When teaching the client how to ambulate with a cane which of the following should you say

Team members should reach consensus on the following questions:

• Which fall prevention practices should you use?
• Which universal fall precautions should be applied throughout the hospital?
• How should a standardized assessment of fall risk factors be conducted?
• How should identified risk factors be used for fall prevention care planning?
• How should you assess and manage patients after a fall?
• How can your hospital incorporate these practices into a fall prevention program?

This section helps your organization address these questions. Further information regarding the organization of care needed to implement these best practices is provided in section 4 and additional clinical details are in Tools and Resources.

Recognize at the outset that implementing these best practices is a complex task. Some factors that make fall prevention challenging include:

• Fall prevention must be balanced with other priorities for the patient. The patient is usually not in the hospital because of falls, so attention is naturally directed elsewhere. Yet a fall in a sick patient can be disastrous and prolong the recovery process.
• Fall prevention must be balanced with the need to mobilize patients. It may be tempting to leave patients in bed to prevent falls, but patients need to transfer and ambulate to maintain their strength and to avoid complications of bed rest.
• Fall prevention is one of many activities needed to protect patients from harm during their hospital stay. How should fall prevention be reinforced while maintaining enthusiasm for other priorities, such as infection control?
• Fall prevention is interdisciplinary. Nurses, physicians, pharmacists, physical therapists, occupational therapists, patients, and families need to cooperate to prevent falls. How should the right information about a patient's fall risks get to the right member of the team at the right time?
• Fall prevention needs to becustomized. Each patient has a different set of fall risk factors, so care must thoughtfully address each patient's unique needs.

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3.1. Which fall prevention practices should you use?

Given the complexity of fall prevention, the task of implementing a program may seem daunting. To simplify things, we have broken down fall prevention activities into separate steps:

• Universal fall precautions, including scheduled rounding protocols (section 3.2).
• Standardized assessment of fall risk factors (section 3.3).
• Care planning and interventions that address the identified risk factors within the overall care plan for the patient (section 3.4).
• Postfall procedures, including a clinical review and root cause analysis (section 3.5).

Your practices should be tailored to your organization. In addition, at the unit level, you should cover these components in a manner tailored to the types of patients and care flow on each unit (go to section 3.6).

Your program is more likely to be successfully implemented and sustained when it is compatible with hospital priorities and what is best for the patient. The hospital's first priority is acute medical care; patients come to the hospital because they are ill and their primary purpose is to receive treatment for their illness.

The goal of patient safety practices like fall prevention is to prevent additional harm to patients while they are hospitalized. Hand hygiene to prevent spread of nosocomial infection is an example of a patient safety practice that avoids patient harm without interfering with the patient's medical care. As you read through this section, think about how you can integrate your fall prevention program with the variety of acute medical treatments that your hospital must deliver.

Another key point to remember is that fall prevention alone cannot be the goal of a fall prevention program. A theoretical example can illustrate this point. In theory, we could prevent all falls by restraining all patients, thereby preventing them from leaving the bed (in actuality, restraints may not prevent falls). But restraining patients would be unethical and represent poor care. It would conflict with the principles of patient autonomy and cause all the complications of bed rest, such as deconditioning, pressure ulcers, aspiration, and deep vein thrombosis, thereby keeping the patient in the hospital longer and making it harder for the patient to recover.

This example illustrates how fall prevention programs need to be tied to the fundamental goal that patient care improve each patient's function and well-being. It also demonstrates that our goal should be keeping fall and injury rates as low as possible, rather than getting to a zero fall rate at the expense of other priorities. Fundamentally, fall prevention is about balancing multiple priorities, as health itself is multifaceted.

Whatever set of recommended practices you select, you will need to take additional steps. Section 4 describes strategies to ensure their successful implementation. The challenge to improving care is how to get these key practices completed on a regular basis.

Understanding the causes of falls is important to developing your prevention program. The classification system developed by Janice Morse is useful. Falls can be classified into three types: Physiological (anticipated). Most in-hospital falls belong to this category. These are falls that occur in patients who have risk factors for falls that can be identified in advance, such as altered mental status, abnormal gait, frequent toileting needs, or high-risk medications. Key actions to take for prevention include close supervision of the patient (go to section 3.2) coupled with attempts to address the patient's risk factors (go to sections 3.3 and 3.4). Physiological (unanticipated). These are falls that occur in a patient who is otherwise at low fall risk, because of an event whose timing could not be anticipated, such as a seizure, stroke, or syncopal episode. Appropriate postfall care (go to section 3.5), coupled with injury prevention measures in the case of recurrence (go to section 3.4), are key for these patients. Accidental. These falls occur in otherwise low-risk patients due to an environmental hazard. Improving environmental safety will help reduce fall risk in these patients but is helpful for all patients (go to section 3.2). For more information, see Morse JM, Tylko SJ, Dixon HA. Characteristics of the fall-prone patient. Gerontologist 1987;27:516-22.

3.1.1. How are the different components of the fall prevention program related?

Each component of the fall prevention program is critical and each must be consistently well performed. It is therefore important to understand how the different components are related. A useful way to do this is by developing a clinical pathway.

A clinical pathway is a structured interdisciplinary plan of care designed to support the implementation of clinical guidelines. It provides a guide for each step in the management of a patient and reduces the possibility that busy clinicians will forget or overlook some important component of evidence-based preventive care.

An example of a clinical pathway detailing the different components of a fall prevention program is found in Tools and Resources (Tool 3A, "Master Clinical Pathway for Inpatient Falls"). This tool can be used by the hospital Unit Team in designing the new system, as a training tool for frontline staff, and as an ongoing clinical reference tool on the units. This tool can be modified, or a new one created, to meet the needs of your particular setting. If you prepared a process map describing your current practices using Tool 2C, you can compare that to desired practices outlined on the clinical pathway.

