Technology and the State of Falls Prevention – a Talk with Pat Quigley
AvaTalk recently interviewed Patricia Quigley, PhD, MPH, ARNP, Associate Director, VISN 8 Patient Safety Center of Inquiry in the Department of Veterans Affairs. She is nationally known for clinical research, publications and presentations on patient safety, particularly in fall prevention. She has co-authored falls prevention toolkits for the VA and for the Institute for Healthcare Improvement.
AvaTalk: Healthcare providers have tried every intervention imaginable to prevent falls, from bed alarms to floor mats to signage to hourly rounding to safety huddles, and yet it is not clear there has been a serious impact on reducing fall rates nationally. Why has there been so little progress?
Quigley: So many complex factors are associated with efforts to reduce falls and fall injuries in healthcare. The science over the last couple of decades lacks empirical rigor needed to confirm effectiveness within and across vulnerable populations based on risk; drive implementation strategies that close the gap between evidence and practice; and engage patients, caregivers and interdisciplinary teams in care delivery and evaluation. The evidence is clear: Effective fall prevention program must be based on multi-factorial fall and injury risk assessment and interdisciplinary care management. When you consider people who are coming into hospitals today, unless they’re coming in for elective surgery, they’re really, really vulnerable. The patient population in hospitals is about 45% over the age of 65 and aging. They are admitted into the hospital with multiple risk factors, and then enter into an unfamiliar environment. Additionally, they’re taking medications that they may not have taken before. Thus, we have a huge opportunity to do something different to control for and reduce risk.
Another important factor to consider is the role of fall-risk screening. Many facilities adopt practices to reduce fall risk that rely on a fall risk score to drive fall-prevention strategies or a level of fall risk, like low, moderate or high. When nurses and teams are implementing interventions based on a score or a level of risk, then they’re not treating someone’s actual fall risk factors. To actually be able to prevent a fall, we have to know why someone is at risk for falls – what the actual fall and injury risk factors are, identify the factors that are modifiable and those that are not, treat those factors that are modifiable and help patients compensate for risk factors that are not modifiable.
Rarely in hospitals do you find organizations addressing fall prevention based on specific populations and their characteristics. For example, what practices are in place to protect vulnerable populations are risk for loss of life or loss of function if they fall – such as people over the age of 85 versus someone under 50? It has to be a different approach.
Having said all of that, I am so thankful for the Affordable Care Act and the Partnership for Patients. Through that program, hospitals engaged in collective and rigorous strategies to reduce falls and falls with injury.
AvaTalk: You and your team at the VA emphasize fall injury prevention, rather than fall prevention. Tell us how that emphasis affects your approach to solving the falls challenge.
Quigley: The patient population that we care for in the Department of Veterans Affairs is an adult population, mostly men. Our veterans are an aging population that we want to help age well and to remain independent. We take care of those who’ve borne the battle for us and others to be free, and we strive to maximize our veterans’ freedom, independence and safety. We accept that not all of our veterans are going to call for help – such as help to go to the bathroom. They are wonderfully independent, autonomous adults. Sometimes they get up without calling for help and accidently fall. We accepted a long time ago that we couldn’t prevent all falls. There are accidental falls, such as those that are due to slips, trips and multi-tasking. People fall because they have sudden heart attacks or strokes or seizures, which are unanticipated physiological falls.
Anticipated falls, in contrast, are falls that happen because of known risk factors inherent to a specific person. People can fall and get up and they don’t get injured, while some falls result in injury. Our priority has been that we don’t want anyone to die from a fall. We also don’t want our patients to fall and break a hip. Men over the age of 70 who do so have a 30% higher mortality within a year. Therefore, we have implemented interventions that reduce the risk of death and reduce the risk of fracture due to a fall.
