1. Falls Program Virtual Breakthrough Series 2: (BTS 2) Reducing Preventable Falls and Fall Related Injuries National Center for Patient Safety & VISN 8 Patient Safety Center of Inquiry Session 4 Wednesday, February 20, 2013 2-3p

2. BTS2 Program Goals: Improve your organization’s infrastructure and capacity to reduce fall-related injures. Enhance environmental safety. Mitigate or eliminate modifiable fall risk factors. Assure reliable handoff communication about patients’ fall and injury risk. Integrate patient (family) as a partner in their fall prevention program. Reduce rate of repeat falls. a Quantify impact of program changes. 2

3. Looking Ahead Ten Sessions of Learning and Sharing Jan 9 th : Improved Organizational Infrastructure and Capacity for Fall Prevention Programs Jan 23 rd : Ensuring a Safe Environment Feb 6 th : Mitigate or Eliminate Modifiable Fall Risk Factors, Part 1 Feb 20 th : Mitigate or Eliminate Modifiable Fall Risk Factors, Part 2 Mar 6 th : Reduce Moderate to Serious Injuries for Vulnerable Populations Mar 20 th : Clinically Relevant and Reliable Handoff Communication: Let’s Talk about Falls and Fall-related Injuries Apr 3 rd : Patients/Families as Full Partners in Fall Prevention Apr 17 th : Post Fall Management: Reducing Repeat Falls May 1 st : Fall Program Evaluation May 15 th : Sharing Program Successes 3

4. Session 4: Mitigate or Eliminate Modifiable Fall Risk Factors - Part 2 Objectives: Differentiate fall risk assessment from injury risk assessment. Emphasize the importance of interdisciplinary participation in identification of both fall risk AND injury risk factors, along with interventions for prevention and protection. Examine direct clinical interventions to mitigate or protect patients from fall-related injury risk for care planning. 4

5. Overview of Session The roles of risk assessment, comprehensive assessment and clinical judgment will be emphasized for specific vulnerable patients across settings of care. The ABCS tool serves as the framework for this discussion, as providers consider your unique populations in your care setting. Focusing on injury risk enables providers to engage in new patient learning and facilitate patient safety post discharge. Participants will be guided in examination of care plans for specific interventions to protect patients from injury.

6. Bundling  Moderate to High Risk –most Vulnerable Fallers interventions that combine  Prevention  Detection  Protection

7. Fall Prevention  Assessment Universal Fall Precautions Care planning  Arm bands  Signage for high risk for injury  Other Report/Assignment sheets/Handoffs Intentional Rounds every hour Environmental Rounds Video Monitoring Mattresses-beveled edges

8. Fall detection  Alarms Chairs  Pull cord alarms  Voice activated alarms  One arm seat belt alarms  Sensor mats- light weight Bed  Pull cord alarms  Mattress sensor mats  Light weight  Built in bed alarms

9. FALL DETECTION  Bathrooms  Call system attachment  Toilet seat alarm  Clips on Emergency Cords? Floor/Door Alarms  Floor Mat alarms  Cordless Motion Detecting Beams over bed  Passive Infrared Alarms on beds  Pull cord alarm to doors

10. FALL DETECTION Wander Detection Devices  Placement  Wrist/ankle  Wheelchair  Video Monitoring

11. LEVELS of DETECTION  Ambulatory Wander detection devices/Monitors  Partially Ambulatory Bed/Chair Alarms/Monitors  Non Ambulatory/Bed rest Bed Alarms/Monitors

12. Fall protection  Floor mats-size? Length Thickness Beveled edges Non-slip/Hygienic Night time glow strip  Special Flooring  Helmets- Hard or Soft Reusable Available for PRN use  Hip protectors Soft pads and hard shell External or Undergarments Sweat pants and shorts

13. Fall protection  Low Beds  Wheel chair  Size/features  Brake extensions  Anti -tippers  Front and  Back Auto Brakes? Chairs/cushions’  Right height  Right cushion  Anti slip materials  Seat lifts Toilet Seat elevation/lifts Swing Away grab bars

14. Hip Fractures  In most cases, the immediate cause of hip fracture is a lateral fall with direct impact on greater trochanter of the proximal femur  Hip fractures are associated with a host of negative outcomes including increased mortality, morbidity and greater risk for institutionalization (men>women)

15. Hip Protectors  Although the evidence is mixed, research generally supports the use of hip protectors to prevent hip fractures, particularly in nursing home settings, when they are worn (Sawka et al., Osteop Int, 2005)  not sufficient evidence to infer HP are protective against hip fractures in community-dwelling population  No serious side effects  low harm, low cost intervention with potential benefit