Implementing Fall Prevention Practices: Locally Relevant Considerations Hospitals have experienced local challenges in trying to implement best practices. Has your hospital experienced any of the challenges listed below? This section of the toolkit will help to address these challenges. Examples of challenges with risk assessment tools include: Hospitals indicate that their current risk assessments do not sufficiently cover some factors (e.g., medications, mobility). The fall risk score is associated with a standard set of interventions that is not customized to individual patients' needs. The current fall risk assessment results in almost all patients being categorized as high risk for falls, which dilutes the value of this designation with staff and their compliance with fall prevention strategies. Examples of challenges with specific interventions include: Some medication order sets include medications that are known to have a high risk for falls. There is overreliance on bed alarms as a fall prevention strategy. The use of various flags to indicate fall risk is so prevalent that their use becomes ineffective. Early mobilization may be compromised by extended bed rest orders that are not discontinued.

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3.2. What are universal fall precautions and how should they be implemented?

Universal fall precautions are the cornerstone of any hospital fall prevention program, because they apply to all patients at all times. Implementing universal fall precautions requires training all hospital staff who interact with patients, regardless of whether they are clinicians (covered more in section 4). Implementation also requires that the importance of fall prevention become embedded into the hospital's culture (covered in section 6).

3.2.1. What are universal fall precautions?

Universal fall precautions are called "universal" because they apply to all patients regardless of fall risk. Universal fall precautions revolve around keeping the patient's environment safe and comfortable. Although the choice of which precautions to emphasize may vary by hospital, a good starting list adapted from the Institute for Clinical Systems Improvement guideline (go to section 3.7) is provided here:

• Familiarize the patient with the environment.
• Have the patient demonstrate call light use.
• Maintain call light within reach.
• Keep the patient's personal possessions within patient safe reach.
• Have sturdy handrails in patient bathrooms, room, and hallway.
• Place the hospital bed in low position when a patient is resting in bed; raise bed to a comfortable height when the patient is transferring out of bed.
• Keep hospital bed brakes locked.
• Keep wheelchair wheel locks in "locked" position when stationary.
• Keep nonslip, comfortable, well-fitting footwear on the patient.
• Use night lights or supplemental lighting.
• Keep floor surfaces clean and dry. Clean up all spills promptly.
• Keep patient care areas uncluttered.
• Follow safe patient handling practices.

3.2.2. Why are universal fall precautions important?

Universal fall precautions constitute the basics of patient safety. They apply across all hospital areas and help safeguard not only patients, but also visitors and staff in many cases. Maintaining a safe and comfortable environment is the responsibility of the hospital independent of a patient's particular risks for falls, because failure to do so can put any patient at risk. For example, virtually any patient could slip and fall if there is a spill on the floor.

3.2.3. How are universal fall precautions performed?

Universal fall precautions should be performed from both the standpoint of the patient and the physical environment. For those precautions that require checking on the patient, such as making sure the patient's personal possessions are within reach, hourly rounding is an excellent basic strategy. (Hourly rounding is typically defined as hourly visits between 6 a.m. and 10 p.m. and visits every 2 hours between 10 p.m. and 6 a.m.; go to Tool 3B, "Scheduled Rounding Protocol").

Hourly rounding can be carried out by a nurse alternating with a nursing assistant (such as a certified nurse assistant, patient care technician, or nurse's aide). Patients are not disturbed if sleeping, except as needed to provide care. Tool 3B, "Scheduled Rounding Protocol," provides a scripted approach to a strategy that can be used during bedside rounds. Called the "4 P's" or "5 P's," it represents a set of items to mentally review when rounding on the patient. For example, the 5 P's could be:

• Pain: Assess the patient's pain level. Provide pain medicine if needed.
• Personal Needs: Offer help using the toilet; offer hydration, offer nutrition, empty commodes/urinals.
• Position: Help the patient get into a comfortable position or turn immobile patients to maintain skin integrity.
• Placement: Make sure patient's essential needs (call light, phone, reading material, toileting equipment, etc.) are within easy reach.
• Prevent Falls: Ask patient/family to put on call light if patient needs to get out of bed.

One benefit of hourly rounding is that it is proactive; it reduces patients' need to use the call light to ask for help and therefore decreases the number of unscheduled call lights that require response. These regular rounds allow many needs like toileting and access to drinking water to be met by staff who are scheduled to visit the patient's room.

Hourly rounding has been carried out in different ways by different hospitals. Despite its seeming simplicity, it requires careful planning to implement. Go to section 4 for strategies on implementing new care processes at your hospital.

To read more about the evidence that supports hourly rounding, see: Halm MA. Hourly rounds: what does the evidence indicate? Am J Crit Care 2009;18:581-4. To read more about the challenges of implementing hourly rounding, see: Deitrick LM, Baker K, Paxton H, et al. Hourly rounding: challenges with implementation of an evidence-based process. J Nurs Care Qual 2012;27:13-19.

Local Approaches to Implementing Scheduled Rounding An opening and closing script for interaction with the patient is provided. The closing script states, "If you need a nurse before I come back, use the call bell or contact the charge nurse at the phone number on the white board." Integrate "5 Ps" into the rounding protocol. Document completion of rounding on an hourly rounding tracking tool kept in the patient rooms. Conduct rounds every 2 hours between the hours of 10 p.m. and 6 a.m. to let the patient sleep.

In addition to nursing staff, many different hospital staff members enter patients' rooms throughout the day, which provides additional opportunities to ensure that universal precautions are followed. Having a member of senior management periodically tour hospital rooms to talk with patients and see that their needs are being addressed is an excellent stimulus to frontline staff to continue their efforts.

