Development of fall prevention program.

January-February 2021 • Vol. 30/No. 128

Susan B. Fowler, PhD, RN, CNRN, FAHA, is Nurse Scientist, Center for Nursing Research, Orlando Health, Orlando, FL.

Ellen S. Reising, MSN, APRN-CNS, ACCNS-AG, RN-BC, is Clinical Nurse Specialist, Advanced Practice Nursing & Research, Dr. P. Phillips Hospital – General Surgery Unit, Orlando, FL.

A Replication Study of Fall TIPS (Tailoring Interventions for Patient

Safety): A Patient-Centered Fall Prevention Toolkit

Susan B. Fowler Ellen S. Reising

T he Agency for Healthcare Research and Quality (AHRQ, n.d.) defined a fall as a sud-

den, unintended, uncontrolled down ward displacement of a pa - tient’s body to the ground or other object. This includes situations in which a patient falls while being assisted by another person but excludes falls resulting from a pur- poseful action or violent blow. The National Quality Forum (2015) identified five levels of injury from falls: • None – patient had no injuries

(no signs or symptoms) • Minor – required application of

a dressing or ice; cleaning of a wound; limb elevation; topical medication; pain, bruise, or abrasion

• Moderate – needed suturing, application of surgical tape strips/skin glue; splinting; mus- cle/joint strain

• Major – required surgery, cast- ing, traction; consultation for neurological (basilar skull frac- ture, small subdural hematoma)

or internal injury (rib fracture, small liver laceration); patients with coagulopathy who receive blood products

• Death – resulting from injuries sustained from fall, but not from physiologic events causing the fall Fall risk is assessed on all patients

admitted to most facilities. The Morse Fall Scale is used widely in many healthcare settings and included in some risk models for inpatient falls (Choi et al., 2018). At the study institution, this scale is used for risk assessment on admis- sion, during the dayshift assessment, when a change in the patient’s con- dition occurs, upon transfer to another unit, and after a fall.

Standard or universal fall preven- tion identified by the AHRQ (2018) includes specific interventions,

such as familiarizing the patient with the environment and having the patient demonstrate call light use. The call light is maintained within the patient’s reach, as are personal possessions. Sturdy hand - rails should be present in the bath- rooms, patient room, and hallway. The bed is in low position and bed brakes are locked; the bed can be raised to a comfortable height when transferring the patient. Wheelchair wheel locks also should be used when the wheelchair is stationary.A night light or supplemental lighting is needed. The patient care area should be uncluttered, with surfaces kept clean and dry. Staff should fol- low safe patient handling practices. Adult patients may be offered assis- tance with toileting every 2 hours as appropriate. If a patient is identified as high risk for fall, a yellow wrist-

Instructions for CNE Contact Hours

MSN J2103 Continuing nursing education (CNE)

contact hours can be earned for completing the evaluation associated

with this article. Instructions are available at amsn.org/journalCNE

Deadline for submission: February 28, 2023 1.1 contact hours

The Fall TIPS (Tailoring Interventions for Patient Safety) Toolkit pro- vides individualized, patient-centered fall prevention measures. In a study exploring the toolkit’s adoption and its impact on patient knowledge of fall risk factors and interventions, fall rates, and injury rates, results demonstrated increased perceived patient knowledge of patient fall risk and related prevention strategies. An overall decrease in fall rates over time supported use of innovative, individ- ualized fall prevention strategies.

January-February 2021 • Vol. 30/No. 1 29

band imprinted with Fall Risk is placed on the patient.

For the period September 2016- August 2017, 36 patient falls oc - curred in the study unit. Three falls occurred on average each month (range one to six). Despite use of standard high-risk fall prevention strategies such as a yellow armband and non-skid socks, falls and falls with injury continued. A research team was formed to investigate a dif- ferent approach to fall prevention.

Purpose The primary purpose of this

research was to replicate a pub- lished study (Dykes et al., 2017) to

determine the suitability of a patient-centered fall prevention tool and its impact on patient knowledge of fall risk factors and prevention interventions, overall fall rates, and falls with injury. A secondary objective was to evaluate ease of use of the patient-centered fall prevention tool and the need for modifications.

Review of the Literature Dykes and colleagues (2017) de -

veloped and pilot tested a patient- centered, individualized approach to fall prevention. Inter ventions were tailored to individual patient needs, including history of falls,

medication side effects, use of walk- ing aid, intravenous-related equip- ment, unsteady gait or walk, and cognition issues such as forgetting or resistance to calling for assis- tance. The approach consisted of a bed poster that included fall risk assessment items on the left side and fall prevention interventions on the right. The bed poster focused on risk of harm, fall risks, and fall interventions and was hung at the bedside (see Figure 1). Dykes and colleagues suggested a patient and family, if possible, must be included in the steps of the fall prevention process.

