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Reducing Falls and Fall-Related Injuries in Mental Health A 1-Year Multihospital Falls Collaborative

Patricia A. Quigley, PhD, ARNP, CRRN, FAAN, FAANP; Scott D. Barnett, PhD; Tatjana Bulat, MD; Yvonne Friedman, MS, OTR

Despite much research on falls occurring on medical-surgical units and in long-term care settings, falls on inpatient psychiatry units are understudied. On the basis of fall injury program character- istics across multiple inpatient psychiatry units, we developed and implemented an operational strategic plan to address each falls prevention program element and enhance program infrastruc- ture and capacity. Expert faculty provided lectures, coaching, and mentoring through biweekly conference calls and collaborative e-mail exchange. Findings support continued efforts to integrate measures to reduce serious fall-related injuries. Key words: fall prevention, fall-related injuries, falls, injury prevention, psychiatry, veterans

A CONSIDERABLE body of research onfalls and falls prevention in hospitals demonstrates that falling is a complex event

Author Affiliations: VISN 8 Patient Safety Center of Inquiry (Drs Quigley and Bulat and Ms Friedman) and HSR&D/RR&D Research Center of Excellence (Dr Barnett), James A. Haley Veterans’ Hospital, Tampa, Florida.

This material is based upon work supported by the Office of Research and Development, Department of Veterans Affairs, Health Services Research and Devel- opment Service award #IIR-03-003-1, and the Patient Safety Center of Inquiry, James A. Haley Veterans Af- fairs Medical Center. The views expressed in this article are those of the authors and do not necessarily repre- sent the views of the Veterans Healthcare Administra- tion or Department of Veterans Affairs.

The authors declare no conflict of interest.

Correspondence: Patricia A. Quigley, PhD, ARNP, CRRN, FAAN, FAANP, VISN 8 Patient Safety Center of In- quiry, James A. Haley VA Medical Center, 8900 Grand Oaks Circle, Tampa, FL 33637 (patricia.quigley@va .gov).

Accepted for publication: July 8, 2013.

Published online before print: October 21, 2013

DOI: 10.1097/01.NCQ.0000437033.67042.63

that typically involves multiple risk factors.1,2

These risk factors involve person-specific in- trinsic risk factors, the physical environment, and the riskiness of a person’s own behav- ior. Patient falls are the most frequent adverse event associated with subsequent injury within the Veterans Health Administration (VHA)3 and are the leading cause of injury- related deaths among people aged 65 years and older.4 The 2 most serious fall-related injuries are hip fractures and intracranial hemorrhages.5,6

Although falls on medical-surgical units and in long-term care settings were the focus of extensive research over the years, falls on inpatient psychiatry units are under- studied. Based on a 2005 summary report completed by the National Center for Patient Safety (NCPS) National Falls Toolkit Impact Evaluation,7 psychiatry units experienced a lower rate of overall falls but a higher rate of injurious falls than nursing homes or medical- surgical units. Within the Department of Veterans Affairs, the NCPS reported rates

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for major fall-related injuries as part of the National Falls Toolkit Impact Evaluation. The NCPS reported major injury rates for falls in mental health as 0.022 per 1000 bed days of care for 2006 quarter 1 and 0.031 for quarter 2. In addition, the NCPS reported that the percentage of falls with major injury in mental health was 5% in 2004 and it reduced to 3.5% in 2005. This level of injury is of greatest concern, as serious fall-related injuries result in loss of function, loss of life, and financial burden. While not all falls can be prevented, serious fall-related injuries can be eliminated with the use of protective equipment and en- vironmental changes that decrease fall-related trauma. Serious injuries are rare occurrences. This report is the only available one in the VA that separates falls for inpatient psychiatry compared with other settings of care and was used as a basis of comparison for our study.

