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www.Nursing2012.com July l Nursing2012 l 65

> PATIENT SAFETY

FALL PREVENTION is an ongoing challenge in older patients in the inpatient acute mental health setting (IAMHS). Fall prevention and patient safety committees should work together to minimize the risk.

This article discusses why falls occur and how to prevent them in older adults with mental health prob- lems in an inpatient setting. Incorpo- rating fall prevention toolkits and evidence-based practices is vital.

Sizing up the problem Each year, one in every three adults age 65 and older falls.1 Preventing or reducing the number of falls is a challenge in most healthcare settings, but the challenge is even greater in the IAMHS. In the psychiatric or behavioral health setting, fall rates range from 4.5 to 25 falls per 1,000 patient days.2

In the IAMHS, many factors con- tribute to patient falls. These factors can be intrinsic, extrinsic, situational, or a combination.3

• Intrinsic factors associated with an increase in falls in an IAMHS include impaired cognition resulting from a chronic condition such as Alzheimer disease or an acute condition such as delirium. In addition, psychotropic medications and their adverse reac- tions may increase the likelihood of patient falls. Other intrinsic factors that may lead to falls include mobility, gait, vision, and balance disorders. • Extrinsic factors (environmental factors) that may contribute to patient falls on the IAMHS include a lack of support equipment, such as side rails when patients are getting into and out

of bed, or a lack of durable medical equipment (DME), such as walkers, canes, and lifting devices. To add to these problems, mental health units have environmental restrictions to protect patients from harm.4 For example, wired chair and bed alarms, side rails, and call systems with cords can endanger patients and staff. These issues can account for the lack of sup- port equipment or DME. • Situational factors (factors related to activities) occur when patients are attempting to perform more than one task at a time, such as getting out of a wheelchair while conversing.

Intervening to improve safety Patient safety programs apply human factors engineering concepts and a systems approach to fall prevention. To help prevent repeat falls, postfall huddles assist in identifying what, when, where, who, and how. Barriers related to communication, staff train- ing, patient education, environment, and equipment are included in each fall analysis.

The Veterans Affairs National Center for Patient Safety created a fall prevention toolkit to help reduce falls. Information in the toolkit includes how to develop and design a fall prevention program, including effective interventions for patients at higher risks for falls; patient, family, and staff education; and use of safety apparatus, such as hip protectors, for patients at high risk for falls.5

Further measures include tracking and trending fall data, including the day of the week, shift, time, loca- tion, assistive devices present or not

present, diagnoses, and medications. Sharing the monthly and quarterly analyses with frontline staff, managers, and leaders of the organization helps improve performance at the unit and facility level.

To take a look at the organization as a whole, an annual retrospective review of all falls occurring during the year by an interdisciplinary group allows for input from subject matter experts to make system improvements. Team members may include nurses, physicians, pharma- cists, and staff from rehabilitation services, prosthetics, and supply distribution.

Tapping the evidence Incorporating evidence-based prac- tices into clinical practices improves patient safety. Some evidence-based practices include using an appropri- ate fall risk assessment tool, proper footwear, suitable signage, staff edu- cation, sitters, and safety rounding. All interventions used provide infor- mation that can be useful in identi- fying trends.

A fall risk assessment tool, including the Morse Fall Scale, should incorporate a list of drugs that place IAMHS patients at highest risk for a fall. Facilities can modify their tool according to their patient population. The medications most often associated with falls include: • selective serotonin-reuptake inhib- itors • tricyclic antidepressants • antipsychotic agents • benzodiazepines • antiepileptic drugs

Step up to prevent falls in acute mental health settings By Angela Malik, MSN, RN, and Norma Patterson, MSN, RN

66 l Nursing2012 l July www.Nursing2012.com

> PATIENT SAFETY

• class IA antiarrhythmic agents • antihypertensives.6

Anticoagulants increase the risk of bleeding, injury, and death in patients who fall.7 Medication recon- ciliation that includes the type of anticoagulant, the duration of the anticoagulant therapy, and dietary restrictions should be considered in fall risk assessment. Report adverse drug reactions, such as abnormal bleeding, to the prescriber so that dosage can be adjusted.

The patient who’s at a higher risk for falls due to osteoporosis may benefit from calcium and vitamin D supplementation to improve bone health.8

Hourly rounding, when executed and used properly, is an evidence- based practice that can reduce falls on any unit. In the case of the IAMHS, hourly rounding is based on patient needs identified after completion of the fall risk assessment. The Ameri- can Psychiatric Nurses Association surveyed nurses about facilities’ stan- dard minimum rounding practices and found that nurses at about 60% of psychiatric facilities are rounding every 15 minutes.9 Many falls can be prevented by combining hourly rounding with other interventions.