Following the Tailoring Interven - tions for Patient Safety (TIPS) inter- vention used by Dykes and coau- thors (2017) at two facilities, patient knowledge of fall risk and preven- tion based on two statements signif- icantly increased (p=0.001-0.31). The mean fall rate comparing 6 months of data before and after intervention decreased from 3.28 to 2.8; fall injury rates decreased from 1.00 to 0.54. Positive results subse- quently have been replicated at other hospitals in the Partners HealthCare system and communi- cated through a formalized Fall TIPS Collaborative (Dykes et al., 2019). The website for the Collaborative (www.falltips.org) provides the toolkit, webinars, and implementa- tion materials.

Because this study’s focus was to replicate previously published re - search, a comprehensive literature review on fall prevention was not conducted. A search was conducted in CINAHL for 2017-2020, focusing on fall prevention, hospital (set- ting), and systematic reviews. Ten articles were found but most focused on fall prevention after hos- pital discharge or older adults, resulting in one applicable study discussed below.

Avanecean and colleagues (2017) conducted a systematic review of the effectiveness of patient-centered interventions on falls in the acute care setting. Five randomized con- trolled trials were included in the narrative synthesis. Three of these studies demonstrated a reduction in fall rates, all using personalized care

Background

Generalized standard interventions based on level of risk are current prac- tices for fall prevention, but not individualized. Dykes and colleagues (2017) developed and tested a patient-centered, individualized approach to fall prevention using an 11 x 17-inch wall poster to engage patients/ families in fall prevention at the bedside.

Aim

Replicate the study by Dykes and coauthors (2017) on a medical teleme- try unit, exploring adoption of a patient-centered fall prevention tool and its impact on patient knowledge of fall risk factors and interventions, fall rates, and injury rates.

Method

A pre- and post-intervention design was used to compare patients’ per- ceived knowledge and actual fall rates before and after implementating the tool and processes. Thirty patients were interviewed before the study and at 1-, 3-, and 6-month time points during implementation (N=120). Number and rates of falls per 1,000 patient days were calculated. Audits were completed randomly to monitor adherence to the process.

Results

Patients were more knowledgeable about falls at months 1, 3, and 6 com- pared to pre-intervention (p=0.001-0.05). Fall rates fluctuated over the 6- month study, with overall reduction from 3.3% (pre-) to 1.9% (post-). Staff was 85% adherent with use of the laminated poster, with adherence increasing over time.

Limitations and Implications

Findings are limited to one hospital and one medical telemetry unit. Results support the potential for a best practice change. Plans are to dis- seminate this new process to other patient units.

Conclusion

Replication in patient units outside the medical telemetry arena is suggested.

A Replication Study of Fall TIPS (Tailoring Interventions for Patient Safety): A Patient-Centered Fall Prevention Toolkit

January-February 2021 • Vol. 30/No. 130

plans and patient-centered educa- tion. One of the three trials is the focus of this replication study.

Recently, LeLaurin and Shorr (2019) conducted a review of the lit- erature on preventing falls in hospi- talized patients and found most publications on this topic addressed quality improvement projects. Strat - egies used singly or in combination included fall risk identification, alarms, sitters, intentional round- ing, patient education, environ- mental modifications, physical restraints, and patient use of non- slip socks. Intentional rounding and patient education involved interaction with the patient, but this was limited due to cognition. Authors suggested a need for focused research on fall prevention strategies.

Ethics The Institutional Review Board

approved the study at the site with

expedited status. A waiver of con- sent documentation was granted. Investigators provided patients with a study information sheet explain- ing the study and participant involvement. No patient identifiers were noted when patients were asked two questions about fall risk and prevention.

Sample Selection The poster was used with all

patients on the medical telemetry unit at a 237-bed community hospi- tal over 6 months (March-August 2018). Average daily census was approximately 30 patients during this period. Four convenience sam- ples of 30 patients each were chosen for interviews before the interven- tion and at 1 month, 3 months, and 6 months during the intervention period (N=120). Patients had to be alert, oriented, and English- or Spanish-speaking to be included in the interview process.

Design and Method

Design The study used a pre- and post-

intervention design.

