NURS 8211C

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Impact of Tailored Interventions for Patient Safety (TIPS)

to Reduce Fall Rates

Amina Khoja Laila Moosa

F alls are the leading cause of injury in adults, as more than 25% fall each year (Bilik et al.,

2017). Falls can lead to physical injuries that may result in pro- longed hospitalization and nosoco- mial infections, adverse medica- tion-related side effects, and death (Florence et al., 2018). Falls among patients represent a physical, men- tal, and financial burden to all stakeholders, including patients, families, and the health team. With falls as a major public health prob- lem, reducing fall rates among hos- pitalized patients is one of the high- est priorities of nurses and health- care leaders (Dykes et al., 2017; Silva & Hain, 2017).

In the United States, about $50 billion is spent annually on medical costs related to non-fatal fall injuries, and $754 million is spent on fatal falls (Florence et al., 2018; Sharif et al., 2018). The cost associated with falls, fall-related injuries, and increased hospital length of stay is not reimbursed by the Centers for Medicare & Medicaid Services (CMS) (as cited by Fehlberg et al., 2017). Falls are considered an adverse event by The Joint Com mission (2021) and

Evidence-Based Practice

Falls continue to pose a chal- lenge to the safety and quali- ty of care for patients admit- ted to medical-surgical units. As described in this article, tailored interventions for patient safety (TIPS) allow nurses to select individualized fall prevention strategies that may reduce falls.

Amina Khoja, DNP, MSN, MS, RN, CMSRN®, CNE, is Director, Simulation and Skills Lab, National University, Los Angeles, CA.

Laila Moosa, DNP, MSN, RN, PHN, CMSRN®, is Associate Professor, Department of Nursing, Mount Saint Mary’s University, Los Angeles, CA.

Clinical Question

The following question guided this project: Among patients admitted to the medical-surgical orthopedic unit (MSOU) (P), will the implementa- tion of tailored interventions for patient safety (TIPS) (I) compared to current practice (C) reduce fall rates (O) over 4 weeks (T)?

EBP Model

Iowa Model of Evidence-Based Practice (Titler et al., 2001)

Patient Outcomes

Decrease falls on the MSOU by 7%.

Search Strategy and Results

A comprehensive literature review was performed to locate research pub- lished 2016-2021 to align TIPS with fall reduction in acute medical-surgi- cal units. Search terms included the following: inpatient falls, inpatient fall prevention program, tailored interventions, causes of falls, tailored interven- tions for patient safety, hourly rounding, reduced fall rates, and the Iowa Model. When the initial search returned over 20,000 articles relevant to the project, the screening process was streamlined to retrieve articles that addressed the clinical question specifically. Screening also was based on the study design, rigor of methodology in relation to study design, publi- cation in a peer-reviewed journal, and study results. Full-text English lan- guage empirical, evidence-based articles on fall rates among inpatient medical-surgical patients were considered. Articles on observation patients, pediatric, and psychiatric studies were excluded. One hundred articles were selected for the project.

Databases

CINAHL, Medline, Cochrane Collaboration, ProQuest, Google Scholar

Clinical Setting

226-bed private, not-for-profit hospital in southern California; average daily census on 50-bed MSOU was 48-50.

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the CMS (as cited by Gray et al., 2017). Leading healthcare organiza- tions, such as the Centers for Disease Control and Prevention (n.d.), Agency for Healthcare Research and Quality (2017), and The Joint Commission (2021), have released strategic guides to prevent medical errors and combat falls.

Tailored interventions for pa - tient safety (TIPS) is an evidence- based fall prevention tool that has been used in fall reduction efforts in many U.S. hospitals. Dykes and col- leagues (2017) developed and tested TIPS, which consists of a formal risk assessment and tailored plan of care using the Fall TIPS toolkit poster (see Figure 1). In their study, TIPS was implemented for patients ad mitted to identified hospital units January-June 2016. Findings showed a drop in falls by 25% in units where interventions were applied, compared to non-interven- tion units. This tool has been used subsequently as a nurse-driven fall intervention tool to provide safe,

coordinated, efficient care to reduce fall rates. TIPS facilitates nurses’ use of tailored fall prevention plans based on patient fall risk assessment using the Morse Fall Assessment (MFA) scale (Dykes et al., 2019). Nurse implementation of TIPS has been shown to reduce patient falls and enhance a culture of safety (Dykes et al., 2017; Dykes et al., 2020; King et al., 2018).

