Background & Goals
Patient falls in acute care hospitals is a longstanding, persistent, and sometimes lethal problem. Falls are a major public health problem globally, and hospitalization increases the risk for falls. In the United States, falls occur in approximately 2-3% of hospital stays, and up to 1 million hospitalized patients fall annually. Fall rates range from 1.3 to 8.9 falls per 1,000 patient days with approximately 30% of falls resulting in injury.
Common fall-related injuries associated with morbidity and mortality include fractures, subdural hematomas, and excessive bleeding. It is estimated that falls with related injuries add 6.3 days to the hospital stay drive up costs.
Over 90% of falls in hospitals are preventable; accidental falls account for 14% and anticipated physiological falls account for 78%. Accidental falls include slips and trips caused by environmental factors such as food or liquid spills, environmental clutter, or improper footwear. Accidental falls can be prevented using "universal fall precautions" – those actions taken by nurses and other hospital staff to keep the environment safe for all patients. Anticipated physiological falls are caused by known physical factors and secondary effects of treatment. These fall risk factors can be predicted using a validated fall risk screening tool such as the Morse Fall Scale (MFS) and prevented when tailored interventions to address these specific risk factors are accurately and consistently carried out by all stakeholders. Physiological risk factors for falls include gait instability, lower limb weakness, urinary incontinence/frequency, need for assisted toileting, previous fall history, agitation/confusion or impaired judgment, and medication side effects.
Unlike other adverse events in acute hospital settings that may be prevented by implementing a standard checklist for all patients, fall prevention plans need to be tailored to individual patients based on their personal risk factors. Evidence suggests that one of the root causes of patient falls is poor communication of the fall prevention plan and failure of staff, patients and families to consistently follow the plan. To maximize communication, patient and family engagement should be integrated into each step of the fall prevention process and the fall prevention plan should be available at the bedside, not simply stored in the electronic health record.
Program Description
The Fall Tailoring Interventions for Patient Safety (Fall TIPS) toolkit makes the fall prevention plan operational. Our goal was to integrate patient engagement into the three-step fall prevention process (properly assessing for fall risk factors; developing a personalized fall prevention plan; consistently implementing the evidence-based plan) seamlessly into nursing workflow.
To address assessment, the Fall TIPS model uses the MFS which, when used properly, addresses all six common predictors of physiological falls. The TIPS model includes Clinical Decision Support in the Electronic Health Record (EHR) to automatically link each MFS risk factor to evidence-based recommendations that are feasible in hospital settings. As nurses complete the MFS in the EHR, an evidence-based plan is generated to address each risk factor.
In a series of clinical trials involving over 40,000 patients, the Fall TIPS Toolkit was associated with a significant decrease in falls and fall-related injuries. The toolkit includes a suite of tools to promote adoption and spread of evidence-based fall prevention best practices. It is currently used in over 250 hospitals and supported by over a decade of research.
Evidence of Success
The Fall TIPS program has demonstrated a 25% reduction in patient falls and 34% reduction in fall-related injuries. The JAMA 2010 study was the first randomized trial that demonstrated a significant reduction in patient falls in acute hospital settings. A systematic review of inpatient fall prevention programs gave the Fall TIPS study their highest quality score reflecting its rigorous design (cluster randomized clinical trial), large number of patients (n=10,264), and the fact that it was conducted in multiple hospitals.
Using a total sample of 1,242,895 patients and over 74 months of data, we categorized fall severity to understand how different degrees of fall-related injury impact costs. For the first time in over a decade, we calculated the cost of a patient fall in the hospital and the cost of associated injuries. These findings are currently under review for publication.
The Fall TIPS approach ensures that all risk factors are addressed and that scarce nursing resources are not used to unnecessarily implement interventions that will not mitigate risk. Nurses reported that efficiencies in patient care compensated for the time spent on the Fall TIPS program. Fall TIPS saved nurses’ time and supported engaging with patient and family in the fall prevention process.