Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

Prevention Strategies to Reduce Falls in Psychiatric Settings

Yasser Al-Khatib, MSN, RN; Paul Arnold, RN, BC; Lois Brautigam, RN, BC; Letty Chan-Domingo, MSN, CRNP, CEN; Barbara Gennello, BSN, RN; Edgardo Jaminola, MA, RN-BC; Kate Meehan, BSN, RN; John Modrzynski, BSN, RN, MPA; Carolyn K. Nicolardi, MHA, RN; L.J. Rasi, MSW, LSW; David Stockton, BSN, RN

Abstract

A Fall Committee was developed in response to an increase in the rate of falls by patients at a primarily behavioral health, urban teaching hospital in the mid-Atlantic region of the United States. The Fall Committee identified interventions to potentially lessen the number of patient falls and areas where documentation could be improved to better describe an incident in the medical record. The Fall Committee developed paperwork to be completed after each patient fall and made changes to the low fall risk and high fall risk treatment plans. This article describes the recommendations submitted by the Fall Committee and its subsequent implementation. Although not causational, the fall rate decreased after the recommendations of the Fall Committee were implemented; however, a recent rise in the fall rate was noted and attributed to higher patient acuity on the unit. The committee investigation into this issue highlighted the paucity of research in this field and the need for a streamlined, easy-to-use, behavioral health fall scale to more accurately judge the fall risk of patients in this specialized subset.

Mr. Al-Khatib is Nurse Manager, Crisis Response Center, Mr. Arnold, Ms. Brautigam, Mr. Modrzynski, and Mr. Stockton are Nurse Managers, Ms. Chan-Domingo and Mr. Jaminola are Clinical Nurse Specialists, Ms. Gennello is Director of Nursing Services, Ms. Meehan is Associate Director, Risk Management, Ms. Nicolardi is Director, Risk/Quality Management, and Mr. Rasi is Director of Utilization Management, Temple University Hospital, Philadelphia, Pennsylvania.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to L.J. Rasi, MSW, LSW, Director of Utilization Management, Temple University Hospital, Episcopal Campus, 100 E. Lehigh Avenue, Philadelphia, PA 19125; e-mail: Luciano.Rasi@tuhs.temple.edu.

Received: July 06, 2012
Accepted: February 21, 2013
Posted Online: April 04, 2013

Abstract

A Fall Committee was developed in response to an increase in the rate of falls by patients at a primarily behavioral health, urban teaching hospital in the mid-Atlantic region of the United States. The Fall Committee identified interventions to potentially lessen the number of patient falls and areas where documentation could be improved to better describe an incident in the medical record. The Fall Committee developed paperwork to be completed after each patient fall and made changes to the low fall risk and high fall risk treatment plans. This article describes the recommendations submitted by the Fall Committee and its subsequent implementation. Although not causational, the fall rate decreased after the recommendations of the Fall Committee were implemented; however, a recent rise in the fall rate was noted and attributed to higher patient acuity on the unit. The committee investigation into this issue highlighted the paucity of research in this field and the need for a streamlined, easy-to-use, behavioral health fall scale to more accurately judge the fall risk of patients in this specialized subset.

Mr. Al-Khatib is Nurse Manager, Crisis Response Center, Mr. Arnold, Ms. Brautigam, Mr. Modrzynski, and Mr. Stockton are Nurse Managers, Ms. Chan-Domingo and Mr. Jaminola are Clinical Nurse Specialists, Ms. Gennello is Director of Nursing Services, Ms. Meehan is Associate Director, Risk Management, Ms. Nicolardi is Director, Risk/Quality Management, and Mr. Rasi is Director of Utilization Management, Temple University Hospital, Philadelphia, Pennsylvania.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to L.J. Rasi, MSW, LSW, Director of Utilization Management, Temple University Hospital, Episcopal Campus, 100 E. Lehigh Avenue, Philadelphia, PA 19125; e-mail: Luciano.Rasi@tuhs.temple.edu.

