seizure disorder - Cardiac arrhythmia - Adverse drug effects - Recovery form procedures or surgeries Slide 24

25 Assessment: Patient Ability to Participate in Fall Prevention A high percentage of falls occur when the patient is not in the presence of a caregiver, emphasizing the importance of patients awareness of risk and their ability to take appropriate actions to reduce risk.(hitcho et al., 2004; Mahoney, 1998; Morse, 1997/2002; Oliver et al., 2000; Shorr et al., 2002). Patients must understand & participate in prevention: Knowing how and when to use of the call light to get help, Using sensory and ambulatory support devices at all times Using of overall safety measures in the patient room. Slide 25

26 Flow Diagram of the Fall Prevention Process: No Continue to screen for development of Risk Factors Screen all adults for Fall Risk: Hx of Falls Altered Mental Status Altered Elimination Altered Mobility Sedative/Hypnotics (Fall-prone factors) No Implement Additional Interventions for Surveillence Implement Environmental Safety Management (to prevent accidental falls) Yes Focused Fall Risk Assessment (Morse Fall Scale) Morse Score > 45 Yes Initiate Diagnosis: Risk for Fall Is Patient Able to Participate in Fall Prevention Yes Implement Plan with Risk- Specific interventions: Mobility, Toileting, Medication Review. Screen all adults for Fall-related Injury Risk Factors Or Special Conditions (Predicting physiological fall) No Initiate Diagnosis: Risk for Fall- Related Injury Implement Plan of Care: Supervise, Assist & Educate No Continue to screen for development of Risk Factors or Special conditions Slide 26

27 Preventing Accidental Falls: Environmental Management Initiate environmental management interventions (e.g. bed in low position, wheels locked, items within reach, non-slip footwear) Provide patient-specific safety measures (e.g. sensory or ambulatory assist devices). Evaluate patient ability to use conventional call light Monitor for changes in patient s willingness or ability to participate in fall prevention. Slide 27

28 Risk for Injury related to Falling Care Plan Outcome: Patient must understand personal risks & take precautions when staff are not present. Interventions: Supervise & assist during times when unpredicted falls could occur based on their disease- or special conditions (e.g. first out of bed after a surgery or procedure, when electrolytes or medication levels are low, etc.) Communicate these precautions to other caregivers. Slide 28

29 Risk for Falling Care Plan Outcome: Patient must understand personal risks & take precautions when staff are not present. Interventions: Initiate Fall Risk Identification Process Communicate risk and patient-specific precautions to all caregivers. Avoiding sedatives & hypnotic (anti-psychotic) medications Interventions for patients with mobility risks Interventions for patients with elimination risks Interventions for patients with altered mental status or not able to participate in fall prevention Slide 29

30 Tailoring Fall Prevention Interventions Create a Care Plan that links patient-specific risk factors with interventions Currie, 2008 Hook et al, 2008 Dykes et al., 2010 Lee et al., 2011 Engaging all caregivers Dykes et al., 2010 Lopez et al., 2010 (reducing workflow/environmental barriers to communication) Engaging Nurses and Nurse Leaders in to Use Evidence Appropriately Thompson & Yang (2009) Dowding, Randelll, et al., 2009 Shever, et al., 2010 Slide 30

31 Engaging Patients in Fall Prevention Engaging patients and family members Hook et al., 2008 Dykes et al., 2010 Haines et al., 2010 Emphasize benefits of interventions on independence and quality (vs. consequences) Slide 31

32 Fall Prevention Patient Education (March 2010) R i s k s I n t e r v e n t i o n s Slide 32

33 Take Home Messages Evidence must be reviewed carefully and applied with a consideration of strength and potential consequences. Assessments must be purposeful and used to drive decision-making and individualize plans of care. Interventions must be carried out. Nurses and nurse leaders need access to data that can help them to identify efficient and effective interventions. Slide 33

34 Selected References Coussement J, De Paepe L, Schwendimann R, et al., Interventions for preventing falls in acute- and chronic-care hospitals: SR and meta-analysis. J Am Geriatr Soc 2008 Jan;56(1): Currie LM. Fall and Injury Prevention. In: Hughes RG, editor. Patient safety and quality: an evidence-based handbook for nurses. Rockville (MD): U.S. DHHS AHRQ Mar. AHRQ Pub No Available at: Dykes, P. C., Carroll, D. L., Hurley, A., Lipsitz, S., Benoit, A., Chang, F., et al. (2010). Fall prevention in acute care hospitals: a randomized trial. JAMA, 304(17), Haines, T. P., Hill, A. M., Hill, K. D., McPhail, S., Oliver, D., Brauer, S., et al. (2010). Patient Education to Prevent Falls Among Older Hospital Inpatients: A Randomized Controlled Trial. Arch Intern Med. epublication, Hook ML, Devine EC, Lang NM. Using a computerized fall risk assessment process to tailor interventions in acute care. In: Henriksen K, Battles JB, Keyes MA, Lewin DI, eds. Advances in Patient Safety: New Directions & Alternative Approaches. Washington, DC: AHRQ Lee, T-T, Liu, C-Y, Kuo, Y-H, Mills, M.E., Fong, J-G, Hung, C. (2011). Application of data mining to the identification of critical factors in pt falls. Int J Med Inf. 80, Lopez, K. D., Gerling, G. J., Cary, M. P., & Kanak, M. F. (2010). Cognitive work analysis to evaluate the problem of patient falls in an inpatient setting. J Am Med Inform Assoc, 17(3), Slide 34

35 Selected References Meade, C. M., Bursell, A. L., & Ketelsen, L. (2006). Effects of nursing rounds: on patients' call light use, satisfaction, and safety. Am J Nurs, 106(9), 58-70; quiz Morse, J. M. (1997). Preventing patient falls. Thousand Oaks, CA: Sage Publications, Inc. National Database of Nursing Quality Indicators (NDNQI). (2010). Patient falls indicator (adult/rehab populations). In Guidelines for data collection and submission on quarterly indicators. Kansas City: Author. Oliver, D., Healey, F., & Haines, T. P. (2010). Preventing falls and fall-related injuries in hospitals. Clin Geriatr Med, 26(4), Shever, L. L., Titler, M. G., Mackin, M. L., & Kueny, A. (2010). Fall Prevention Practices in Adult Medical-Surgical Nursing Units Described by Nurse Managers. West J Nurs Res. The Joint Commission. (2008). Standards FAQ Details on Fall Reduction Program - NPSG - Goal qid=201&programid=1 The Joint Commission. (2009). Patient falls (NSC-4) and patient falls with injury (NSC-5). Implementation guide for the NQF-endorsed nursing sensitive care measures set 2009 (Version 2.00). Oakbrook Terrace, IL: Author. Available from: Slide 35