Friends of Flo - Patient Falls

This week Dr. Rebecca Porter PHD, RN and Dr. Andrew Whitters DNP, ARNP sit down to discuss patient falls, including Dr. Porter's recent study on the subject. How can you nurses use fall prevention culture? Link to Dr. Porter's study on patient falls in the American Journal of Nursing: https://journals.lww.com/ajnonline/Fulltext/2018/05000/CE___Original_Research__Exploring_Clinicians_.22.aspx?WT.mc_id=HPxADx20100319xMP

Transcript

Narrator: 0:00

This episode of Friends of Flo is brought to you by NCLEX mastery. If you're a nursing student and you're about to take your NCLEX, you need to go to the app store right now and download NCLEX mastery.

Andy: 0:12

Hey everyone this is Dr. Andy Whitters here from Friends of Flo

Rebecca: 0:15

and Rebecca Porter. Hi Andy

Andy: 0:17

Hi Rebecca.

Rebecca: 0:21

I'm missing Tess today.

Andy: 0:21

We're missing our third leg here

Rebecca: 0:23

Yeah she's teaching today. Oh well, hi Tess.

Andy: 0:27

Well hey Tess

Rebecca: 0:27

So what do we talk today?

Andy: 0:30

Well I think we've got a couple of exciting things to talk about. You have published a couple of papers. And so, first of all, congratulations.

Rebecca: 0:38

Thank you. And so the one that I would like to talk about is the one on falls. Oh, that was a big project. So that's a huge nursing issue. And you know what's really crazy is that it's been going on for decades

Andy: 0:53

Yeah decades, right.

Rebecca: 0:54

People haven't figured out how to prevent falls.

Andy: 0:59

Right. And what about tracking, I would imagine tracking falls has changed

Rebecca: 1:05

Tell me about that

Andy: 1:05

Well I would imagine the advent of just computer charting and making it easier to harvest that....

Rebecca: 1:15

That's a very surgical word

Andy: 1:15

Yeah...is it a surgical word?

Rebecca: 1:19

Yeah

Andy: 1:19

Well I don't know what other word you use?

Rebecca: 1:24

Mine the data

Andy: 1:25

That sounds like an industrial word to me I guess.

Rebecca: 1:28

Yeah but I think that's a technology that we use in research is you go and mine data.

Andy: 1:33

Sure that makes sense

Rebecca: 1:34

Harvest the data

Andy: 1:36

Yeah, harvest the data, mine the data

Rebecca: 1:40

You've been in the OR too long

Andy: 1:42

(laughs) Harvest some vein to while I'm at it. So anyway, can you talk about your awesome publication

Rebecca: 1:49

This was a really interesting study so it was published in the May issue of the American Journal of Nursing. And you can get it free online if you just go google American Journal of Nursing and look at the May 2018 issue. I don't have it up in front of me, Andrew what's the title of the paper.

Andy: 2:11

So yeah,"Exploring Clinicians Perceptions about Sustaining Evidence Based Fall Prevention Program" so we can put this up even next to our broadcast.

Rebecca: 2:23

Oh, good idea, great idea.

Andy: 2:27

I like what you state in the conclusions of this study about how it's everyone's responsibility. Part of fall prevention is indeed the culture that is there on a unit. So I was wondering if you could just maybe speak to the culture and specifically how that relates to a nurse's responsibility of being that patient advocate too.

Rebecca: 2:56

Quality indicators for nursing are monitored and tracked very closely by insurance companies and particularly by Medicare and Medicaid. And so what we noticed was that despite having instituted a long time ago a fall risk assessment on every patient that falls were not going down.

Andy: 3:30

No pun. Right.

