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J Nurs Care Qual Vol. 22, No. 2, pp. 138–144 c 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright 

Falls Prevention at Mayo Clinic Rochester A Path to Quality Care Stephanie J. Sulla, MS, RN; Eileen McMyler, MS, RN,BC Falls prevention is a complex problem. Following in the footsteps of an earlier fall prevention team, the Safe Landings Fall Prevention Team used many strategies for implementing a fall prevention/ reduction program. The tactics we used to prevent falls combined with the adoption of a fall assessment risk model are shared. Key words: accidental falls, fall prevention strategies, fall risk assessment, Hendrich fall risk model, patient falls, patient safety, safety management

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IMILAR to most hospitals, Mayo Clinic Rochester hospitals have been challenged with how to prioritize and implement quality initiatives across all units. Since patient falls can have implications for outcomes of care, fall prevention has been a priority initiative at Mayo Clinic Rochester hospitals since 2000. This article provides an overview of and the challenges encountered by the fall prevention teams within a large, highly specialized medical facility. OVERVIEW The first interdisciplinary fall prevention team in 2000 identified gaps in the admission process for fall risk screening, and recognized the need for educating staff and patients about fall risks. A variety of initiatives were implemented including: • a history of falls screening question added to the admission nursing assessment; • standardized patient education pamphlets developed; and

From the Mayo Clinic, Rochester, Minn. Ms McMyler is now with the University of Michigan, Ann Arbor, Mich. Corresponding author: Stephanie J. Sulla, MS, RN, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (e-mail: [email protected]). Accepted for publication: November 28, 2006

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an internal Web site highlighting information and resources redesigned. It also became evident during the evaluation of this fall prevention strategy how important it was to have a collaborative, interdisciplinary approach for fall assessment and prevention rather than rely only on a nursing strategy. Despite the efforts of this initial team, falls continued to occur in the hospital settings. In 2002, the rehabilitation unit began to focus specifically on fall prevention for its patient population and created a new program called Falling Star. The name Falling Star, as in “Catch a Falling Star,” was used to capture the attention of the nursing staff. The program introduced a graphic symbol resembling a comet with a star placed at the patient’s room door to identify patients at risk for falling on the basis of specific criteria developed by the unit. The use of a different symbol for identifying risk was continued on as part of the future teams’ work. Three other patient care units also recognized that their patient populations continued to be at risk for falls and replicated the main concepts of the rehabilitation unit’s Falling Star program, including the symbol. These units developed their own in-depth fall prevention assessment and intervention criteria for their specific clinical patient populations. The Falling Star programs demonstrated some success, which prompted Mayo Clinic

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Table 1. Interdisciplinary membership for the Safe Landings Fall Prevention Team

Collaborative groups Physicians Pharmacy Nursing

Research services Systems and procedures Facilities operations

Safety and ergonomics Information services

Team members Geriatricians/hospitalists Pharmacist Staff nurses, clinical nurse specialist, continuous improvement specialist, nurse managers Research analyst Systems analyst

Contributors (ad hoc members)

Nursing informatics specialist

Environmental services—hospital equipment expert Ergonomist

Rochester to replicate those successes by having a multidisciplinary team reexamine fall prevention in a comprehensive, house-wide manner. In 2003, the Safe Landings Fall Prevention Team was chartered to review the previous teams’ work and to enhance the existing processes for reducing falls while overcoming any existing barriers. Team membership included staff from multiple disciplines (Table 1). QUALITY IMPROVEMENT PROCESS The team started with literature reviews, internal falls data analysis and reporting processes, benchmarking, internal falls sentinel events analyses, and updates from the Falling Star units. Literature review Fall prevention has been a topic of interest in the literature for the last decade. Equipment needs, environmental changes, and variables associated with fall risk were cited as significant issues related to preventing falls in hospitals in most studies reviewed. The Health Care Advisory Board1 in 1998 reinforced the concern by nurses and hospital risk managers of the severity of patient falls and need to identify risk factors in patients for prevent-

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ing them. A standard, consistent process for identifying patients and applying safety measures within a fall prevention program helped to reduce falls in 4 participating hospitals. In 2000, the Joint Commission on Accreditation of Healthcare Organizations published a Sentinel Event Alert2 for fatal falls. More than half of the hospitals involved identified communication among providers as a root cause. A recommendation included creating a formal fall prevention protocol using staff education and training. Savage and Matheis-Kraft3 identified in the geripsychiatric patient population a need for a formalized fall prevention program involving staff education, fall risk assessment, and tailored nursing interventions. The American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention4 created an algorithm for the assessment and management of falls in orthopedic patients, addressing risk factors with a standardized assessment by the provider. McCarter-Bayer et al5 implemented a formal fall prevention protocol focusing on the definition of a fall, use of an assessment tool to identify patients at risk, communicating the risk to providers, implementing interventions, and educating staff including the use of postfall assessments.