To cover environmental safety, regular environmental inspection rounds with nursing staff and facilities engineers (Tool 3C) can be valuable. In between regular inspections, staff can use a hazard reporting form (Tool 3D) to alert the unit manager to items that require fixing.

In addition to thinking about patient needs and environmental safety, remember to consider the interaction of the patient with the environment. An environment that is safe for one patient may not be safe for another. For example, a bathroom door may be wide enough for an independent patient to enter but not wide enough for a patient with an assistive device, thereby putting the latter patient at risk.

Another critical element of universal fall precautions is safe patient handling (Tool 3E, "Clinical Pathway for Safe Patient Handling"). This is particularly important for patients who require assistance with transfers. If staff members are not trained in safe patient handling, a patient could fall or staff could be injured because appropriate assistive equipment was not used.

	The following tools can be found in Tools and Resources: A clinical pathway that illustrates appropriate application of safe patient handling principles (Tool 3E, "Clinical Pathway for Safe Patient Handling").
	The way that hospitals are designed is an important part of reducing fall risk. The Facilities Guidelines Institute provides guidelines for the design and construction of health care facilities, including hospitals. Some design changes (e.g., recommendations for furniture) can be incorporated into existing hospitals. The guidelines are available for purchase and are also available for free reading at: http://openpub.realread.com/rrserver/browser?title=/FGI/2010_Guidelines. A draft of updated guidelines (Guidelines for Design and Construction of Hospitals and Outpatient Facilities) is also available at the Facilities Guidelines Institute website www.fgiguidelines.net/comments/draft.php . The Center for Health Design (www.healthdesign.org ) features workshops and seminars on the relationship between hospital design and patient safety.
	One hospital found that performing an environmental inspection identified stability problems with existing patient beds. The hospital was able to justify implementation of a bed replacement plan in the subsequent year.
	To read more about the evidence for improving hospital design, including safe patient handling, see: Sadler BL, Berry LL, Guenther R, et al. Fable hospital 2.0: the business case for building better health care facilities. Hastings Cent Rep 2011;41:13-23.

3.2.4. How should universal fall precautions be documented?

Universal fall precautions can be documented in many ways, including progress note templates in the chart and logs used for hourly rounding (hourly rounding is described in section 3.2.3). Any documentation strategy should be carefully integrated into workflow, so as not to become just another charting task.

3.2.5. What are some barriers to implementing universal fall precautions?

The rapid pace of activity in the hospital can be a barrier to implementing universal fall precautions. Patients are frequently transported on and off the unit for tests and procedures. In addition, patients may be required to change beds within the unit or be transferred to a new unit. Every time a change occurs, universal fall precautions such as making sure the patient's call light is within reach and that the patient is oriented to his or her environment need to be reassessed.

Another barrier to implementing universal fall precautions is that some precautions require patient understanding and cooperation. For example, patients may need to cooperate with using appropriate footwear or using the call light when they need help. Patients who do not know their own limitations may put themselves at risk for a fall despite the best efforts of hospital staff.

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3.3. What is a standardized assessment of risk factors for falls, and how should this assessment be conducted?

Assessing the patient for fall risks gives you the information you need to develop an individualized care plan. There are multiple risk factors for falls, and different patients may have different combinations of risk factors. These can change over time while a patient is in the hospital. To identify the risk factors most important to the patients on your unit or in your hospital, you need a system in place to ask the same key questions of each patient so that risks are not missed. This can best be accomplished through a standardized assessment of fall risk factors.

3.3.1. What is a standardized assessment of risk factors for falls?

After universal fall precautions, a standardized assessment of risk factors for falls is the next step in fall prevention. By virtue of being ill, all patients are at risk for falls, but some patients are at higher risk than others. Assessment of risk factors for falls is a standardized and ongoing process with the goal of identifying patients' risk factors, which can then be addressed in the care plan.

3.3.2. Why is a standardized assessment of risk factors necessary?

Assessment of risk factors for falls is essential for a number of reasons:

• It aids in clinical decisionmaking. Use of a standardized assessment helps ensure that key risk factors are identified and therefore can be acted on.
• It allows the targeting of preventive interventions to the correct patients. Fall prevention is resource intensive. Resources should be targeted toward those who would most benefit.
• It facilitates care planning. Care plans can better focus on the specific dimensions that place the patient at greatest risk.
• It facilitates communication between health care workers and between care settings. Workers have a common language by which they describe risk.

3.3.3. How is the assessment of risk factors performed?

An assessment of risk factors for falls is a standardized process that uses an assessment tool. The tools evaluate several different dimensions of risk, including fall history, mobility, medications, mental status, and continence. A tool could be a simple checklist of risk factors, or it could be more complex, depending on the needs of the hospital or unit.

Because assessment is a defined task, clinicians can perceive that completing the assessment tool is all they need to do. The Unit Team can help staff understand that these assessment tools are only one small piece of the process. The risk assessment tools are meant to complement clinical judgment, not to replace it.

Many other factors that are not listed in a typical risk factor assessment may be considered as part of clinical judgment. In fact, specialized wards may need to collect additional risk factors as part of their intake assessment. For example, on geriatric psychiatry wards, because of the medications patients are taking, orthostatic hypotension may be an important fall risk factor (go to Tool 3F for instructions on measuring and evaluating orthostatic vital signs). However, for consistency, we recommend that your hospital use a standard assessment tool throughout adult units in the hospital as a foundation on which additional unit-level risk factors may be added. This permits staff floating across different hospital units to share a common and familiar tool.

