Developing a Fall-Prevention Program

Nurse Leader Insider, November 15, 2018

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This is an excerpt from Patient Safety Strategies: Evidence-Based Practices for Fall Prevention.

There are three main elements to developing a fall-prevention program. The first is assessing the patients to identify the risk factors facing each individual and the hospital as a whole. The second is planning interventions to address the risk factors. The third is modifying the risk factors, partly through extensive staff, patient, and family education.

Patient assessment and risk factor identification

Every patient admitted to a hospital should be assessed for fall risk upon admission because every patient is potentially a fall risk. Every time a patient falls, assess the patient again for fall risk. This assessment can be undertaken in a variety of ways, using a number of available tools. Conduct a post fall huddle to determine what happened and what other intervention may need to be put into place.

Patients who are at risk for falling may need to be identified in some way, depending on your hospital’s policies. For instance, patients with high fall risks could be identified with “falling” stars or leaves. Place the falling stars on patient’s medical records, on their doors, or in their rooms to alert staff to the patient’s particular fall risk issues. Some hospitals use the whiteboard in the patient’s rooms and “code” the fall risk patient with a special code and also use the whiteboard to communicate such things as new medications started or falls on a previous shift. The whiteboard can also be utilized for instructions on how to transfer the patient. Be conscious of the Health Insurance Portability and Accountability Act of 1996’s (HIPAA’s) regulations and privacy concerns if you use this kind of identification system. Be sure to follow your organization policies.

Also consider implementing a stoplight system, which involves posting a picture of a stoplight in a patient’s room with either a red, yellow, or green light, with these meanings:

A red light means the patient should not be up without assistance and cannot be left unattended when in the bathroom.
A yellow light means the patient requires a minimum of standby assistance for any activity.
A green light means the patient may be up without assistance.

At best, risk assessment can identify that a patient has a potential to fall. It cannot tell you why the patient is at risk of falling or how to intervene. Risk assessment highlights for the caregiver that there is a need to further assess and determine the best interventions for the specific person.

Intervention planning

As noted previously, the most successful intervention programs are multifactorial, addressing multiple possible causes and risk factors. Successful interventions are also individualized, developed for each patient based on a careful assessment of that individual’s condition and situation. Interventions that include a detailed medical assessment followed by referral to appropriate services, such as ophthalmologists and therapists, consistently result in a reduction in fall risk.

Multifactorial intervention programs should include these elements:
•    Gait/transfer training by physical therapists.
•    Assistive device training and fitting by physical therapists.
•    Obtaining and teaching use to all personnel caring for the patient of assistive devices by occupational therapists.
•    Individualized exercise programs including:
•    Review and modification of medication regimens, especially psychotropic and sympathomimetic drugs. Reduce overall medications taken when possible. Remember that patients on many (polypharmacy) medications have an increased fall risk.
•    Treatment of postural hypotension.
•    Treatment of cardiovascular disorders, including carotid sinus syndrome and arrhythmias.
•    Modification of environmental hazards, including toilet and bath safety, with appropriate adaptive devices, bath mats, and assistance.
•    Treatment of foot problems.
•    Appropriate footwear and clothing.
•    Addressing sensory deficits with vision and hearing evaluation and correction/aids. Interventions should always be planned to address the problems identified in the assessment.

Interventions that are appropriate for a patient are incorporated into the patient’s care plan.

Once you have assessed a patient and planned specific interventions, implement the interventions and have a system for evaluating their effectiveness periodically. The first step requires thorough education of staff, patients, and family members.

Educating staff, patients, and family members
Use the resources in this manual to help plan training sessions. Teach the risk factors that are responsible for falls and the specific modifications that can prevent falls. Help staff, patients, and family members understand the root causes of falls so they can appreciate the importance of the interventions you want to implement.

Basic environmental interventions apply to everyone in a hospital and to the hospital as a whole. Stress to staff that fall prevention is everyone’s responsibility. Plan and conduct repeated training sessions for staff, patients, and families. Enlist the assistance of nurses, physical therapists, and occupational therapists for these sessions. The primary goal is to teach prevention, but this is also a good time to teach the patients and families how to respond to a fall when it occurs. Demonstrate how to gently assist patients to the ground if they have lost their balance. Teach patients how to have a “good fall,” by showing self-rescue techniques such as backing up against a wall and sliding down it.

You need a system in place for implementing patient-specific interventions. Putting the interventions on the patient’s care plan is the first step. Emphasize these interventions at every care meeting. Holding the staff accountable for implementing the interventions is essential. This accountability can be provided through routine follow-up and evaluation of the success of the interventions.

Track and trend systems
Accountability requires a way to track and trend falls that occur in your hospital. Examine each patient’s history of falls and evaluate interventions in place. Ask these questions:

•    Is the patient complying with the interventions? If not, why?
•    Is the staff implementing the interventions? If not, why?
•    Are the interventions effective? (The measure of effectiveness is whether the number of falls has been reduced.)
•    If the interventions aren’t effective, what different interventions should be tried?

Every fall should lead to a reassessment of the patient in question, taking a close look at the cause of the fall and the interventions that were implemented. Every fall requires an incident report, which should be the starting point of the investigation into why the fall occurred and what needs to be done to prevent further falls.

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