Since the VA’s early patient safety efforts, dating to before the 1999 Institute of Medicine’s report, To Err Is Human, our patient safety leadership focused on injury reduction as a primary outcome. That’s how we focused on hip protectors to reduce hip fractures; conducted research on the effectiveness of hip protectors; developed and disseminated hip protector toolkits; and persuaded veterans to wear them to reduce hip fractures.
Also, we examined how to reduce trauma if someone falls from bed. We tested the effectiveness of floor mats to reduce trauma sustained from a fall. Thus, the risk for injury and the interventions to reduce injury when a fall occurs are separate and distinct from the interventions that are specific to preventing falls.
AvaTalk: The VA, through its National Center for Patient Safety, has recently updated its Falls Toolkit. What was the goal for this update?
Quigley: VAs national Falls Toolkit had been in the public domain since 2004 and available to the entire healthcare world. It provided guidance on how organizations establish fall-prevention programs that were aligned to someone being at risk for falls – irrespective of low, moderate or high fall risk. This toolkit had guidance resources on how to create an interdisciplinary team for your whole program in a hospital, the roles of each member of that team, and how that team should lead the fall and fall injury prevention program throughout an organization – not just at the unit level, but to own the program and to be able to evaluate its effectiveness. In addition, we had resources that were made available, including educational videos and fall and injury reduction posters to increase awareness.
The toolkit was over a decade old, though. In the past 10 years, our efforts have focused on reduction of head injuries and hip fractures due to falls. We also implemented a population-based approach to injury reduction. That’s how we got started with what’s called the ABCS populations. A is for age – people over the age of 85 and those who are frail. B is people at risk for bone fracture or already had a fracture. C is for people on chronic anticoagulation, since as Coumadin. If they fall, no matter where they are, they’re going to bleed. And your S population is post-op patients, for whom a fall can have serious consequences.
In addition, we did a lot of cross-referencing our new toolkit with other toolkits that are available. The Agency for Healthcare Research and Quality released its national falls toolkit in 2013, led by Dr. David Ganz, a geriatrician out of the greater Los Angeles VA. Julia Neily (the Associate Director of the VHA National Center for Patient Safety Field Office) and I both served as clinical experts to shape that toolkit’s prioritized clinical practices. VA’s tools have actually shaped and contributed to many toolkits. We were able to build upon other published works and still really focus on injury reduction as a primary outcome, in addition to our population-based approach to fall prevention and injury reduction.
Another significant component that we added to the updated falls toolkit that has really helped nurses and teams is the post-fall huddle. That is an essential intervention to prevent repeat falls due to the same immediate or root cause. When a patient falls in our care, we need to figure out why they fell and what was the immediate cause, and then determine, based on the immediate cause, what interventions to implement.
AvaTalk: What are the essential elements of a successful fall injury reduction program?
Quigley: Well, the four recommendations that really guide all of our work, all of our strategic planning and our population-based toolkits come from an article by Dr. David Oliver and colleagues, “Preventing Falls and Fall Injuries in Hospitals,” in the November 2010 volume of Clinics in Geriatric Medicine. The first recommendation that we are responsible for is to create a safe environment. We need to reduce the risk factors associated with an unfamiliar, equipment-filled environment to reduce accidental falls.
The second recommendation is to make sure that the interdisciplinary team should determine patients’ fall risk factors and which ones are modifiable. People have risk factors that are modifiable and those that are not. One factor that is not modifiable, for example, would be the permanent functional limitations after a stroke.
The third recommendation is that we treat the modifiable risk factors for falling and in so doing reduce anticipated physiological falls.
The fourth recommendation is to protect patients from injury should such a fall occur. This recommendation is actually our first priority – to protect our veterans from injury.
In the VA, we do not have an overreliance on a screening scale. We don’t focus on a score; we don’t focus on low, moderate or high fall risk. We focus on reducing fall risk by creating safe environments and reducing fall risk factors, and protecting patients from injury should a fall occur.