Received: July 06, 2012
Accepted: February 21, 2013
Posted Online: April 04, 2013

A primarily behavioral health teaching hospital in the mid-Atlantic region of the United States examined its fall rate after an increase in these events was noted. Prior to the implementation of change, the hospital staff documented fall risk using the Morse (2009) Fall Scale (MFS), and minor changes in treatment planning were instituted for those deemed to be at high risk for falls. A falls assessment of the environment was also conducted.

After the hospital recorded a high fall rate of 3.65 per 1,000 patient days in 2006 and a subsequent escalation in the rate early in 2007, a committee was convened to explore the problem. Past falls were reviewed by medical record, and several recommendations were developed by the committee and subsequently implemented. This article describes these changes and how their implementation may have helped lower the fall rate. Terms used throughout the article are defined in Table 1.

Definition of TermsDefinition of Terms

Table 1: Definition of Terms

Literature Review

A focused Internet search was performed to identify literature regarding patient falls relevant to the program initiated. The most common focus of studies and articles was found to be reducing fall incidence and severity. Professional journal databases were explored, and selected peer-reviewed articles were cited as appropriate. Emphasis was given to articles that were more recent and relevant. Due to the paucity of research on this topic, some older studies with significant findings were included. Additionally, several studies reviewed were conducted in medical hospital units or nursing homes. Although not a heavily researched area, more recent articles have focused on fall rates and fall prevention strategies for inpatient psychiatric units, which are referenced below.

Kulik (2011) stated that up to 50% of hospital patients are at risk for falls, and those who do fall commonly have longer lengths of stay. Several risk factors have been identified including chronic illness, medication use, and cognitive disorders (Blair & Gruman, 2006). According to Detweiler, Kim, and Taylor (2005), history of falls, inability to call for assistance, and inability to remember safety instructions contribute to a patient’s fall risk. Rubenstein, Josephson, and Robbins (1994) reported that “long-term care patients have more fall risk factors, and they fall about three times more frequently than community dwellers” (p. 442). Tideiksaar (1988), citing other studies, noted that in terms of mortality in older adults, falls represent the leading cause of death due to unintentional injury. He added that “while falls are associated with excess mortality, most falls do not end in death. However, the morbidity associated with falling is considerable. A fracture is the most common injury, and the hip is the most common fracture to result in acute hospitalization” (p. 145). The Nursing Home Quality Indicators Development Group (1999) of the Centers for Medicare & Medicaid Services noted that falls not only contribute to the quality of life of the residents but are also a significant quality indicator in long term care.

Among adult psychiatric patients, published reports on falls primarily describe the characteristics of patients who fall (Estrin, Goetz, Hellerstein, Bennett-Staub, & Seirmarco, 2009) as well as adverse reactions to psychotropic medications that increase the risk for falls (American Geriatrics Society/British Geriatrics Society, 2011; Blair & Szarek, 2008; Boyd, 2002; Howland, 2009; Lavsa, Fabian, Saul, Corman, & Coley, 2010). Howland (2009) wrote that “falls are the single most important serious complication associated with all types of prescription and nonprescription drug use in older adults” (p. 17). Howland also noted that psychotropic drugs contribute to, or cause, falls by various direct and indirect mechanisms, including sedation, confusion, vision changes, blood pressure changes, cardiac rhythm changes, balance problems, and neuromuscular incoordination.

Blair and Gruman (2006) found that the incidence of falls on psychiatric units tends to be higher than that on general acute care hospital units, with estimated fall rates of 13.1 to 25 per 1,000 inpatient days. Tideiksaar (2005) explained that this increased incidence of falls may be due in part to the high rate of cognitive disturbance and behavioral manifestations, such as agitation and wandering, both of which are strongly associated with fall risk in psychiatric patients, as well as predictable side effects of psychotropic medication use.