Rebecca: 3:32

No pun intended but falls were continuing to happen. And indeed when we went to the literature we found that there's a huge rate of falling still and the cost not only to the patient for the injury, physical injury, but the emotional impact of falling is huge. It makes them more afraid which increases the risk again for falling. And so we thought that we would do a qualitative study. I really like doing qualitative research. So I was asked if I would lead this part of the study. And we tried to talk to people from all disciplines besides nursing mostly nurses so I did focus groups with it and then I talked to some individual providers

Andy: 4:30

In the hospital setting though, correct?

Speaker 12: 4:33

In a hospital setting, this was an acute care hospital. We talked to nurses primarily from adult world and physicians and other groups from the adult world and we wanted to know why, what is going on that we have this really good fall prevention program. What is going on. And so we interviewed, I interviewed all these people and then we did this qualitative data analysis which is another discussion for another time but we came up with these two themes and one of the themes was how information is communicated. And the second issue is what is a hospital as an organization doing to help prevent falls. So when we look at the communication issue where the data came from was that everybody assumes that nursing holds the responsibility for preventing a fall. The non-nursing people didn't even know that fall data was collected.

Andy: 5:58

Oh interesting

Rebecca: 5:59

They didn't know that there is a very specific fall risk assessment tool that we use.

Andy: 6:09

So operationally speaking, I mean the management at this care facility wasn't passing that down the chain so to speak.

Rebecca: 6:18

Every unit was doing it differently. So nothing was standardized

Andy: 6:24

Interesting

Rebecca: 6:24

But going back to the communication. So a nurse would assess a patient for fall risk and put that information either in the chart on the electronic record and on the whiteboard in the patient's room and they would just have FRA, fall risk assessment with the number corresponding to the risk were following. And sometimes they would put a leaf on a door which meant that that patient is at a risk for falling. So when I talk to the non-nurses they had no idea, oh and it's talked about in bed huddle and patient care rounding, but two things, people who weren't nurses didn't know what the leaf was about. They had no awareness of what fall risk assessment was.

Andy: 7:27

Sure

Rebecca: 7:27

And they just figured that nurses would take care of it and if there was a problem they would talk to them. One of the non-nurse participants said well I just never talked to the nurses unless there's a problem.

Andy: 7:40

Wow.

Rebecca: 7:40

Wow. And one of the non-nurses said well if a nurse comes and tells me that somebody is at a risk for falling I just go do an assessment on my own.

Andy: 7:53

Which can be different then from the nursing assessment which is different you know perhaps from another unit.

Rebecca: 7:58

And the things that they look for are different than what the nurses look for. So then what the nurses talked about going into what you were asking about the culture and how an organization, what does the organization do to help prevent falls. One of the nurses in the nursing focus group said basically, if I'm with another patient how am I supposed to be with somebody else at the same time. Did I hear the alarm going and the nursing assistant is with somebody else and there's nothing I can do. I can't be in two places at the same time. So that becomes an issue of staffing within the hospital in the acute care setting that you can't be in two places at the same time, there aren't enough people. Bed alarms are used and there going. Another issue that came up in the culture of the hospital is are you standardizing across the whole hospital that everybody in a whole hospital knows that a leaf on the door means that this person has a risk for falling.

Andy: 9:19

Yeah I see what you're saying.

Rebecca: 9:21

And one of the other issues that came up was what about patients who want or need the door to their room closed. You know how when you're on a unit you kind of looking in on a room as you walk by.

Andy: 9:35

Right.

Rebecca: 9:35

You just see how somebody is doing and they might catch your eye and say oh could you move or get this for me. If you see somebody trying to get out of bed I hope you're one of the nurses that will run in and say,"whoa whoa whoa wait a minute I'm right here to help you" or"hold on while I get some help for you" But if the doors closed and what about people who are on immune suppression and have to have your door closed for isolation reasons and you can't be there. What do you do? How do you balance that? And what do you do in your unit. Do you make sure that everybody has your call bell right there and that you promise to be there as fast as you can when the door is closed. So those were things that were really important. What else struck you Andrew?

