Falls prevention in the acute hospital setting

Anna Barker [email protected] Senior Research Fellow Centre of Research Excellence in Patient Safety

Falls prevention... yesterdays news... 1986 1999 2001 2003 2004 2005

National Health Priority Area The National Falls Prevention for Older People Initiative $8.9 million Key priority in the National Injury Prevention Plan “Steady on their feet” project $752,000 The National Falls Prevention for Older People Initiative $9.6 million. National Falls Prevention for Older People Plan: 2004 Onwards Best practice guidelines 2000-2010 NHMRC Falls prevention research funding $20 million

Problem solved? • U.S. Centres for Disease Control and Prevention – Every 15 seconds, an older adult is treated in the emergency room for a fall – Every 29 minutes, an older adult dies following a fall – Falls are the most common cause of nonfatal trauma-related hospital admissions among older adults

Problem solved? • Australian hospitals – Falls are the most common accident accounting for 38% of patient incidents Briggs and Steel 2007

– A fall in hospital increases length of stay by 11 days and doubles the hospitalisation costs Hill, Vu et al. 2007

– Up to 60% of in-hospital falls result in injury Barker, Kamar et al. 2009

Can we prevent falls in hospitals? The evidence... •

Level I: Systematic review – –

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Sub-acute: multifactorial interventions ↓falls by 31% Acute: multifactorial interventions questionable Cameron, Murray et al. 2010

Level II: Randomised controlled trials –

Acute: Multifactorial program ↓ falls but not fallrelated injuries Dykes, Carroll et al. 2010

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Acute and sub-acute: Patient education appears to decrease falls in cognitively intact patient Haines, Hill et al. 2010

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Acute and sub-acute: Low-low beds no impact on falls or fall-related injuries Haines, Bell et al. 2010

Can we prevent falls in hospitals? The evidence... •

Level III: Observational study

9 year observation 356,158 inpatients 3,946 falls 1,005 fall-related injuries→ 60 (5.9%) were serious

– – – – •

55 fractures and 5 subdural haematomas

• 1 low-low bed to 9 or more standard beds →no decrease in serious fall-related injuries • 1 low-low bed to 3 or more standard beds →falls injuries and serious fall-related injuries ↓ 12% each year of observation Barker, Kamar et al. 2012

Can we prevent falls in hospitals? The practice... • 1998-2008 – No decrease in the rates of fall-related fractures in Victorian public hospitals

Brand and Sundararajan 2010

FALLS IN ACUTE HOSPITALS: PROBLEM UNSOLVED

The 6-PACK trial • Compare the 6-PACK falls prevention program to current falls prevention practice in acute hospitals • Largest falls prevention trial ever to be undertaken – 40,000 patients – 7 hospitals – 26 acute wards

INTRODUCING OUR INVESTIGATORS

The 6-PACK team

Chief Investigators Dr Anna Barker Centre for Research Excellence in Patient Safety

Associate Investigators Prof Bob Cumming

A/Prof Caroline Brand Centre for Research Excellence in Patient Safety

A/Prof Cathie Sherrington

A/Prof Terrence Haines

Dr Trish Livingston

A/Prof Damien Jolley Centre for Research Excellence in Patient Safety

Dr Silva Zavarsek Centre for Health Economics

Prof Keith Hill Head School of Physiotherapy

Other Project Staff Ms Jeannette Kamar 6-PACK Program Facilitator

A/Prof Sandy Brauer Ms Renata Morello 6- PACK Project Manager

Prof Mari Botti Ms Fiona Landgren 6- PACK Project Change Management facilitator

6-PACK

TNH fall injury rates Fall injuries ↓ 50%

6-PACK

6-PACK care plan

Falls alert signs

Low-low beds

Bathroom supervision

Bed/chair alarms

Walking aid is within reach

Toileting regime

The 6-PACK trial • Three study phases – Phase 1: mapping of current practice including assessment of falls prevention barriers and enablers – Phase 2: Cluster RCT – Phase 3: Sustainability

Aims 1. To investigate the impact of the 6PACK program on falls and fall-related injuries 2. To determine the cost-effectiveness of the 6-PACK program 3. To assess effectiveness of the program implementation including identification of barriers, enablers and sustainability

6-PACK Phase 1: Preliminary findings

6-PACK Phase 1: Preliminary findings • Falls prevention knowledge and beliefs – Nurse survey – Nurse focus groups – Key informant interviews

• Profile of falls and current practice – 5,431 patients – 386 falls – 159 fall injuries

6-PACK Phase 1: Preliminary findings • 7 hospitals 26 hospital wards – 420 surveys – 12 focus groups 94 nurses – 24 key informant interviews – 5,431 patients • 386 falls • 159 fall injuries

6-PACK Phase 1: Preliminary findings 1. Falls remain a big problem 2. Falls are inevitable 3. Nurses want more education, leadership and support in falls prevention 4. Falls risk assessment is important but current tools are limited and poorly used 5. Falls most commonly occur in relation to toileting 6. Falls injuries most commonly occur in falls from bed

6-PACK Phase 1: Preliminary findings 1. Falls remain a big problem – Rated as more of a problem than other patient adverse events such as medication errors and pressure ulcers • • • • •

Almost 1 in every 15 patients fell during their admission 1 in 4 falls resulted in an injury 8 fractures 3 head injuries 1 death

6-PACK Phase 1: Preliminary findings 2. Falls are inevitable • Nurses felt

– Many falls are inevitable and can not be prevented – Injuries were more ‘preventable’ than falls – Primary prevention strategy is use of a sitter/special/patient watch/constant observer • We recorded 9 falls occurring when a special was present

TNH falls and fall injury rates

6-PACK Phase 1: Preliminary findings 3. Nurses want more education, leadership and support in falls prevention

– Nurse dislike eLearning – Small group on-ward training is best – Most ward nurses were NOT familiar with the Falls Prevention Best Practice guidelines or key recommendations – Nurses value the use of audit, feedback and reminders • •

Benchmarking is good Spot audits and ward walk-rounds useful

6-PACK Phase 1: Preliminary findings 4. Falls risk assessment is important but current tools are limited and poorly used – Good way to identify and communicate risk – Often completed on admission then never updated unless a patient falls – Too long – Inaccurate – Difficult to interpret

76% of patients correctly classified by the tool when completed in usual care setting.

6-PACK Phase 1: Preliminary findings 5. Falls most commonly occur in relation to toileting • 1 in 3 falls occur in relation to toileting –