Project Title: Impact of System Factors and
Processes of Nursing Care on Patient Falls
Presented to
3rd Annual Nursing Research and EvidenceBased Practice Symposium
September 10, 2009
By
Fran Vlasses PhD, RN, NEA-BC
Becky Schuetz, RN-BC, BSN
Members of the Investigative Team
Principal Investigators
–Marita G. Titler PhD., RN, FAAN;
–Loreen Herwaldt, MD;
–Leah Shever PhD, RN
Investigators
–Shelia Barron, PhD;
–Gary Rosenthal, MD
–Marcia Ward, PhD
Site Coordinators and data collectors at each site – big thanks
for their work and participation
***Acknowledgement: Robert Wood Johnson Foundation
2
RN Data Collectors for Medical Record
Abstraction
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Becky Schuetz, RN-BC, BSN
Dan Fraczkowski, RN, BSN
Rhonda Abdulla, RN, BSN
Catherine Scheidler, RN
Tacora Love, RN, BSN, CRN, CMSRN
Charisee Bedrejo, RN
Katie Houser, RN, BSN
Daisy Abraham, RN, BSN
Cherileen Niemiec, RN
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Byron Lindsay, RN, BSN
Cherylyn Stark, RN
Bekka Beil, RN, BSN, CVN
Leslie Klemp, RN, BSN, CVN
Maureen Swiderski, RN, CHPN, OCN
Angela Tosaw, RN, BSN
Tania Rademacher, RN, CVN
Clelia Dompe, RN, MSN
Study Purpose
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To investigate linkages among 2 National Quality
Forum (NQF) patient outcomes of falls and injury
from falls, NQF system-centered measures such as
skill mix, nursing care hours per patient day (HPPDs),
and professionalism, and processes of care to
prevent falls (i.e. interventions to prevent falls).
IMPACT
P4P NMs
RN HPPD
Focus on
risk specific
fall prevention
interventions
5
Data Sources
Data: Quarter 1 (1/08-3/08) &
Quarter 5 (1/09-3/09)
• Administrative Discharge Abstracts (age,
severity of illness, primary medical
diagnoses)
• Nurse staffing (components to build HPPDs,
skillmix, turnover) at the unit level.
• Falls (rate and fall injury rate; severity)
• Chart Abstractions (Daily Fall Risk
Assessment and Interventions done Related
to Fall Prevention)
Interviews with the CNO,
Person in charge of Quality,
and Nurse Managers.
Questionnaires
completed by
staff nurses on
each of the
study units
(Quarters 2, 3, 4)
Description of Sites
Number of Hospitals
48
Number of Units
185
Number of States that Hospitals are Located in
18
Hospitals
Units
Number
Percent
Number
Percent
Community
30
63%
109
59%
Academic/Teaching Hospital
13
27%
65
35%
VAs
4
8%
7
4%
Other
1
2%
4
2%
Small (< 100 beds)
5
10%
7
4%
Medium (101-400 beds)
20
42%
66
36%
Large (> 401 beds)
23
48%
112
60%
Type of Hospital
Hospital Size (Licensed Beds)
States with Participating Hospitals
RWJ
Nursing Falls Study
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Preliminary Findings
Preliminary Findings: Fall
Rates and Fall Injury Rates
Variable
Quarter 1
Mean (SD)
Quarter 5
Mean (SD)
T- value (p)
Fall Rates
3.78 (2.2)
4.15 (2.3)
1.71 (NS)
Fall Injury
Rates
1.14 (1.25)
1.01 (.89)
-1.28
(NS)
Data: Quarter 1 (1/08-3/08) & Quarter 5 (1/09-3/09)
RN HPPDs and Turnover
Variable
Quarter 1 Mean
(SD)
Quarter 5 Mean
(SD)
T-value (p)
HPPDs
5.9 (1.7)
6.1 (1.5)
1.71 (NS)
Turnover
1.9 (2.6)
.97 (1.2)
-4.74 (p<.0001)
Frequency of Fall Prevention
Interventions: MRA
Intervention
Patient days
Patients
PT session
13%
23%
Ambulation
38%
61%
Toileting
17%
22%
Delirium Scr.
7%
10%
Pharm referral
1%
2%
Chg. Meds- Dr.
0.6%
1%
Cues/signs
25%
32%
Pt. instructed
33%
44%
Patient days = 29,706; Patients = 7,699
Frequency of Fall Prevention
Interventions: MRA
Intervention
Patient days
Patients
Sitter < 24 hrs
1%
4%
Sitter = 24 hrs./day
1%
3%
Bed rails adj.
