Project Title: Impact of System Factors and Processes of Nursing Care on Patient Falls

Presented to 3 rd Annual Nursing Research and Evidence Based 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

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RN Data Collectors for Medical Record Abstraction

• • • • • • • • • 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 • • • • • • • • 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

• 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

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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 Number of Units Number of States that Hospitals are Located in Number Hospitals Percent Type of Hospital

Community Academic/Teaching Hospital VAs Other

Hospital Size (Licensed Beds)

Small (< 100 beds) Medium (101-400 beds) Large (> 401 beds) 30 13 4 1 5 20 23 63% 27% 8% 2% 10% 42% 48%

Number

109 65 7 4 7 66 112 48 185 18

Units Percent

59% 35% 4% 2% 4% 36% 60%

States with Participating Hospitals

RWJ

Nursing Falls Study

• 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) .97 (1.2) -4.74 (p<.0001) Turnover 1.9 (2.6)

Frequency of Fall Prevention Interventions: MRA

Intervention PT session Ambulation Toileting Delirium Scr.

Pharm referral Chg. Meds- Dr. Cues/signs Pt. instructed Patient days 13% 38% 17% 7% 1% 0.6% 25% 33% Patients 23% 61% 22% 10% 2% 1% 32% 44% Patient days = 29,706; Patients = 7,699

Frequency of Fall Prevention Interventions: MRA

Intervention Patient days Patients Sitter < 24 hrs Sitter = 24 hrs./day 1% 1% 4% 3% Bed rails adj.

Bed rails adj.: lower down Bed alarm Physical restraints Low bed (6”) 60% 47% 8% 0.8% 19% Patient days = 29,706; Patients = 7,699 66% 51% 11.% 1% 23%

Selected Findings: NM Interviews

Category Primary Resp QI data: NM Frequency 117 Fall Prevention Team: Yes 81 Percent 80.1% 55% NM Compensated: NO 123 84.8% 58.9% Annual Staff Competencies for FP: Yes 86 Focused F/U - > 1 fall: Yes N=146 54 37%

Selected Findings: NM Interviews

Category Frequency Percent Referral for > 1 fallers: Yes 15 Satisfaction with fall rates in unit: Ext & Very 38 94 Recall patient injury: Yes Injury type: Death, Major, Moderate 54 Use of Physical Restraints Some=23 Not at all = 17 10.3% 26.2% 65.3% 60.7% 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

(cross sectional analysis for Q 1; HLM) p=.047

Implications

• • • • • Variety of fall prevention interventions used Most nurse managers (86%) believed their fall prevention standard (p/p) 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

falls.” –Katie Houser ……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 • “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 2 nd set of data collection • Enthusiasm on the nursing units • “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?