I'd like to introduce our speaker to get us started today. Ms. Laura Dixon most recently served as the Director of Risk Management and Patient Safety for the Colorado region of Kaiser Permanente. Prior to joining Kaiser, she served as the Director of Facility Patient Safety and Risk Management and Operations for COPEC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services, and pain management. Prior to joining COPEC, she served as the Director of Western Region Patient Safety and Risk Management for the Doctors' Company in Napa, California. In this capacity, she provided patient safety and risk management consultations to physicians and staff for the western United States. As a registered nurse and attorney, Laura holds a Bachelor of Science from Regis University, a Doctor of Jewish Prudence from Drake University College of Law, and a registered nurse diploma from St. Luke's School of Professional Nursing. She is licensed to practice law in Colorado and in California. Thank you for being here with us today, Laura, and we invite you to go ahead and get us started. Okay. Thank you very much and welcome, everyone. We're talking on a topic that's near and dear to many nurses' hearts, and that is patient falls. We don't like them, but we know they occur, and sometimes we can't avoid them. But there are times we can, that there are steps that not only the nurses but other clinical staff in the hospital can take in order to keep our patients safe and prevent those falls and prevent any subsequent injury that might occur. So my disclaimer, of course, is always in here, and this information that I'm providing today is strictly that. It's only information. It is not meant to serve as legal advice nor establish an attorney-client relationship, so please consult with your in-house counsel, your own attorney, your professional legal representative, whoever that happens to be, for advice, and especially if you've got a particular incident on how you might want to handle it. Well, I always like to go over and just do a quick introduction. So between almost a million people within the United States will fall every year, and some of the research has shown that about a third of them could have been prevented. CMS, as we know, has not reimbursed us for those injuries that could happen as a result of falls or other injuries, and that's been since 2008. And that's why the Fall Prevention Program, that really involves managing those underlying fall risks. You know, problems with transfers and just walking down the hall. Maybe it's simple medication interactions. Falls are the third most leading cause for readmissions. 14% of patients were readmitted after discharge, and 5% were due to falls, and that's the main reason elderly patients come back to the hospital after discharge. And that's why we found that preventing those falls, especially in our older population, has become so important to prevent those preventable readmissions. Fall rates from 3 to 11 falls per 1,000 hospital beds, that's 25% that do result in injuries, and that can be anything from an actual fracture, a head injury, or simply the fear of falling that prevents them from moving, which is what we want them to do. Hospitalized older adults, they're at risk of falling, but the problem is they don't realize that risk, and that's why patient education is so important. Those of you who work in joint commission accredited hospitals know we have what's called those never events, and as a result, some states have stopped billing for some of those never events. Now they are called serious reportable events in healthcare. National Quality Forum, they've identified 29 adverse events that they consider to be largely preventable, and that would include death or disability due to a fall while they're actually cared in the facility. And by the way, as I go through this, I have a couple case studies, one in particular at the end that I do want to talk about, and it's one that we had encountered on, okay, how are we going to handle this particular fall? Well, just some studies and some findings, CMS, of course, we know that as a hack, they no longer pay Medicare for those hacks, those hospital-acquired or healthcare-acquired conditions that might happen, and that includes injuries from falls, whether it's a fracture, dislocation, could include also a burn, but falls is the number one hack that we do have. Data was showing that almost 2,600 cases had an average cost of $24,000, almost $25,000 back in 2006. That's when it first started doing this study, and so now we're starting to see an increase. The cost of falls for serious injury was almost $13,000 more than non-falls. Up to half of the falls in the hospital did have some sort of an injury, and those related injuries account up to 15% of rehospitalizations within the first 30 days after that patient has left. Healthcare-associated falls, 20% of patients may have a fall within your hospital, and of course, it's not unlikely or not surprising that the increased number would happen in rehab, geriatric, if you have a special unit, or even your neurosurgery or neurological units. Falls related to injuries, that's up to 6% of medical expenditures. That's for 65 and older. 40%, up to 40% will have an injury that would be a major injury, up to 8% of those, and that means we've got an increased charges of 4,000-plus falls and trauma. That is a hospital-acquired condition with no additional payment. And there was a study done a couple years ago that showed that falls injure a million Americans with a cost of $50 billion per year, and there's a financial case for trying to prevent them, if nothing else. Well, a couple studies came out a little while after that and showed that if we have more nurses and we utilize our bed alarms a little better, that can actually help reduce them. This came from Washington State, because 11 states, and including Washington State, they are required to report falls to their Department of Health when it does happen. Some hospitals have now installed monitors, alarms, to keep patients so that we keep them from sleepwalking. You know, they're sleeping, they get up out of bed, and the alarm goes off. Also, having enough nurses and staff to respond when that alarm goes off, that will help reduce falls by 66%. And of course, those patients who get sleeping medications, particularly Ambien, that seemed to be the one of their focus, four times more likely to have a fall. Other new studies that came out, Mayo, they studied, again, Ambien, and that that was an increased risk four times the fall. Women having chemotherapy-induced peripheral neuropathy, they found an increased incidence of falls for those type of patients and individuals. Other studies, having that no-pass zone where, and this is not for the patient, this is for the staff, where if you see a call light on, doesn't matter whose patient it is, you go in and help. It doesn't matter if you're passing meds, if you, you don't have another patient with you, of course, but if you can at least stop and say, can I help you, if you need anything. A personalized recorded message for that alarm. Maybe you can help that confused patient, that alarm goes off and says, oh, Mr. So-and-so or Ms. So-and-so, you're trying to get out of bed, would you mind waiting, just lay back down and we'll be on our way to come get you. Something personal so that the patient knows it's about them. Maybe put a patient board in the room that says, hey, I'm at risk, I need a cane, a walker, something that can help me get up and down. They've also found, Mass General, found that infections also lead to falls. Bloodstream, UTIs, respiratory, the most common associated with those infection-related falls, because that can cause them to have dizziness, of course, that leads to falls, and maybe coming back into the ED, now that's, of course, on those, and it's not just the elderly. 20% of the patients, a fifth of those patients that they studied were under 65. 2017 JAMA article, number of falls of 65 and older was 672. It goes up when they reach that wonderful age of 85, up to 820, and that does increase among patients as they start to develop dementia. And there is evidence support actions that, that's why we need to start preventing these. American Hospital Association, another study, they put out Pursuit of Excellence, joint commission, they were combined in this effort, and they released a guide to help prevent falls. It's about 20 pages long, and it talks about factors and solutions to prevent them. I have that information in the appendix for you, by the way. Now, this is based on 30 root cause analysis and 21 targeted solutions that they were trying to see as their comparison. Well, those hospitals that put it into effect reduced their falls 35%, and those who happened to have injury, down to 62%. So yes, you still had some falls, but the injury rate decreased dramatically. And it helped, doing this study really helped analyze what are the contributing factors that result in falls. So here were the top contributing factors. Well, using those falls risk assessment, sometimes it's not a valid predictor or simply inconsistent rating. Hand-off communication issues. The risk was not communicated, so that was one of the factors that contributed to it. Toileting issues. Patients didn't get help that increased that risk, or even the medication, once, you know, they had to get up and go to the bathroom, the medication kicked in, and it increased that risk for them. Call light issues. Where's the call light? Do they know what it is because of their dementia? Do they remember to use the call light? Education. Organizational, cultural issues. An organization is, this is crucial. We have to try and prevent this and do the best we can. And then medication issues. One or more medications that this patient is taking is really going to increase that risk. So the goals here was to focus on prevention and, of course, decreasing that severity. And also, increased mobility. Immobility was one of the contributing factors. We have to get these patients up and moving because immobility, well, it's going to cause an increased length of stay, not just pressure ulcers, but functional loss. Those legs get weak. They've lost muscle mass. Foley catheters, those can really increase the fall risk could they get their feet trapped up into it. And this study also showed 30% of our elderly patients had an initial order of bedrests. And another study showed the amount of time the patient is actually up and walking around, just standing, it's only 43 minutes. Because up ad lib, what that meant was 97% of the time, the patients are not moving. They're immobile. That's 23 hours and 17 minutes. Immobility leads to deconditioning. And that's why they believe so many patients fall while they're toileting. Immobility increases the risk when they do need to get up and move. And all of these studies, I have them listed there for you. So I'm going to move on to the Joint Commission, excuse me. So Falls was a Joint Commission National Patient Safety Goal back in 2009. Well, they've now