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JOURNAL OF NURSING CARE QUALITY/APRIL–JUNE 2007 be relevant when implemented broadly across entire hospitals. The team also became aware of an assessment tool from new research related to fall prevention led by a Mayo Clinic physician, Dennis Manning.9 The tool was called the I-MOVE and by predicting mobility skills could potentially identify “fallers.”However, the tool had not yet been validated at the time the team was searching for an assessment tool to implement across the hospitals. Focus areas

Figure 1. Mayo Clinic Rochester Patient S.A.F.E. Program symbol. Reprinted with permission from Mayo Foundation for Medical Education and Research. All rights reserved, November 14, 2006.

In another project, Poe and colleagues6 stressed the use of an evidence-based assessment tool and created their own using identified risk factors in the literature at the time: patient age, fall history, mobility, elimination, mental status changes, medications, and patient care equipment. Education and standardized interventions led to successful fall reduction. The group also identified when fall assessment was not appropriate, such as for patients who were comatose. Szumlas et al7 also initiated a standardized process for fall assessment with stratified fall precautions based on the patient’s risk. Signage in the rooms reinforcing call light usage and incorporating interventions in the plan of care helped enlist all providers for fall prevention. Hitcho et al8 described the risk of falls among patients attempting eliminationrelated activities without assistance and the limited availability of assistive devices. One of the findings was that patients did not use their call lights, believing that they did not need assistance. The literature review provided many suggestions about what should be in a successful fall prevention program. However, most of the recommendations were dependent on specific patient characteristics that may not

Based on the literature review and the complexity of fall prevention, subgroups from the team were formed to examine specific areas of improvement. The subgroups focused on 5 different components of fall prevention: (1) risk assessment and screening, (2) communications, (3) culture and delegation, (4) education, and (5) facilities and environmental design (Table 2). The team was well positioned to address the 2005 National Patient Safety Goal, “reduce the risk of patient harm resulting from falls,” sponsored by the Joint Commission on Accreditation of Healthcare Organizations. The National Patient Safety Goal criteria required that hospitals “assess and periodically reassess each patient’s risk for falling, including the potential risk associated with the patient’s medication regimen, and take action to address any identified risks.”10 The Safe Landings Fall Prevention Team developed aggressive aims that addressed the new safety goal: 1. Define effective strategies or best practices for fall prevention. 2. Replicate successful strategies throughout the acute care settings. 3. Reduce the fall rate in Mayo Clinic Rochester hospitals by 50% by year-end 2005. 4. Decrease the level of injuries related to falls and increase the time between major events. 5. Identify appropriate equipment and unit design configuration to maximize fall prevention.

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Table 2. Subgroups and associated work identified from the Safe Landings Fall Prevention Team Subgroup

Component

Risk assessment and screening

Identification of new fall assessment/screening tool

Communications

Incorporate Hendrich II Fall Risk Model into electronic medical record nursing flow sheet

Culture and delegation

Education

Facilities and design

Determine method for “flagging” patient at risk Inform institution of the fall risk program and significance to each provider Developed the name of program Patient S.A.F.E. Program Communicate meaning of the symbol Identify impact of change on nursing workflow Recognize role of nursing patient care assistants in the initiative Develop education materials using assessment tool and associated nursing interventions that should be initiated if patient identified at risk for falling Recruit unit nursing safety coaches as champions Recommend facility enhancements to decrease risks for falls

Identification of a new fall risk assessment/screening tool to replace the current screening question on admission was recognized as the first priority and evolved into a significant challenge. The goal was to implement a tool in 2005 to meet the new

Outcome Conducted literature search and selected Hendrich II Fall Risk Model Developed presentations and materials about program, disseminated them in internal publications, e-mail notices about new program Redesigned intranet Web site Placed electronic “flagging” on hold pending technological changes Created snowflake symbol for patient door jams

Provided education to nursing patient care assistant group on its specific interventions and responsibilities for fall risk patient population Provided formal scheduled education for nursing staff