60%
66%
Bed rails adj.: lower
down
47%
51%
Bed alarm
8%
11.%
Physical restraints
0.8%
1%
Low bed (6”)
19%
23%
Patient days = 29,706; Patients = 7,699
Selected Findings: NM Interviews
Category
Frequency
Percent
Primary Resp QI data:
NM
117
80.1%
Fall Prevention Team: Yes 81
55%
NM Compensated: NO
84.8%
123
Annual Staff
86
Competencies for FP: Yes
58.9%
Focused F/U - > 1 fall:
Yes
37%
N=146
54
Selected Findings: NM Interviews
Category
Frequency
Percent
Referral for > 1 fallers:
Yes
15
10.3%
Satisfaction with fall
38
rates in unit: Ext & Very
26.2%
Recall patient injury:
Yes
94
65.3%
Injury type: Death,
Major, Moderate
54
60.7%
Use of Physical
Restraints
Some=23
Not at all = 17
15.9%
11.7%
Findings
H1 & 2: Fall rates and fall injury rates explained by skill mix, HPPD,
voluntary turnover, PES-NWI, when controlling for age, SI, and PMD
Variable
Coefficient
p value
Fall rates
PES Comp = 1.487292
p=.02
Fall Injury rates
RN HPPD = .113985
p=.047
(cross sectional analysis for Q 1; HLM)
Implications
• Variety of fall prevention interventions used
• Most nurse managers (86%) believed their fall prevention standard (p/p)
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was based on evidence but when asked to identify the evidence, many
were unable to
P4P – target nurse manager
Need focused follow-up for patients that have fallen once or more
Risk factor assessment provide a score but it is the specific risk factor for
patients that guide risk specific interventions – work on risk specific fall
prevention interventions individualized to the patient.
Research Plan
• Still analyzing data
• Results presented today are preliminary
• Thank you for participating
Unanticipated Ways Research Improves
Practice
Chart Abstraction Tool
Fall Risk Assessment Done?
 Yes
 No
Score:
______
Pt at risk for falling?
 Yes
 No
Mobility
 Attended Physical Therapy (PT)
session
 Gait training by PT
 Exercises (e.g. ROM, strength
training) by PT
 Scheduled ambulation with
supervision
 Scheduled ambulation without
supervision
 Assistive device readily available
for use by patient
Tool Continued…
Elimination
 Toileting regimen (e.g. toileting
rounds every 2 hours)
 Physician orders to reduce dose
and/or discontinue diuretics
 Physician orders to reduce dose
and/or discontinue laxatives
Pharmacological
 **Medication orders were
modified by the physician for the
specific purpose of minimizing
fall risk
Education
Cues or signs are placed to
identify patient as being at risk
for falling
 Patient instructed to call for
assistance when getting out of
bed or chair
 Patient/family provided with
written educational materials on
fall prevention
Tool continued…
Bed/Restraints
 Physical restraints applied
 Bed alarm activated
 Low bed (6 inches from ground)
 Mats on floor next to bed
 Hip protectors applied
 Bedrails adjusted
 All up
 Lower down
 One side down
Referral/Follow-up
 INR obtained
 Referral to Gerontological Nurse
Practitioner (GNP)
 Comprehensive assessment by
GNP performed
 Referral to interdisciplinary fall
prevention team
 Comprehensive post-fall
assessment completed
 Pharmacy referral
 PT referral made
 Other ____________
Impact on Documentation:
In Their Own Words
• “The Falls Study taught me to be more consistent in charting the
musculoskeletal, fall risk and functional mobility assessments…to be
concise in charting items used to decrease fall risk, such as assistive
devices by the bedside.“ -Tania Rademacher
• “The Falls Study helped me to recognize gaps in nursing documentation
…. I was able to improve my documentation as a nurse by incorporating
multiple fall prevention techniques into my charting….my documentation
more accurately reflects measures taken to improve patient care and
prevent falls.“ -Katie Houser
Documentation (Continued)
• “The Titler Falls Study helped highlight areas of fall prevention needing
improvement. Recognizing these areas helped me to improve my
nursing practice by incorporating multiple disciplines and practices into
fall prevention for my patients……I have been able to sooner recognize
signs of high fall risk patients, and therefore been able to facilitate the
implementation of appropriate means to keep my patients safe from
falls.” –Katie Houser
• “Abstracting data ….. encouraged me to change my charting habits.
Doing chart audits really opens your eyes to the good and the bad. I
have definitely started to be more meticulous with my
charting…Participating as a data abstractor was a learning experience ..
and has resulted in positive changes in my daily charting as a nurse.” –
Bekka Beil
Growing Culture of Inquiry
• Nurses valued the Medical Record Abstraction process:
More nurses joined for the 2nd set of data collection
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Enthusiasm on the nursing units
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“Opened doors”
Increased Interest in Research (Outcomes)
• Chapman Scholars
• Data Collectors for other studies
• Attending graduate school
• Enrolled or have taken the Nursing Research & Evidence•
Based Practice: A Nurse’s Guide course
Participated in the Nursing Research Lunch & Learns
Questions?