In Veterans Integrated Service Network (VISN) 8 (South Georgia, Florida, and Puerto Rico), the incidence rates in inpatient psychiatry units are second only to those of long-term care (B. Ballot, MD, written communication, July 2009). Further research suggests that inpatients aged 75 years and older and those on geropsychiatry units were more likely to sustain serious fall-related injury (adjusted odds ratio, 2.8; 95% confi- dence interval, 1.3-6.0).8 Older adults with select mental health and substance abuse problems fall between 1.5 and 4.5 times more than the general elderly population. Psychiatric inpatients having recurrent falls have a significantly longer length of hospital stay than other inpatient populations.9

Furthermore, the odds of a fall-related in- jury among patients with cognitive disorders such as Alzheimer disease and other demen- tias were at least 3 times greater than those among the general elderly population and the differential increases with age.10 Increases in total costs resulting from a fall injury were greater among both elderly men and women with mental health conditions or dementia. The substantial burden of fall injuries among elderly with either mental health or substance

abuse conditions suggests the need to di- rect fall prevention and protection strategies specifically toward this vulnerable popula- tion.

Fall risk factors among inpatient psychia- try populations are similar to those in long- term care and medical-surgical units.11 These risk factors include history of falls, general- ized weakness, confusion or disorientation, difficulty with mobility or walking, elimina- tion problems, and temperature elevation.12

Prior analysis of conditions involving falls sug- gests that the majority of falls occur when patients are attempting to get out of bed, walk to the bathroom, or change from a sitting to a standing position.12 Prescribed medication in psychiatry presents a unique fall risk. A number of psychotropic drugs including antidepressants, antipsychotic, and sedatives or hypnotics have been associated with increased risk for falls.13 The mecha- nisms involved include medication-induced orthostatic hypotension, ataxia, psychomotor slowing, and extrapyramidal symptoms.14

RESEARCH EVIDENCE READY FOR TRANSLATION

According to a recent Cochrane review, the rate of injurious falls decreased after the in- troduction of population-based programs fo- cusing on age, diagnosis of osteoporosis or history of hip fracture, and use of anticoagu- lation therapy.15 During this project, we ini- tiated a number of translational projects in both acute and long-term care settings specif- ically addressing fall prevention and protec- tion. Over the years, we have received nu- merous inquiries from psychiatry providers on how best to implement programs in that setting. Because of the risk for harm to self and others introduced by routine technology use in other health care settings (eg, height adjustable low beds with electrical cords), psychiatry staff have difficulty in making deci- sions about the safe use of technology.

In 2009, we hosted an expert panel meet- ing with identified experts in geriatric psychi- atry, psychology, geriatric medicine, nursing,

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Reducing Falls and Fall-Related Injuries in Mental Health 53

ergonomics, patient safety, and physical ther- apy, and a representative from each of the VHA’s NCPS, VISN 8, and Veterans Health Administration Central Offices to identify needed tools for translating evidence-based fall prevention and safe patient handling to in- patient psychiatry units. While the evidence supporting interventions in inpatient psychia- try is limited, the panel recommended that we customize existing evidence-based interven- tions from long-term care and medical-surgical units to inpatient psychiatry. Our subsequent strategic plan included developing, testing, and evaluating several best practices in inpa- tient psychiatry settings.

METHODS

Participating hospitals

All institutions were located in similar metropolitan cities (eg, size, socioeconomic factors) with more than 100 000 veterans serv- ing in their respective catchment areas. Five hospitals participated in this project. Table 1 provides a summary of total beds and inpa- tient psychiatry beds.

Project kickoff

In 2010, the VISN 8 project began with all inpatient psychiatry nurse executives and nurse managers invited to participate in the

project. For the participating Veteran Affairs Medical Centers, peer leaders and participat- ing staff were identified for each inpatient psychiatry unit. Three projects were imple- mented simultaneously with concurrent goals of both expanding the program and empow- ering innovation.

