Contact email

msd4cs@virginia.edu

Overview

This project compared patient engagement with the three-step fall prevention process across the three Fall TIPS (Tailoring Interventions for Patient Safety) modalities (an electronic health record (EHR) version, a laminated paper version, and a bedside display version) to reduce in-hospital fall incidents.

Department

Department of Medicine

Collaborators

Megan Duckworth, BA
Jason Adelman, MD, MS
Katherine Belategui, RN
Zinnia Feliciano, RN
Emily Jackson, RN, MBOE, NEA-BC
Srijesa Khasnabish, BA
I-Fong Sun Lehman, DrPH, MS
Mary Ellen Lindros, EdD, RN
Heather Mortimer, RN
Kasey Ryan, RN
Maureen Scanlan, MSH, RN, NEA-BC
Linda Berger Spivack, MS, RN
Shao Ping Yu, MPH
David Westfall Bates, MD, MSc
Patricia C Dykes, RN, PhD, MA

Status/Stage of Development

Completed

Funding Sources

Funding of an unspecified amount came from the Agency for Healthcare Research and Quality.

Practice Setting

Academic Hospitals - (Brigham and Women's Hospital), Montefiore Medical Center (Bronx, NY), New York-Presbyterian Hospital (Manhattan, NY)

National/Policy Context

  • Across the nation, falls in hospitals pose a threat to patient safety and increase length of stay. National in-hospital fall rates vary between 3.3 to 11.5 falls per 1000 patient days, with 25% of these falls resulting in injury.
  • This issue led to the development of the electronic Fall TIPS Toolkit, which is a three-step fall prevention program consisting of: (1) assessing fall risk, (2) developing a tailored fall prevention plan, and (3) partnering with patients and families to ensure consistentconsistent implementation of the plan. The Fall TIPS Toolkit is available in three modalities (selected by champions at each site to fit with workflow): a laminated poster, an electronically generated poster, and a paperless patient safety bedside display.

Local/Organizational Context

  • Although implementation of the Fall TIPS Toolkit resulted in a 25% reduction in fall rates, there are a number of patients who receive the Fall TIPS intervention and still fall. This is most commonly due to lack of patient adherence to their fall prevention plan. This project aims to determine the most effective modality of educating patients and families in the three-step fall prevention plan.

Patient Population Served and Payor Information

  • Patient characteristics by site:
    • The patient population at Brigham and Women’s Hospital is 54% female and 46% male; 86% Non-Hispanic, 9% Hispanic, and 5% unavailable; and has an average age of 60.5.
    • The patient population at Montefiore Medical Center is 56% female and 44% male; 48% Non-Hispanic, 37% Hispanic, and 15% unavailable; and has an average age of 60.1. 
    • The patient population at New York-Presbyterian has an average age of 60.3. Ethnicity and gender distributions are unavailable.

Project Research + Planning

  • The original Fall TIPS study was a mixed-methods study that began with a qualitative phase, interviewing stakeholders to assess the requirements for an effective and practical fall prevention toolkit. Before launching the project, the laminated Fall TIPS toolkit was developed using these requirements and piloted for 6 months at two sites. The pilot studies showed a high rate of adherence (>80%) and a reduction in injury rates (up to 47%). The >80% adherence rate was then used a benchmark for clinical significance for lowering frequencies of fall-related injuries.

Tools or Products Developed

  • Laminated Fall TIPS Toolkit: Used by hospitals that lacked access to EHRs. This laminated tool utilizes a color-coding system to highlight patients’ fall risk factors and tailored evidence-based interventions. 
  • Patient Safety Bedside Display: Nurses would document the risk assessment and tailor the fall prevention plan in the EHR. This modality guarantees that the displayed information on the bedside is up-to-date.