Key risk factors common to assessments include:

• History of falls: All patients with a recent history of falls, such as a fall in the past 3 months, should be considered at higher risk for future falls.
• Mobility problems and use of assistive devices: Patients who have problems with their gait or require an assistive device (such as a cane or a walker) for mobility are more likely to fall.
• Medications: Patients on a large number of prescription medications, or patients taking medicines that could cause sedation, confusion, impaired balance, or orthostatic blood pressure changes are at higher risk for falls.
• Mental status: Patients with delirium, dementia, or psychosis may be agitated and confused, putting them at risk for falls.
• Continence: Patients who have urinary frequency or who have frequent toileting needs are at higher fall risk.
• Other patient risks include being tethered to equipment, such as an IV pole, that could cause the patient to trip; impairment in vision that could cause a patient not to see an environmental hazard; and orthostatic hypotension, which could cause the patient to become lightheaded or pass out when standing.

3.3.4. What is the role of fall risk scores?

Assessment of risk factors for falls includes both the use of a standardized tool and an assessment of other factors that may increase risk of falls. Which other factors to consider beyond the standardized tool depend on clinical judgment and unit-specific policy.

Some tools that assess risk factors for falls also include a scoring system to predict risk for falls, and many facilities plan care according to the amount of risk (according to high, moderate, and low risk, for example). The problem with using the risk score to plan care is that the care plan is not tailored to the individual patient's risk factors. For example, two patients deemed "high risk" by score might have different risk factors; one could have delirium, and the other could have impaired gait. The responses to these risk factors need to be different. Trying to apply the same care plan to all "high risk" patients may distract staff from implementing the elements of the care plan that actually address each individual patient's risk factors.

For these reasons, we think the most important application of an assessment tool is to identify fall risk factors for which care plans can be developed. Because it takes time for a hospital's culture to move away from relying on a summary score, we provide the scales in full here, but we do not recommend excessive focus on the score.

3.3.5. Which assessment tools are used most often?

While some institutions have created their own tools, two tools have been studied most: the Morse Fall Scale (Tool 3H) and the STRATIFY (Tool 3G). Both scales have established reliability and validity. When used correctly, they provide valuable data to help plan care. Because each hospital setting is unique, we do not take a position as to which scale you should use. Also, these scales do not cover all key fall risk factors, so for your unit's needs, you may have to supplement these tools with additional assessment items, such as those found in some of the other tools covered in this section.

The Morse Falls Scale is made up of six subscales (history of falls, secondary diagnosis, ambulatory aid, IV/heparin lock, gait, and mental status). The STRATIFY is made up of five subscales (transfer/mobility, history of falls, vision, agitation, and toileting). Other scales may be used instead of the Morse Falls Scale or the STRATIFY. The key point is to ensure that a standard scale is used throughout adult units in the hospital, with additional risk factors assessed as needed for specific units or as suggested by clinical judgment.

We also encourage you to review medications as part of fall risk assessment (go to Tool 3I, "Medication Fall Risk Score and Evaluation Tools"). Strategies for reviewing medications will depend on your hospital but may consist of a pharmacist reviewing medications for patients with other risk factors or a nurse checking the patient's medications against a standard list and referring patients with a high-risk medication to a pharmacist. In either case, the pharmacist will make recommendations back to the medical team regarding medications to discontinue or doses to change.

3.3.6. How should risk factors be assessed in pediatric populations?

The risk assessment tools described above are appropriate for the general adult population. However, these tools may not work as well in differentiating the level of risk for hospitalized children. Risk assessment tools exist for pediatric settings but they may not have been as extensively validated as the Morse and STRATIFY scales.

For a review of pediatric assessment tools, see: Harvey K, Kramlich D, Chapman J, et al. Exploring and evaluating five paediatric falls assessment instruments and injury risk indicators: an ambispective study in a tertiary care setting. J Nurs Manage 2010;18:531-41.

3.3.7. How often is the assessment of fall risk factors done?

Consider performing a fall risk assessment in general acute care settings on admission, on transfer from one unit to another, with a significant change in a patient's condition, or after a fall. For patients with longer lengths of stay, performing a fall risk assessment at some regular interval may be valuable. However, the optimal frequency of risk assessment is unclear and may vary by unit.

Considering the specific patient situation, ask yourself and your team: How often should the assessment of fall risk factors be done on your unit? How often is it actually being done?

3.3.8. How can we improve the accuracy of the fall risk factor assessment?

The accuracy of a risk factor assessment tool depends on the person using the tool. Experience has shown significant variability among untrained staff even when evaluating the same patient. The results of the fall risk factor assessment need to be trustworthy; otherwise, they will be ignored. Therefore, training in how to complete the risk factor assessment is needed.

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3.4. How should identified risk factors be used for fall prevention care planning?

Knowing which patients have risk factors for falls is not enough; you must do something about it. Care planning guides what you will do to prevent falls. Once risk assessment has helped identify patient risk factors, care planning should match the identified risks. This includes planning for any risks found on the risk factor assessment tool, such as mobility challenges, medications, mental status, and continence needs. It also includes planning around a patient's personal risks that may not have been captured by the assessment tool.

3.4.1. What is fall prevention care planning?

Fall prevention care planning is a process by which the patient's risk assessment information is translated into an action plan to address the identified patient needs. These are the patient-specific actions that, in addition to the universal precautions described in 3.2, aim to prevent falls. Care planning's specific purpose is to identify specific care practices that will be implemented so that the patient is less likely to fall during the hospitalization.

Care planning accounts for multiple factors that pertain to the patient's problems, and the clinician therefore must synthesize multiple types of clinical data rather than just relying on one specific piece of information. Because each patient has a unique risk profile that needs to be integrated with care for the condition that caused hospitalization, the care plan should be individualized for each patient.

A carefully written care plan is a document that ensures continuity of care by all staff members. In addition, it can keep the patient safe and comfortable and can be used to educate the patient and family prior to discharge. The care plan is an active document. It needs to incorporate the patient's response to the interventions as well as any changes in his or her condition.