Project 1: Fall prevention program customized for inpatient psychiatry

The evidence is strong to support multifac- torial fall prevention programs for injurious falls in long-term care and acute care.16,17 An Institute for Healthcare Improvement collab- orative on the prevention of injurious falls in acute care across 9 hospitals identified the lack of an organizational assessment to ex- amine readiness at the organizational level to prevent serious injurious falls for inpatients as an apparent gap. To fill this gap, members of the Institute for Healthcare Improvement Falls Collaborative developed and pilot tested an organizational assessment tool that quantified the extent of fall and injury program imple- mentation at organizational, unit, and patient levels. Project 1 required validation that the injurious fall prevention organizational self- assessment tool was clear and relevant for use in psychiatry.

The original tool was modified for inpa- tient psychiatry on the basis of content expert

Table 1. Description and Number of Beds by Hospital Unitsa

Hospitals

Total Inpatient

Beds

Total General Psychiatry

Beds

Total Geropsychiatry

Beds

1. Hospital, long-term care facility, residential treatment program

397 1a: 23 1b: 10

2. Hospital, tertiary care center 191 32 0 3. Hospital, tertiary care center 348 50 0 4. Hospital, tertiary care

center, long-term care facility

415 4a: 40 4b: 12

5. Hospital and community living facility

390 24 0

aHospitals 1 and 4 contain 2 units each designated as “a” and “b.”

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review from advanced practice nurses, clin- ical nurse leaders, and mental health chief nurses. After expert revision, the question- naire was examined for content validity by independent mental health experts and one of the hospitals that was a tertiary care cen- ter and had a long-term care facility. Seven staff nurses in psychiatry volunteered to crit- ically examine the clarity and relevance of each question to their practice. Changes were made on the basis of their feedback and then reviewed with the advanced experts for fi- nal consensus. The original questionnaire was modified to remove select items, including grab bars, that are not allowed because of sui- cide risk. The final version was reviewed by VA Research and Development Committee, along with an invitational letter, for distribu- tion to units. This organizational assessment was distributed to all inpatient psychiatry staff by their respective unit nurse managers. Re- sults for each Veteran Affairs Medical Center inpatient psychiatry unit were then reviewed by the project director, with the associate chief nurses, nurse managers, peer leaders, and designated key nursing staff. In addition, common program elements to all units across all hospitals were identified.

Common fall and injury prevention pro- gram elements that were identified as requir- ing further implementation across all partici- pating sites were to

1. implement a unit peer leader program, 2. customize use of hip protectors to

reduce risk of hip fractures, 3. customize use of floor mats to reduce

trauma from bed-related falls, 4. expand patient assessment to include

injury risk on admission, and 5. expand patient education to include pro-

tection from fall-related injury. Following the identification of program

elements, a VISN-wide strategic plan was sub- sequently developed to address each element and enhance its program infrastructure and capacity. Over the next 6 months (June to December 2010), expert faculty provided monthly lectures on the basis of previously identified strategic needs, with additional

coaching and mentoring through biweekly conference calls and e-mail exchange.

The project team consisted of clinical ex- perts and researchers in fall and fall injury reduction program implementation and eval- uation. Additional faculty invited to present were fall experts from other Veterans Affairs Medical Centers and patient safety centers and injury centers. These faculty included engi- neers and injury epidemiologists able to teach about equipment and technology for fall pre- vention, fall detection and surveillance sys- tems, and fall injury protection, as well as how to use strategies to test change and to spread and sustain implementation. The faculty and topics are listed below:

� Geriatrician: Hip protector toolkit. � Nurse scientist/nurse practitioner: Floor

mats selection and use, patient educa- tion resources, men and osteoporosis, and nonskid flooring and footwear.

� Geriatric clinical nurse specialist and falls consultant: Innovations in equip- ment alarms and wandering technology for fall prevention, detection, and protec- tion.

� Occupational therapist: Available raised toilet seats.

� Nurse scientist and implementation spe- cialist: Role of peer leaders.

