QIPS TIPS #33: Falling for You!
Shari Welch, MD, FACHE, FACEP
As you now know, in 2008 CMS identified ten categories of conditions that will no longer be reimbursed. The implementation of this rule is now being felt by hospitals and providers. On a gut level the change does not seem unreasonable. The new rule basically says that if something bad happens to a patient in the hospital, the hospital does not get paid to treat that condition. These so-called Hospital Acquired Conditions include one entity particularly relevant for the emergency department: Falls and Trauma.
The cost of patient falls in elderly persons is expected to reach $32.4 billion dollars in 2020 (Chang 2004). Patients fall most often in their bedrooms followed by the bathroom and this holds true both at home and in the hospital. A growing body of research surrounding falls in the hospital helps us understand some of the conditions and circumstances that contribute to falls.
Are their process changes and design changes that can reduce the risk of falls for emergency department patients? One important process change is the identification of patients that are fall risks. Checklists at intake can help identify patients that are at risk for falling and risk factors for falling include a history of recent falls, decreased level of consciousness, use of a walking aid, difficulty rising from a chair, balance problems or orthostatic hypotension. The presence of a Foley catheter, brace or cast, feeding tube and even an IV or heparin lock all increase the risk of falling. Certain diseases such as stroke, seizures or Parkinson’s increase the likelihood of falls and simply taking more than 3 medications has been associated with increases in falls. Any visual or hearing impairment ratchets up the patient’s risk of falling. There are a number of fall risk assessment tools available and there is one that is likely good for your department
Once risk factors for falling have been identified, how is that information effectively communicated to all members of the ED team? While noting that the patient is a fall risk in the chart has become commonplace, the use of more visual cues is gaining momentum. Some organizations are using color coded booties, typically red, to identify patients and these booties often have non-skid design elements. These brightly colored booties are readily identified by staff including transport techs, radiology techs and ED techs from the doorway, who may have only brief encounters with the patient and inadvertently put the patient at risk. There are also commercial products like Patient Care Sign that allow the staff to use sign icons on the patient door such as Fall Risk, NPO, Isolation etc. The point is that identification alone will not reduce falls if the risk is not conveyed to staff and there are not policies and procedures in place to reduce the risk. And what are some of the procedures and policies that have become part of effective Fall Reduction Programs? Use of a low rise bed, easy access to call lights, non-skid slippers or floor mats, alarm mats that chime when the patient gets out of bed and decreased clutter in patient rooms are all strategies that can reduce falls.
There are other design features that have demonstrated the potential for reducing falls. Slippery floors (the proverbial polished linoleum) contributes to falls and there is much experimentation afoot using antibacterial carpet tiles with non-skid surfaces. Adding floor lighting to improve visibility for the visually impaired patient and adequate railings can both improve safety in clinical areas. The direction in which a bathroom door opens can increase or decrease patient falls in the bathroom. When the door opens into the bathroom, the patient becomes crowded into the sink or commode and can fall, so it is best that the restroom door swing outwards. There are some new modular designs which have the commode fold down from the wall right next to the patient’s bedside so the patient does not travel far to the toilet. New room designs are now also including a family space to encourage family members to monitor their loved ones for safety.
The height of furniture, especially beds and toilets can be tricky. You will often read that these should be of low heights for ill patients but that is not entirely correct. Research from the Center for Healthcare Design suggests that beds and toilets be high so that the patient (whose limb girdle muscles are the first to become weakened during illness) does not have to lower himself/herself such a long way down to the furniture. On the other hand, lower beds and commodes are associated with less severe injuries when the patient does fall.
A final design change that is associated with decreasing fall rates is one that is still not wildly popular with nurses: The Decentralized Nurses Stations. Clinical Units are being designed with work stations scattered throughout the department and that allows the nurse more opportunity to do paperwork while observing patients. This decentralization has other advantages including decreased noise levels (which is critically important to patient satisfaction) and decreased amounts of walking for the nurses who have multiple sites from which work can be carried out.
How much can these kinds of process and design changes reduce falls? The Center for Healthcare Design estimates that design changes alone can reduce patient falls by as much as 17%. Methodist Hospital in Indianapolis ramped up its Fall Reduction Program with rigorous procedures and design changes that included a family space in every patient room and decentralized nurse stations. Their efforts resulted in a reduction of patient falls from 6 per 1000 patients to 2 per 1000 patients in a CCU (Heinrich 2002). Shouldn’t we be applying some of these strategies in the ED? If we do not embrace these efforts it is clear that our patients will keep Falling for Us!
- Marberry SO. Improving Healthcare with Better Building Design, The Center for Health Design, ACHE Management Series, Health Administration Press, 2005, Chicago IL.
- Chang JT et al, Interventions for the Prevention of Falls in Older Adults: Systematic Review and Meta-Analysisi of Randomized Clinical Trials, BMJ, 2004, 328(7441) 680.
- Hendrich et al, Courage to Heal: Comprehensive Cardiac Critical Care, Healthcare Design, 2002, September issue, 11-13.
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