moved it over to a standard. It's under provision of care. And what they're finding is that the hospital under this standard now, this is what you're expected to meet. You assess and manage the patient's risk for fall. Now, I know one of the contributing factors were those risk assessments weren't that good or they were inconsistent findings. But nonetheless, we still have to check out our patients. So you also then, as a result, put into place a fall reduction interventions. Looking at your population, what setting are they in? Because that could be, again, your neurosurgical unit, could be a surgical unit, a pediatric unit, and then the individual patient. What's your patient like? The performance improvement standard, as we all know, like QAPI, we collect that data. We monitor how we're doing. And so during this time, the surveyors may want to see your falls policy during their document review. How are you doing that in order to prevent these falls? Joint Commission has that definition of a fall as a sentinel event. And I've got the link there for you. I last assessed it just a couple days ago just to make sure it was still how they did it because a year or so ago, they managed to change a few of the warnings. This is a fall that occurs in a staffed around-the-clock setting or it's in a care setting that is not staffed 24-7, but during the time when staff is present. And it results in these type of injuries, any fracture that requires surgery, casting, or traction, because a lot of them were saying, oh, I only had to put on a splint, so therefore it didn't qualify as a sentinel event. And that wasn't the intent. It was in a fall with an injury of a certain degree that the patient just didn't get up, dust himself off, and keep going. Something that required a consultation or management or even comfort care because of a neurological or internal injury. Those with coagulopathy who receive blood products as a result of the fall. And then, of course, the worst case scenario where it's death or permanent harm as a result of that fall. So they did beef up a little bit to that, and in particular, the one with traction. So as far as the assessment, that should be part of, once the patient walks in, that's your initial nursing assessment. From there, you develop your plan of care. You put interventions based upon what their score is if you're using a particular tool. Now, most of these will have two or three types of interventions depending on how high that risk is. So their data from Joint Commission, it's the number one cause of sentinel events that they were tracking. And I've got the list here of their most recent data from 2022, 42% of the sentinel events. Top of the list right there. And that's a 27% increase from the year before. So it still remains a major concern. Falls while walking, ambulating, the leading mechanism. Followed shortly thereafter when they were getting up from the bed while toileting. Some of the contributors Joint Commission found were not following our own policies like the risk assessment and implementing our plan of care. Not enough staff, really, and also staff communication that was inadequate during handoff and lack of a shared understanding. What is the plan of care for this patient? So Joint Commission does have resources for us. This is still in place. It was back in 2015. But it's still their resource on falls. They talk about the average cost of $14,000, but the factors, again, inadequate assessment, we're not communicating with each other on what is the risk, not enough orientation. If you're using a lot of float or pool nursing, you might want to look at your orientation that occurs on the floor. Environmental deficiencies, how high is that toilet? I've noticed a lot of the new builds or reconstructions for some hospitals, they're making that toilet seat higher, especially on orthopedics. When my husband had his knee surgery in this hospital, and the hospital was a little bit older, but they had refurbished the bathrooms. And so now the toilets are up higher that you don't have to stoop down so far and put pressure on perhaps a surgical incision. And then lack of leadership, where, okay, what do we have to do and who are we going to assign it to? Now, Lindsay did mention we have a few questions. So here's our first question, again, all voluntary. Lindsay, will you put that up for me? Absolutely. Okay, so this question should now be on your screen. It says, our facility's fall policy applies to inpatients over the age of 30, all inpatients regardless of age, all inpatients and outpatients, or all patients, staff, and visitors. And if you joined us after we got started this morning, I did also mention that as we go throughout these polling questions, there'll be several that will come up on the screen throughout the webinar. We will pause to address any questions that you have for Laura up to that point in the presentation. I don't see any pending questions at this time, but if you do have any for Laura, go ahead and type those into the Q&A option found there at the bottom of your Zoom window. Or for some reason, you don't see that as an option, you can, of course, utilize the chat and type in your questions there as well. Okay, we've gotten a good mix here so far. I'll go ahead and... And again, there's no right answer, no right answer. Some of the information, once you hear it, you may want to go back and re-evaluate your policy on it. So, again, just strictly informational only. So, oh, good, everybody's really kind of all over the board. Good split there. Yes, it was. So, the reason I bring this up is because, and excuse me, there we go, newborn falls. Who ever knew a newborn could fall? But then I start to think about it, sure. And really, this quick safety they put out, number 40, from Joint Commission, showed that this was an unrecognized issue because that can cause some major injuries for these little babies. 600 to 1,600 falls and drops every year. And the risk factors, mom gets pain medication, C-section after birth, breastfeeding, second, third postpartum night around midnight to early in the morning when it's starting to kick in, and mom's tired, mom's exhausted, and perhaps the baby falls off the bed. So to prevent them, yes, we want to promote rest for mom. That's a key because they need to get back and start taking care of the little one. Hourly rounding. Now, this is, of course, for those moms who are staying over. If mom's sleepy, maybe we can put the baby in the bassinet so that baby doesn't accidentally get rolled off the bed. Listen to the parent using that assessment and counsel them if there is a high risk of injury. In other words, yes, I know you want to sleep with the baby, but you are extremely tired. You are exhausted. You've been through a lot. And let's just make sure the baby is safe. Develop an assessment tool for those newborn falls and the risk, and also cautioning the parent falling asleep with that newborn actually in bed with them. Now, there is a matrix for falls for root cause analysis, and again, we know Joint Commission requires that to be done. And there are certain elements that need to be included in that RCA. You've got the area marked like, okay, what was your physical assessment? How did you do this on the baby or the mom too? Did you look at your observation? Did you look at the mom and the baby? How were they doing? And then management, staffing levels, those are a couple of the things you want to keep in mind. And advise one, strictly up to you if you want to use it. I don't endorse any of them because those are so policy and facility related. And then finally, thank you, Joint Commission, you actually came up with a video on talking about preventing falls. And again, you can access this, but I don't believe you need to be a member for that. A March 20 study from Joint Commission found there's a three-step program, and it mentions the role of patients and patient activation in this fall, it's tailoring interventions for patient safety. So again, you do your risk assessment, develop a personalized plan, and then follow the plan using universal fall prevention tips and precautions. So again, Joint Commission has these resources for us, so if you're getting started, start there. Really, these are the experts, they've done a lot of the study and research, and it's a good starting point for you. Let's move over to now CMS, conditions for Medicare and Medicaid. As we know, that if you do participate in Medicare and Medicaid, you have to meet all of the conditions for all patients, not just Medicare patients. So overall, you have to have a safe environment and a setting. This was a big area for immediate jeopardy, and in the guidelines also, that not... Violation. And that could come up during a validation survey. Hey Laura, I'm sorry. We lost sound for just a second. I'm not sure if it was your mic or something there, but just happened to lose it. You're back now, but just let you know we did lose it for a second. Okay. Very good. And I apologize for that. Just in the interest of time, Lindsay, I probably won't go back over that with you if that's okay with you. Yeah, yeah, yeah. We only lost a few seconds. We just want to make sure you know. Very good. Okay, so why do we want to look at falls? Well, it's a standard of care. Substandard care could be the basis of a lawsuit. Average cost 70,000. Compliance issue, you know, billing for substandard care, you're not going to get reimbursed. Fraud and abuse. Now you think, why would that be fraud and abuse? Because you are billing for something that you're not supposed to be billing for. In 2015, we had a hospital settle for $2.5 million because of a fall in the emergency department. This patient came in by EMS, had a fall at home, and absolutely no orders for falls precaution. That should have been probably one of the first or second order is falls precaution. There were some serious injuries with that patient too, by the way. Restraints. I can't tell you how many times many years ago that I do not want to admit how many years we used restraints as a fall prevention program because it was nighttime. These were older patients, they were confused, sometimes a little bit of delirium included in that with the medication, and they kept trying to get out of bed. And we were busy. We didn't have time to sit there and keep an eye on them. So we put them in a waist restraint. You can't do that anymore. This should not be considered a routine use in your fall prevention program. And because they might fall, that's not sufficient. It does not actually reduce the fall rate, use of restraints. And they occur sometimes more often when they are restrained and usually more serious injuries because they are restrained to a point where perhaps limbs can get compressed and those fragile bones can snap pretty easy. Other things you might want to consider when you are assessing, is there something going on with that patient? Underlying, maybe we do need to have those protective measures. History of falling without any basis, that's not adequate. So are there other