16. Hip Protectors  2 separate studies were conducted: 1. Multiple Impact Investigation examining the effects of multiple impacts (falls) on hip protectors 2. Laundering/Durability Investigation examining the effects of the laundering process on the protectors’ ability to attenuate force

17. Barriers to Adoption/Adherence  Lack of adherence=lack of effectiveness  Acceptance (30% refusal); Adherence – (short-term, long-term); Day/night wear  Different populations: community living vs. institutionalized (or functionally/cognitively impaired) Goal: 1) To understand the provider-perceived barriers toward the use of hip protectors among nursing home patients 2) To evaluate patient-perceived barriers and facilitators to hip protector use

18. Conclusion  Staff buy-in and administrative support were main factors influencing hip protector use in long-term care

19. Preferred interventions: patients  Talk to someone who wore hip protectors (87%)  See a display of hip protectors in clinic (84%)  Written information (77%)  View a video (77%)  Try hip protectors in clinic (73%)  Education for significant other (64%)  Access information on a web site (52%)

20. Hip Protector Implementation Toolkit o Posted on NCPS (www.NCPS.gov) as a new addition to the existing National Falls toolkit and our web sitewww.NCPS.gov o http://www.visn8.va.gov/patientsafet ycenter/fallsTeam/default.asp

21.  This web-based toolkit includes:  prescribing guidelines  standardized CPRS orders  selection of brands and models  sizing guidelines  protocol for replacement  policy template  laundering procedure  stocking procedure  monitoring tools  patient education materials  provider education materials HP toolkit

22. Hip Protector Guide Providers  Prescribing guidelines  Hx of osteoporotic fracture  Hx of multiple falls (in the last 12 months)  Diagnosis of osteoporosis and falls risk  Movement or gait disorder  Acute delirium (change of mental status)

23. Standardized orders for CPRS  Prosthetic consult  Brand, model, size (hip circumference)  Number of pairs  Duration of wear (e.g. daytime, 24 hours, high risk activities only)

24. Selection of brands and models of Hip Protectors  No national or international standards- minimal risk devices  Based on work done at the VISN 8 PSC we would like all manufacturers to demonstrate that  Their brand decreases the energy of impact bellow 3100N (an average force needed to fracture a 75 yr old female hip),  Their brand is durable after repeated washings and dryings or multiple impacts, and  Their testing was preformed under ISO certification to ensure quality control

25. Sizing  varies by manufacturers, may be color coded  some facilities mark the size on the outside of the garment using a black permanent marker to more easily identify sizes  Using separate bins by size for storage

26. Laundering procedure  Studies at the VISN 8 Patient Safety Center of Inquiry have found that the protective properties of hip protectors may be reduced with repeated launderings  The most important factor in the reduced protective properties for soft hip protectors was residual moisture found in the pad after laundering  For hard hip protectors, the most important factor in reduced protective properties was the warping or “flattening out” of the hard protective outer shell after multiple launderings

27. Laundering procedure  Your facility should:  Review laundering procedures to insure adequate drying of all hip protectors.  Whoever is responsible for removing the pads from the dryer should make sure they are dry to the touch  Examine the outer shell of the hard hip protectors to assure they still are retaining their protective dome shape. If they are not, remove them from circulation.  The adequate length of a drying cycle to completely dry a hip protector will vary with respect to how hot the dryer is and the specific brand of hip protector. For these reasons, it is difficult to recommend a specific drying time

28. Protocol for hip protector replacement  In the absence of independent evaluation, we have to rely on manufacturers' guidelines for when to replace hip protectors  For the pads without a guideline, we arbitrarily chose 100 launderings as a cut-off for replacement  Each site should determine the intensity of HP use and decide on a time frame for replacements  All new HP should be dated when they are used for the first time.  It is probably more feasible and less disruptive to care if a portion is changed over a certain time interval (e.g. 25% every 3 months, or 50% every 6 months, etc.)

29. Protocol for hip protector replacement  we recommend replacing hip protectors after a direct fall onto the pad or shell  hip protectors should be inspected before each use for any obvious sign of damage and discarded (e.g. flattened or ruptured shell, stretched-out, poorly fitting surrounding garment, etc.)