� Engineer and researcher: Nonskid footwear and flooring.

� Injury epidemiologist and scientist, The National Institute for Occupational Safety and Health consultant: Nonskid footwear and flooring.

All education sessions were Web-based, of- fered virtually by conference call and shared PowerPoint presentation via Web communi- cation. Each program component was sub- sequently implemented using expert lecture, plans for small tests of change, report of re- sults, coaching, and mentoring. In addition, a follow-up plan over 5- to 8-week intervals based on the principles of Plan, Do, Study, and Act was initiated. Emphasized through- out the program were strategies for patient engagement and improved health literacy. To enhance adoption and spread of program

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Reducing Falls and Fall-Related Injuries in Mental Health 55

elements, we reported results to all partici- pants and shared lessons learned across sites. Thus, the results of the survey from across sites were critical in designing a program that was relevant to all mental health units across our medical centers.

Project 2: Unit peer leader program for falls

Peer leadership at the hospital unit level of- fers the potential to reduce the occurrence of injurious falls by decreasing practice vari- ations. Peer leadership has been successfully used in health contexts, mainly in health pro- motion for adolescent populations18 and per- sons with chronic illness.19 Our objectives were to (1) have each unit identify at least 1 volunteer staff member as a unit-based fall prevention peer leader, (2) provide the peer leaders with coaching and mentoring to de- velop their peer leader skills, and (3) develop and disseminate a toolkit that could be modi- fied for their use at the unit level.

Using an expert consensus model, we de- veloped the Peer Unit Leader Program and Toolkit. Two nurses, considered fall experts, drafted this toolkit specific to fall and injury prevention. A draft revision of the toolkit was subsequently presented to additional fall ex- perts and nurse fall prevention champions at the participating Veteran Affairs Medical Centers.

Following additional revisions, the peer leader toolkit was disseminated to inpatient psychiatry unit peer leaders for review, com- ment, trial use, and revisions over a 2-month period. Based on peer leader feedback, final changes were made to this toolkit, and it was then distributed to each unit. We sub- sequently developed a functional statement for an Inpatient Psychiatry Unit Peer Leader for Fall Prevention and selection criteria. Dur- ing the initial 3 months of the program, des- ignated peer leaders from each hospital pre- pared an individualized Peer Unit Manual and Toolkit for their respective units and hospital leadership. For example, peer leaders added their own unit fall policies and procedures to the Manual. All peer leaders found the Manual

to be helpful to them, and each reported plan- ning to use the peer leader criteria to further expand this role to other nursing shifts. The feedback from the unit peer leaders verified that the Manual was a successful resource for their use.

Project 3: Customization of hip protectors and floor mats in psychiatry settings

As medically fragile patients with multiple medical comorbidities are admitted to VA psy- chiatry units, staff is faced with the need to reduce injurious falls (fall protection). Two technologies are useful for fall protection: hip protectors and floor mats.

Hip protectors

While the evidence of hip protector effec- tiveness has been mixed, the most recent conclusion is that hip protectors are protec- tive when used in high-risk patient popula- tions at risk for hip fracture.20,21 We educated all sites about hip protector products, imple- mentation methods, and strategies to increase patient adherence, referring all staff to our Hip Protector Toolkit. This toolkit includes pre- scriptive guidelines, patient adherence inter- ventions, laundering guidelines, and replace- ment protocols.

Floor mats

Although hip fractures in the older adults can result from falls from a standing height, falls from bed account for the majority of falls and injurious falls in institutional22,23 and home settings.24 Height-adjustable beds have become a standard of care in long-term care to reduce the incidence of injuries from falling out of bed. However, the standard for psychi- atry settings is a platform bed that cannot be height-adjusted. Psychiatry beds do not have cords and other features that could be used to inflict self-harm, yet they are required for making beds functional from a fall injury pre- vention standpoint. The demand for safe beds to prevent falls, fall-related injuries, and self- harm is high, yet safe beds are not readily avail- able. Therefore, use of floor mats is critical to

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reduce the trauma that results from a fall to the floor.