AvaTalk: Much of your program centers on nursing practices, but there is also emphasis on using technology, such as alarms. How important is advancing technology as a part of a fall prevention program?
Quigley: Well, the way that I like to be able to help people think about the use of technology is that it needs to be considered as part of the toolkit. Nurses need more options to be able to help with fall injury prevention strategies, but they have to be used appropriately.
For example, bed alarm use seemed to spread like wildfire, even though bed alarms were never designed to prevent falls. They were designed to be early warning systems. But yet, so many organizations started linking bed alarm usage to high fall risk. I ask people, “How did this happen?” If a bed alarm was never designed to prevent a fall, how did it get linked to a score on a fall risk screening scale? When nurses do that, all they’re doing is implementing universal fall precautions, and that alone doesn’t work. There are also so many false positives with alarms. So here you have all this noise, all these false alarms that’s driving staff to this bedside, and the patient isn’t even trying to get up.
If technology is going to be used, people have to consider what’s the right piece of technology for the right patient; how are we going to orient a patient to this technology, and how are we going to educate family about this technology so they know beforehand why and how it’s going to be used.
AvaTalk: What is your view of remote video monitoring as a potential solution?
Quigley: Well, I think the AvaSys program by AvaSure is very exciting and it has emerging effectiveness. Being able to maintain real-time surveillance for patients at risk for falls or have other issues that make them unsafe has real promise. We’ve actually had real-time camera surveillance systems for patients in emergency departments, psychiatric holding areas and critical care areas for a long time. What the AvaSys program does is bring this kind of technology to the point of care for something as specific as fall prevention.
I am particularly excited by the mobile component of AvaSys, where you can move that technology from one room to another or put it at the end of a hallway or in a rehab unit or in long-term care, where you know that people are trying to get up – such as a day room. This technology has the opportunity to be able to eliminate all the noise that’s associated with bed alarms.
AvaSys also has the opportunity to reduce the use of sitters. We’ve all known for a long time that sitters don’t prevent falls. To be able to prevent a fall means you have to be paying attention and you have to be within arms’ reach, and even at those times you can’t prevent a fall. If a patient was to fall, and if someone was within my arms’ reach, that person must protect the patient from a serious injury, protecting the head on the way down – not the whole body. Literature specific to the relationship of sitter and fall prevention effectiveness lacks scientific rigor, but describes that fall rates are not reduced.
The other unique aspect of AvaSys is that there’s two-way communication. So the person watching the monitor, if they see someone getting up, the monitor tech can actually talk to patient. Now, that might be a concern for patient who’s got confusion or delirious might be looking to find the source of the voice. So again, it’s really important in trying to know who are we going to be able to use this aspect of our technology with, or who we need to have concerns about.
AvaSys also has capabilities to collect data, put in specific notes about a patient for the monitor technician. There are just a lot of aspects to the program that are very exciting for today’s healthcare industry.
AvaTalk: Any advice for people who are looking at this technology?
Quigley: Yes, actually there is. All the organizations that are actually evaluating the effectiveness of this technology and are presenting their results – whether they’re at conferences or getting ready to do some publication – they need to be very clear about the falls that are being prevented, and not just presenting effectiveness in relationship to all falls and overall fall rate. Did the technology help reduce near falls – patients who were trying to get up from bed and received attention? Did the technology prevent a fall that was associated with walking to the bathroom? Did the technology prevent a fall due to an environmental hazard, such as spilled water? Because you’ve got real-time surveillance, you can actually quantify the risk factors for a near fall, an actual fall, and then the type of fall.
To advance research related to the effectiveness of this technology, they need to report the fall, location, contributing factors, what happened – the immediate or root cause, the type of fall, was it an assisted fall and was the patient injured. The real opportunity is to quantify the number of near falls and true falls where someone really was getting up and someone got there in enough time to be able to prevent that fall, as well as those falls that were not prevented, but still someone got to the patient in time to reduce the risk of injury. These data capture your safety net.