How can your hospital incorporate these practices into a fall prevention stay, higher rates of discharge to nursing homes, and greater health care

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The information in this toolkit is intended to assist service provider s and hospitals in developing falls prevention protocols. This toolkit is intended as a reference and not as a substitute for professional judgment. The opinions expressed in this document are those of the authors and do not necessarily reflect the views o f AHRQ. No statement in this toolkit should be construed as an official position of AHRQ or the U.S. Department of Health and Human Services. In addition, AHRQ or U.S. Department of Health and Human Services endorsement of any derivative product may not be stated or implied.

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Preventing Falls in Hospitals A Toolkit for Improving Quality of Care Prepared for: Agency for Healthcare Research and Quality 540 Gaither Road Rockville, MD 20850 Prepared by: RAND Corporation Boston University School of Public Health ECRI Institute Contract No. HHSA290201000017I TO #1 AHRQ Publication No. 13 – 0015 – EF January 2013

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ii Authors RAND Corporation David A. Ganz, M.D., Ph.D., VA Greater Los Angeles Healthcare System, University of California at Los Angeles, and RAND Corporation Christina Huang, M.P.H., RAND Corporation Debra Saliba, M.D., M.P.H., VA Greater Los Angeles Healthcare System, UCLA/JH Boru n Center for Gerontological Research, and RAND Corporation Victoria Shier, M.P.A., RAND Corporation Boston University School of Public Health Dan Berlowitz, M.D., M.P.H., Bedford VA Hospital and Boston University School of Public Health Carol VanDeusen Lu kas, Ed.D., VA Boston Healthcare System and Boston Uni versity School of Public Health ECRI Institute Kathryn Pelczarski, B.S. Karen Schoelles, M.D., S.M. Linda C. Wallace, M.S.N., B.S.N. Patricia Neumann, R.N., M.S. This document is in the public domain an d may be used and reprinted without special permission. Citation of the source is appreciated. Suggested citation: Ganz DA, Huang C, Saliba D, et al. Preventing falls in hospitals: a toolkit for improving quality of care. (Prepared by RAND Corporation, Bos ton University School of Public Health, and ECRI Institute under Contr act No. HHSA290201000017I TO #1.) Rockville, MD: Agency for Healthcare Research and Quality; January 2013. AHRQ Publication No. 13 – 0015 – EF .

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iii Contents Roadmap .. .. .. .. . v Acknowledgments .. .. .. .. ix Overview .. .. .. .. . 1 The Problem o f Falls .. .. .. 1 The Challenges of Fall Prevention .. .. .. 1 Toolkit Designed for Multiple Audiences .. .. .. 2 Implementation Guide Organized To Direct Hospitals Through the Change Process .. 3 Sections of the Guide .. .. .. .. 3 Adaptation of t he Guide to Your Organization .. .. . 3 Improvement as Puzzle Pieces .. .. .. 4 Icons .. .. .. .. .. 5 1. Are you ready for this change? .. .. .. . 6 1.1. Do organizational members understand why change is needed? .. .. 6 1.2. Is there urgency to change? .. .. .. . 8 1.3. Does senior administrative leadership support this program? .. 9 1.4. Who will take ownership of this effort? .. .. .. 11 1.5. What kinds of resources are needed? .. .. . 12 1.6. What if you are not ready for full – scale change? .. 12 1.7. Checklist for assessing readiness for change .. .. . 13 2. How will you manage change? .. .. .. .. 14 2.1. How can you set up the Implement ation Team for success? .. 15 2.2. What needs to change and how do you need to redesign it? .. 19 2.3. How should goals and plans for change be developed? .. . 25 2.4 . Checklist for managing change .. .. . 26 3. Which fall prevention practices do you want to use? .. .. 27 3.1. Which fall prevention practices should you use? .. .. 28 3.2. What are universal fall precautions and how should they be implemented? .. 30 3.3. What is a standardized assessment of risk factors for falls, and how should this assessment be conducted? .. .. . 34 3.4. How should identified risk factor s be used for fall prevention care planning? . 38 3.5. How should you assess and manage patients after a fall? .. . 46 3.6. How can your hosp ital incorporate these practices into a fall prevention program? .. 49 3.7. What additional resources are available to identify best practices for fall prevention? 51 3.8. Checklist for best practices .. .. . 51 4. How do you implement the fall prevention program in your organization? .. 52 4.1. What roles and responsibilities will staff have in preventing falls? .. . 53 4.2. What fall prevention practices go beyond the unit? .. .. 59 4.3. How do you put the new practices into operation? .. 60 4.4. Checklist for implementing best practices .. .. .. 67 5. How do you measure fall rates and fall prevention practices? .. 68 5.1. How do you measure fall and fall – related injury rates? .. .. 69 5.2. How do you me asure fall prevention practices? .. . 77 5.3. Checklist for measuring progress .. .. . 80