Floor mats are considered an essential com- ponent of any comprehensive injury reduc- tion program in which injurious falls are a concern.25,26 Our prior research attempted to quantify the relationship between bed height and injury risk and protectiveness of floor mats in a laboratory setting using a Hybrid III mannequin.27 Older psychiatry inpatients are at higher risk for fall-related injury than the general older adult population, but floor mats are not used consistently in inpatient psychiatry settings on the basis of the as- sessment results. We educated all sites about floor mat products, implementation methods, and strategies for acceptance, referring to our Floor Mat Selection Guide. This guide includes impact properties, stability properties, coeffi- cient of friction, thickness, weight, and over- all size; use of these is only for those patients at risk for injury if a fall occurs (eg, patients with osteoporosis and those taking anticoag- ulants). Mental health unit peer leaders of 3 hospitals in our project reported no barriers to use of the products, with 2 of them report- ing success with the use of floor mats.

At the end of the implementation project, a 2-day meeting was held to bring unit peer leaders together from each site and review re- sults of the postimplementation survey. The meeting allowed each unit to report on its tests of change and progress in expanding use of protective equipment, patient educa- tion materials, increased communication, and handoff related to patient fall and injury risks.

RESULTS

Our program evaluation included both quantitative and qualitative methods. Quan- titative methods analyzed changes in orga- nizational fall injury program elements and analysis of fall and fall injury data over time. Qualitative data were extracted from unit re- ports during a face-to-face meeting from all sites to report lessons learned and interven- tions adopted.

Postimplementation data analysis was com- pleted in 2011, 1 year after baseline. The fi- nal sample included 86 direct care staff re- sponses, of which 77 were usable (89.5%). Because of the small number of responses (range: 1-3) from each unit for the lead- ership section of the survey, only staff re- sponses were analyzed and compared pre and post implementation. For staff, 41.8% prac- tice on the day shift (8- and 12-hour shifts) and 27.0% practice on the evening/night shift, with 36.2% missing shift information.

Changes in level of implementation for each fall injury program component are re- ported in Table 2 and are based on survey responses. Data analysis revealed changes in pre- and postimplementation survey scores by subscale. Scores ranged from 0 (no activ- ity) to 3 (fully implemented). Improvements were evident in fall injury risk assessment ( + 1.7%) and discharge education ( + 3.0%). The largest positive change was reported for environmental safety to reduce the severity of injury ( + 8.6%), which includes use of hip protectors and floor mats. Presurvey full im- plementation of hip protectors was reported as 55.8%, the same as after the intervention. Full implementation of floor mats, however, was 24.4% preintervention, and this increased to between 36.3% to 49.0% (P < .001).

Falls and fall-related injuries in mental health units

The primary objective of this program was to facilitate adoption and integration of fall and injury prevention practices and equip- ment into mental health units in participat- ing hospitals. Fall rates reported by VA NCPS (4.3 falls per 1000 occupied bed days of care [OBDC]) served as our within-VA comparison reference.28

Falls Cumulative and unit quarterly fall rates (per

1000 OBDC) are reported in the Figure. Forty- five percent (n = 29 quarters) of the quarterly fall rates were below the lower limit of the NCPS 2004-2006 fall rates (4.3 falls per 1000

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Reducing Falls and Fall-Related Injuries in Mental Health 57

Table 2. Average Changes in Staff Reponses per Survey Subscales, Pre and Posta

Items

Range of Scores (No. of

Questions) Pre Post Delta

(% Change) P

Fall Injury Risk Assessment and Identification

0-15 (5) 14.0 14.2 0.2 (1.7) .14

Screening for Likelihood of Falling

0-21 (7) 18.9 18.8 − 0.1 ( − 0.3) .95

Environmental Safety to Reduce Severity of Injury

0-30 (10) 15.0 16.3 1.3 (8.6) .48

Post Fall Assessment 0-12 (4) 11.3 10.9 − 0.4 ( − 3.6) .12 Discharge Patient/Family

Education 0-15 (5) 10.0 10.3 0.3 (3.0) .33

aStatistical testing was accomplished via paired t tests.