Tech Involved
  • Electronic medical record
Team Members Involved
  • Administrative Assistant
  • RNs
Workflow Steps

  • The Fall TIPS information would be available in three modalities: (1) EHR form, (2) laminated Fall TIPS poster, and (3) bedside display of fall risks.
    • When a patient is assigned to a room, the nurses would assess a patient’s risk of falling with the patient and complete documentation in the EHR at least once per day (varies by hospital protocol). 
    • The nurse would then tailor the fall prevention plan in the EHR guided by the built-in clinical decision support. 
      • In rooms without a Fall TIPS poster, the bedside monitor was also populated with the information the nurse collected. The bedside display would therefore serve to present the most up-to-date information at all times. 
    • Throughout this process, the patient and family should be engaged to develop a partnership in executing the fall prevention plan. 
      • All clinical staff, not just the nurse, are encouraged to reinforce the fall prevention plan with the patient and family.
    • The plan must be updated per hospital protocol and as the patient’s status changes. The plan should be reinforced at least daily, reiterating the partnership between patient and clinical staff. 
  • For the study, nurses audited patients selected at random to assess their knowledge of Fall TIPS. 
    • Nurses would also check for the presence of the Fall TIPS fall prevention plan at the bedside to measure protocol adherence. 
  • Nurses provided peer-to-peer feedback to remedy any issues (i.e lack of knowledge) that were barriers to nursing staff completing the three-step fall prevention process.

Outcomes

  • Knowledge of fall risk factors and plan: All three modalities achieved clinically significant rates of >80% of patient engagement and adherence.
  • Patient and Family Engagement: Measured as percentage of patients and family members who reported knowing their personal fall risk factors and plan across the three Fall TIPS modalities.
    • Results did not show any significant difference in engagement across the three modalities.
  • Protocol adherence: All units achieved 80% adherence, measured as display of personalized fall prevention plan at bedside.

Benefits

With an 80% adherence rate with the Fall TIPS protocol, this study suggests that all three modalities (EHR, laminated version, and bedside display) are effective approaches for preventing falls.

Intervention-Specific Challenges

  • Since this intervention was deployed at three different hospitals, there are limitations to the study due to differences in communication channels, social systems, and leadership. These factors could potentially confound the levels of patient engagement in terms of Fall TIPS utilization and protocol adherence. 
  • Not all hospitals have EHR access. To address this, the team implemented laminated Fall TIPS as an alternative modality option.

