Implementation

Guide for Falls

February 11, 2014

 Contents
1. Introduction ......................................................................................................................... 3
2. Falls Prevention Evidence-Based Practices ........................................................................ 3
2.1 Background Information ................................................................................................. 3
2.2 Risk Factors .................................................................................................................. 4
2.3 Evidence-Based Practice Guidelines ............................................................................... 5
2.4 MHS Falls Performance Measures .................................................................................. 8
3. References .......................................................................................................................... 9
4. Appendix ........................................................................................................................... 10

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 1. Introduction
This implementation guide was created to support the Partnership for Patients, a national initiative
sponsored by the Department of Health and Human Services to reduce harm in health care facilities.
Military Health System leadership has pledged its support to the PfP, and has made a commitment to
specific, identified aims. Improving the quality and safety of health care in all Department of Defense
facilities will only be possible with universal support at every level in the MHS.

This guide is one of 10 harm-specific guides designed to assist you as you implement identified
evidence-based practices to improve patient care. Common to all guides are resources that support
efforts to educate the health care team by providing MHS-selected EBPs and quality improvement
strategies.

In addition, implementation strategies and tools relevant to all harm categories are included in a guide
titled “Practical Applications for Process Improvement and Change Management.” This guide supports
efforts to equip the health care team with rapid-cycle process improvement methods and engage the
health care team through the use of change management strategies.

2. Falls Prevention Evidence-Based Practices

2.1 Background Information
According to the National Quality Forum, a fall is a sudden, unintended, uncontrolled downward
displacement of a patient’s body to the ground or other object. This includes situations where a patient
falls while being assisted by another person, but excludes falls resulting from a purposeful action or
violent blow.1

1
National Quality Forum Patient Safety Terms and Definitions. www.qualityforum.org/Topics/Safety_Definitions.aspx.
Accessed 6/11/2012.

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 Falls Burden of Illness

 Falls among older adults cost the U.S. health care system more than $23.6B in 2005
 Falls are a serious public health problem among older adults. More than a third of adults
age 65 years or older fall each year
 A study of people age 72 and older found that the average health care cost of a fall injury
was $19,440
 Of those who fall, 20 to 30 percent suffer moderate to severe injuries that reduce mobility
and independence, and increase the risk of premature death

Sources:
1. CDC Falls-Older Adults Data and Statistics. http://www.cdc.gov/HomeandRecreationalSafety/Falls/index.html
Accessed 6/12/12.
2. Rizzo JA, Friedkin R, Williams CS, Nabors J, Acampora D, Tinetti ME. Health Care Utilization and Costs in a
Medicare Population by Fall Status. Medical Care 1998; 36(8):1174–88.

2.2 Risk Factors

The following factors are commonly associated with falls and are often used to determine a patient’s
risk of fall23

 Older age
 Polypharmacy
 Impaired gait
 Ambulatory aid
 Cognitive impairment

2 Morse Fall Scale. http://www.patientsafety.gov/CogAids/FallPrevention/index.html#page=page-1. Accessed 8/31/2012.

3 Degelau J, Belz M, Bungum L, Flavin PL, Harper C, Leys K, Lundquist L, Webb B. Institute for Clinical Systems Improvement.
Prevention of Falls (Acute Care)

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 2.3 Evidence-Based Practice Guidelines
To reduce the prevalence of falls in adults, the evidence-based practice selected for standardized
implementation across all MHS direct care hospitals is the Johns Hopkins tool for adult patients. Each
Service maintains licensing for these tools; contact your Service Lead to gain access to the tools.

 Clinical Protocol and Procedures: Fall Risk Assessment, Prevention and Management, Adult

o The Johns Hopkins Fall Risk Assessment tool – one page document outlining fall risk
factors

o Fall Prevention Guidelines by Risk Category (Low Fall Risk, Moderate Fall Risk, High Fall
Risk)

o Suggested Format for Comfort and Safety Rounds – Strategy for conducting patient
safety rounds

o Management of Falls Events – Actions to take immediately following a fall event

 Patient Safety: A Guide to Preventing Falls in the Hospital – an educational tool for the
inpatient

 Patient Safety: A Guide to Preventing Falls at Home – an educational tool for the patient being
discharged to home

 Patient Information Guide to Preventing Falls in the Hospital.