Project Site and Reason for Change

The medical-surgical orthopedic unit (MSOU) faced challenges in reducing fall rates and meeting benchmarks from the National Database of Nursing Quality Indicators® (NDNQI®). Despite vari- ous fall prevention interventions (bundled interventions), fall reduc- tion had not been achieved. The unit MFA scale and fall bundle interventions had not been linked to identify patients at risk for falls so tailored fall interventions could be

implemented. Fall rates on the unit rose from 4.01 falls per 1,000 patient days in 2015 to 6.98 falls per 1,000 patient days in 2020. Re - ducing patient falls became critical.

Summary of Literature Search

Dykes and co-authors (2017) developed the Fall TIPS toolkit, a three-step fall prevention process that involves completing a fall risk assessment, developing an individ- ualized fall prevention plan, and implementing the tailored fall prevention plan consistently. Re - searchers found patients fell due to a lack of communication among patients, families, and the care team. The Fall TIPS poster was pilot- ed on high-risk units at two large geographically and ethnically di - verse medical centers. A Fall TIPS poster was hung at each patient’s bed January-June 2016 to ensure transparent communication. The mean fall rate decreased from 3.28

Evidence-Based Practice

FIGURE 1. Tailored Interventions for Patient Safety (TIPS) Tool

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

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Impact of Tailored Interventions for Patient Safety (TIPS) to Reduce Fall Rates

per 1,000 patient days (January- June 2015) to 2.80 per 1,000 patient days for the study period. In addi- tion, mean adherence to the Fall TIPS protocol was 82%.

Duckworth and colleagues (2019) assessed the effectiveness of TIPS in fall prevention when pa tients and family members were engaged in all three steps of the fall prevention process. Random audits were con- ducted with the question, “Does the patient/family member know their fall prevention plan?” Champions from three hospitals reported data for April-June 2017, evaluating the patient engagement measure and the presence of the Fall TIPS poster at the bedside. Units reached clinically significant adherence (>80%) by the final month (no level of statistical significance identified). This result encouraged main tenance of a high level of patient engagement in TIPS.

Dykes and co-authors (2019) encouraged nurse leaders to use the evidence-based fall prevention TIPS toolkit as a best practice in their organizations. Authors recommend- ed nurse leaders in the healthcare systems adopt Fall TIPS, a tailored intervention for patient safety to reduce falls. The Fall TIPS team pro- vided fall prevention program re - sources to several hospitals within and outside the United States. Implementing TIPS with the con- tinued support of nurse leaders, staff involvement as nurse champi- ons, patient engagement, routine audits, and peer feedback could sus- tain the evidence-based practice change to reduce falls.

Dykes and colleagues (2020) completed a nonrandomized con- trolled trial November 2015-October 2018 to evaluate TIPS effectiveness by comparing fall rates before and after its implementation in 12 med- ical units at two sites. After imple- menting use of the TIPS laminated paper poster, falls de creased from 2.92 per 1,000 patient days to 2.49 falls per 1,000 patient days.

Answer to the EBP Question

Healthcare organizational lead- ers work consistently to identify

and adopt evidence-based fall pre- vention tools to reduce falls among hospitalized patients. The TIPS has been used widely and has reduced falls in many U.S. hospitals (Dykes et al., 2017). In the reviewed litera- ture, use of TIPS allowed nurses to engage patients in fall safety meas- ures to reduce falls. Nurses were able to ensure clear communication among patients, family members, and the care team, resulting in decreased falls (Duckworth et al., 2019; Dykes et al., 2019; Dykes et al., 2020).

According to Dykes and co- authors (2017), TIPS can help nurs- es build a connection between fall risk assessment and fall prevention interventions to reduce falls through use of individualized fall prevention strategies. Implemen - tation of TIPS has eliminated the use of non-specific fall interven- tions in hospital settings. The evi- dence in the literature provided a solid foundation for using TIPS for this project.

Implementation of the Change in Practice

Identifying a practice gap is piv- otal in translating and synthesizing evidence-based knowledge to bring positive health outcomes by reduc- ing falls (Tucker et al., 2019). The practice gap identified at the project site was the lack of a tailored fall prevention plan based on the assessment with the MFA scale.