Intervention The intervention involved use of

a risk assessment poster and inter- vention guide, as well as nursing action, to engage the patient and family in discussions of fall risk and prevention. The tool was a laminat- ed copy of a poster (11 x 17 inches). The poster, which was an exact copy of the one used by Dykes and associates (2017), was hung on the wall opposite the patient’s bed for visibility. It was removed easily from the wall to be held by nurses during discussion of fall risk and prevention with the patient and family. The laminated surface allowed nurses to write and remove notes made in nonpermanent marker. Nurses updated the poster

FIGURE 1. Fall Risk Factor and Intervention Poster

Source: Brigham and Women’s Hospital. Used with permission.

January-February 2021 • Vol. 30/No. 1 31

based on the patient’s current con- dition (e.g., peripheral intravenous catheter discontinued). They re - viewed the information on the tool with the patient at least once dur- ing each 12-hour shift.

Patients were asked to indicate their level of agreement with the same two statements described by Dykes and colleagues (2017) regard- ing knowledge of current fall risk and prevention: (a) I am able to identify my risks for falling, and (b) I know what I need to do to prevent myself from falling. A 5-point Likert scale was used (1=strongly disagree, 5=strongly agree). When statements were combined, range of scores was 2-10.

Additionally, audits of documen- tation adherence on the poster were conducted twice weekly by mem- bers of the study team for the first 3 months of the intervention (March- May). Five data items were collect- ed: room/bed number, patient name, current date and time, iden- tification of risk factors, and nota- tion of fall prevention plan. All items except the room/bed number were used in the Dykes and coau- thors (2017) study. In April and May, there was a decrease in adher- ence to use of the Fall TIPS tool; therefore, managers then mandated the Falls TIPS poster be completed by 11:00 a.m. on all patients. Clinical nurses strategized to build completion of the Falls TIPS tool into their workflow to meet unit expectations.

Fall and fall injury rates were obtained for 3-6 months before implementing the patient-centered fall prevention intervention. After written permission was obtained to use the fall risk assessment poster and intervention guide, focused staff education materials were shared with all nursing staff on a medical telemetry unit. Topics included the benefits of integrating an individualized fall risk assess- ment and intervention with the current standard or universal inter- ventions for a comprehensive, patient-centered fall prevention program. Current fall rates and fall reduction goal statements also were reviewed with the staff. Small

groups of staff were educated at a time, providing more one-to-one time to review a case study. The clinical nurse specialist (CNS) held additional small group education workshops over 2 weeks before implementation for nursing staff who needed or wanted further training. Sessions took approxi- mately 15 minutes and included a case study that allowed nurses to apply the Falls TIPS tool. Role play was used to demonstrate nurse- patient interactions. Team members unable to attend workshops and any newly hired staff were given individual education by the CNS using the same format. Study refer- ence binders were available at each nurses’ station as an immediate resource.

Before the start of the study, a convenience sample of 32 alert, ori- ented patients was approached by investigators with a study informa- tion sheet to seek their willingness to participate in the study. Thirty who agreed then were asked to respond to two Likert-style state- ments about knowledge of fall risk factors before intervention imple- mentation.

Following the initial question- naire collection period, all patients were assessed each shift using the current process of the Morse Fall Scale followed by individualized teaching to patient and family (if present) using the patient-centered Fall TIPS prevention tool. Investi - gators monitored adherence to doc- umentation on the poster using the audit form three times a week Monday through Friday (patient name, date, risk factors, prevention plan).

After the first 30-day implemen- tation period, an additional con- venience sample of 30 alert, orient- ed patients was approached at 1 month, 3 months, and 6 months with a study information sheet to assess willingness to participate in the study. Each sample was asked to respond to the same two Likert-type statements about knowledge of fall risk factors. Data collection occur - red over 2 weeks for each group.

Team meetings were scheduled to evaluate project implementation:

ease of use of patient-centered fall prevention tool, issues with use, and needed modifications. Data (patient knowledge and fall rates and fall injury rates) were analyzed 3-6 months following implement- ing the patient-centered fall risk assessment and intervention poster. Adherence to documentation on the patient-centered fall risk and intervention poster was captured with a percentage. For example, if three of five items were document- ed, adherence would be 60%. An independent t-test was used to com- pare pre- and post-scores of patient knowledge of falls. Fall rates and fall injury rates were based on 1,000 patient days.

Findings Overall adherence to documen-

tation on the fall risk assessment and intervention poster in the study period was 84%, with improve ment over time. Initial adherence of 45% steadily increased to 100% at the end of the study. In 183 of 259 observations, documentation on the poster was 100% completed with the five key elements of the patient’s name, date and time, iden- tification of risk factors, and nota- tion of an individualized preven- tion plan.

