All In for Falls Prevention

PM&R’s role in a traditional nursing domain

Falls prevention in the hospital is too important to be relegated largely to a single discipline. That was the notion behind the July 2015 launch of Cleveland Clinic’s Enterprise Falls Steering Committee, charged with equipping all caregivers — including physicians, therapists, nurses, pharmacists, care coordinators and others — to effectively prevent and manage patient falls throughout the continuum of care.

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Cleveland Clinic leadership recognized that this quality committee for the overall Cleveland Clinic health system would benefit if it were directed by representatives of disciplines in addition to nursing, which has traditionally led falls-prevention efforts in many health systems. Physiatry was one natural area to turn to.

“As a physiatrist, I’m always taking a global view of the patient to help improve function,” says Sree Battu, MD, of the Department of Physical Medicine and Rehabilitation, who serves as co-chair of the falls steering committee. “I’m looking at medical issues, patient preferences and social determinants of care when caring for patients for the long term. So many factors are variables that can cause a fall, so it makes sense to adopt an interdisciplinary approach to managing falls.”

“Nursing has driven falls prevention campaigns for a long time, but the medical literature tells us you will be more successful reducing falls with an interdisciplinary approach,” adds the committee’s other co-chair, Dana Wade, DNP, RN, CNS-BC, CPHQ, NEA-BC, Associate Chief Nursing Officer of Nursing Quality and Practice. “Nurses may touch patients more, but we are all caregivers and we are all responsible for patient falls.”

The effort’s early days

Cleveland Clinic leadership decided to launch the falls steering committee with two primary goals in mind:

  • To achieve zero falls with significant harm
  • To implement interventions to support a 15 percent decrease in all falls in 2016

The steering committee’s first meeting last July brought together dozens of representatives from 26 areas across Cleveland Clinic health system, ranging from geriatrics and family practice to pharmacy and environmental services. Attendees discussed what they could contribute to falls prevention, from which the committee generated a long list of ideas and actions. Ideas were grouped for further work, and now more than 100 caregivers serve on the following six subcommittees that arose from those groupings: Care Environment, Data, Education and Communication, Medication Safety, Screening and Identification, and Transitions of Care.

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Empowering for prevention at both the population and patient levels

“We are looking at our resources across the whole health system and approaching falls at the population level,” explains Wade, “just as you would for a group of patients with congestive heart failure or diabetes.”

At the same time, the initiative’s Patient Engagement Design Team found that patients wanted education surrounding falls to be individualized and consistent, as well as patient- and family-centered.

“Our mission is giving every caregiver the knowledge and tools to prevent falls,” says Dr. Battu. “We have a variety of initiatives to achieve that mission.”

Sampling of early initiatives

Ideas developed within subcommittees are implemented at Cleveland Clinic’s main campus and its nine regional hospitals, four inpatient rehabilitation hospitals, skilled nursing facilities and more than 50 outpatient therapy venues — as well as through home care services.

Here’s a sampling of ongoing or completed projects undertaken by each of the subcommittees:

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  • Care Environment: Developed a checklist tool that helps caregivers screen the environment for things that might contribute to a fall. These recommendations will be used for planning future Cleveland Clinic facilities.
  • Data: Simplifying the way falls are tracked and risk factors are associated with falls in Cleveland Clinic’s quality reporting system, with the goal of making meaningful use of this information.
  • Education and Communication: Revised patient education materials, created a new falls video for patients and developed a teach-back tool to help bedside nurses teach patients about factors that can contribute to falling.
  • Medication Safety: Redesigning medication order sets to ensure safer and easier prescribing. Developing a pharmacist tool to help identify patients likely to benefit from a pharmacist consultation.
  • Screening and Identification: Creating an EMR-embedded screening tool to help identify inpatients who are at risk for falls and patient-specific interventions to prevent falls according to each patient’s needs. These efforts align with existing tools for delirium and early mobility.
  • Transitions of Care: Developed recommendations for changing the ambulatory process to incorporate awareness and interventions for patients who screen positive for fall risk. Educating the entire health system on Cleveland Clinic resources for fall risk management, such as specialized falls clinics and specialized therapy programs for falls prevention.

Initial effects on patient care

Three of the first ideas to make it to the hospital floor center on easily spotting at-risk patients: A yellow sign with a picture of a person falling is placed in high-risk patients’ rooms, and those patients wear a yellow wristband (see image at top of post) as well as yellow gripper socks.

While other changes may not be so visible, they are equally important. Paramount is the renewed focus on communication across caregiving disciplines. “Being part of a multidisciplinary team has been invaluable, as the entire team is now thinking in terms of the patient’s overall course of care more often and more comprehensively,” says Christine Schulte, PT, MBA, Outpatient Director of Cleveland Clinic Rehab and Sports Therapy. “The discussions we have surrounding the reasons for falls risk are critical: Is it a medication issue, a toileting issue, a strength issue, a vestibular issue or something else?”

Hints of an impact on fall rates

The preliminary results of this holistic approach to falls prevention look promising. From the beginning to the end of 2015, falls resulting in serious injury decreased by one-third, according to Dr. Battu.

Although a large majority (about 70 to 80 percent) of patient falls result in no injury or harm, she notes that vigilance around falls prevention remains imperative for all. “Our mission is to improve the overall culture of safety by having all caregivers know what resources are available, how best to care for patients to avoid falls, and how to keep patients as safe as possible,” she says. “We’re optimistic that we’re well on our way.”