30. Template for policy on hip protectors  Local teams reviewed existing fall policy; Discuss/refine elements to include, e.g. laundering, stocking, sizing, who orders, risk assessment, selection guidelines, documentation  Goal: Incorporate HP content into existing fall policy or develop new policy specific for hip protectors  Obtain concurrence from all services/departments named in policy

31. Stocking procedure-target audience Supply  Process for supplying units with number/sizes needed, storage on units.  Inventory of Best practices: separate bins for different sizes and different products, supplying in nurse servers, adding hip protector to check list for nurse servers

32. Hip Protector Fair (annual)  A display of different brands and models of HP to allow staff to become more familiar and have input into what type/model would be best suited for their particular patients  30 minute didactic session (15 min PowerPoint + 15 min Caregiver DVD)  15 minutes demonstration of hip protectors

33. Communication-Unit Staff  standardize the process how is information communicated; the whole team should know who is supposed to wear HPs  use the form of communication that you know already works on your unit (e.g. Kardex hand off documentation, white boards)  Someone should be responsible for making sure that the hip protectors are always stored in the same place so that staff can easily find them when they need them

34. Monitoring tools  target audience- nurse managers with HP site champions  Post fall template check box for hip protector use  HP in treatment sheet, or in ADL template  Observation, chart review  Implementation checklist

35. Impact 1 -2 years later  At each facility, hip protector use has been integrated into their fall prevention program and policy

36.  the prescription of hip protectors has been linked to level of fall risk for anticipated physiological falls based on the Morse Fall Scale, rather than injury risk.  Do NOT prescribe or discontinue hip protector use based on the Morse Fall Scale  1.Use Risk for Injury (Hip Fracture) or History of Hip Fracture as the clinical indicator(s) for prescribing hip protector use Recommendations:

38. HP toolkit evaluation  2. Increase involvement of prescribing providers (MDs, NPs, PAs) in hip protector program, resident persuasion, esp. when patients’ refuse to wear hip protectors  3. Utilize peer counseling  4. Use signage to identify residents at risk for injury or have a known history of injury, and eliminate use of signage for fall risks, as nearly all nursing home residents are at risk for falls

39. HP toolkit evaluation  4. Increase brands and products of hip protector clothing (pants and shorts) for CLC residents to deceased residents’ issues with undergarment discomfort and difficulty with dressing and undressing associated with daily dressing and toileting.  5. Increase social marketing skills of persuasion, used by staff with patients (give 2 yes options to residents – to select which brand/model to wear, rather than option to say no)

40. BEDSIDE MATS Lab evaluation – simulated falls  the force of falls from a bed can cause mild, moderate or severe injury depending on height of bed and floor surface.  Head first falls were compared to feet first falls.  Falls into an unprotected surface did not present any significant risk of hip fracture and use of a bedside floor mat reduced pelvis impact forces by only 6%.

41. Lab evaluation - simulated falls

42. Lab evaluation – simulated falls

45. Summary Head Injury Criteria (HIC) values (correlates acceleration with injury severity), Feet First Fall from Bed  No Floor Mat fall over top of bedtails: ~40% chance of severe head injury  No Floor Mat, low bed (No Bedrails): ~25% chance of severe head injury  Low bed with a Floor Mat: ~1% chance of severe head injury  The use of a mat significantly reduced risk by an average of 72% across bed heights ranging from 0.34 to 0.98m

46. Lab evaluation – simulated falls  In some of the trials the mannequin’s head hit the bare floor at the headboard end of the bed, off the mat and occasionally hit the floor to the side of the mat. The head may also strike furniture in near the head of the bed.  Based on this finding, we recommend to use a mat that extends beyond the head of the bed and one that is at least 44 inches wide.  Furniture near the head of the bed should be placed with care or sharp edges padded

47. Laboratory Evaluation of Commercially- Available Bedside Floor mats  Several objective variables were investigated for each mat including: impact force reduction, stability, weight, thickness and coefficient of friction.  10 commercially available, unused mats were selected for testing (6 different manufacturers, $60-$390 USD).

48. Bedside mats tested  Floor Mat 1: Posey Sure-Step Cushioned Bath Mat  Floor Mat 2: SATECH Smart Cell Floor Mat (0.5” thick)  Floor Mat 3: SATECH Smart Cell Floor Mat (1” thick)  Floor Mat 4: Posey Beveled Floor Cushion (Wide)  Floor Mat 5: Comfortex Landing Strip  Floor Mat 6: Posey Economy Floor Cushion  Floor Mat 7: NOA Floor Mat  Floor Mat 8: Safetycare Soft Floor Mat  Floor Mat 9: AliMed QualCare Easy Clean  Floor Mat 10: AliMed Fall Mat w/Alarm (4”)

49. Impact testing results Mat #Avg. Force of Impact (N)Force Reduction (%)HIC* Unprotected (Control) 20,0000.00%775.31 Floor Mat 7< 20099.00%- Floor Mat 10< 20099.00%- Floor Mat 81,33693.32%5.31 Floor Mat 91,34393.29%4.47 Floor Mat 31,37893.11%12.56 Floor Mat 22,03389.83%15.58 Floor Mat 12,10489.48%27.03 Floor Mat 53,95180.25%22.59 Floor Mat 44,06279.69%46.72 Floor Mat 64,71676.42%39.87