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 General Strategies for Falls Prevention in Adult Patients

Low Risk:
 Conduct a fall risk assessment utilizing the Johns Hopkins Hospital Fall Risk Assessment Tool
 Conduct a fall risk assessment initially at admission (within time prescribed by policy) and
every shift or when needed based on patient status changes
 Maintain a safe unit environment with limited excess equipment and supplies
 Orient patients to their room and bathroom
 Educate the patient and his/her family and visitors regarding falls risk and prevention
activities
 Place bed in lowest position with wheels locked
 Place side rails in an upright position as needed
 Ensure patients wear snug-fitting, non-slip footwear while ambulating
 Ensure personal items and ambulatory devices are within easy reach at all times

Moderate Risk:
 Identify patients at risk for falling with visual cues
 Discuss and identify all patients deemed at risk for falling during nursing shift reports
 Conduct patient-centered bedside rounds every 2 hours
 Use a bed exit or personal alarm

High Risk:
 Remain with the patient while toileting
 Conduct patient-centered bedside rounds every hour
 Move patient to a room with the best visual access to the nursing station
 Encourage the family to stay with the patient or consider using a sitter
 Provide diversion therapy such as TV or a volunteer reader

Source:

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 General Strategies for Falls Prevention in Pediatric Patients
Low Risk:
 Conduct a fall risk assessment utilizing an evidenced-based fall risk assessment tool
 Conduct a fall risk assessment initially at admission (within time prescribed by policy) and
every shift or when needed based on changes in patient status
 Keep hand contact with infants, young children, developmentally delayed or cognitively
impaired children on treatment tables or scales
 Educate the patient and his/her family and visitors regarding falls risk and prevention
activities
 Place bed or crib in lowest position with wheels locked
 Place side rails in an upright position as needed
 Ensure patients wear snug-fitting, non-slip footwear while ambulating
 Maintain direct surveillance of children in bathtub/shower
 Fasten safety belts on high chairs, strollers and swings

High Risk:
 Identify patients at risk for falling with visual cues
 Discuss and identify all patients deemed at risk for falling during nursing shift reports
 Conduct patient-centered bedside rounds every hour
 Accompany patients with ambulation
 Move patient to a room with the best visual access to the nursing station
 Encourage the family to stay with the patient or consider using a sitter
 Provide diversion therapy such as (age appropriate) TV, lacing cards or volunteer reader

Source:

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 2.4 MHS Falls Performance Measures
In order to collect and interpret data that documents success in reducing the incidence of falls, it is
imperative that process and outcome measures be utilized. The MHS has committed to using the
measures listed below. MTFs are expected and encouraged to report facility-wide falls to the Patient
Safety Reporting System.

Description Data Source Metric

Percentage of patients that had the initial falls Essentris Process Measure
assessment:
Patients with initial falls risk assessment
-------------------------------------------------------- X 100
total number of patients

Patient Fall Rate: (Tracked by month) PSR Outcome Measure

System/M2
Total Number of Patient Falls
-------------------------------------------------------- X 1000
Total Number of Patient Bed Days

Patient Falls with Harm Rate: (Tracked by month) PSR System Outcome Measure

Total Number of Patient Falls with Harm

-------------------------------------------------------- X 100
Total Number of Patient Falls

Numerators for the above metrics will be calculated using the following PSR data
parameters:
Patient Fall Rate
Numerator: PSR data where event type= “fall”; patient status=”inpatient”; degree of harm=”no harm”,
“emotional distress or inconvenience”, ”additional treatment”, “temporary harm”, “permanent harm”,
“severe permanent harm”, or “death”

Patient Falls with Harm Rate

Numerator: PSR data where event type=”fall”; patient status=”inpatient”; degree of harm=”additional
treatment”, “temporary harm”, “permanent harm”, “severe permanent harm”, or “death”

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 3. References
Army. (2011). Fall Prevention Clinical Practice Guideline (For Adult and Pediatric Inpatients of Military
Medical Treatment Facilities). https://www.qmo.amedd.army.mil/NurseCPG/NurseCPG.html

Center for Disease Control. (2011). Falls- Older Adults Data and Statistics. Retrieved April 26, 2012,
from Center for Disease Control: http://www.cdc.gov/HomeandRecreationalSafety/Falls/index.html
Accessed 7/11/12.