Sources

  • Dykes PC, Bogaisky M, Carter EJ, Duckworth M, Hurley AC, Jackson EM, Khasnabish S, Lindros ME, Lipsitz SR, Scanlan M, Yu SP, Bates DW, Adelman JS. Development and Validation of a Fall Prevention Knowledge Test J Am Geriatr Soc. 2019 Jan; 67(1):133-138. PMID: 30300920.
  • Dykes PC, Duckworth M, Cunningham S, Dubois S, Driscoll M, Feliciano Z, Ferrazzi M, Fevrin FE, Lyons S, Lindros ME, Monahan A, Paley MM, Jean-Pierre S, Scanlan M. Pilot Testing Fall TIPS (Tailoring Interventions for Patient Safety): A Patient-Centered Fall Prevention Toolkit Jt Comm J Qual Patient Saf. 2017 Aug; 43(8):403-413. PMID: 28738986.
  • Dykes PC, Carroll DL, Hurley A, Lipsitz S, Benoit A, Chang F, Meltzer S, Tsurikova R, Zuyov L, Middleton B. Fall prevention in acute care hospitals a randomized trial JAMA. 2010 Nov 03; 304(17):1912-8. PMID: 21045097
  • Carroll DL, Dykes PC, Hurley AC. Patients’ Perspectives of falling while in an acute care hospital and suggestions for prevention. Appl Nurs Res. 2010 Nov; 23(4):238-41. PMID: 21035035
  • Dykes PC, Carroll DL, Hurley AC, Benoit A, Middleton B. Why Do Patients in Acute Care Hospitals Fall Can Falls Be Prevented J Nurs Adm. 2009 Jun; 39(6):299-304. PMID: 19509605
  • Dykes PC, Adelman J, Alfieri L, Bogaisky M, Carroll DL, Carter E, Duckworth M, Erickson JI, Flaherty LM, Hurley AC, Jackson E, Khasnabish S, Lindros ME, Manzano W, Scanlan M, Spivack L. The Fall TIPS (Tailoring Interventions for Patient Safety) Program: A Collaboration to End the Persistent Problem of Patient Falls. Nurse Leader. 2019; In press.
  • Duckworth M, Adelman J, Belategui K, Feliciano Z, Jackson E, Khasnabish S, Lehman IS, Lindros ME, Mortimer H, Ryan K, Scanlan M, Berger Spivack L, Yu SP, Bates DW, Dykes PC. Assessing the Effectiveness of Engaging Patients and Their Families in the Three-Step Fall Prevention Process Across Modalities of an Evidence-Based Fall Prevention Toolkit: An Implementation Science Study. J Med Internet Res. 2019 Jan 21; 21(1):e10008. PMID: 30664454.
  • Dykes PC, Adelman J, Adkison L, Bogaisky M, Carroll DL, Carter E, Duckworth M, Herlihy L, Hurley AC, Khasnabish S, Kurian S, Lindros ME, Marsh K, McNinney T, Ryan V, Scanlan M, Spivack L, Shelley A, Yu SP. Preventing Falls in Hospitalized Patients. American Nurse Today. 2018; 9(13):8-13.
  • Duckworth M, Leung E, Fuller T, Espares J, Couture B, Chang F, Businger AC, Collins S, Dalal A, Fladger A, Schnipper JL, Schnock KO, Bates DW, Dykes PC. Nurse, Patient, and Care Partner Perceptions of a Personalized Safety Plan Screensaver. J Gerontol Nurs. 2017 Apr 01; 43(4):15-22. PMID: 28358972.
  • Leung WY, Adelman J, Bates DW, Businger A, Dykes JS, Ergai A, Hurley A, Katsulis Z, Khorasani S, Scanlan M, Schenkel L, Rai A, Dykes PC. Validating Fall Prevention Icons to Support Patient-Centered Education. J Patient Saf. 2017 Feb 22. PMID: 28230576.
  • Dykes PC, Leung WY, Vacca V. Falling Through the Crack (in the Bedrails). AHRQ Web Morbidity and Mortality Cases and Commentaries. 2016. View Publication
  • Katsulis Z, Ergai A, Leung WY, Schenkel L, Rai A, Adelman J, Benneyan J, Bates DW, Dykes PC. Iterative user centered design for development of a patient-centered fall prevention toolkit. Appl Ergon. 2016 Sep; 56:117-26. PMID: 27184319.
  • Dykes PC, Stade D, Chang F, Dalal A, Getty G, Kandala R, Lee J, Lehman L, Leone K, Massaro AF, Milone M, McNally K, Ohashi K, Robbins K, Bates DW, Collins S. Participatory Design and Development of a Patient-centered Toolkit to Engage Hospitalized Patients and Care Partners in their Plan of Care. AMIA Annu Symp Proc. 2014; 2014:486-95. PMID: 25954353;
  • Dykes PC. Adding targeted multiple interventions to standard fall prevention interventions reduces falls in an acute care setting. Evid Based Nurs. 2012 Oct; 15(4):109-10. PMID: 22809569.
  • Carroll DL, Dykes PC, Hurley AC. An electronic fall prevention toolkit: effect on documentation quality. Nurs Res. 2012 Jul-Aug; 61(4):309-13. PMID: 22592389.
  • Dykes, PC Hurley, AC Lipsitz, S. JAMA. Preventing Falls in Acute Care Hospitals—Reply. 2011; 305(7):671-672. View Publication
  • Zuyev L, Benoit AN, Chang FY, Dykes PC. Tailored prevention of inpatient falls: development and usability testing of the fall TIPS toolkit. Comput Inform Nurs. 2011 Feb; 29(2):93-100. PMID: 20975543
  • Dykes PC, Carroll D, McColgan K, Hurley AC, Lipsitz SR, Colombo L, Zuyev L, Middleton B. Scales for assessing self-efficacy of nurses and assistants for preventing falls. J Adv Nurs. 2011 Feb; 67(2):438-49. PMID: 21073506
  • Dykes PC, Carroll DL, Hurley A, Gersh-Zaremski R, Kennedy A, Kurowski J, Tierney K, Benoit A, Chang F, Lipsitz S, Pang J, Tsurkova R, Zuyov L, Middleton B. Fall TIPS: strategies to promote adoption and use of a fall prevention toolkit. AMIA Annu Symp Proc. 2009 Nov 14; 2009:153-7. PMID: 20351840
  • Hurley AC, Dykes PC, Carroll DL, Dykes JS, Middleton B. 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. PMID: 19592885
  • About Fall TIPS. Retrieved from http://www.falltips.org/about-fall-tips/ 

Innovators
  • Megan Duckworth, BA
  • Patricia C Dykes, RN, PhD, MA
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