3.4.2. How should care planning address risk of falls?

The care plan indicates specific actions that should, or should not, be performed. All care planning needs to be individualized to fit the patient's needs. Each risk factor should have a corresponding plan of care.

There are many interventions available to prevent falls and fall-related injuries that you can implement based on the patient's specific risk factors. Below we list some of the major categories, by risk factor, that you can consider in your care plan, with electronic resources where appropriate.

Altered Mental Status

Patients with altered mental status should be assessed for delirium (Tool 3J, "Delirium Evaluation Bundle: Digit Span, Short Portable Mental Status Questionnaire, and Confusion Assessment Method"). Trained nurses or physicians can carry out a delirium assessment. If the patient is found to be delirious, a medical provider should evaluate the patient for causes, such as infections, medications, and electrolyte imbalances. But it is more effective to prevent delirium than to treat it. Delirium prevention may be an important part of the care plan for units that have patients at high risk for delirium (e.g., patients with hip fractures, advanced age, or baseline dementia, for example). Delirium prevention protocols are available on the Hospital Elder Life Program (HELP) Web site at no cost after registration: www.hospitalelderlifeprogram.org/public/public-main.php .viii

For cognitively impaired patients who are agitated or trying to wander, more intense supervision (e.g., sitter or checks every 15 minutes) may be needed. These patients should have their medications reviewed, as medications can both contribute to agitation as well as help calm patients whose agitation is a threat to themselves or others or is interfering with the delivery of necessary care.

We do not recommend bed alarms for the purpose of fall prevention in cognitively impaired patients. Unless the patient can be rescued rapidly after the bed alarm goes off, the patient may be able to exit the bed well before anyone can come to help. One large trial of bed alarms failed to show a benefit for prevention of falls.ix

Assess whether patients with altered mental status are delirious and therefore require further medical evaluation for delirium using the delirium evaluation bundle found in the Tools and Resources section (Tool 3J, "Delirium Evaluation Bundle: Digit Span, Short Portable Mental Status Questionnaire, and Confusion Assessment Method").

Safety Zones:A Strategy for Supervising Cognitively Impaired Patients Some hospital units have designated areas for patients at high fall risk. These areas have enhanced staffing to observe patients more closely. One hospital implemented this strategy using safety zones, which consisted of four patient rooms in each unit with one dedicated staff member responsible for those patients. The staff member checks on the patients every 15 minutes. These rooms are designated for cognitively impaired patients requiring (1) closer supervision, and (2) specialty equipment and activities. Safety zone room equipment includes low beds, mats for each side of the bed, night light, gait belt, and a "STOP" sign to remind patients not to get up. This model was originally implemented as a less costly alternative to the hospital's patient sitter program. The hospital reports the program has been successful in reducing fall rates and improving patient and family satisfaction.

Impaired Gait or Mobility

Patients with impaired gait or mobility will need assistance with mobility during their hospital stay. All patients should have any needed assistive devices, such as canes or walkers, in good repair at the bedside and within safe reach. If patients bring their assistive devices from home, staff should make sure these devices are safe for use in the hospital environment. Even with assistive devices, patients may need help from staff for mobility.

Patients with impaired mobility fall into three groups:

• Patients without mobility problems at home who were admitted to the hospital for a non-mobility-related reason (e.g., pneumonia). Some of these patients are at risk for deconditioning during their hospital stay, which can cause weakness and loss of mobility. These at-risk patients should participate in a mobility program. The HELP website includes information about a mobility program for use by trained volunteers, companions, or nursing aides. For appropriate patients admitted for non-mobility-related reasons, this program can help maintain mobility and decrease the risk of deconditioning during hospitalization.
• Patients who enter the hospital with a prior mobility deficit (e.g., from Parkinson's disease) but who are admitted for a non-mobility-related reason. Depending on the severity of the mobility deficit, these patients can be handled through physical or occupational therapy or through a mobility program. Tool 3K, "Algorithm for Mobilizing Patients," provides an algorithm for determining whom to include in a mobility program.
• Patients who were admitted to the hospital for a procedure that directly affects their mobility (e.g., total knee replacement) or a medical event that affects their mobility (e.g., acute stroke). These patients should be seen by a physical or occupational therapist.

Frequent Toileting Needs

Patients with frequent toileting needs should be taken to the toilet on a regular basis, via a scheduled rounding protocol (for example, go to Tool 3B).

Visual Impairment

Patients with visual impairment should have corrective lenses easily within reach.

High-Risk Medications

Patients on high-risk medications (go to Tool 3I, "Medication Fall Risk Score and Evaluation Tools") should have those medications reviewed by a pharmacist with fall risk in mind. Recommendations made to the treating provider for discontinuation, substitution, or dose adjustment. If a pharmacist is not immediately available, the treating provider should carry out the medication review.

The medication review may sometimes indicate that the patient needs to stay on a medication that increases the risk for falls because the benefits outweigh the risks, but the important point is that fall risk was considered. In addition, each hospital may need to develop its own approach to pharmacist-physician communication around medications to ensure that physicians carefully consider pharmacists' recommendations.

Units with a high proportion of patients on medications that cause orthostatic hypotension, such as psychotropic medications, may want to use a protocol for checking and reporting orthostatic vital signs (go to Tool 3F). Finally, the patient and patient's family should be alerted and educated about fall risk and steps to prevent falls when the patient is taking these medications.

If you have an electronic health record, be cautious about using computerized alerts to identify medications that put the patients at high risk for falls. If these alerts occur too frequently or inappropriately, they will be ignored. We recommend targeting the alerts to the specific population of interest and carefully pilot testing alerts with providers before a full-scale rollout.