In general, patients perceived they were knowledgeable about their risk for falls and how to pre- vent a fall throughout the study and the lead-in period (pre-inter- vention). The mean score for state- ment 1 (identifying fall risk) increased from 4.13 to 4.6 at 1 month; it remained largely un - changed at 3 and 6 months (4.57 and 4.47, respectively). The mean for statement 2 (how to prevent a fall) increased from 3.97 to 4.67 at 1 month; it also remained mostly unchanged at 3 and 6 months (4.53 and 4.7, respectively). Patients’ per- ceived knowledge of both state- ments significantly increased after intervention (see Table 1).

During the first month of using the patient-centered Falls TIPS tool (March 2018), no falls occurred in the study unit. The fall rate increased during April-June 2018

A Replication Study of Fall TIPS (Tailoring Interventions for Patient Safety): A Patient-Centered Fall Prevention Toolkit

January-February 2021 • Vol. 30/No. 132

but not to the rate before imple- mentation (see Figure 2). Following the decision to incorporate tool completion into daily nurse work- flow by 11:00 a.m. in June, the fall rate decreased again in July and August (see Figure 2). At 1 month following study completion, the fall rate remained low; this may be attributed to the standardized work- flow process using the fall risk assessment and intervention poster.

Only two falls with major injury occurred in the 7 months before study implementation. However, one of those falls escalated in sever- ity because of anticoagulant med- ication used for venous throm- boembolism prophylaxis. Through - out the study period (March-August 2018) and 24 months afterward (September 2018-August 2020), no falls with major injury occurred in the study unit.

Discussion Adherence (84%) to use of the

patient-centered Fall TIPS tool was comparable to findings noted in the study by Dykes and colleagues (2017) (82% & 91%). Adherence to documentation indicated poster use increased through the course of the study partially because its use became part of the workflow for nurses and nursing assistants. Continuous communication about number of falls, fall rates, and falls with injury supports awareness and sustained use of the patient-cen- tered Fall TIPS tool. Huddles and

Gemba or other communication boards provide verbal and visual opportunities for communication about falls.

Patients’ perceived ability to identify risk and knowledge of safe- ty actions was already high before the study. Perceived identification of risk and knowledge of fall pre- vention increased slightly at each timeframe (1 month, 3 months, 6 months), but differences were not statistically significant. However,

the baseline increase compared to 1-month, 3-month, and 6-month survey periods was statistically sig- nificant (p=0.001-0.05). This find- ing was similar to that of Dykes and coauthors (2017), although patients at baseline for this study had higher perceived knowledge. Patients and family members should be educated on their fall risk based on findings from fall risk assessments.

Dykes and colleagues (2017) identified barriers to implementa-

TABLE 1. Comparisons of Means (t-test)

Pre (n=30 patients) Compared to 1 Month

(n=30 patients)

Pre (n=30 patients) Compared to 3 Months

(n=30 patients)

Pre (n=30 patients) Compared to 6 Months

(n=30 patients)

Question 1 (identify fall risk)

-2.16 (58) p=0.035*

-2.00 (58) p=0.05*

-2.27 (58) p=0.034*

Question 2 (knowledge of prevention)

-3.46 (58) p=0.001*

-2.67 (58) p=0.013*

-4.00 (58) p=0.000*

Combined questions 1 & 2 -3.43 (58) p=0.05*

-2.57 (58) p=0.013*

-3.66 (58) p=0.001*

*p<0.05 level of significance

FIGURE 2. Fall Rates Before, During, and Immediately After Study Period

Fall Rate

7

6

5

4

3

2

1

0

3.7

5.3

1.8 2.1 2.1

3.9

3.3

1.1 1.1

4.4

1.1

0

O ct

-1 7

N o v-

1 7

D e c-

1 7

Ja n -1

8

F e b -1

8

M a r-

1 8

A p r-

1 8

M a y-

1 8

Ju n -1

8

Ju l- 1 8

A u g -1

8

S e p -1

.1

Fall Rate Linear (Fall Rate)

Staff education.

Fall TIPS tool implementation

Mandatory completion of tool by 11:00 a.m. rounds

January-February 2021 • Vol. 30/No. 1 33

tion of the Fall TIPS assessment dur- ing their investigation. One obsta- cle was decreased awareness or unawareness of the new guideline or evidence. The poster seemed to increase awareness of falls in this study, as evidenced by discussions at shared governance meetings. Additionally, it highlighted the complexity of falls and increased the need for a team approach involving the patient, family, clini- cal nurse, nursing assistant, and nurse leaders. Fall risk and preven- tion were reported during shift handoff by all nursing staff.