interventions that we can use to help keep this patient from falling? So where do we want to start? Of course, we want to start by assessing falls in our facility. And there's multiple definitions and how we also measure falls within our facility. So that's where we need to start. The WHO says a fall is any event that results when a person comes to rest inadvertently on the ground or floor or other lower level. AHRQ, unplanned ascent to the floor with or without injury. There's a little bit broader. Unplanned ascent to the floor by the national quality form or lower form. Now CMS goes into a little bit more detail with what they consider a definition of a fall. So if you are looking to beef up your policy or review it, take a look at this definition. It is in the long-term care manual. That's appendix PP, if you want to have one. Because then you're going to pretty well cover your basis. And that says coming to rest on the ground, the floor, some lower level, not from other external force. Like the patient got pushed by another patient. Or an episode where the patient lost their balance. Would have fallen if not for another person. In other words, a nurse helped ease him to the floor. If they even have no injury, it's still a fall by CMS. Unless you have evidence suggesting otherwise, when they're found on the floor, it's a fall. So how do we classify them? Well, we look at a couple things. One environmental or physiological. This is one approach that Jana Morris put together. And she calls them accidental, unanticipated physiological, anticipated physiological. And, of course, the prevention depends upon that particular type of fall. So we have accidental. So here we've got a low-risk patient. You've got your really healthy individual. They're fairly young. And they slip on water, an environmental hazard. And, of course, it goes to reason that you want to reduce that environmental hazard. Then we have an anticipated physiological fall. That's someone who we believe to be at risk. That could be maybe they have an abnormal gait. Or they have to get up and down to the bathroom consistently. Those high-risk medications. What do we do here? Close supervision. Help address those risk factors. You see this picture here where the nurse is actually assisting the patient. Now, there's one thing in here that you might want to reevaluate when you're looking at this picture. The handrails that the patient would actually use to help support them are blocked by beds in the hallways. So just keep an eye on your environment when you're looking at, okay, how are these patients going to get up and ambulate if we made their access or blocked their access? And then we have our unanticipated physiological falls. Those are ones that we cannot predict before the first fall. They have a seizure. They have a syncopal episode. Maybe they're going in the episodes of a stroke. Now, those situations where I had no idea that was coming. So in this situation, you're just looking at appropriate post-fall care and taking care of them. Okay, now where do we go from there? She also put out some questions that you might want to ask. Do you have a common definition of a fall? One of my step-sons works in a healthcare situation. I asked him, in your hospital, how do they define a fall? And the answer was pretty much what CMS says. If they're found on the floor, it's a fall, period. What strategies, best practices do you have for prevention? How do you reduce that fall rate in your facility? How can you decrease that severity of injury related to the falls? Do you have a falls committee? How do you communicate risk for falls? How do you educate the patient? Do you do it during handoffs, during report? How do you do that? Do you educate the patient and their family on those falls? In other words, mom is in the hospital. She's had surgery. And just her normal behavior, she gets up to go to the bathroom by herself. Family is sitting there. Family, do not let her say, I don't need help. She has to have help. Do you utilize a standard assessment tool? A fall injury risk assessment, a standardized one. How do you evaluate and monitor falls? How do you ensure accountability through audits? In other words, are you using your fall risk assessment tools and interventions? Are they done correctly and consistently? Maybe you have equipment. Great. What about the unit design? Does that help maximize fall prevention? Do you have standardized interventions for those who are at risk? Maybe you put them closer to the nurse's station. Is there understanding of that definition and inconsistencies in reporting? And the WHO did note there's a lot of inconsistency in reporting and not reporting a fall. So when a patient came to rest on the ground. And then finally some more questions. What are your common risks for falls? What's a good incident report specific for falls? Do you want to use one? Do you want to use two? Do you want to use three? Do you want to use four? Do you want to use five? Do you want to use six? Do you want to use seven? Do you want to use eight? Do you want to use nine? Do you want to use 10? Do you want to use 11? Do you want to use 12? Do you want to use 13? Do you want to use 14? Do you want to use 15? Do you want to use 16? Do you want to use 17? Do you want to use 18? Do you want to use 19? Do you want to use 20? Do you want to use 21? Do you want to use 22? Do you want to use 23? Do you want to use 24? Do you want to use 25? So, we talked about first, okay, there's the first one you assess. And then how about measurement? Because this is difficult to really benchmark between facilities because of the different definitions that are all out there. And also how you collect and report the data. And then, of course, the lack of risk adjustment. One hospital may see twice as many elderly patients than the other. So, you may have more high-risk patients from a surgical component, or perhaps you're a neuro unit, and your neuro unit's a pretty good size, where they have gait issues, or an orthopedic hospital where they may have major gait issues. So, whatever you want to do to assess them, here's just an example that you can consider taking the information off. So, under the National Quality Form, they use a common method. And that's what they recommended. Measure and track your fall rate. Number of patient falls times 1,000 over the number of patient days. Now, this will look at the total number of eligible falls, and then you divide it by the total number of days. And then you multiply that by 1,000. So, there you get your fall rate per 1,000 days. You can look at patients at risk, maybe those who fell, falls per bed. But there are other fall rate measurements that you can use. So, I have two different comparisons. One is those who are at risk, where you do the number of falls times 1,000 over the number of patients at risk. This is commonly used in your long-term care. And then the other one is the number of patients who fell, those, again, who are at risk. This one takes repeated falls and the experience by the same person, but that's only included once in the numerator. So, other fall rates, again, there's no one rate. It's what works for you. Number of falls per bed. So, let's say you had four falls last month. That's great, considering how many falls you could have. You have 900 beds in the last month. So, really, you're doing pretty good. For every 1,000 bed days of care, you can expect, again, this predictor, you can expect to have about four falls. So, again, not too bad for you. And here's our second question. Lindsey. Okay, let's get that one up here on the screen. Okay, you should all see this one now, and this does give you the option to select any and all options that apply to your organization here. I'll give you a couple seconds to select your options here. I don't see any pending questions now. So, if you do have any for Laura, go ahead and be typing those in, and we're happy to help address those as we go throughout the program. And, again, I agree that the author who brought up the benchmarking between hospitals and care providers, can be challenging, because you could serve totally different patient populations. Your hospital setup could be different. Your staffing types could be different, depending on your patient population, how big you are. It's hard to benchmark between hospitals in a community, unless you're, you know, a small hospital. So, if you're a small hospital, it's hard to benchmark between hospitals in a community. Unless you're, you know, same size, same patient, everything. It's very challenging to benchmark on those type of items. Okay, we've got some good results. Great, good. Delineates between floors. Encompasses everything. Part of our QA. Yay, thank you very much. Okay, so what is the fall rate? Again, studies show the fall rate of acute is just between 2.5 to 3.5. And it's, again, very hard to compare between unit to unit, let alone hospital to hospital, unless you're doing that risk-adjusted, depending on who you have, how big you are. And you have to take into account your population, what types of care. Do you have a long-term care facility, rehab, and neuro? Because those are the higher ones. Those have the higher number of falls. And, again, other difficulty, we're using different calculations. And some that they found in the past just simply weren't risk-adjusted. Inpatient rate, 1.7 to 25 falls per thousand, depending on the care. That's with the gerophysiatry. That's the highest. And then I've just got some others. More shows the fall rate, 2.2, 11 to almost 25% long-term care, up to 20% in rehab. And of those, up to 7.5 have serious injuries. So here we've tried to get them while they're back on the road to recovery, and now they're back with another one, with another acute injury. So just some other types of numbers, the fall rate per thousand, according to what you have. Neuro, rehab, geriatrics, they are the top. Med surge unit, 3.6 falls. And then different calculations. Some emergency departments calculate their fall rates per 10,000 visits as opposed to beds. And that makes sense. Others use per thousand visits. The fall rate just under about 2%, 2%. And hospital compare. Some of you may have heard of that. It's a program through CMS where they have hospitals, long-term care, rehab units. They collect this data and submit it to CMS. It's part of their quality data. And falls was one of them. And they have 5.27 per 10,000 discharges that they have noted. And then just some others that use some of the tools. Veterans, they report a fall rate of 3. Quality indicator from Maryland, they project at 3.7. California nursing outcome, 3.2 per thousand. So these are pretty consistent numbers. But again, you have to adjust that, risk adjust it. And then finally, falls and staffing. AHRQ did put out a study that with an increase in nurse turnover, we've got an increase in our fall rate. American Nurses Association, National Quality Forum, they also have falls as a nursing sensitive or quality indicator. And then adding one extra patient to an LPN and nurse aid, you've