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iv 6. How do you sustain an effective fall prevention prog ram? .. .. 81 6.1. Who will be responsible for sustaining active fall prevention efforts on an ongoing basis? .. .. .. 82 6.2. How will you continue to monitor fall rates and fall prevention care processes? 82 6.3. What types of ongoing organizational support do you need to keep the new practices in place? .. .. .. .. 83 6.4. How can you reinforce the desired results? .. .. 84 6.5. Summary .. .. .. 87 7. Tools and Resources .. .. .. 89 Appendix: Bibliography of Studies Implementing Fall Prevention Practices .. 185

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vi Tool 2 D, Assessing Current Fall Prevention Policies and Practices Implementation Team leader Determine staff knowledge about fall prevention Tool 2 E, Fall Knowledge Test Staff nurses and nursing assistants 2.3 Set goals for improvement based on outcomes and processes Tool 2 F, Action Plan Implementation Team leader with quality improvement/safety/ris k manager Section Action Steps Tool That Supports Action Who should use the tool 2.4 Assess your progress on completing the managing change activities Tool 2G , Managing Change Checklist Implementation Team leader Sec tion 3 Wh ich fall prevention practices do you want to use? 3.1 Identify how fall prevention care processes connect to one another Tool 3A , Master Clinical Pathway for Inpatient Falls Quality improvement/safety/ris k ma nager, staff nurses, nursing assistants 3.2 Implement universal fall precautions Tool 3 B, Scheduled Rounding Protocol Tool 3 C, Tool C overing E nvironmental S afety at the B edside Tool 3 D, Hazard Report Form Tool 3 E, Clinical Pathway for Safe Patient Handling Unit manager, staff nurses, nursing assistants, facility engineer, hospital employee who enters patien t rooms

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vii 3.3 Identify important risk factors for falls in your patients Tool 3 F, Orthostatic Vital Sign Measurement Tool 3G , STRATIFY Scale for Identifying Fall Risk Factors Tool 3 H , Morse Fall Scale for Identifying Fall Risk Factors Tool 3 I , Medication Fall Risk Scale and Evaluation Tools Staff nurses, pharmacist, nursing assistants 3.4 Use identified fall ris k factors to implement fall prevention care planning Tool 3J , Delirium Evaluation Bundle: Digit Span, Short Portable Mental Status Questionnaire, and Confusion Assessment Method T ool 3K , Algorithm for Mobilizing Patients Tool 3 L , Patient and Family Education Tool 3 M , Sample Care Plan Educators, staff nurses, physicians, nurse practitioners, physician assistants, n ursing assistants 3.5 Assess and manage patients after a fall Tool 3N , Postfall A ssessment, C linical R eview Tool 3O , Postfall A ssessment for R oot C ause A nalysis Staff nur ses and physicians Section Action Steps Tool That Supports Action Who should use the tool 3.8 Assess your progress on completing the best practices activities Tool 3P , Best Practices Checklist Implementation Team Lead er Section 4 How do you implement the fall prevention program in your organization?