Nurse leaders at the project site, including the nursing director as chairperson of the hospital’s Fall Advisory Council, made attendance at the project educational session mandatory for all clinical nurses in the MSOU. They supported imple- mentation of TIPS in an effort to reduce patient falls. TIPS relies on the MFA scale, the most rigorously validated fall risk assessment tool for inpatient hospital settings, to guide nurses in conducting patient fall risk assessment (Dykes et al., 2017; Dykes et al., 2019). The TIPS tool is used to support evidence- based fall prevention interventions, such as communication of recent falls, use of toileting schedules and

bed alarms, providing assistance out of bed, and use of walking aids (Dykes et al., 2017).

The primary investigator (PI) developed a PowerPoint presenta- tion to provide detailed informa- tion about the significance of the project, the need for practice change, and the impact of TIPS on falls. The hospital’s Fall Advisory Council committee chairperson provided an expert review of the content. Handouts and copies of the slides were developed for all clinical nurses who attended the educational session. A color-coded TIPS tool was used to allow nurses to select interventions that matched associated fall risk factors.

The unit manager emailed clini- cal nurses to attend a mandatory 1- hour training session on TIPS. The PI delivered four face-to-face educa- tional sessions on TIPS so all day and night shift clinical nurses could attend. During the educational intervention, all clinical nurses had an opportunity to ask questions or voice concerns about efforts to reduce fall rates in the MSOU. No demographic information about the nurses was collected. Of 50 eligible clinical nurses, about 80% (n=32) attended the educational session. The PowerPoint was up loaded to the unit’s online educational platform to be accessed by all nurses who were unable to attend a live session.

After the TIPS educational ses- sions were completed, the 4-week intervention period was initiated. All nurses implemented the TIPS tool on all patients admitted to the MSOU. They used TIPS during handoff to ensure clear communication about tailored, patient-centered fall pre- vention interventions. Primary nurs- es posted the TIPS tool on the white- boards in patients’ rooms. Night nurses collected the posted TIPS tools and placed them on clipboards outside patient rooms. Charge nurs- es and the unit director reminded clinical nurses to use TIPS every shift and communicate fall-related infor- mation during bedside handoffs. Consistency of results was achieved through regular staff reminders to use TIPS by unit leaders during shift huddles and handoffs.

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Evidence-Based Practice

Evaluation of the Initiative Pre-and post-intervention data

included patient falls and demo- graphic information. Patient-spe- cific demographic information in - cluded age, gender, medical diagno- sis, comorbidities, and cause of fall. This information could help assess the physical, emotional, and finan- cial burden on patients and the organization (Florence et al., 2018). Data were summarized using de - scriptive statistics for the 4-week pre-intervention and 4-week post- intervention periods and were used to assess the efficacy of TIPS use in reducing falls. An independent t- test was used to compare the num- ber of falls in pre- and post-inter- vention periods.

Results and Limitations All patients admitted to the

MSOU during the pre- and post- implementation periods were eligi- ble to participate in the project. Thirty patients were in the pre- intervention group, and 28 in the post-intervention group. Demo - graphic and fall data were obtained from the electronic health record for all patients.

Mean patient age was 76 in the pre-intervention period and 70 in the post-intervention period. More female (n=21) than male (n=9) patients were involved in the pre- intervention period, as well as in the post-intervention period (n=17, n=11, respectively). The most com- mon pre-intervention diagnosis was

hip arthroplasty (n=8), followed by syncope (n=5). Hip and knee arthro- plasty (n=7) were the most common diagnoses in the post-intervention period. The most common co-mor- bidities in the pre-intervention sam- ple were arthritis (n=9), diabetes mellitus (n=7), and hypertension (n=5). Arthritis was also the most common comorbidity in the post- intervention sample (n=14). Dizzi - ness (n=15) was the cause of most falls in the pre-intervention period, while urinary urgency (n=12) was the primary cause of falls in the post-intervention period.