The Pennsylvania Patient Safety Authority (PPSA) reviewed falls reported by behavioral health hospitals in 2009. They reported that falls in behavioral health areas were more likely to involve patient harm than those from medical units; 9.6% of behavioral health falls were serious events compared to 3.7% of those submitted by other hospitals. In 2009, falls accounted for 21.7% of submitted reports in behavioral health hospitals compared to 15.4% in nonbehavioral health hospitals (PPSA, 2010).

Program Description

This new fall program was implemented at a primarily behavioral health, urban teaching hospital located in the mid-Atlantic region of the United States. After several months of a steadily increasing fall rate, a Fall Committee was formed in 2007 to investigate this trend and recommend solutions to the problem. The Fall Committee conducted an in-depth review of all falls that occurred January through April 2007. The review showed a lack of consistent documentation after a patient fall, as well as several common themes; many patients had received medications within 6 hours of the fall, had a seizure prior to the fall or a history of seizures, and/or involved ambulation to or from the bathroom.

A second in-depth chart review performed by a pharmacy student was completed and verbally presented to the Fall Committee in June 2008. This review identified that behavioral health patients are at an increased risk for falls due to the following: the presence of a coexisting medical diagnosis of diabetes, seizures, and cardiac disease; side effects of the medications associated with these diseases; and/or the side effects of the psychiatric medications given for treatment of their behavioral health diagnosis.

The Fall Committee recommended several steps to improve documentation and lower the fall rate. These recommendations take place at various points during the hospital stay and are noted below. Each subheading refers to a specific area identified for improvement by the Fall Committee.

Assessment/Documentation Tool

Upon admission, required documentation for each patient includes an initial assessment for fall risk, which is recorded on the Nursing Fall Reassessment Record tool. This tool uses the MFS to numerically determine a patient’s risk at three different levels: no fall risk, low fall risk, and high fall risk (Table 1). Low fall risk and high fall risk interdisciplinary treatment plan templates were also developed to aid the multidisciplinary care team. These templates are multidisciplinary guidelines on how to better individualize the prevention strategies for fall reduction according to patient risk level. These treatment plan updates are based on the initial admission assessment of the patient and subsequent daily assessments. Currently, these treatment plans are updated as any other treatment plan in this facility: every 7 days, or more frequently when needed.

To promote patient safety and prevent falls, all members of the treatment team should be aware of the patient’s fall risk. If a patient meets the criteria for high fall risk, a yellow identification band is placed on the patient and he or she is given yellow, non-skid, slipper socks. In addition, yellow dots are placed on the white communication board at the nursing station next to the patient’s name, outside the patient’s room, in the medication book, and on individual charts.

Communication from the referring crisis response center (CRC) to the inpatient unit was also seen as critical. The Committee recommended and implemented adding history of falls to the intake form (admission communication) used by both the CRC staff to give—and the inpatient staff to accept—report on a transfer.

Education

Patient and family education on fall prevention is provided and enforced at the hospital. A “Help Us Keep You Safe” form was developed and is provided to patients and their families upon admission to the inpatient units. Education on fall prevention is also conducted on discharge, including a “Fall Prevention At Home” form that is distributed to patients and families upon discharge to assist them in post-hospitalization fall prevention efforts. New employees receive extensive education in fall risk and the Behavioral Health Fall Program at orientation. This staff education is similar to what was provided to all current employees when the new Fall Program was originally launched.

Post-Fall Tool

In the event of a fall, additional documentation is required. A multi-page Post-Fall Documentation Tool was developed and printed on yellow paper to be consistent with the color theme of high fall risk designation. The Post-Fall Documentation Tool includes a post-fall assessment, nursing and physician progress notes, documentation of interventions ordered after a fall, and a high fall risk interdisciplinary treatment plan. The post-fall documentation has been incorporated into a Fall Prevention at Home Tool, which is given to the patient at discharge.