actually increased your fall rate. Staffing in ICU, that was significant to the fall rate. That's very understandable. Those of you who have worked in the critical care units, you know patients are very disoriented many of the times. And they just forget where they are and start to get up. So if you have lower fall rates where you have nurses that are happy, satisfied nurses with what they're doing in care, you've got a lower fall rate. That's all part of that AHRQ study. Now I want to talk about some risk factors and assessment tools. There are common risk factors that you're probably very familiar with. Do they have a history of falls? How old are they? Arthritis or balance deficit. Cognitive impairment. Visual deficit shows a double risk. Cardiac arrhythmias because they're not getting the blood supply to their head all the time. Maybe they've got a gait deficiencies. They can't do ADLs because of their unsteady gait or they're using an assistive device that may just get in the way sometimes too. Special toileting needs where they have to get up a lot. And it just seems like it's almost every hour. And the response time is longer. If they're connected to something, whether it's an oxygen tube, an IV also, a Foley catheter. Dizziness, lightheaded, fatigue. Anyone who's ever experienced vertigo can understand how that could result in a fall because you can't get your bearings on where you are and you're trying to compensate. Other risk factors, electrolyte imbalance. Low potassium, low sodium. That can result in a balance issue. Multiple medications, orthostatic hypertension. Longer length of stay. That shows an increased risk, especially those who happen to have bleeding disorders. Medication fall risk scale and evaluation. You can use this to look at those meds that are related to those risk factors. The pharmacist is generally the one to do that assessment because they have a really good grasp on what those medication side effects are and how it affects that individual. They add it on admission and regular intervals, especially for those long-term patients. And then they add a point for every medication for a patient taking one of the three particular risk categories. So the total score, and from that the pharmacist can determine, can we taper any of these meds? Can we stop them? Can we change it maybe to a different drug? Of course, that's all based upon what you would recommend to the ordering provider. So here is how they did that risk fall scale. Perhaps if you check with your pharmacist, see if they are doing that for some of your patients. Patient taking four or more types of medication has a higher risk. If they're taking more than one, it goes up to 20%. Over-the-counter meds can really increase also, so we have to take and factor those OTCs. And those who are on anticoagulant, of course, they're at risk of serious injury. 85 prolonged steroid use, bone conditions, osteoporosis, metastatic bone cancer, that increases their risk, of course, for serious injury. Half of fall student medication like anti-anxiety, antipsychotic accounted for half of them. And those most frequently associated with increased risk, tricyclic antidepressants, serotonin reuptake, neuroleptics, benzos, anticonvulsive, class 1 antiarrhythmics, antihypertensive, diuretics, nonsteroidal, your Aleve can do this, psychotropic, sedatives, vasodilators, pretty much any medication you can order on a patient may fall into one of those classifications. So on your risk category, looking at medication, this is what one hospital did. They added risk categories according to the medication. And if they got up to the level of category 4, they got a little orange sticker. Number one, antidepressants, antipsychotics. What they were trying to do here is really look at the dose adjustment that they were made in the past five days. Did that contribute or maybe increase the risk? Two, bowel preps and diuretics. Anybody who's had a colonoscopy can definitely relate to how this works. That can lead to electrolyte imbalance. You get dehydrated, hypotension, and then you have that increased need. Got to go and you got to go now. Number three, now we're starting to raise it up there. We got your opiates, your narcotics. That can lead to sedation, impact motor coordination, cut down on your reflexes. In other words, you feel like you're falling, you go to grab, but your reflex is much slower. Benzos is number four, your alpha blockers. That's where you get your dizziness, your balance control. Now they also note the BEERS list. These medications should not be given to the elderly as they can increase and AHRQ had that toolkit. I have that listed here. This is on slide number 80 for those of you who are listening. The BEERS criteria is in the appendix and that's the list of meds. These drugs, class of drugs, and explains why it should not be used and the severity such as low risk or high risk. So that's the medications. Another factor was intrinsic versus extrinsic because false can not just be one factor, usually multiple factors. So that was another classification. Those from complex interaction of these two intrinsic extrinsic factors. Intrinsic, that's the patient. That's our physical, mental, cognitive condition. Extrinsic on the other hand is what's in their environment. Intrinsic, those that are really integral to their functioning. Yes, we have a lot of age-related changes. Maybe it's a previous fall. They've got a history with significant factor those who are more likely to fall again. Reduce vision or visual acuity because they can't, okay, how far is that step? Do I have enough space there? Night vision is also highly impacted. Maybe glare intolerance where they get a sudden glare from turning on the bathroom light and they back up because it's so bright. And then the unsteady gait. How do they walk? Mental status, confusion, disorientation. History of a CBA where you have sustained neural impairment. Of course, the low physical activity where they've just been sitting in the chair and that's their routine. Now we give them a laxative or another drug. We give them a psychotropic that could have caused them to be dizzy and lightheaded or not quite react or they don't appreciate the risk. And then they have an acute illness, a rapid onset, a stroke, orthostatic hypotension, a fever. Fever, chronic illnesses, these are all still intrinsic. Arthritis, cataract, again, that has to do with, can they see? Postural orthostatic hypotension. Incontinence, four or more prescriptions. Maybe a belief that asking for help is not okay. It's inappropriate. That's what we need to help work them through. Please call me, I want to be here. And then fear of falling actually increases the rate after they've started to get up. AHRQ, they have an evaluation bundle for delirium and those patients with impaired mental activity. The proper evaluation, their standardized testing and direct observation. So it's not just one or the other, you have to do both if you're going to use this bundle. And there's training that is required. And these are done by your practitioners, whether it's a physician or advanced practice provider. So this is generally not an RN to do it. It is one of the practitioners. What do they cover? Of course, the digit spam. Can you repeat those digits? Three of them. Do they read them backwards? Can they recite them backwards and the repeat them forwards and backwards? And any of you who've ever done this, even though you think you're in really good shape, it's still a bit of a challenge. Short portable mental status questionnaire. What date, year, time, place? What's the current president? A confusion assessment. Now there's a 50 minute training video on this. And again, training is required on this one. Sensory aids can help orient the patient to help prevent or at least cut down on the impact of that delirium. National Institute for Health and Care, there's a resource on it. Again, I have that in the appendix. And also on the next slide, you'll see what that looks like. Guidelines, risk factors of delirium. How do we treat them and maybe prevent them if they do happen? Because we need to identify and manage that underlying cause. Now this is out of the UK, but I still think it's a really good one. And that's all the intrinsic ones. That's the patient. Let's move on to the extrinsic ones. This is their environment. And that includes meds, believe it or not. Those that affect their CNS, sedatives, benzos. What about their bathtub and toilet? Do they have a grab bar? Are the toilets in a good position? So they don't have to maybe use their legs so much. Is it so low? How about the furnishings? What's the height of the chairs and beds? Tables or beds that are on wheels and have sharp edges. So if they fall and they can cut themselves. How many of you work in an orthopedic area? You see a lot of the chairs, even in the waiting room and the physician's office now, they're higher up. So the patients don't have to rely on that affected knee or hip in order to gain, to stand up. How's your ground surfaces? What kind of coverings do you have? Any loose tiles? Is that carpeting so thick that they can't pick up their feet? Highly polished wet floors. What are the illumination conditions? Is it too intense where they have to keep their eyes closed? Monochromatic colors, schemes, colors that agitate their eyes where they just have to close them. Distracting noises, maybe prolonged length of stay. Use of restraints, we've already talked about before. CMS does not see that as an appropriate fall prevention program. Post-draft training, are they comfortable? Do they have adequate training? Are they competent in helping transfer a patient from the bed to the commode or to the toilet? Not getting to those call lights promptly, attached to equipment, time of day. Of course, more falls at night. We get a little disoriented when it's dark. Electrotherapy, ECT therapy, and behavioral health. And then being physically challenged in rehab. They're examples of the assessment tools. I have that in the appendix for you. What about home health? Tenetti, they had a community risk assessment for community dwellers. And there were nine factors that they included in here. And just some of them, mobility, morale, and mental distance. Once again, their vision, hearing, blood pressure, medications, able to perform their ADLs, and a back exam. Then the risk of falling for children. We can't forget about those folks. We've already talked newborns. It is relatively rare, but the risk factor is seizure medication, orthopedic diagnosis, IVs. Maybe we have PT or OT, length of stay, just like with the adults. There's quite a comparison here with the kids. When you're talking policies and procedures, many will use those recommendations. Keeping the bed low, nightlight on, making sure, hopefully if the family can stay with the patient, that they're also oriented to the setting. If they're under three, we put them in cribs. Now, you can put them in a junior bed as long as the parent signs off on a written release. That's where your legal counsel can