Frequent Falls

Patients with frequent falls should have their injury risk assessed. This assessment should include checking for a history of osteoporosis, including prior low-trauma fractures or osteoporosis noted on a bone mineral density test. Although the effects are long term, treatment for osteoporosis should be considered if the patient is not already on treatment. Also, the patient's physical environment should be reviewed to reduce the risk of injury (e.g., making sure the patient's bed is set low when the patient is resting in bed).

In hospital units known to have a high prevalence of patients at risk for injury after a fall, consider making an injury risk assessment part of the admission evaluation. For thorough coverage of options to prevent fall-related injuries, go to the VA Sunshine Healthcare Network (VISN 8) Patient Safety Center of Inquiry Web site at www.visn8.va.gov/visn8/patientsafetycenter /fallsTeam/default.asp.

3.4.3. How should patients and families be involved in the care plan?

Patients and their families should understand the patient's fall risk and how the proposed care plan addresses this risk. Specific aspects of the care plan that patients and families can help implement should be identified. If learning needs have been identified, teaching to address knowledge gaps can occur.

Use of educational resources, such as written materials appropriate to language and reading level (go to Tool 3L, "Patient and Family Education"), can augment but not replace instruction. Patients and their significant others need to understand the potential consequences of not following a recommended prevention care plan as well as feasible alternatives and possible outcomes.

Every patient has the right to refuse the care designated in the care plan. In this case, staff are responsible for several tasks, including:

• Documenting patient's refusal.
• Trying to discover the basis for the patient's refusal.
• Presenting a rationale for why the intervention is important.
• Designing and offering an alternative plan and documenting the patient's response, including the patient's comprehension of all options presented. This alternative strategy needs to be described in the care plan and documented in the patient's medical record.

	Patient Education One hospital trains volunteers to provide fall prevention education to patients. Each volunteer spends 5-10 minutes visiting each patient every Monday, Wednesday, and Friday to review the fall prevention handout. This education is supplemental reinforcement and does not replace education provided by the nursing staff.

3.4.4. How should the risk factor assessment and care plan be documented and communicated?

Document fall risk factors, and interventions to address those risk factors, in the care plan. Documentation of care planning ensures continuity of care and staff knowledge of what should be done for the patient. Most hospitals choose to have a dedicated care plan form within the medical record. The care plan helps all staff members to be aware of a patient's risks.

Consider the following strategies to enhance awareness of fall risk factors and appropriate documentation:

• Incorporating fall risk factors and interventions in daily patient flowsheets.
• Including a discussion of fall risk factors and interventions as part of patient report or handover.
• Creating an automated daily report at the unit level that identifies which patients on the unit have which risk factors and which interventions are needed for those patients.

Because many of the risk factors for falls are important for other aspects of good care (e.g., mental status, continence status), try to set up a documentation system where the risk factor information is collected as part of a broader assessment of the patient's needs. That way, you only have to collect and document the information once.

Remember that while medical record documentation is necessary, it alone will not be sufficient. Communicating the patient's risk factors should occur orally at shift change, and by review of the written material in the medical record or patient care worksheet. The oral shift handoff should include any change in fall risk factors during the shift, including relevant medication changes, and should incorporate findings from hourly rounding.

	The following article describes an effort to communicate a patient's specific fall prevention needs by posting, above the head of the bed, icons that identify specific fall risk factors: Hurley AC, Dykes PC, Carroll DL, et al. Fall TIP: validation of icons to communicate fall risk status and tailored interventions to prevent patient falls. Stud Health Technol Inform 2009;146:455-9.
	Be thoughtful about the use of color-coded nonskid socks, magnets, and wristbands to identify patients at high risk for falls. In some units where virtually all patients are at high risk for falls, these cues may simply be ignored.

Patients demonstrating particularly high risk behaviors can be discussed as part of the unit's safety huddle (or safety briefing). A safety huddle is a short, informal meeting to cover issues related to patient safety. The safety huddle can be enhanced by a standard report (preferably gathered electronically) that summarizes which patients on the unit have which risk factors for falls.

In addition to shift change, medical rounds are an opportunity for interdisciplinary communication. For example, pharmacists may attend these rounds and provide an update to medical providers about medications that put the patient at higher risk of falls. Or, if attendance on rounds is not possible, pharmacists can place recommendations to change drug therapy as a consult note in the medical record.

Mobility programs that combine services of nursing and rehabilitation personnel offer another example of interdisciplinary communication and collaboration. Nursing assistants mobilize patients at risk for deconditioning who are in the hospital for non-mobility-related reasons. Physical or occupational therapists see patients with a need for skilled care or with weight-bearing limitations. Go to the resource box titled "One Hospital's Approach to Maintaining Patient Mobility" in section 6.4 for details.

Remember that the fall prevention component of the care plan needs to be updated periodically to be accurate. The care plan needs to be reassessed when a patient's risk factors are reassessed and are found to have changed. Typically this is when a patient changes units, has a change in health status, or has a change in medication associated with increased risk of falls. These updates also need to be followed up by a change in your actual care practices for the patient.

	Check whether the fall prevention component of the care plan is being updated appropriately on your unit.
	Read more about how one hospital developed a "ticket to ride" that summarized key aspects of the care plan for patients who needed to be transported between the unit and procedural areas. The ticket was designed to ensure a smooth handoff of care: Pesanka DA, Greenhouse PK, Rack LL, et al. Ticket to ride: reducing handoff risk during hospital patient transport. J Nurs Care Qual 2009;24:109-15.