All patients who fall are immediately regarded as high fall risk. The treatment team meets to evaluate the situation, determine the possible cause(s) of the fall, identify any opportunities to prevent future falls or subsequent injuries, and reassess the fall risk status. Some treatment teams requested the ability to decrease the patient’s fall status from high fall risk to low fall risk based on the team’s evaluation of the cause of the patient fall, even if the patient meets the criteria for high fall risk. To address this concern, the Fall Committee developed a justification form that supports the treatment team’s decision and documents the rationale for the patient fall status downgrade. All high fall risk indicators were populated into the justification form to identify the resolution of, or improvement in, the specific elements that led to the high fall risk designation.

Monthly Reporting

The Fall Committee meets monthly to categorize all falls, assess documentation, and review outcomes of treatment team reviews. As more experience is gained, the Fall Committee has begun looking at specific issues, such as falls occurring within 48 hours of admission and whether a fall patient was correctly assessed prior to the incident. The monthly meetings also help identify trends, contributing factors within the client population, and successful prevention strategies developed within the treatment team reviews. This information, including the fall rate, is presented at a monthly behavioral health quality management meeting.

Results

The overall behavioral health fall rate per 1,000 patient days is 3.05 for calendar years 2006 through 2011 (Figure 1). Each year the fall rate steadily decreased; however, increases were noted in 2010 and 2011. An internal benchmark of 4.1 falls per 1,000 behavioral health patient days was established through the health system’s risk management committee in April 2007. The fall rate is below the internal benchmark as well as the average fall rate for behavioral health patients reported in the literature.

Behavioral health inpatient fall rates.

Figure 1. Behavioral health inpatient fall rates.

A second results analysis was conducted in January 2012 to address the increase to 3.4 falls per 1,000 patient days in 2011. Significant findings included a single outlier patient accounting for 42 falls per 1,000 patient days for 2009 to 2011 with comparison data outlined in Figure 2. Removing the single outlier patient decreased the overall fall rate, but the upward trend over the previous 2 years remained. It was hypothesized that the patients on the unit may be more acute than in years past, a result of several factors including the closing of a nearby CRC and more stringent medical necessity criteria placed on admissions.

Behavioral health inpatient comparison fall rates.

Figure 2. Behavioral health inpatient comparison fall rates.

Intramuscular as-needed (PRN) medication administration was used as a proxy measure for patient acuity. Haldol® (haloperidol) and Ativan® (lorazepam) injections were selected, as they are the most commonly used PRN medications at this facility. Figure 3 demonstrates a dramatic increase in the use of these PRN medications over the past 3 years.

Behavioral health inpatient as-needed (PRN) medication use.

Figure 3. Behavioral health inpatient as-needed (PRN) medication use.

The Fall Committee tried to determine the underlying reason for each fall episode. In the past 3 years, the primary cause of falls has been patient behavior followed by medical issues. Additionally, falls are categorized by type. Falls while ambulating or observed and falls found on floor are the most common (Table 2 and Table 3).

Behavioral Health Inpatient Falls, By Cause, Per Calendar Year (2009–2011)

Table 2: Behavioral Health Inpatient Falls, By Cause, Per Calendar Year (2009–2011)

Behavioral Health Inpatient Falls, by Fall Type, Per Calendar Year (2009–2011)

Table 3: Behavioral Health Inpatient Falls, by Fall Type, Per Calendar Year (2009–2011)

Discussion, Conclusion, and Future Directions

Results demonstrated a decrease in the number of falls, which is attributed to the implementation of the Fall Prevention Program with the use of the MFS. Specifically, the team believes the two most successful interventions were the development of a unique falls documentation form and the discussion of patient fall events in treatment team meetings, leading to modifications in the individualized care plan in an attempt to prevent future falls.

The recent increase in fall activity is likely attributable to the increased patient acuity on the unit. One limitation of this article is that there was no control group; therefore, results could only be described as correlational and not causational.