help you with. But if the parent does request a full bed, ask them to stay with the child. In other words, stay overnight with the child. Non-skid footwear, if ambulating, they have what's called I'm Safe. This is an actual pediatric-focused fall risk assessment that you can utilize. And it talks, again, any impairments, medication, sedation, admission diagnosis, fall history, and environmental care. So it's nice because it covers all of those for your assessment. So the goal here is to eliminate falls with injury through your program and increase the percentage of those who get appropriate assessment and interventions. And you have your low risk score. Any patient, any pediatric patient is gonna get a zero. Then you have your moderate, high risk, or greater. And then you have patients two and younger. They're scored at a high risk. Those in ICU, also scored at high risk. Kinder one has a fall risk also for an emergency department. Here, the nurse does perform this assessment and can make it pretty quick. And then they have some additional elements. Why did they come to the ED? And that was because of a risk. Heinrichs, they have a fall risk model. It incorporates pretty much everything we've covered from disorientation to the medications. What are they taking? And for some reason, they did put in here delineate between males and females, where males got a one. I didn't see anything in here as far as females, how they were quoted. And then number two, where they do the get up. Can they rise in a single moment? Do they have to push up? Multiple attempts with or without assistance and were they successful? And so you document this under your observation record. So that's just another way you can do an assessment. And our third question, Lindsey. Well, if I could get myself off of mute there. Okay, I'm gonna read this first part to you and then I'll post the question up here or the options up here for you. So this says hospital D has hired a new quality manager who identified preventable falls as a QAPI project. The manager is developing a falls prevention squad to investigate and develop strategies to lower the fall rate currently at 200 per 1000 days. Who would you suggest to be a part of that squad? Let me get these options up here on the screen for you. Okay, and you can check all that apply here. So CMO, physician, CNO, unit managers, staff nurses, PT, OT, patients and or family, and maybe who else. And if you have ideas of who else that you don't see listed here as an option, you can type those into the chat box. And Laura, it looks like we did have one question come in. Okay. That asks, are you recommending a benchmark of 4.44 for the one measure? No, I don't recommend any benchmark because it depends on your facility setup. Patients, what type of patients, what's your physical setup? I really cannot give any recommendation on a benchmark. Seeing some good responses here. I see in the chat, pharmacy, food, nutrition, techs, secretaries. Great. CNAs. Perfect. Because CNAs are, usually they're the frontline people who are there and they know these patients sometimes. So that's an excellent suggestion. Food and nutrition. What's going on with these patients? Are they eating? Are they cascadic? What is it with them? And then pharmacy for sure, because we need to find out, okay, what meds are they on? Is that impacting it in order to really maybe cut down on the number of falls? Having the physician and pharmacy together, that really helps because then there can be that hopefully open dialogue on, well, how else would we do this? Are there any other generations of these medications that we can utilize? Sometimes you don't. Sometimes you simply don't have an option on certain meds. That's unfortunate the way it is. See, engineering just came into the chat. Oh yes, engineering. Yeah, how can we make this place safer? At times you wonder, okay, I've got tile down here. And at times water is gonna get on the floor. Now, if I had carpet on there, that'd be great because it could absorb it. But then they can't lift their feet up because they're tripping over it. And there's holes in it. And so you really, that's where engineering and even maintenance as in your housekeeping, they need to be at least a part of some discussions. How can we make this safer? How can we keep it clean or keep it dry? Will we prevent each and every fall? That'd be the great thing we could do, but I have to admit that's probably unrealistic that to prevent each and every fall. We do as much as we do to try to prevent them, especially causing injury. So excellent responses, everyone. Thank you so very much. All right, now John Hopkins, they had a fall risk assessment tool. Great tool, evidence-based, wonderful. But you have to buy a license. Now I've included the link there to see what it looks like. So that is one of the downfalls to this one. Again, very excellent and evidence-based. Here are just some of the things they did. Poor mobility, got four points. In other words, they couldn't get up and out of the chair without help. They had to have an assistive device or someone needed to be there. Once they were up, they had an unsteady gait. Then going down a little bit, another three points where we had incontinence or frequency where they had to have assistance with toiletry also. Another one right up there with three points is our mental status. Poor judgment, memory problems. They can't remember, oh yeah, I'm supposed to help or not asking for instructions. Dizziness, vertigo. That could be because of medications. INR, orthostatic changes. Maybe they have a blood volume loss also. Also with three points is our medications, psychotropics, your antidepressants, cardiac hypertensive meds because we're dropping our pressure. Same with diuretics and laxatives. Multiple meds with sleep aids. Poor judgment. They just don't recognize that we need to help you because they want to be independent. I can do it. I can do it. Just bear with me and humor me and let me help you. Eyesight, age, that's giving one to two points depending on how old they are. And that's what the intervention is all based on the score. But every patient will get a one. So here's what we do. These are what you do based upon their scores. Level one, you orient them. Here's the call light. Keep the bed low. Nightlight on. None, slip footwear. Yes, those slippers are very pretty, but they are going to call you to slip. Visual hearing devices, safety rail position, three or less. The room, free from obstacles. Number two, they get everything plus. Or something that can help staff know this person needs help. Getting them to the bathroom before bedtime. And if they have to wake up every four hours, just don't leave them alone. Bedside commode, if that's a possibility. Check them every two hours. Do you need to go to the bathroom? What are their orthostatic symptoms? Or increasing their daytime activity so maybe they can sleep at night. Educating the family and the patient. You're at risk. I know you want to be independent, but you want to get out of here safely and without any injury. Communicate that risk during report. And use a gait belt, if need to be, or other assistive devices. Maybe you want to have PT screen them, because this is a new onset. And transport on the cart to procedures and facilitating those transportation. Then we go up to level three. This is a score of eight or more. That's the last level, by the way. Everything in one of two. But now we're observing them more closely. Every hour, check on them. Do you need to go to the bathroom? Maybe we're going to move them closer to the nurse's station for better visibility. Supervising them, no matter what, when they're on the toilet, ambulating, transferring. Getting a high-low bed, keep it down. Encourage family to stay with them, or maybe going to the expense of getting a sitter and then using those alarms. Now, I do want to mention, there is some controversy on the alarms that causes more disorientation, can frighten them. So they get up and move quick, hear the alarm, and they're just startled and fall. And then the other with the alarms is it has to be used. If staff is not using them, forgetting to turn them off, modifying so it can't be heard, that's the education with your staff. What can we do to make that better? So of course, with every fall, we have to do documentation and check out our patient. They are, again, a nursing-sensitive quality indicator. Injuries that are reported, up to about 44% in acute care. Serious injury, anywhere from two to 8%, with less than a 1% resulting in death. So as far as documentation, the fall assessment must be performed on all patients and put in their record. Same with the interventions. Complete that incident report. If you want to use a special form, that's fine. That's your decision. What is the description of the fall? Where was it? And where was the patient when you found him? How did you assess him? Are they injured? What do you see? Any lacerations, hematoma starting to form, range of motion? Can they move their arms and legs? What's the patient's response to the fall? Oh, I just, I lost my balance, or I got real dizzy, or I didn't realize. You can also ask them, how did you fall? Did you, well, I just kind of sat down. That's how I ended up on the floor, as opposed to falling face forward. Any medical nursing interactions that you put into place as a result of it? You splinted him, took him down for X-ray. And of course, we notify their provider, notify the family if there is one. Did you take pictures? In other words, did you take pictures of the patient reported tripping over a certain area? Take a picture of it so you can see, yes, indeed, that's a risk. Did it occur bedside, in the bathroom? Where were they when it called? What were they doing? Wet floor, glass, anything on the floor that potentiated it? Some considerations in the assessment. Are they high risk? Do we need to do PT screening? Are they on psychotropic meds? Then maybe we need to look at our pharmacist to look at these again. Antidepressants, elevil, norepinephrine, anti-psychotics, Haldol, some of these do tend to increase the risk potential. Then modify your plan of care. Institute those high risk interventions if you didn't do it already. Communicate to all shifts that the patient fell and they're at high risk to fall again. And that physician checklist to assess them or doing that post-assessment evaluation. So these are just some of them that you can do. I always like to include them that you can evaluate. Managing your patient. Someone who is licensed needs to evaluate them. That can be a nurse and get the physician in there. If life-threatening, maybe your rapid response team. Check their blood glucose if you have a known diabetic. An assessing document, even if they deny striking their head and not visible head trauma, kind of keep an eye on them. Do that quick neuro check on them. Watch them for 24 hours, including biosigns and neuros. Any restrictions on mobility. Determine in your policy how often you're going to do those vitals. Are you gonna