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viii 4.1 Assign staff roles and responsibilities for tasks identified in set of best practices Tool 4 A, Assigning Responsibilit ies for Using Best Practices Tool 4 B, Staff Roles Implementation Team Leader, Unit manager 4.3 Assess current staff education practices and facilitate integration of new knowledge on fall prevention into existing or new practices Tool 4 C, Assessing Staff Education and Training Implementation Team Leader 4.4 Assess your progress on implementing best practices activities Tool 4 D, Implementing Best Practices Checklist Implementation Team Leader Section 5 How do you measure fall rates and fall prevention practices? 5.1 Collect the right data to learn about falls, fall – related injuries, and their causes Tool 5 A, Information T o Include in Incident Reports Quality improvement/risk manager, information systems staff 5.2 Measure fall prevention practices Tool 5 B, Assessing Fall Prevention Care Processes Unit manager and unit cha mpions 5.3 Assess your progress on measuring progress activities Tool 5 C, Measuring Progress Checklist Implementation Team Leader Section 6 How do you sustain an effective fall prevention program? 6.3 Identify fa ctors need to sustain your fall prevention efforts Tool 6 A, Sustainability Tool Implementation Team Leader

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ix Acknowledgments William Spector, Ph.D., Senior Social Scientist at AHRQ, acted as project officer for t hi s task order to develop a toolkit. Rhona Limcangco, Ph.D., Health Analyst at AHRQ , provided additional support in carrying out the project. The development of this toolkit was facilitated by the assistance of quality improvement teams at six medical center s: Joyce Dolin, Jena Reilly, and Kendra Belkin at Charlton Memorial Hospital (Fall River, MA) ; Jerry Lockett, Clover Irving – Wiggins, and Mariely Maldonado at Florida Hospital East Orlando (Orlando, FL) ; Martha Syms, Kelley Williams, and Kaye McMullin at Center (Enid, OK) ; Myka Whitman, Emmet Polster, and Amanda Mahaffee at Northwest Texas Hospital (Amarillo, TX) ; Linda Gehring, Marie Cicerone, and Sarah Knuckles at Temple University Hospital (Philadelphia, PA) ; and Pat Bens on, Michele Davis, and Terry Bryan at Augusta Health (Fishersville, VA). We thank them for their valuable contributions . We also thank the authors of the evidence review that provided background information for this toolkit: Susanne Hempel, Ph.D.; Sydne N ewberry, Ph.D.; Zhen Wang, Ph.D.; Paul G. Shekelle, M.D., Ph.D.; Roberta Shanman, M.S.; Breanne Johnsen; and Tanja Perry. We thank Walid Gellad, M.D., our internal peer reviewer process, for his constructive and detailed comments. We thank our technical expert panel, Katherine Berg, PT, Ph.D.; Sharon K. Inouye, M.D. , M.P.H. ; Suzan N. Kucukarslan, R.Ph., Ph.D.; Dale M. Needham, M.D., Ph.D.; Julia B. Neily, R.N., M.S., M.P.H.; Patricia Quigley, A.R. N.P., Ph.D.; Laurence Ru benstein, M.D., M.P.H.; Blair L. Sadler, J.D.; Stephanie Studenski, M.D., M.P.H.; and Catherine ( Cait ) Walsh, R.N., M.S.N, for their advice on this document. We also thank Andrew Bernard, M.D. , and colleagues at University of Kentucky Medical Center and U K Healthcare ; Cynthia J. Brown, M.D. , M.S.P.H ; Patricia C. Dykes, D.N.Sc., R.N. , F.A.A.N., F.A.C.M.I. ; Anne M. Drolet, M.S., A. N.P. – B.C. , C.C.R.N. ; Vic toria Fraser, M.D.; Terry Haines, Ph.D.; Frances Healey, R.N., Ph.D.; Serena Koh, R.N., Ph.D.; David Oliv er, M.B. , B.Chir., D.G.M., D.M.E., M.H.M, M.D. , M.Sc., M.A., F.R.C.P ; and Ron ald I. Shorr, M.D. , M.S. , for sharing their advice and materials.

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