Identified unit resources for questions and concerns New unit was undergoing redesign incorporating safety features such as sensor lighting, bed placement and proximity to the bathroom, color schemes, and ceiling lifts, which coincided with recommendations for fall prevention from the team

National Patient Safety Goal as well as to improve patient care by more accurately identifying patients at risk. The group reviewed the literature and compared existing evidence-based tools that were already in use in other organizations with demonstrated

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effectiveness. Tools that were considered included the Morse Fall Scale,11 the STRATIFY,12 and the Hendrich II Fall Risk Model.13 The Hendrich II Fall Risk Model was chosen because it included the evaluation of specific medications and fall risk, had a prepared educational module, and had solid evidence of success during its development and use. After receiving education about the tool, many specialty practice committees supported its implementation as part of the shared decision-making philosophy of the Department of Nursing. The next step involved getting the tool into the medical record. An informatics nurse specialist and systems programmer assisted with the design of the language and screen shots. Each risk criterion has an associated score that is automatically calculated by the software and totaled for the nurse. The nurse then fills in a row called “fall criteria,”documenting whether the patient is at risk or not. This row alerts all caregivers to the patient’s fall risk status. The nurse then initiates the North American Nursing Diagnosis Association’s nursing diagnosis guideline “risk for falls”14 in the plan of care. The pertinent nursing interventions, depending on the risks, are selected from an electronic “order set” developed by the clinical nurse specialist on the team. LESSONS LEARNED Our new fall prevention program was named the Patient S.A.F.E. Program (Stop All Fall Events). Since implementation of the program in August 2005, follow-up of each component and of fall rates has continued. The team is monitoring the documentation of the Hendrich II Fall Risk Model for consistency and unanticipated issues. Initial documentation was occurring 88% of the time, with improvements reached in 2006 to 91%. Modifications were then made to the screen to minimize human error factors and prevent any of the criteria from being omitted during the documentation while still automatically calculating the patient’s risk scores (ie, the “fall criteria” row). Data collection is in

progress for evaluating further improvement, but anecdotal feedback from nursing staff has been positive of this change. Accurately interpreting the definitions of the risk factors/criteria in the tool for specific clinical areas was recognized as a potential barrier and source for possible confusion. Wording changes in the electronic screen were made to clarify the nurses’ questions about when the patient was at risk for a specific criterion (eg, “prescribed medications” was changed to “administered medications”).The department clinical nurse specialists also conducted an audit; on the basis of the patient’s condition, they found between 91% and 100% accuracy in the documentation of the criteria by staff nurse. The creation in the electronic documentation system of a row called “unable to assess” allowed for unique circumstances and accommodations during the documentation process without affecting the validity of the tool. The critical care areas can use this feature for patients who are heavily sedated and on a ventilator, thereby having no opportunity to fall. Nurses use this feature approximately 3% of the time. Nurses were educated on when the patient status may warrant not using the entire tool or only using part of it. Nurses from every unit had the opportunity to audit the Patient S.A.F.E. Program process and provided input as to how to make the program better. Issues related to workflow on the unit relating to the use of the symbol needed clarification. Nurses could also send in comments about the documentation process to the programmers of the electronic medical record. The list and ranking of the interventions order set in the plan of care was changed on the basis of this feedback. As determined by the Joint Commission on Accreditation of Healthcare Organizations National Patient Safety Goal and the team, the goals for daily frequency of documentation of the Hendrich II Fall Risk Model assessments and the appropriate interventions for the clinical practice specialty areas are 90%. If not met, improvement plans are implemented by the affected groups, which include

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Falls Prevention at Mayo Clinic Rochester reinforcement of the information about fall prevention and the Patient S.A.F.E. Program, available on our Web site, and use of additional digital learning aids. Many of the group’s strategies to achieve the aims have been put into place. The assessment tool was implemented as best practice throughout the inpatient setting. Some of the new room design configuration recommendations will be implemented on units undergoing renovation. Fall event data are continuously collected to measure the number, rate, and severity of falls. Fall rates have not decreased since implementation of the Patient S.A.F.E. Program, but the number of serious falls and the time in between them has markedly decreased. With an emphasis on event reporting in general for quality and safety initiatives, it is difficult to know whether the rates have actually improved because of the possibility that more falls are being reported now than before implementation of our program. A new focus for the team is preventing falls with injury, and we are piloting an initiative in a specialty unit with one of the highest fall rates. A new subgroup was also formed to evaluate the nursing interventions implemented at the departmental level. SUMMARY The Safe Landings Fall Prevention Team faces many challenges ahead, including the