50. Stability testing results Mat #Sway Area (cm2)% Change Flat Rigid Floor (Control)1.850.00% Floor Mat 11.745.68% Floor Mat 21.95-5.59% Floor Mat 62.27-22.69% Floor Mat 42.31-24.86% Floor Mat 32.60-40.64% Floor Mat 82.86-54.63% Floor Mat 93.05-64.74% Floor Mat 54.03-118.08% Floor Mat 76.38-244.96% Floor Mat 1010.08-445.08%

51. Thickness Mat #Thickness (cm) Floor Mat 41.02 Floor Mat 21.57 Floor Mat 12.39 Floor Mat 52.64 Floor Mat 32.69 Floor Mat 63.81 Floor Mat 85.16 Floor Mat 95.21 Floor Mat 710.19 Floor Mat 1011.33

52. Guidance for providers on selection of bedside mats  Added to the VA National Falls Toolkit; provides ranking of different mats for each variable (impact, size, coefficient of friction, weight, etc.)  The best mat for one setting or patient may not be the best mat for another; thicker mats usually have better protective properties, but may increase instability and propensity to fall in patients with PN  From a providers’ perspective, thicker or heavier mats may increase the tripping hazard or risk of back injuries for the staff.

53. Impact-Fall Related Injuries (3.27/100K BDOC in 2005 to 1.92/100K BDOC in 2011)

54. Anticoagulation and fall risk  study looking at the risk of developing a subdural hematoma (SDH) after a fall in anticoagulated individuals with chronic a. fib. (Man-Son-Hing M,1999)  Risk of embolic CVA with a.fib. 5%>65, incr’d >75, CHF,HTN, DM, Hx CVA (8%)  Reduced risk of CVA: warfarin 68%, ASA 21%  Risk of falling >65: 33%/yr;Subdural hematomas are rare  Persons taking warfarin must fall 295 times in 1 yr for warfarin not to be the optimal therapy (risk of SDH outweighs the benefit)

55. Anticoagulation with falls risk  Did not account for adverse outcomes other then SDH (increased morbidity or mortality with injury);Risk of bleeding increased if ETOH use, NSAID’s, hx GI bleed, noncompliance with med or lab monitoring  patients at high risk for falls with a. fib are at substantially increased risk of intracranial hemorrhage (ICH) (2.8 vs. 0.34), c but ischemic stroke rates/100 patient-years were 13.7 in patient at high risk for falls and 6.9 in other patients  Patients at high risk for falls with a. fib. because of their high stroke rate, appear to still benefit from anticoagulant therapy, if they have multiple stroke risk factors (Gage et al., 2005).

56. Anticoagulation with falls risk  www.fponline.com www.fponline.com  “There is no evidence of increased risk for major bleeding as result of falls in hospitalized patients taking warfarin (strength of recommendation B) (Garvin and Howard, 2006) “In the average patient taking warfarin for atrial fibrillation, the risk of intracranial hemorrhage from a fall is much smaller than the benefit gained from reducing risk of stroke” ( SOR A)  The decision to stop or continue anticoagulation in patients with a.fib at risk for falls requires clinical judgment and should be made after a complete risk benefit assessment including patient preferences (Somerfield, Barber, Anderson et al, 2006).

57. Osteoporosis screening and treatment  Fall protection intervention from a long- term perspective  Osteoporosis in men is prevalent and increasing  Men with hip fracture are more likely to die  Treatment is available- lifestyle modification, pharmacologic and injury prevention (fall risk evaluation, hip protectors)

58. Suggested Small Tests of Change  Categorize 10-15 patients in your setting of care using the ABCS tool.  Examine 5-10 care plans of 5-10 patients with diagnosis of osteoporosis or hip fracture diagnosis for inclusion of injury protection strategies.  Examine 5-10 fall patients receiving chronic anticoagulation for inclusion of injury protection strategies

59. Next Session Session 5 – 60 minutes – 3/6/13, 2-3 PM Eastern Reduce Moderate to Serious Injuries for Vulnerable Populations Faculty: Julia Neily, RN, MS, MPH, Associate Director, NCPS Field Office Pat Quigley, PhD, ARNP, CRRN, Assoc. Director, VISN 8 PSCI Gail Powell-Cope, PhD, ARNP, Acting Director, Research COE: Maximizing Rehabilitation Outcomes Objectives:  Separate Vulnerable Populations at greatest risk for serious fall- related injury.  Illustrate evidence to support separate vulnerable populations.  Assimilate results of risk modeling research to predict rare injurious falls as adverse events associated with high mortality and high costs. 59