do it like a post-op patient? Q15, Q30, Q1 hour, Q4 hours, post-fall. And again, that's going to differ according to what their injury are. If it's a minor head trauma, no loss of consciousness, no change in mental status, follow what was on that previous slide. If you do have something, you might want to up your neuro checks. Of course, notify the physician and make sure the physician aware if they're on anticoagulant therapy because that will increase the risk of further injuries, whether it's internal injuries or hematoma. And then know your policy incident reporting. What do you have to report? To whom do you report it? Does it go internal? And of course, all of those requirements, date, time, location. When were they admitted? Description of the fall if you can get one. If pictures were taken, any of those intrinsic extrinsic factors we covered and that you did your assessment according to policy. Did you have any implemented strategies in place that you had done? Yes, the bed alarm was on. And yes, the patient got out of bed. Patient was found on the floor by the time the nurse reached the room. Anything else that was a news walker? Factors that contributed, maybe it's a wet floor or any new interventions or revision to plan a care. That's what goes into your incident reporting per policy. And debrief. Bring everyone in if you can. Staff, patient, family. What's going on at the time this happened? How can you prevent it in the future? Now, if you're going to do this, have a facilitator who's got some expertise in doing it. Having your charge nurse sit down and start glaring at you and asking, how did this happen? It's probably not a good approach. Having someone who just says, I just need to understand what happened so we can try and figure out a plan going forward. What is that root cause? If so, share it with the staff because they can be converted into frequency charts. What is the safety equipment that may help in this situation? What is the sensitivity of that bed alarm? Have a huddle, if anything else. This is interdisciplinary where you can bring in others. That's why that fall committee and one of those questions that really helped can help prevent these falls. Now, this one you want to have convened within 15 minutes so the information is still fresh in their mind. And a clinician usually leads it someone who's responsible for the patient. And they also say include the resident, the patient when possible because they can help identify some contributing factors. Use discovery to determine that root cause. This is from HRQ. So we can at least find out. Did you have a falls contract, bedside alarms? Do monthly fall review during your meetings. How are we doing? Is there anything else we can change? And it could be, maybe it is staff related. You were short some people when that happened. Flu season happens. People call in sick at the last minute. You might not be able to have it. So just some tools and strategies. Preventing falls, that's of course multifaceted. It is not just one thing by one person. So you may want to create this position. Have a really good policy staff know it. Make sure they're comfortable filling out those incident reports, doing that assessment, documenting it, using that individual approach to that prevention. Having universal fall precautions, great. Just identify those interventions you are using. Bed in low position, toileting, incontinence programs, appropriate armchairs. Make sure the wheels are locked at the patient's bedside. It's a little embarrassing when you're trying to, or hard. So when you're trying to get a patient up from sitting, put him on the commode and the wheels aren't locked and the commode shuttles away. And you're sitting there trying to hold onto this patient. Maybe you're going to use comprehensive patient environmental assessments together. Look at the room and the patient that's coming in there. Maybe you have osteoporosis, vitamin D deficiency, platelets, make sure pathways are clear and free from obstacles to and from the bed to the bathroom. And there's good lighting, good handrails in the bathroom. And hallways are free and clear from obstacles. The bed, if you have a bed that you can put close to the bathroom, great. Or maybe a commode. Look at the medications. Increase the mobility, get them moving. The more they move, then the better off they're going to get that muscle mass back. Always ask and instruct the patient. Please call for help and say patient handling. Can your staff adequately and safely transfer that patient to and from the bed to the next one? Call lights, answer promptly. And use the teach back regarding the call light. Here's your call light, this is how you use it. Then take it off. Now show me how you're going to use it. Have patient demonstrate to you that, yes, they know where it is. Wear a non-skid footwear. Most of us now supply those beautiful socks that have the non-skid on the bottom. Have assistive devices close. Evaluate the chair and bed height. Reassess frequently, reassess the patient. Maybe you need to bump it to one-to-one monitoring. And what are the peaks on your meds that could affect their gait? Reduce their use of restraints because that can increase confusion. There may be times you absolutely have to use it based upon their emotional status, but if you can try to reduce that use. Look at your environment for conditions. Again, loose carpeting. Maybe your tile is starting to come up. Maybe an ambitious housekeeping person really whacks that floor and it's nice and shiny, but it's slippery. Make sure they know who to contact if your staff see these events. Alarm devices. Look and monitor and treat their deficiencies. Have patients transported, have all side rails up so they can help. Floor mats, that's been a discussion. Which floor mats are the best? I have no information on which one is the best. There's the facility guide that can help you perhaps identify what works best for you, your facility, and your patients. Keep those items within reach. Have a transfer belt. Do not leave at risk unattended even if they're having an X-ray. Make sure your X-ray tech knows this person has a habit of falling. So you're gonna have to be there by them. And it's especially when they have that one little stand that you put your foot on and this poor elderly patient who's just had major back surgery is supposed to be able to support their legs. So make sure they're aware of it. Planet care, that's of course dependent on what came out of their assessment. I've listed just some of those scales and assessment tools that you wanna consider using. You may also wanna look, when was it last fall? Have you fallen within the past three months? Then you get an extra seven points. North American Nursing Diagnosis Association, there's a guideline they have on risk for falls. And then there's also transforming care. Seven hospitals came together in a study back in 2014, targeted solutions for preventing them. The average fall patient increased their length of stay from 6.3 days, a little over almost a week. And that could have saved 400 bed hospital beds, excuse me, 400 bed hospital, almost 2 million a year by doing so. That's why they put these targeted solutions into place. You may wanna do a FEMA, failure modes effects analysis before it happens. What's the worst thing that could happen in this area? And then pulling it together. And I always like looking at here, this is a typical bed, hospital room. And what do you have? You know, the bedside's close, the commode's close to the bedside. You have a non-skid floor. Maybe you have their walker, really handy within reach. Now the rails can be up if the patient wants them because it can help them get into position and keep them steady. And then you have the support for the, excuse me, the bed trapeze. If you use that, that you're gonna have those. And then just a nice reminder, please call for help. Don't get up by yourself. Real briefly on sitters. First off, if they're at risk for harm, self-harm, they're impaired, they can't follow instructions or if the physician orders it, then use them. They provide continuous one-to-one observation. They are responsible to maintain that safe environment. So have a policy on it. This person needs to understand, especially a staff member, of course, that that's their job to keep an eye on this patient. That unless you are using video and audio at the same time, and it is not safe for the person to be there, then you can use telecommunicate, teleaudio. Never leave them alone. They work under the direction of a nurse. You can, this could be a CNA, that's fine. Hospital employee, but they should go through that completed sitter competencies so they know what's expected of them and how they help the patient, what they do if it's something that's beyond them, the patient saying, I'm having pain. There are mixed results in the literature on using a sitter. If you have a patient who's confused and there's a stranger sitting next to them, that could cause an increase in the delirium. So again, some mixed use and mixed results in literature on using it. Otherwise you assess your patient on a mission and anytime that condition changes. Maybe they're getting a new medication added or it's a new onset. They've had a stroke during surgery. When a fall or a good catch occurs, again, do that assessment. If they're coming to a new unit and more often usually you're gonna be doing this if they're high risk. For toileting, studies show 50% of falls are related to it. This is because they were left alone to go to the bathroom after being assisted up. And that's why regular training, it could be especially helpful and especially those who have that cognitive impairment. Another trait was hourly rounding, day and night. Reduce the number of call lights and falls. Answer the call lights more promptly when they have to go to the bathroom. Nurse visiting, even hours. Aid goes on the opposite hours. Use that form so that you know who did it and what did you find. And evaluate if rounding does reduce your falls. Maybe that's a QAPA project you wanna consider. So briefly on bed alarms. I've got a couple of slides here. That we know they warn the caregivers when they try to get out of bed. Joint commission. They see it as an effective risk reduction technique. Also, one of the root cause problems when they malfunction or they're misused. So they come in various form. Pressure sensitive pads that you can put under their bottoms. Cords or garment clips. Wearable alarms like an ankle bracelet. Some patients get a little uncomfortable with that. They feel like it's a home detention unit for felony purposes. Floor mats with sensors. This one's a little bit much. Infrared beam detectors on the beds or next to the walls. So if you see a movement, then it would alarm. But monitor the frequency because that may cause a patient not to move. And then CMS might see that as a restraint. It's a really fine line. Keeping the patient safe and not violating the CMS requirements. Of course, patient education is so crucial for both patient and the