Technological innovations include virtual side rails that serve as moni- tors to alert staff to patients who are attempting to get out of bed without assistance. While these aren’t physi- cal rails that might harm patients, they allow for immediate staff notifi- cation and rapid response to patients who may fall and need assistance.

Nursing interventions Assess a patient’s fall risk upon admis- sion, change in status, transfer to another unit, and discharge from the facility. Implement an electronic fall risk assessment that will trigger a consult for rehabilitation services.

Use sitters and assign high-risk patients to rooms closer to the nurses’ station to increase patients’ visibility. • Engage patients and their families in all components of a fall prevention program. Teach patients about their medications and potential adverse reactions. • Before assisting with mobility, eval- uate the patient’s coordination and balance, then make sure resources needed are available. Ensure that all movable equipment such as beds and wheelchairs are locked before moving the patient. • In the mental health environment, don’t leave equipment unattended that could be mobilized by the patient. For example, wheelchairs and bedside commodes can be used as weapons to harm patients and staff. • Before leaving a patient, be certain that lighting is adequate to prevent tripping. • Initiate a bowel and bladder pro- gram to decrease the patient’s attempts to get up without assistance due to urgency. • Apply appropriate nonskid foot- wear to help provide traction. • Assess and optimally manage pain. • Assess for orthostatic hypotension and teach the patient to change posi- tions slowly.

Partnering with providers Inform healthcare providers of changes in a patient’s gait, posture, or spasticity. Performing medication reconciliation will help the provider and pharmacist prevent duplication of medications and drug interactions that can adversely affect patients. Be aware that changes in the medication regimen by providers may lead to adverse reactions associated with polypharmacy and could contribute to a fall.

Although the environment of psy- chiatric patients must be regulated,

physical rehabilitation services should be initiated early to assess, evaluate, and manage gait issues. Having an electronic trigger to notify the healthcare provider when physi- cal rehabilitation is needed closes the gap in communication. You initiate the trigger by completing a fall risk assessment.

Standing up for safety When mental health problems are coupled with decreased or limited mobility, patients are at high risk for falls. Initiating fall prevention mea- sures is a collaborative effort. ■

REFERENCES

1. CDC. Home and recreational safety. Falls among older adults: an overview. 2012. http://www.cdc.gov/ HomeandRecreationalSafety/Falls/adultfalls.html.

2. Tideiksaar R. Falls in Older People: Prevention and Management. 4th ed. Baltimore, MD: Health Profes- sions Press; 2010.

3. Falls in the elderly. The Merck Manual for Health Care Professionals. Whitehouse Station, NJ: Merck Sharp and Dohme; 2010-2011. http://www.merck- manuals.com/professional/geriatrics/falls_in_the_ elderly/falls_in_the_elderly.html.

4. Cardell R, Bratcher K, Quinnett P. Revisiting “suicide proofi ng” an inpatient unit through envi- ronmental safeguards: a review. Perspect Psychiatr Care. 2009;45(1):36-44.

5. National Center for Patient Safety. Fall prevention and management. 2011. http://www.patientsafety. gov/CogAids/FallPrevention/index.html#page= page-1.

6. Lavsa SM, Fabian TJ, Saul MI, Corman SL, Coley KC. Infl uence of medications and diagnoses on fall risk in psychiatric inpatients. Am J Health Syst Pharm. 2010;67(15):1274-1280.

7. Garwood CL, Corbett TL. Use of anticoagula- tion in elderly patients with atrial fi brillation who are at risk for falls. Ann Pharmacother. 2008;42(4): 523-532.

8. Kalyani RR, Stein B, Valiyil R, Manno R, Maynard JW, Crews DC. Vitamin D treatment for the preven- tion of falls in older adults: systematic review and meta-analysis. J Am Geriatr Soc. 2010;58(7): 1299–1310.

9. American Psychiatric Nurses Association. What is your facility’s minimum standard rounding practice? http://www.apna.org/i4a/pages/index. cfm?pageID=4365.

Angela Malik is systems RME coordinator at the Ten- nessee Valley Healthcare System in Nashville, Tenn., and Norma Patterson is a clinical care facilitator at the Murfreesboro VA Medical Center in Murfreesboro, Tenn.

The authors have disclosed that they have no fi nancial relationships related to this article.

DOI-10.1097/01.NURSE.0000415322.94128.1f