3.4.5. What are barriers to care planning and solutions to these barriers?

Sometimes, putting together all the discrete parts of a care plan based on patient risk factors can be akin to putting together a puzzle. It takes time and the ability to see the whole picture, and it definitely requires patience and skill. There are many potential barriers to accurately completing care planning. Some that should be considered include:

• Time: Acuity of the patient population may mean the staff's time must be spent at the bedside and the development and documentation of care planning is delayed, thus increasing the chances of missed information.
• Expertise: Staff may not have the needed expertise to know which interventions to include or what they can do without a health care provider's order.
• Value of care plan: There may be a prevailing attitude that taking the time to write the care plan is not a priority. This is a unit or facility culture issue that needs to be addressed systemwide.
• Responsibility: The plan of care should be interdisciplinary. It is not just the nursing staff who develop and implement treatment plans. Physical and occupational therapists, pharmacists, and others are important contributors to fall prevention and need to be an integral component of the care planning process.
• Information technology: Some facilities have computerized charting that prompts care planning based on risk. These care plans may not be sufficiently individualized to the needs of the patient. With other systems, staff have to go to multiple screens, which can be time consuming and increases the chance of overlooking key elements.

Some solutions to the barriers above include:

• Using or creating systems that make care planning more streamlined by linking to the admission and followup fall risk factor assessments. Computer systems that tie assessment results directly to the care plan can provide useful decision support to staff, as long as the systems are flexible in allowing individualized care planning. For example, patients who are newly identified as at risk due to mobility problems may generate an automatic order for a physical therapy consult or a mobilization protocol, avoiding delays arising from care planning.
• Linking the care plan to routine practice. The plan of care, including addressing fall risk factors, should be routinely included in shift reports and patient handoffs. Prompts may be needed at first to incorporate the prevention program into everyday care practices.

Read more about how one health care system that uses an electronic health record developed a new system of tailored fall prevention care plans and overcame anticipated barriers through careful usability testing: Zuyev L, Benoit AN, Chang FY, et al. Tailored prevention of inpatient falls: development and usability testing of the fall TIPS toolkit. Comput Inform Nurs 2011;29:TC21-8.

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3.5. How should you assess and manage patients after a fall?

Despite our best efforts, patients will nonetheless fall. Some may even sustain an injury. When a fall happens, you will need to carefully assess the patient for any injuries in a systematic way. After the patient's needs are attended to, you need to document your findings in the medical record and complete an incident report.

In this section we highlight some elements of a careful clinical review for injuries and also discuss conducting a root cause analysis to understand the causes of the fall. An understanding of the events surrounding a fall can inform the care plan for the patient who fell, as well as guide ongoing quality improvement efforts at the unit level. Using data on falls to monitor your improvement efforts is discussed in more detail in section 5.

3.5.1. What is a postfall clinical review?

A postfall clinical review is a structured way to collect information after a fall. The clinical review aims to determine whether there are injuries or other complications (Tool 3N, "Postfall Assessment, Clinical Review"). The clinical review focuses on immediate risk of injury or complications. Depending on the type of fall and patient comorbidities, including clotting disorders and use of anticoagulants, the clinical review may include assessment for injury, serial neurologic exams, and a fresh fall risk factor assessment. The new assessment will include medication review and ordering of laboratory tests.

3.5.2. How is the clinical review performed?

Key components of the clinical reviewx include:

• Checks for signs or symptoms of fracture or potential for spinal injury before the patient is moved.
• Safe manual handling methods for patients with signs or symptoms of fracture or potential for spinal injury.
• Regular neurologic observations for all patients where head injury has occurred or cannot be excluded (e.g., unwitnessed falls).
• Medical evaluation, with an expedited examination of patients who have signs of serious injury or high vulnerability to injury or have been immobilized.

3.5.3. What is a root cause analysis?

Root cause analysis is used in organizations to evaluate and understand what problems contributed to error or undesired outcomes. After a fall, you will collect data to reconstruct the event and determine the causes of and contributing factors to the fall (Tool 3O, "Postfall Assessment for Root Cause Analysis"). The data collection will obtain information that may help prevent the next fall in this patient or future patients. The postfall assessment for root cause analysis captures information from the patient, staff, and other witnesses about how the fall occurred. For more on root cause analysis, go to section 5.1.6.

3.5.4. How are the clinical review and root cause analysis documented and communicated?

Many components of the clinical review and root cause analysis overlap. For example, understanding the circumstances of the patient's fall can assist in assessing the patient for injuries, while also being important for understanding potential causes. You may need to adapt Tools 3N and 3O to your hospital's specific needs.

Documenting and communicating the clinical review are critical to the patient's safety, because a medical provider may need to take action based on the assessment, such as ordering lab tests or imaging studies or changing medications. In cases of falls with significant trauma, the patient may need to be taken to surgery. An oral handoff to the treating medical provider is therefore essential.

Careful documentation and communication of your root cause analysis are critical to preventing future falls in the same patient. For example, if a patient was given a sedative overnight for insomnia and then fell due to being drowsy, the entire treating team (including nursing, pharmacy, and medical provider) needs to know what happened. That way, they will not prescribe the sedative again to that patient or future patients in similar circumstances. After a fall occurs and the patient's root cause analysis is complete, a safety huddle (go to section 3.4.4) may be appropriate so that the whole unit can learn from the event.

With frequent handoffs between hospital personnel, whether it be nursing staff who change shift every 8 hours, or hospitalists who rotate every week and have separate night or weekend coverage, communication is critical. The care plan discussed in section 3.4 (also Tool 3M, "Sample Care Plan") is an ideal place to document findings from the clinical review that the unit team should keep in mind throughout the hospital stay.

If applicable, the patient's risk factor profile can also be updated electronically by a designated member of the unit team to reflect the recent fall and any new risk factors that were discovered. For more information about what information should go into the hospital's incident reporting system, go to section 5.