family. Make sure that they're given verbal information because they won't read it. They just won't. Show them where the call light is. Where's the bathroom? Call before you fall, please. And then here is our next question. This will be our fourth question. Lindsey. Okay, let's get that one up here on your screen. And it says, I'm Hospital X is a nursing staff shortage and sitters are impossible to find. Tele-sitting is not financially feasible. So what suggestions would you offer to the hospital? And let's get those options up here for you. And again, you can check all that apply here. So unlicensed agency staff, family as long as over 18 years of age, family, spouses, regardless of age. Keep patients close to the nurse's station and hope for the best. And then other options here. And again, you can always type in your other suggestions there into the chat. And again, it's another reminder as we are getting towards the end of the polling question options, you can go ahead and type your questions that you may have for Laura into the Q&A or the chat. Then of course we'll have some time reserved at the end to address questions as well. Okay, I see option here in the chat for staff to sit close to the room, keep the door of the room open. Good, yes. A couple more sponsors coming in here. Rotate staff to sit. Yes. Yeah, some of them might like to be able to sit down and take a breather. That's a good question. Okay, I'll go ahead and end that and show those results there. So yeah, all these are really good suggestions. Yeah, 18 or older, sometimes that does help because they'll, excuse me, it does help with the legality behind it also. But if you're, you know, the age, you gotta really go by the person. I think if they're under 16, I wouldn't push a person to do that. I think that's just adding too much responsibility on someone who may not be really emotionally prepared to handle that. So those are all great suggestions. Unlicensed agency staff, yeah, you can do it because all they're gonna be, they're gonna essentially be a sitter. That's what they're going to be. So on your information for your, excuse me, if I could, there we go. For patients, there is a National Institute of Aging. This is really what we wanna target at older patients once they are discharged so that they're familiar with it. You know, you have a little trouble in here and we wanna make sure you keep going safely. High-risk male patients, of course, ask them to urinate sitting. Explain that risk of falling for meds. You might have to do this a few times. You may actually have to do it. Walk close to the wall. Lean on it if they feel like they're ready or going to fall. Assess your older patients, even during a home visit. Are they doing your exercises? How's your vision? Let me go, how's the bathroom all set up? A lot of the bathrooms now, and especially those who, if you're doing a remodel, that a lot of the contractors in some states, I know in my state they're required to do this, they have to put in grab bars. It's not optional. They must put in grab bars, and that's in private homes. Looking at meds, standing up slowly. Are you getting enough sleep? What's your shoes like? Let me take a look at those shoes and how are they. Are they non-skid, low-heeled? How about walking on wet or icy surfaces? That's always a challenge for those of us who aren't physically impaired. Though they do have, from the National Institute of Aging, good articles on what causes them and steps to prevent. Recommendations to lower their risk of falling. It is a safety practice. They're from National Quality, 34 of them. They have safe practice 33. That's actually on falls prevention. Take action to prevent their falls and reduce the injury. Number four, it includes falls as one of the identification and medication risk in healthcare, and that's why we need to monitor the effectiveness of our program. Environmental redesign. Talking to patients. Have a fall reduction program. Educate the staff on the program. That's at orientation, and if you're starting to see an uptick in your falls, maybe go back and visit it again. How effective is it? Organizational support is so crucial. This sounds very familiar to QAPI. AHRQ has a good toolkit, no cost, preventing falls. A roadmap to prevent them. Good evidence-based tools through AHRQ. It's geared at negotiating a change within your hospital, that this is an interdisciplinary process. Implementation guide. Organize into six major questions, and it's focused on putting preventive strategies into practice, and again, having that committee to oversee that program. Somebody who is responsible and then can step it up if it needs to be. Five-program module from AHRQ. This helped one rehab hospital actually reduce their falls by 21%. They have a case study. Another hospital in Mississippi reduced them by a quarter, and it helped Vanderbilt University substantially reduce their falls, and they have case studies in there. JAMA, they talk about the U.S. Preventive Services Task Force. Final recommendations on preventing falls. That was back in June of this year. Exercise can help prevent those falls in 65 and over that are at risk. Some of you may know through a program called Silver Sneakers through Medicare and Medicaid, where it's paid. They get their memberships free at their local gyms. So that's why they're pushing the exercise to help prevent them. Of course, the clinicians, they need to individualize that decision on is this a safe person to have exercise? So which ones are they doing? What are the benefits and harms? So if you've had a lot of falls, maybe you don't want to send them to the gym to get on a treadmill. Maybe there's other that they can do, actually sitting to start building up the strength. What are their comorbidities? What do they have underlining that might impact or impair their ability to do some of that exercise? And then what's the patient's values? I did mention tele-sitting. You can use it. It's video monitoring. It has split screen usually. They can see if the patient's in danger. If you have that two-way audio, they can be able to talk to them. Oh, Mr. So-and-so, please sit down. Speak to health nurse to make sure that they can get down there and intervene. And if the patient doesn't respond when they are talking to them through tele-sitting, there's an alarm that really can activate and get people into that room. They actually found it reduces the use of splitters. So there was a financial support too, and that's how it would look. You've got them, they're off in a separate room, and it's a multi-visual item that they can keep an eye on. So CDC also wanted to get involved in falls. It's a major issue for those of us over 65. One in four report falling yearly. So you've got, you're sitting around three other people, one of you is probably gonna fall. 65 and older, 50 billion spent on cost, 754 million on falls that were fatal. There's multiple resources. As with anyone, they have a fall prevention packet for physicians and a fall risk perception and assessment project and information on community Tai Chi. There's a fall prevention program through them that helps. STEADI is a really good one. That's the acronym for stopping elderly accidents, deaths, and injuries. And this again is for your healthcare providers. Exercise regularly. Have meds reviewed by your physician or pharmacist. What do you got cooking in there? Adequate calcium and vitamin D if your diet allows for that. Weight-bearing exercise, build up that bone density. Getting screened for osteoporosis, getting your eyes checked annually and having your glasses updated. Look at your home. What's going on in there that could cause a trip? Lighting, the four C's of falls. Consistent, all patients at risk. Cross-discipline, interdisciplinary approach. It's coordinated from the minute they hit your door until they leave, maybe even after home. And then culture. How do you respond to these errors and prevention? And older patients, you ask them, have you fallen in the past year? Well, how often do you fall? Any trouble with balance, walking, going up and down steps? If there is a risk, then we need to assess them. There are updated guidelines from their Academy of Orthopedic Surgeons that can help with that. Having all healthcare practices for older adults include that fall screening and assessment, especially the footwear and feet. Do they have diabetes and peripheral neuropathy? Can they feel their feet? I have a good friend who, she has peripheral neuropathy. And she, even though she's not that old, still has much difficulty going downstairs because she can't feel the bottom of her feet because of the neuropathy. Interventions, maybe an exercise component. Again, Tai Chi is very low impact, but can help with balance. And those with recurrent falls, gait issues, again, they undergo that fall risk assessment. This is from the American Journal of Geriatric Society. Otherwise, vitamin D supplement, low blood pressure, manage your heart rate, cataracts when you need them, medication reduction or withdrawal, sedatives, antidepressants, environmental adaptations to reduce those falls. Again, a lot of good resources out there to help us. This was one hospital's approach from American Hospital Association. They did five things, that's all they did. Medication, pharmacy looked at the meds and made recommendations. Patient education on the risk and what to do to help themselves. An RN reviews it with them and a family on admission, and then they reinforce it. Number three, safe room setup. They looked at the room. How is this thing set up? Where's the call light? Where are their personal items? Do they have an IV? Can they get to the IV? Is it stuck on the bed? Signage, in other words, call for help. It's in all bathrooms and the rooms. And then rounding. A log so the nursing staff completes it hourly and that they can come to the room. They check for pain. Do you have to go to the bathroom? And where's your position? During hourly rounding, they reviewed them. There was a five Ps here, pain, pump, pathway, that's how do you get there, potty, and phone. The phone, a lot of hospitals report that patient cell phones have resulted in falls because they're trying to reach for it to either get it or plug it in. Increased falls in the ED with patients walking while using their cell phones. Maybe you have a contract that you share with the family how to reduce falls that patients and family are asked to sign it. And the patient agrees not to get out of bed or the chair alone. And the family agrees that while they're there, they're going to make sure the patient isn't doing that. They're not walking alone. And then the hospital was also doing hourly rounding and using mats. Shower shoes, one hospital had four falls even though it had grab bars and four foot grips. So they use shower shoes now to prevent them and they haven't had one fall since then. That was from the American nurse back in 2016. Preventing falls in most effective trials to prevent falls in older, looked at multiple and for just one. And previous studies