Although the fall rate at this hospital decreased, opportunity remains for improvement. The study group noted that the less intricate elements of the MFS are not sufficient to capture all components of the hazards for falls of behavioral patients. The group further recognizes that for the most part, the components of the MFS are believed to be designed for medical patients or other patients with nonbehavioral issues. This review was not able to generate a specific fall tool that assesses the risks of falls explicitly for behavioral patients. For better patient outcomes, more research is needed to explore and identify a new instrument or fall scale system designed precisely for patients with behavioral problems, while avoiding the complexity of the currently available fall scales designed primarily for behavioral health settings. Future studies may also include the delineation of intrinsic and extrinsic factors affecting patient fall rates to assess whether the institution could prevent any other potential falls.

 

References

  • American Geriatrics Society/British Geriatrics Society. (2011). Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. Journal of the American Geriatrics Society, 59, 148–157. doi:10.1111/j.1532-5415.2010.03234.x [CrossRef]
  • Blair, E. & Gruman, C. (2006). Falls in an inpatient geriatric psychiatric population. Journal of the American Psychiatric Nurses Association, 11, 351–354. doi:10.1177/1078390305284659 [CrossRef]
  • Blair, E.W. & Szarek, B.L. (2008). Exploring relationship of psychotropic medications to fall events in an inpatient geriatric psychiatric population. International Journal of Psychiatric Nursing Research, 14, 1698–1710.
  • Boyd, M.A. (2002). Atypical antipsychotics: Impact on overall health and quality of life. Journal of the American Psychiatric Nurses Association, 8(4 Suppl.), S9–S17. doi:10.1067/mpn.2002.127061 [CrossRef]
  • Detweiler, M.B., Kim, K.Y. & Taylor, B.Y. (2005). Focused supervision of high-risk dementia patients: A simple method to reduce fall incidence and severity. American Journal of Alzheimer’s Disease and Other Dementias, 20, 97–104 doi:10.1177/153331750502000205 [CrossRef] .
  • Estrin, I., Goetz, R., Hellerstein, D.J., Bennett-Staub, A. & Seirmarco, G. (2009). Predicting falls among psychiatric inpatients: A case-control study at a state psychiatric facility. Psychiatric Services, 60, 1245–1250. doi:10.1176/appi.ps.60.9.1245 [CrossRef]
  • Hayes, W. (1994). Prevention of falls and hip fractures in the elderly. Rosemount, IL: American Academy of Orthopedic Surgeons.
  • Howland, R. (2009). Prescribing psychotropic medications for elderly patients. Journal of Psychosocial Nursing and Mental Health Services, 47(11), 17–20. doi:10.3928/02793695-20090930-06 [CrossRef]
  • Kulik, C. (2011, March). Components of a comprehensive fall-risk assessment. In Best practices for falls reduction: A practical guide [Supplement to American Nurse Today], 6–7.
  • Lavsa, S.M., Fabian, T.J., Saul, M.I., Corman, S.L. & Coley, K.C. (2010). Influence of medications and diagnoses on fall risk in psychiatric inpatients. American Journal of Health-System Pharmacy, 67, 1274–1280. doi:10.2146/ajhp090611 [CrossRef]
  • Morse, J.M. (2009). Preventing patient falls: Establishing a fall intervention program (2nd ed.). New York: Springer.
  • Nursing Home Quality Indicators Development Group. (1999). Facility guide for the nursing home quality indicators: National data system. Madison: University of Wisconsin Madison.
  • Pennsylvania Patient Safety Authority. (2010). Data snapshot: Falls reported by behavioral health hospitals. Pennsylvania Patient Safety Advisory, 7, 149–150. Retrieved from http://patient-safetyauthority.org/ADVISORIES/Ad-visoryLibrary/2010/dec7%284%29/Pages/149.aspx
  • Rubenstein, L.Z., Josephson, K.R. & Robbins, A.S. (1994). Falls in the nursing home. Annals of Internal Medicine, 121, 442–451 doi:10.7326/0003-4819-121-6-199409150-00009 [CrossRef] .
  • Tideiksaar, R. (1988). Falls in the elderly. Bulletin of the New York Academy of Medicine, 64, 145–163.
  • Tideiksaar, R. (2005, February15). Benchmarks for psychiatric patient falls. Retrieved from the Nurse Assist website: http://www.nurseassist.com

Definition of Terms

Fall (health system definition)—

An untoward event that results in the patient coming to rest unintentionally on the ground or other lower surface.