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increasing acuity of patients in the hospitals, complexity of the healthcare system, and challenges of the team to maintain the gains achieved with the program. Since resources are not available to “reinvent the wheel,” it is important to standardize successful strategies as part of the normal workflow for all units, and therefore improving the efficiency and patient outcomes. The culture that embodies all healthcare disciplines in the organization has influenced the success of the team’s strategies for the Patient S.A.F.E. Program. Interdisciplinary involvement has improved the communication about the process, thereby influencing the culture and probability of success. There is still room for reduction in falls and especially falls with injury. The Safe Landings Fall Prevention Team is developing new aims for 2007, which will focus on reducing falls with injury by 30%, evaluating the use of the Hendrich II Fall Risk Model, piloting changes in processes to address the culture of safety, changing bathroom design, and ensuring that consistent interventions are being done across all inpatient units. Also assisting the team are experienced researchers who are assessing other clinical indicators for specific patient populations that may put them at risk for falls with injury. The team will continue to be the oversight group until all fall prevention strategies have been incorporated into the daily practice of staff.

REFERENCES 1. Health Care Advisory Board. Fact Brief: Programs to Reduce Patient Falls. Washington, DC: Health Care Advisory Board; 1998. 001-216-073. 2. Joint Commission Accreditation of Healthcare Organizations. Fatal falls: lessons for the future. Sentinel Event Alert. July 12, 2000;issue 14. 3. Savage T, Matheis-Kraft C. Fall occurrence in a geriatric psychiatry setting before and after a fall prevention program. J Gerontol Nurs. 2001;27(10):49– 53. Available at: http://gateway.ut.ovid.com/gw1/ ovidweb.cgi. Accessed October 26, 2006. 4. American Geriatrics Society, British Geriatrics Society, American Academy of Orthopaedic Surgeons Panel on Falls Prevention. Guideline for the

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prevention of falls in older persons. J Am Geriatr Soc. 2001;49(5):664–672. McCarter-Bayer A, Bayer F, Hall K. Preventing falls in acute care. J Gerontol Nurs. 2005;31(3):25– 33. Poe SS, Cvach MM, Gartrell DG, Radzik BR, Joy TL. An evidence-based approach to fall risk assessment, prevention, and management: lessons learned. J Nurs Care Qual. 2005;20:107–116. Szumlas S, Groszek J, Kitt S, Payson C, Stack K. Take a second glance: a novel approach to inpatient fall prevention. Jt Comm J Qual Saf. 2004;30:295–302. Hitcho EB, Krauss MJ, Birge S, et al. Characteristics and circumstances of falls in a hospital

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setting: a prospective analysis. J Gen Intern Med. 2004;19:732–739. 9. Manning DM, Keller AS, Frank DL. Independent Mobility Validation Exam (I-Move): A Tool for Periodic Reassessment of Fall Risk and for Discharge Planning. Department of Medicine, Mercy Hospital of Pittsburgh, Pa, and the Division of Internal Medicine, Mayo Clinic, Rochester, Minn; 2004:1–28. 10. Joint Commission Accreditation of Healthcare Organizations. 2006 Critical Access Hospitals and Hospital National Patient Safety Goals. 2005. Available at: http://www.jointcommission.org/Standards/ NationalPatientSafetyGoals/06 npsg cah.htm. Accessed May 11, 2006. 11. Morse JM, Morse RM, Tylko SJ. Development of a

scale to identify the fall-prone patient. Can J Aging. 1989;8:366–367. 12. Oliver D, Britton M, Seed P, Martin FC, Hopper AH. Development and evaluation of evidence based risk assessment too (STRATIFY) to predict which elderly inpatients will fall: case control and cohort studies. BMJ. 1997;315:1049–1053. 13. Hendrich AL, Bender PS, Allen N. Validation of the Hendrich II Fall Risk Model: a large concurrent case/control study of hospitalized patients. Appl Nurs Res. 2003;16(1):9–21. 14. Gordon M, Avant K, Herdman H, Hoskins L, Lavin MA, Sparks S, Warren J, eds. NANDA Nursing Diagnoses: Definitions and Classification. Philadelphia: NANDA; 2001:73–74.