3.5.5. What are challenges to performing the clinical review and root cause analysis?

There are significant challenges to performing a good clinical review and root cause analysis:

• Many falls are unwitnessed, and the patient may not be able to provide accurate information about what occurred.
• Falls often occur due to the confluence of multiple risks, which makes it difficult to identify a "smoking gun." For example, a new medication may interact with a patient's underlying cognitive or mobility limitations to precipitate a fall.
• A good root cause analysis requires input from multiple team members, and it may be difficult to assemble them rapidly.
• Time to perform a root cause analysis may be limited, especially at certain busy times of the day, such as at change of shift. Having a standard protocol, as described in 3.5.6 below, may address this challenge.

3.5.6. How can performance of postfall assessments be improved?

Performance of postfall assessments, whether for clinical review or root cause analysis, may be improved by having a standard protocol and ensuring that this protocol is easily accessible to staff on the unit. Also, the information gathered on the assessment tool should contain all the information needed to file an incident report (go to section 5) so that information does not need to be gathered twice. In settings where a medical provider makes scheduled rounds, having a nurse or pharmacist join rounds to discuss potential culprit medications related to the fall may improve the assessment process.

Read more about how one hospital used a dedicated fall evaluation service to improve postfall assessment: Shorr RI, Mion LC, Chandler AM, et al., Improving the capture of fall events in hospitals: combining a service for evaluating inpatient falls with an incident report system. J Am Geriatr Soc 2008;56:701-4. A modified version of the tool used in this study is presented as Tool 3O.

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3.6. How can your hospital incorporate these practices into a fall prevention program?

In section 3, we have outlined best practices in fall prevention that you can use to improve your fall prevention program. Research evidence suggests that your program is most likely to succeed when it addresses multiple components, including universal precautions (section 3.2), risk factor assessment (section 3.3), care planning (section 3.4), and postfall assessment (section 3.5). However, it may not be possible to tackle all these elements at once. In addition, you may want to include additional items beyond what is discussed here. Some of these items can be identified through the use of additional guidelines (go to section 3.7).

In addition to creating a program that is tailored to your hospital, you will need to customize the fall prevention program to each unit due to patient acuity and specific individual circumstances. Thus, it is important to identify fall risk factors that are more prevalent on each specific unit. For example, a neurology unit may have a high proportion of cognitively impaired patients requiring closer monitoring. A rehabilitation unit may have a high number of patients with mobility problems. Other units may have patients whose needs fluctuate rapidly or involve frequent patient transport. These include the emergency department, observation units for patients staying less than 24 hours in the hospital, and radiology. In addition, pediatric patients have special assessment tools, as discussed in section 3.3.5.

	Identify the units that will require customization of the fall prevention program. Adapt your program to meet the needs of the specific units.
	Examples from some hospital units addressing fall prevention. Note that some of these examples include activities that may be applicable to other units as well. Geri-psych unit: Direct line of sight to patients. 1:1 staff assignment for selected patients. Rounds every 15 minutes. Annual fall prevention education for staff. Routine assessment and documentation of orthostatic blood pressure and pulse changes. Medical unit: Nurses assess whether patient has a mobility deficit and request a physician order for a physical therapy consult if needed. The unit also uses patient sitters if a patient has had a fall. Patients are moved near the nurses' station if they do not follow instructions to get assistance to get out of bed. Pharmacists review medication profiles of patients. Triggers in computerized physician order entry provide an alert indicating high fall risk for various medications. Pharmacy tries to eliminate medications with high fall risk from formulary. Patient care technicians take patients to the bathroom. Physical therapist or nurse shows patient how to use mobility aid. Inpatient rehab: Interdisciplinary care planning includes nursing, occupational therapy, physical therapy, speech therapy, dietary, nurse practitioner, and social services. Nurse practitioner has responsibility for trying to wean patients off narcotics, and clinical pharmacist consult is ordered if needed. Pharmacy reviews each patient's medication profile within 24 hours of admission. Some patients are placed in safety zone (semiprivate rooms with a patient care observer on duty; go to section 3.4.2). Rehab aide is available to assist patients in ambulating during the day. Nurses assist during the evening and on weekends. Delirium prevention efforts include pharmacist review of patient medication profile, infection control program, and environmental factors. Neurology and/or postneurosurgical units: For high-risk patients, a computerized evaluation is conducted to determine required assistance with mobility aids or use of lift equipment. Decisions from evaluation are posted on white board in patient room. Floor has a dedicated physical therapist. If PT consult is ordered, PT determines progressive ambulation needs and fall prevention interventions are customized. Interventions for patients with cognitive deficits include involving more staff in care planning, asking family to stay with patient, and moving patient closer to the nurses' station. Nurses and physicians work together to evaluate medications that interfere with neurologic exam and alter patient's fall risk status. Physician is actively involved with delirium prevention, including avoidance of medications that may contribute to delirium. Pharmacy reviews medication profile for each patient.
	Read more about preventing falls in radiology in an article released by the Pennsylvania Patient Safety Authority: Falls in radiology: establishing a unit-specific prevention program. Pa Patient Saf Advis 2011 Mar;8(1):12-7. Available at: http://patientsafetyauthority.org/ADVISORIES/ AdvisoryLibrary/2011/mar8(1)/Pages/12.aspx.

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3.7. What additional resources are available to identify best practices for fall prevention?

A number of guidelines have been published describing best practices for fall prevention in hospitals. These guidelines can be important resources for improving fall prevention programs.

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3.8. Checklist for best practices

Once you have read through this section, use the checklist for best practices to monitor your progress on completing the activities that have been described here.

viii These materials are copyright protected, and all forms or their adaptations should acknowledge: © 2000, Hospital Elder Life Program, LLC. The user assumes all risk for use of the materials.
ix Shorr RI, Chandler AM, Mion LC, et al. Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients. Ann Intern Med 2012;157(10):692-9.
x Adapted from the U.K. National Patient Safety Agency, "Essential care after an inpatient fall." Available at: http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=94054&type=full&servicetype=Attachment .