Another barrier identified by Dykes and associates (2017) was decreased familiarity with the tool. Staff in the current study lacked familiarity with the assessment but were educated on its use before and throughout this research. Limited self-efficacy also was noted by staff who were unsure how to use the tool or forgot how to use it. Adherence increased over time, not only for properly writing on the assessment but also for using it in conversation with patients and families. The barrier of lack of out- come expectations (Dyke et al., 2017) was evident in the current study through staff members who thought the assessment would decrease the number of falls. However, the evaluation was only one part of a fall prevention plan; other factors have to be considered, such as rounding and toileting.

Other simple barriers were iden- tified to use of the laminated Fall TIPS assessment in practice. Often dry erase markers were not available to staff to document on the poster. The grade of the laminate material is important as cheaper items make it harder to maintain integrity of the poster, with repeated use leav- ing it looking dirty. Using high- grade laminate and hanging fresh wall posters every 6 months is sug- gested to ensure a clean surface between patients. Other considera- tions were the poster’s location in the patient room and materials to adhere it to the wall/board. The poster must be visible from the patient bed; however, this was not always possible because of existing

items on the walls, so sometimes alternative locations (e.g., bath- room door) were used. The hooks also were problematic. The hooks should allow the poster to be removed and replaced easily when using it for patient teaching. If not, the hooks pull off the wall and leave no place for the poster to hang. This affects nurses’ ability to adhere to the process.

Limitations Study results are limited due to a

single patient care unit with a focus primarily on medical patients. Generalizability to other specialty units is not possible. The 120 patients interviewed before and during the study were a conven- ience sample. It is unknown if other patients had the same or different perceived knowledge about falls and prevention strategies. Although the poster was visually available in patients’ rooms, frequency of its use in conversation with patients and families is unknown.

Recommendations for Future Research

Study of the patient-centered Fall TIPS assessment in other patient care areas, including critical care, is warranted. A standardized approach to overcome barriers before and throughout an investigation using the assessment should be developed to limit variability. Future research might include family members’ knowledge of personal fall risks and related precautions to address fami- ly-centered care fully. Dykes and coauthors (2019) suggested clinical nurses be involved in redesigning their workflow to engage patients and families in fall prevention using the TIPS assessment. A study com- paring the effectiveness of various workflow redesigns thus may add to understanding of best practices. As new fall prevention strategies are developed, they should be added to a fall prevention program that includes the TIPS assessment to evaluate processes and outcomes.

Nursing Implications The Health Research & Educ -

ational Trust (2017) has promoted the Fall TIPS assessment through the hospital improvement innova- tion network as an individualized, patient-centered fall prevention measure. The patient-centered Fall TIPS assessment may not be appro- priate for every patient care unit based on the patient population. The poster often is used interactive- ly with patients. Confused patients may not understand the informa- tion. Still, staff can use the bottom purple area to designate patients as impulsive, in need of a chair or bed alarm, or choosing not to follow fall precautions. This communicates the patient’s need for close constant observation when out of bed.

The assessment increased aware- ness of falls, focusing on multifac- eted fall prevention efforts for staff and leaders. Outcomes associated with a fall prevention program are not only decreased falls. A signifi- cant outcome might be decreased falls with injury, as suggested by Dykes and colleagues (2017). The current study unit also realized this outcome during the research peri- od. Findings showed success and potential for a best practice change. Changes should be based on best evidence, clinician expertise, and patient preferences – the three com- ponents of evidence-based practice (Melynk & Fineout-Overholt, 2015). All three factors were relevant to this investigation. Best evidence included evidence from research (Dykes et al., 2019; Dykes et al., 2017), as well as fall data. Clinician expertise was the knowledge and experience of clinical nurses and nurse leaders in fall prevention and logistics of implementing fall pre- vention strategies. Patient prefer- ences focused on their understand- ing, recognition, and behaviors associated with their fall risk and prevention. Dissemination of study findings to other patient care units is being done with possible oppor- tunities to use the tool outside the medical-surgical unit. To date, two additional units have adopted the fall risk assessment poster and inter-

A Replication Study of Fall TIPS (Tailoring Interventions for Patient Safety): A Patient-Centered Fall Prevention Toolkit

vention guide at the same institu- tion; five other units are incorporat- ing the poster and guide at another facility in the system.

Conclusion Study results demonstrated in -

creased perceived patient knowledge of patient fall risk and related pre- vention strategies. An overall decrease in fall rates over time sup- ported innovative, individualized strategies such as a colorful poster. Replication of a study exploring the patient-centered TIPS Fall assess- ment (Dykes et al., 2017) yielded similar results. Replication should continue in patient care areas out- side medical telemetry settings.

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Agency for Healthcare Research and Quality (AHRQ). (2018). Preventing falls in hospi- tals. https://www.ahrq.gov/professionals/ systems/hospital/fallpxtoolkit/index.html

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