shows it's more effective. But because we looked at not just what the recommendations were given, but what was carried out. And that was from Dr. Mary Tinetti. A physician's office, if you have physician offices or you're part of one, they didn't leave you out. They also have you and some education information for you on how to screen and assess them. And especially those when they're in your community. And I mentioned the physician toolkit for steady. You can download it with other materials. CDC has a fall risk checklist if you wish to use them. Again, these are all free that you can tap into and medications linked to falls. A good pocket guide for the physicians. One of the facilities that I had worked out, they gave them to all of their doctors so that they had them handy. Of course, we have our technology to help reduce the 2010 JAMA article did help reduce falls. So the nurse entered the assessment into the computer, computer spits out interventions, and then they give education material and also a fall plan, a plan of care that they all sign off on. So it did help with it. And so now I have a quick video. I hope you can hear it. I'm going to rely on Lindsay to let me know. Yes, indeed, you can hear it. It's about three plus minutes, which will leave us more enough time because we have one case study to go through. So I'm gonna go ahead and start this. And again, Lindsay, tell me if the sound does not come through. Okay. Yes, I can hear it. Great, thank you. Thank you. I'm colored black and blue I'm pretty dizzy too That's why I'm wearing yellow I had to go I didn't call for you And took a whoopsie-doo So now I'm wearing yellow Look out for spills and slippery soles Tripping over chairs and ivy poles Check the gown and ask me if I'm okay Just ask me if I'm okay guitar solo I called Aunt Jo She wasn't quite so strong And turned her walker on Now we're both in yellow It's up to you You can't prevent my fall Just know the protocol Look for my yellow guitar solo Yellow cows, they mean a risk of fall In the bathroom, outside or in the hall If you see me, make sure you offer your help You've got to offer your help Look at my scars I'm colored black and blue I'm pretty dizzy too So for those of you who are able to hear, and I believe it was audible. This is from UMC Health Systems. I believe you'll have access to the link when you're ready for it and if you wanted to use it for education and training. So moving on. Actually I had a couple of comments from the chat, Laura. People saying they loved it. It was amazing asking for the link. So I'm actually going to go directly to YouTube. I think whenever you get, so you do have access to the slides, we send those to you in a PDF format so you won't have actual clickable access to the YouTube link. So I'm going to post the link there for you in the chat so you can all share with your teams as well. Great, yeah. And I liked it because it really covered everything that we covered today. the shoes, the floor being wet, the patient having to go to the bathroom quickly, things being in his way. He was dizzy from his medication, so everything was covered. It was great. Good timing on that. Here's our last case. This actually happened. We have an 86-year-old came to the hospital. She was a visitor. She was there to visit her husband. She uses a cane for stability. The hospital's main entry had some areas of cracked loose and missing cement, noticeable gaps with holes. She's walking toward the revolving door to enter, and her right foot caught on one of the gap areas. This poor thing, and it was caught on video, she ends up falling face forward onto the cement. It looks so awful when you saw it. It's witnessed also by three bystanders. They assist her into a sitting position and then call for help. Rapid response team did come out and according to policy, got her into a wheelchair, took her to the emergency department to get her checked out and see how she was doing. Well, it did show a close head injury, facial fracture, not surprising, fractured right ulnar radial bones and a fractured left patella. Her right arm is splinted and she's admitted for observation. The Sentinel event policy with this hospital was in the process of review and update. Well, the policy was silent on falls involving visitors, not within the actual four physical fall walls of the hospital. Unfortunately, overnight, her condition got worse. She became confused and she actually had to go in for surgery, have a decompression of a right temporal hematoma. Ended up having a three-week stay. She is discharged to a long-term care facility. Here's the question, now what do you do? Nothing. She wasn't a patient, so it's not covered under a Sentinel event policy. Do an RCA. We're modifying the policy, so now maybe we need to include visitors. How far are these visitors going to go? Do it because we had a serious patient injury that required surgery. Conduct an RCA and immediately address the walkway. Anything else you can recommend for this one, and I will tell you how it eventually turned out with that. Those are your options. I believe those options will stay up, Lindsay, if they go away, tell me and I'll come back. But I do just want to say I have about, I'm not going to go through them, I have 50 more slides, and these are all resources for you. It's everything that I mentioned, how we prevent falls, some of the articles that I had touched upon, the joint commission events, how we prevent falls, the toolkit, and also NQ, National Quality Forum. Here's one on bedside floor mats. There's some resources on selecting. There's nine pages on selecting a particular floor mat. Again, 50 of them, I don't want to go through all 50 just in the interest of time, or just that again, we've touched on these, and perhaps you can find one that might fit within your facility. Perfect. Okay, let me end this poll and share those results here. It looks like we're at 82% in that fourth option, the conduct an RCA and immediately address the walkway condition, and then kind of close responses 11 and 8% on the second and third options there. Here we go. Great. Because you're all in agreement that we need to do an RCA here, because something happened here. And the facility recognized that we have this gap between patients who were coming to our I'm sorry, people who are coming to our facility. Now in most states, you have a duty to create a safe environment outside of your building, in particular, if you own that area of your sidewalk, which the hospital did. They owned it. So they had to make sure it was safe. They didn't have cones up around that area. Now granted, it was very obvious. We had a problem here. Watch your step. They didn't have a cone up saying danger. They didn't have it cordoned off. So people wouldn't go that direction. So they also felt, okay, we're reviewing the policy, we need to update it. And we need to include this. So that's why they opted to do that RCA. Yes, they did put up cones and immediately cordoned it off. They ended up paying for this lady's hospital bill, because of that injury. And again, watching that video was just, oh, you knew she was going to hurt because of it. But they did end up paying for, they didn't bill, they didn't bill Medicare for any of it either, which I thought was a very smart move, because they caused that problem to occur. Even though she owned the patient, they thought that was the lesser of two evils, so to speak, to go ahead and pay for it, make sure that, you know, they did help her with that. And this was in a state where it was allowed to have disclosure and make recompense to an individual or help them with those bills. And it wasn't an issue with anyone. So they did avoid any lawsuit as a result of it. She eventually did recover. But yeah, for an 80-some-year-old patient, that was a hard impact that she did face. So with that, Lindsay, unless there's no other questions, I'll turn it back to you. And thank you, everyone, for participating. Wonderful. Thank you so much, Laura. I'm going to go ahead and post some information for you all in the chat here. So you should now see that, just as a reminder, that you will receive an email tomorrow morning. But just note that it does come from educationnoreplyatzoom.us. And those emails that come directly from Zoom very often seem to get caught in your spam, quarantine, your junk folders. So if you don't see that email in your inbox in the morning, I would encourage you just to check those additional folders. And then if it's still not there, and you'd just like to go back and access the recording, you can just use the same Zoom link that you used to join the live session today to also access that recording. Just remember that the link to the recording is available for 60 days from today's date. And we do have an additional security measure in place so that we're protecting Laura's intellectual property here. So when you click on that Zoom link, it will prompt you to enter your information. And once complete, that will send an email to us for approval of that recording access request. We do approve those very quickly, but we ask that you give us one business day to grant approval to that access. And then again, you will have access to the recording for 60 days from today's date. And then also included in that email tomorrow morning will be a link to the slides that Laura did present today, but I did go ahead and provide that link there for you in that chat message. So you can have that as a resource now as well. And then if you'll scroll up a little bit in the chat, you should see that YouTube link that will take you directly to the video that Laura just showed as well. And then if you're joining us as a member of the Georgia Hospital Association, please do pay special attention to that final link in that email tomorrow morning. That will be a link to a survey. You'll need to complete that in order to obtain your continuing education credits and to receive your certificate of attendance as well. Now, if you're joining us as a member of a partner state hospital association, please reach out to your contact at your association to obtain any supporting CEs that they may be able to offer you for today's session. And if we can help by answering any questions, you can always reach us at education at gha.org. We'll be happy to get those questions over to Laura. Thankfully, she is so wonderful about being thorough and very timely in her responses back. We so appreciate her going above and beyond always to do that. Okay. I don't see any pending questions at this time, Laura. So we thank you all so much for joining us today. Laura, as always, thank you so much for your time and the information that you share with us. Hope you all have a wonderful afternoon and we look forward to having you back with us for future webinars. Thank you so much.

patient falls

risk management

patient safety

fall prevention

healthcare facilities

readmissions

medication interactions

never events

CMS reimbursement

monitoring technologies

organizational commitment

staff education

environmental management