An event that results in the patient, or a body part of the patient, coming to rest inadvertently on the ground or other surface lower than the patient.

Patients who experience an unplanned descent to the floor.

An unwitnessed event—self-reported by patient, family member, or significant other—classified as a fall.

Serious event—An event, occurrence, or situation involving the clinical care of a patient in a medical facility that results in death, or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health care services to the patient.
Injury—Harm or damage that is done to self, others, or property.
Morse Fall Scale (MFS)—A method of assessing an individual’s likelihood of falling as measured by the following variables:

History of falls within the past 3 months

Secondary diagnosis

Ambulatory aid

Intravenous (IV)/heparin loc tube

Gait

Mental status

MFS scorea

History of falling

No (score as 0)

Yes (score as 25)

Secondary diagnosis

No (score as 0)

Yes (score as 15)

Ambulatory aid

None/bed rest/nurse assist (score as 0)

Crutches/cane/walker (score as 15)

Furniture (score as 30)

IV or IV access

No (score as 0)

Yes (score as 20)

Gait

Normal/bed rest/wheelchair (score as 0)

Weak (score as 10)

Impaired (score as 20)

Mental status

Knows own limits (score as 0)

Overestimates or forgets limits (score as 15)

No fall risk—A risk level of fall assessment with an MFS score of 0 to 14 requiring good nursing care and no fall prevention intervention(s).
Low fall risk—A risk level of fall assessment with an MFS score of 15 to 34 requiring implementation of low fall prevention intervention(s).
High fall risk—A risk level of fall assessment with an MFS score ⩾35 requiring implementation of high fall prevention intervention(s).

Behavioral Health Inpatient Falls, By Cause, Per Calendar Year (2009–2011)

No. of Falls (%)
Cause 2009 2010 2011 Total
Behavior 36 (36) 39 (32) 60 (42) 135
Medical 24 (24) 35 (29) 44 (31) 103
Environmental 16 (16) 11 (9) 15 (11) 42
Unknown 13 (13) 7 (6) 9 (6) 29
Medications 4 (4) 8 (7) 12 (8) 24
Seizures 7 (7) 14 (12) 1 (1) 22
Psychiatric diagnosis 1 (1) 7 (6) 1 (1) 9
Total 101 121 142

Behavioral Health Inpatient Falls, by Fall Type, Per Calendar Year (2009–2011)

No. of Falls (%)
Fall Type 2009 2010 2011 Total
Fall while ambulating/observed 38 (38) 55 (45) 44 (31) 137
Found on floor 35 (35) 20 (17) 28 (20) 83
Self-reported/unwitnessed 11 (11) 11 (9) 20 (14) 42
Toileting (to/from bathroom) 4 (4) 19 (16) 18 (13) 41
Other 5 (5) 0 (0) 16 (11) 21
Equipment involved (walker/wheelchair) 2 (2) 10 (8) 8 (6) 20
Smoking related 4 (4) 4 (3) 3 (2) 11
Getting out of bed 2 (2) 2 (2) 5 (4) 9
Total 101 121 142

Keypoints

Al-Khatib, Y., Arnold, P., Brautigam, L., Chan-Domingo, L., Gennello, B., Jaminola, E. & Stockton, D. (2013). Prevention Strategies to Reduce Falls in Psychiatric Settings. Journal of Psychosocial Nursing and Mental Health Nursing, 51(5), 28–34.

  1. The use of an assessment/documentation tool improves post-fall management.

  2. Multidisciplinary treatment team discussions led to effective fall prevention strategies.

  3. The paucity of research on falls in behavioral health settings and the need for a streamlined behavioral health fall scale were identified as areas requiring further investigation.

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