A t-test was conducted to analyze the mean fall rate in the two patient samples. The mean pre-invention fall rate was 0.10 (SD=0.305) for all 30 patients admitted to the MSOU in that period. The post-intervention fall rate was 0.07 (SD=0.262) for all 28 patients admitted to the MSOU (see Table 1). Results of an inde- pendent t-test were t(56)=0.381, p=0.705, indicating no statistically significant difference in fall rates between the pre- and post-interven- tion periods (see Table 2). However, the decrease in mean fall rate from 10% to 7% was clinically significant.

Limitations of this project in - cluded the short implementation period. Many nurses from various departments floated to the MSOU, and they lacked knowledge about the TIPS intervention. Nurses who were on medical leave or leave of absence may not have attended the educational session and were unaware of this practice change. Due to differences in education delivery among nurses (those who received the intervention vs. those who did not), the implementation of TIPS may have been uneven and impacted the project results. Nurses were able to access the presentation on TIPS from the unit’s electronic educational platform, but this could not be assured and was not assessed.

Collecting qualitative data from clinical nurses about fall-related interventions was not part of the project. Many nurses working in the MSOU were graduate nurses with time management challenges when performing a fall risk assessment and implementing TIPS to reduce falls. The ability to collect qualita- tive data from clinical nurses regarding their perceptions of TIPS implementation represents a future opportunity.

TABLE 1. Pre- and Post-Intervention Fall Rates

n Min Max Mean SD Percent

Pre-Intervention 30 0.00 3.00 0.10 0.305 10.0

Post-Intervention 28 0.00 2.00 0.07 0.262 7.0

Levene’s Test for Equality of Variances t-test for Equality of Means

F Sig. t df Sig.

2-tailed Mean

Difference Std. Error Difference

95% Confidence Interval of the

Difference

Lower Upper

Fall Rates

Equal variances assumed

.588 .446 .381 56.0 .705 .029 .075 -.122 .179

Equal variances not assumed

.383 55.6 .703 .029 .075 -.121 .178

TABLE 2. Independent t-Test on Fall Rates

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Lessons Learned/Nursing Implications

Nurses should embrace TIPS as an evidence-based intervention for reducing falls. A noteworthy impli- cation of this project was the use of TIPS in patients’ rooms, which allowed them to engage actively in their fall prevention plan. Because many hospitalized patients do not believe they will fall, their engage- ment is a valuable strategy that puts them in charge of their own health.

Implementing TIPS enhanced staff knowledge and empowered them with an evidence-based tool to reduce patient falls. Several implications for sustainability were noted during this project. First, the nurse educator should monitor clinical nurses when a new practice change is implemented and mentor them when needed. Further, teach- ing float nurses about TIPS and monitoring them to ensure they are using it with all patients can con- tribute to reduced falls. The unit educator could add TIPS to the ori- entation package so newly hired nurses and float nurses are educated on implementing TIPS as part of the daily care plan. Second, unit-specif- ic TIPS champions should be identi- fied. They could audit nurses ran- domly on the use of TIPS and report their outcomes in the monthly Fall Advisory Council meetings.

The same project could be con- ducted over 5-6 months to capture more clinical nurses, including float pool nurses, and evaluate the long- term impact of TIPS on reducing falls. The project also could explore nurses’ knowledge, attitude, and skills in using TIPS to reduce falls. Nurses could be surveyed to explore perceived causative factors of falls and barriers to adapting TIPS as a practice change. As nurses are the main caregiver stakeholders in reducing falls, exploring their moti- vation and knowledge to imple- ment TIPS to reduce falls would be beneficial.

The TIPS champions of MSOU can assist leaders and Fall Advisory Council in bringing this practice change to other units in the hospi- tal. Each unit has its workflow and nurse-patient ratio, and each has a diverse patient population with needs. The Iowa Model could be used by others in replicating the project.

Conclusion The MSOU had multiple fall pre-

vention interventions that were not linked with fall risk assessment. Use of the TIPS as an evidence-based fall prevention tool helped reduce falls from 10% to 7% over 4 weeks. The TIPS tool was posted on the white- board in patients’ rooms, allowing nurses to select tailored fall preven- tion interventions linked to patients’ MFA scores. Use of TIPS during patient handoff ensured the tailored fall intervention plan was sustained from nurse to nurse. Educating clinical nurses about TIPS enhanced their clinical judg- ment in addressing patients’ safety needs, thus reducing falls.

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Impact of Tailored Interventions for Patient Safety (TIPS) to Reduce Fall Rates

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