OBDC); 33% (n = 22 quarters) were within this range (4.3-6.6 falls per 1000 OBDC); and 22% (n = 14 quarters) had fall rates reported over the higher rate limit (6.6 falls per 1000 OBDC). Only hospital 3’s mental health unit maintained fall rates between 2 and 4 falls per 1000 OBDC. The mental health unit in hospital 1 reported the highest fall rate for 1 quarter (17 falls per 1000 OBDC), which is still within the reported range for geropsychiatry units.

Fall-related injuries

Of the 65 quarters of fall and injury data that were reported, 56 (86.2%) reported in- jury fall rates. During the survey period, 32 quarters (49.2%) reported fall injury rates be- tween 0.08 and 2.00 or less OBDC, and 13 quarters (20.0%) reported fall injury rates be- tween 2.00 and less than 3.00 OBDC. Fall injury rates of 3.00 or more OBDC were reported in 17% of the surveyed quarters (Figure).

Figure. Average quarterly inpatient mental health fall rates and fall-related injury rates and percentage of falls with serious injury in mental health.

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The quarterly percentage of falls with se- rious injury is reported in the Figure. The data indicate that in 1 quarter, 70% of the falls that occurred resulted in major serious injury, 3 quarters reported that 50% of the falls resulted in major serious injury, and 50 quarters (76.9%) reported no serious injuries. This finding supports continued efforts to in- tegrate measures to reduce serious fall-related injuries in our VISN 8 Mental Health Unit, with the goal to eliminate hip fractures.

DISCUSSION

It is important to examine trends in falls, fall-related injuries and percentage of fallers with injury over the most recent 2-year pe- riod. When evaluating the impact of the NCPS National Falls Toolkit 2004-2006, these pro- gram evaluation measures were key measures specified by the VA NCPS working with our in- stitution. At that time, NCPS separated mental health units as Behavioral Health and provided the first large scale comparative rates for this clinical specialty area in the United States.

According to Oliver et al,1 falls are rarely evenly distributed across units in hospitals. In mental health units, this uneven distribu- tion may be particularly apparent, with over- all fall rates in the range of 2 to 4 falls per 1000 OBDC. Rates of falls in some geropsy- chiatry units are even higher. In mental health units, most patients are ambulatory, with the majority of falls occurring while walking. Hos- pital administrators, clinicians, patient safety

officers, and researchers continually reassess and build on current fall and injury reduction strategies. However, falls and fall-related in- juries occur and remain a significant cause of morbidity and mortality among seniors in mental health programs. Successful falls pre- vention programs typically use a combination of interventions with environmental adapta- tions, such as assessing patients before and after a fall to identify and address risk fac- tors and underlying medical conditions, ed- ucating staff about fall and injury risk factors and prevention strategies, reviewing medica- tions, enabling patients to move safely in their environment, and providing patients with hip protectors and floor mats that may prevent a hip fracture if a fall occurs.29

Given the aging veteran population, we en- courage other programs to build on our work with implementation of effective falls preven- tion programs that focus on protection from injury. While progress is being made, we be- lieve that the percentage of falls resulting in serious injuries can be decreased. Equipment use specifically designed to reduce trauma during a fall, such as hip protectors and floor mats, should be integrated into patient care. Although the risk of suicide among the psy- chiatry inpatient population is always a con- cern, a safe balance can be achieved between suicide prevention and protection from seri- ous fall-related injuries by addressing the com- plex relationships among individual, organi- zational, and cultural factors, and patients’ diverse and age-specific needs.

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