Q&A: Toolkit reduces falls among hospitalized patients

A fall prevention toolkit that engages hospitalized patients and their families was linked to fewer falls and injuries, according to research published in JAMA Network Open.

Fall Tailoring Interventions for Patient Safety, or Fall TIPS, is a nurse-led intervention that uses bedside tools, including posters and computer screensavers, to provide information to patients, families and health care workers on the patient’s specific risk factors for falls and a tailored prevention plan based on those factors.

Researchers tested the toolkit during a nonrandomized controlled trial with a stepped wedge design at three academic medical centers in the United States from November 2015 through October 2018.

Using the toolkit, nurses worked with patients and their families to fill in a laminated poster that identified the patients’ risk factors for fall. The poster also included information on appropriate fall prevention interventions.

Once these were completed, additional posters were generated from the institution’s electronic health record system that provided more detailed information on patients’ risk factors and their tailored fall-prevention plan. These posters were either hung at the patients’ bedsides or displayed as a screensaver on bedside computers.

A total of 17,948 patients were evaluated before the intervention and 19,283 patients were evaluated after it was implemented.

Researchers determined that there was a 15% reduction in falls overall (adjusted rate ratio = 0.85; 95% CI, 0.75-0.96) and a 34% reduction in injurious falls (adjusted RR = 0.66; 95% CI, 0.53-0.88) after Fall TIPS was implemented vs. before it was used.

Healio Primary Care spoke with study co-author Patricia C. Dykes, PhD, RN, FAAN, FACMI, program director for research in the Center for Patient Safety, Research and Practice at Brigham and Women’s Hospital and an associate professor of medicine at Harvard Medical School, to learn more about the toolkit and how it can be implemented at hospitals across the country.

Q: Why was this toolkit needed?

A: We developed the Fall TIPS toolkit in 2007 to 2009 after reviewing 30 years of negative fall prevention clinical trials. We interviewed professional and paraprofessional providers, patients who had fallen in the hospital and their family members to learn their perspectives on what they believed was effective. We learned that nurses routinely assess for fall risk when patients are admitted and throughout hospitalization. While the results of that assessment are documented in the patient chart, they are not routinely viewed or communicated to other members of the care team, including patients and family. In addition, we learned that fall prevention interventions need to be tailored based on patient-specific risk factors. The usual practice at that time was providing fall prevention bundles based on whether a patient was found to be at high, medium or low risk for falls. Patients at high risk for falls were prescribed a long list or bundle of interventions. Low-risk patients received no interventions or just standard environmental precautions. With other adverse events like line infections, we can bring rates to near zero if we follow a simple checklist that includes a bundle of interventions. However, to prevent falls, the plan needs to be tailored to each patient’s risk profile and the team AND the patient need to follow it. We learned from the clinical staff that most medical patients are at high risk for falls, so based on the traditional fall prevention approach, they all get assigned a long list of interventions. We heard that there aren't enough staff and resources to carry out this list of interventions. Nurses and other hospital staff are busy caring for complex patients at risk for many adverse outcomes — not just falls.

We determined that a toolkit was needed to integrate fall prevention evidence into practice to help with identifying patient-specific risk factors and to ensure that interventions were in place to mitigate risk. Patients at risk due to a gait disturbance require different interventions than patients with cognitive deficits. Patients at risk because they have a gait disturbance get physical therapy. Patients who are at risk because they are getting lots of fluids get frequent toileting rounds. Patients who do not reliably call for help are not left in the bathroom unattended. The tailored fall prevention plan should be communicated to all team members, including patients and family. Therefore, it needs to be at the bedside. The Fall TIPS Toolkit ensures that everyone is on the same page about the fall prevention plan and everyone knows their role in carrying it out consistently.

We also found that patient and family engagement is needed to ensure that the fall prevention plan is consistently executed. In our original Fall TIPS study, we reduced falls by 25%, but we knew that over 90% are preventable. The most common reason patients with the Fall TIPS intervention fell was that they did not follow their plan. In this current study, we demonstrated a 34% reduction in fall-related injuries when patients and family were engaged in the fall prevention process using Fall TIPS. Here, we demonstrated that patient and family engagement increases the effectiveness or “dose” of the Fall TIPS program.

Q: How easily could this be implemented at other institutions? What costs are associated with it?

A: Fall TIPS has been implemented at over 150 hospitals in [the] U.S. and around the globe. It is straightforward to implement, and the Fall TIPS Toolkit and implementation tools are all available for use without charge from our website, www.FallTIPS.org. Because the Fall TIPS Toolkit is based on over a decade of evidence, we ask that our tools are not modified without written permission.

Q: Can this toolkit help reduce falls in patients when they return home after discharge?

A: The Fall TIPS Toolkit targets risk factors commonly associated with hospitalized patients. Evidence-based resources for fall prevention at home and in the community — for providers and patients — can be found on the CDC’s STEADI website. Our team is currently working on two projects that are developing strategies for integrating primary care fall prevention evidence into practice targeting community dwelling older adults.

Q: Why is it important to address fall risk in younger patients in addition to older patients?

A: Because the medications and treatments we provide in the hospital can increase risk for falls for both older and younger patients. We found in our research that many younger people do not believe that they are at risk for falls in the hospital, especially if they are independent at home. Conducting the fall risk assessment with the patient — young or older — helps them to understand their personal risk factors. Developing a tailored or personalized fall prevention plan with the patient makes them more likely to engage in their fall prevention plan.

References:

Dykes PC, et al. JAMA. 2010;doi:10.1001/jama.2010.1567.

Dykes PC, et al. JAMA Netw Open. 2020;doi:10.1001/jamanetworkopen.2020.25889.