Degelau J, Belz M, Bungum L, Flavin PL, Harper C, Leys K, Lundquist L, Webb B. Institute for Clinical
Systems Improvement. Prevention of Falls (Acute Care). Updated April 2012.
http://www.icsi.org/guidelines_and_more/protocols_/patient_safety___reliability_protocols/falls__acute_care__
_prevention_of__protocol_/falls__acute_care___prevention_of__protocol__24254.html Accessed 7/11/12.

National Quality Forum. (2011). NQF Patient Safety Terms and Definitions.
http://www.qualityforum.org/Topics/Safety_Definitions.aspx Accessed 7/11/12.
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Department of Veterans Affairs National Center for Patient Safety Falls Toolkit, Measuring Success.
http://www.patientsafety.gov/SafetyTopics/fallstoolkit/notebook/07_measuringsuccess.pdf Accessed
8/31/2012.

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 4. Appendix
Attachment A: Adult Falls Guideline Compliance Form

Adult Falls Guideline — Compliance

Objective: Suggested tool to provide documentation of compliance with implementation of Adult
Falls Guidelines

Falls Guideline Compliance Checklist Yes No Identified Barriers/ Plans

to Overcome Barriers
Patients at Low Risk:

1. Remove excess equipment / supplies from rooms and

hallways
2. Coil and secure excess telephone and electric wires

3. Clean spills in patient room or hallway immediately

4. Place signage to indicate wet floor damage

5. Restrict window openings

6. Orient patient to their room and the bathroom

7. Show the patient how to use the call bell and ensure it
is within reach
8. Educate the patient and family on falls risk prevention

9. Encourage patient and families to call for assistance if

needed
10. Place bed in the lowest position with the wheels locked

11. Ensure the patient is wearing snug-fitting, non-slip

footwear while ambulating
12. Clearly identify any hazardous areas or obstacles upon
which the patient might trip
Patients at Moderate Risk:
1. Consider additional yellow fall risk indicators (such as
identification bracelet, blanket or socks) as per Service
policy
2. Conduct patient bedside rounds at least every 2 hours
and check patient for pain, positioning, elimination,
possessions
3. Remind patient to request assistance whenever
necessary
4. Reorient patient as necessary

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 5. Supervise and/or assist bedside sitting, personal
hygiene and toileting
6. Place side rails up (no more than 3 rails at a time)

7. Communicate factors influencing the patient’s risk to

licensed independent provider
8. Post an at-risk indicator in a visible area within/outside
the patient’s room
Patients at High Risk:
1. Remain with the patient while toileting

2. Offer toileting every 2 hours while awake

3. Conduct patient-centered bed rounds every hour

4. Use seatbelt when in a wheelchair

5. Move the patient to a room with best visual access to

the nursing station

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 Attachment B: Pediatric Falls Guideline Compliance Checklist

Pediatric Falls Guideline — Compliance

Objective: Suggested tool to provide documentation of compliance with implementation of Pediatric
Falls Guidelines

Pediatric Falls Guideline Compliance Checklist Yes No Identified Barriers/ Plans

to Overcome Barriers
Patients at Low Risk:

1. Orient patient to the room

2. Ensure the bed is in a low position with the brakes on
3. Ensure the side rails are up and assess large gaps
4. Fasten straps on wheel chair, stroller, swing or high chair
5. Use non-skid footwear and appropriate size clothing
6. Check patient for pain, positioning, pottying and possessions
7. Ensure the call light is within reach and the patient/family is educated
on its functionality
8. Environment is clear of hazards (unused equipment, furniture)
9. Assess for adequate lighting
10. Educate patient and parents on falls protocol precautions
11. Include fall prevention in plan of care
Patients at High Risk:
1. Consider additional yellow fall risk indicators (such as identification
bracelet, blanket or socks) as per Service policy
2. Post an at-risk indicator in a visible area within the patient’s room
3. Accompany patient with ambulation
4. Place patient in appropriate bed
5. Move patient closer to nursing station
6. Remind patient and parents to request assistance when necessary
7. Offer toileting every 2 hours while awake
8. Assess need for a 1:1 supervisor
9. Evaluate medication administration times
10. Remove all unused equipment out of the room
11. Protective barriers to close out all spaces and gaps in the bed
12. Ensure door is open at all times
13. Ensure bed is in the lowest position
14. Document in nursing narrative teaching and plan of care

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