Executive Summary
Patient falls are a focus of a new Sentinel Event Alert from The Joint Commission.
- Assess patients for fall risk beginning at the preoperative telephone calls.
- Educate patients about avoiding falls when they return home.
- Communicate which patients are at risk using wrist bands, white boards, and/or electronic medical records.
How many patients fall in healthcare facilities each year? Hundreds of thousands, and up to 50% of the patients who fall are injured, according to The Joint Commission (TJC).1
Such events add to the length of stay, as well as the cost, which averages about $14,000, according to the TJC.1
Consistently, falls accompanied by serious injury are in the top 10 sentinel events reported to TJC. Now The Joint Commission has released a Sentinel Event Alert on falls, with tips and tools for reducing these incidents.1 The Accreditation Association for Ambulatory Health Care (AAAHC) also has a toolkit that targets falls.2
According to the TJC’s analysis, most falls are related to the following:
- inadequate assessment;
- communication failures;
- lack of adherence to protocols and safety practices;
- inadequate staff orientation, supervision, staffing levels, or skill mix;
- deficiencies in the physical environment;
- lack of leadership.1
Accrediting groups aren’t the only ones looking at patient falls. The Centers for Medicare and Medicaid Services (CMS) is requiring ambulatory surgery centers (ASCs) to report on ASC-2: Patient Fall, as well as other quality measures to avoid future Medicare payment reductions. In addition, CMS has labeled falls as a “never event” and doesn’t reimburse for the costs associated with treating a patient who has fallen in a healthcare facility.
Keep in mind, every patient who has had sedatives, anesthetics, or pain medicine is at risk for falls, says Jan Davidson, MSN, RN, CNOR, CASC, director of the Ambulatory Surgery Division at the Association of periOperative Registered Nurses. “Given that all patients have gone through some kind of invasive procedure, it puts them all at risk for falls,” Davidson says. “Everyone who works there needs to have heightened awareness that patients they’re taking care of have that risk.”
Another concern is that many elderly patients are undergoing ambulatory surgery. According to AAAHC, patients who are 65 years and older are at increased risk of falls.2 Elderly patients might have poor vision, an unsteady gait, confusion, and/or decreased reflex responses, Davidson says. Additionally, they might have difficulty hearing, which might interfere with their understanding instructions and directions. “All of those already put them at risk for falls,” Davidson says.
The concerns increase as ambulatory surgery programs take on older and sicker patients for major surgical procedures, including total hips and knees, says Girish P. Joshi, MBBS, MD, FFARCSI, professor of anesthesiology and pain management, University of Texas Southwestern Medical Center, Dallas. Joshi is a board member with The Accreditation Association, the parent company of AAAHC, and Acreditas Global, which is AAAHC’s international program.
“The same emphasis given to inpatients now needs to be given to outpatient populations,” Joshi says. AAAHC says that anesthesia/surgical factors in patient falls include lower extremity surgery and lower extremity nerve blocks.2
Take a look around
Some fall prevention efforts should begin before patient contact, says Michelle Feil, MSN, RN, senior patient safety analyst at the Pennsylvania Patient Safety Authority. The Authority is planning to develop a falls risk assessment tool for ambulatory facilities.
Look at how patients arrive at your facility and move into the building, Feil advises. Do you need a handicapped ramp? Also look at your doors and chairs to determine how easily they can be maneuvered, she suggests.
Consider these additional suggestions:
• Identify patients at risk.
Begin the fall prevention efforts with the preoperative telephone calls, sources suggest.
TJC says to use a standardized assessment tool to identify risk factors for falls and injuries. The examples listed in the Sentinel Event Alert are Morse Fall Scale or Hendrich II Fall Risk Model. TJC prefers that these tools are integrated into the electronic medical record (EMR).
“In addition to the tool, a comprehensive, individualized assessment for falls and injury risk should be performed,” TJC says. “Ensure that the patient’s age, gender, cognitive status, and level of function are included in the assessment.”1 (Editor’s note: The Morse Fall Scale is available in the AAAHC falls toolkit at http://bit.ly/1MiqjpH.)
According to AAAHC, risk factors for falls, in addition to age, are history of a recent fall; co-morbidities including dementia, hip fracture, type 2 diabetes, Parkinson’s disease, arthritis, depression, or poor cardiovascular health; functional disability that requires use of assistive devices; fear of falls; poor vision; pain; cognitive impairment; gait, balance, or visual impairment; use of high-risk medications, such as tranquilizers, sedative-hypnotic, or antihypertensive drugs; urge urinary incontinence; bare feet or inappropriate footwear; use of anticoagulants; and osteoporosis.2
Also remind patients that their risk of falls continues after they are discharged home, Davidson says. Tell them to remove rugs and cords that could be tripped over, she says.
• Take steps in the facility before surgery.
Providers need a standardized communication process to communicate which patients are at risk for falls, the TJC says.1 They can use white boards or prompts in the EMR, it says.
Receptionists who see patients come into the facilities can alert staff if they notice patients have an unsteady gait, difficulty with balance, are using assistive devices, or have difficulty getting in and out of chairs, Feil says. Some facilities that care for many frail elderly patients arrange for staff members to meet patients at their cars and escort them into the facilities, she says.
However, even young, healthy patients can be at risk of falls if they’re left alone after a procedure, she points out. “They don’t realize the risk of anesthesia they just had,” Feil says. Explain to them that they will be experiencing the effects of anesthesia and that their blood pressure will be lower than normal. Also tell the patient’s family and friends what to expect, Feil says.
Determine how you will identify patients who are at risk for falls. AAAHC recommends colored bracelets,2 but any creative method can be used, Joshi says.
• Take steps in the facility postoperatively.
Once patients are in your facility and have been identified as fall risks, there are steps you can take to reduce risks, Davidson says. One step is to put those patients closer to the nurses so they can be watched, she says.
Also, allow family members to come to the recovery areas as soon as possible, Davidson suggests. “It will comfort patients and make them less confused and agitated,” she says.
Guard rails and a call light within reach of the patient also are useful, Davidson adds. “Make sure they know to call before they try to get up,” she says.
At discharge, provide detailed written instructions, Joshi emphasizes. (See story in this issue about what to do after a fall. For more information, see “11 ways to reduce rates of falls with injuries,” Same-Day Surgery, March 2014.)
REFERENCES
- The Joint Commission. Preventing falls and fall-related injuries in health care facilities. Sentinel Event Alert 2015; 55. Accessed at http://www.jointcommission.org/assets/1/18/SEA_55.pdf.
- AAAHC. Patient Safety Toolkit: Ambulatory Surgery and Preventing Falls. 2013. Web: http://bit.ly/1MiqjpH.
RESOURCE
- From AHC Media, publisher of Same-Day Surgery: “On-Demand Webinar: Give Falls the Slip: TJC & CMS Hospital CoPs & Standards.” This webinar offers two hours of CME and CNE credit until Aug. 18th, 2016. Product code: T150818. Telephone: (800) 688-2421. Web: http://bit.ly/1RBArOE.
How many patients fall in healthcare facilities each year? Hundreds of thousands, and up to 50% of the patients who fall are injured, according to The Joint Commission.
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