Andy: 10:29

Yeah so as I think about how this relates to the primary care practice particularly in the elderly population and long term care for instance, you mentioned standardization which is a great point. I for one visit several different facilities, long-term care facilities that to your point within the organization that you are evaluating, they all have different practices. They all have a different way of going about doing their fall risk assessment as well as what to do when somebody does have a fall. So for instance identifying a patient that has a fall risk. I've seen things like that leaf iconography on the door. But instead it might just be a black line that everybody knows that this black color means that you know indeed this patients at risk for a fall. But that's only within this one organization. Others are a little more direct and I prefer the direct verbiage of just saying fall risk. There's nothing to be ashamed of and I think that when you see a patient that's a fall risk you tell them that they're a fall risk and say hey, and it's an opportunity for a nurse or frankly whoever on the medical or health care team to say you're a fall risk, I need you to before you get up we prefer that you call your call light. Have one of the nursing aides or assistants or nurses come in here and help get you up and ambulating to where you need to go. That is an approach that I've seen as as a provider I can't empirically prove it. I've not done any research, but I think that's the best approach that works well.

Rebecca: 12:37

I think that you have good words. And I agree I think just the words fall risk. And we have isolation signs on...

Andy: 12:48

Yeah, exactly

Rebecca: 12:48

You know this person is at risk for falling and it may be just a risk for a few days or a couple of hours or whatever. But I think the signs should be in multiple languages and not assume everybody going into the room speaks English or reads English

Andy: 13:05

Sure that makes some sense.

Rebecca: 13:06

And maybe have a universe sign for falling on the door for people that don't read English or are illiterate and don't read. But standardizing that throughout a hospital is really important. I think from a hospital culture, facility culture is making sure that everybody understands what a fall risk is. How do you do the assessment. How is that information passed along to every single person including housekeeping. Housekeeping might see that somebody is trying to get out of bed and can ring a bell for the patient or go get help for the patient that physicians need to be taught how to ambulate a patient. We can no longer practice in these silos. This is a team...

Andy: 14:08

It's truly a team approach. You're absolutely right.

Rebecca: 14:10

It has to be and nurse practitioners who are doing patient care rounds, you still have RN behind your name.

Andy: 14:18

Absolutely.

Rebecca: 14:18

And you still have a responsibility of somebody needs to go to the bathroom to respect the human dignity of needing to go to the bathroom. It doesn't matter what letters you have behind your name.

Andy: 14:30

That's right

Rebecca: 14:30

It only take five minutes and surely you have five minutes. The other thing is a door closing on the unit and arriving. How do we handle this as a hospital or as a facility for people that are at risk for falling. One of the other things that came up that was really interesting, our facility has had a lot of renovations done and all the rooms are private rooms are moving towards being a private room which I would really appreciate if I were a patient. But it also means that nurses are divided between rooms. And it may be that your patient gets transferred to another bed within the unit. And you've followed them so that you've got a patient now on another end of the unit or you need to do some charting and the only computer available for you to chart on is on the other side of the unit away from where you see your patient. So these pods that are very popular in current hospital design isolate nurses from one another so that you cannot see another nurse, but you're supposed to be able to visualize all of your patients.

Andy: 15:58

Sure, sure

Rebecca: 16:01

So those are some of the things that came up...what other questions do you have Andrew?

Andy: 16:09

Yeah this is a good stopping point here just for this part of the discussion. We'll take a quick break and we'll be right back.

Narrator: 16:17

Here at NCLEX Mastery we love nurses and especially nursing students, but we need your feedback about this podcast. If you have ideas on topics or questions you want us to answer, shoot us a message, leave a comment, go to our Facebook page and just tell us what you think because we want to help you in the most specific way that you need that help. Thank you so much.

Andy: 16:40

And we're back, this is Andy from Friends of Flo

Rebecca: 16:42

and I'm Rebecca

Andy: 16:43

Hey Rebecca. So we got a great conversation going here....Yeah, the article of the the fall risk. We mentioned very briefly, I want to talk about the cost...

Rebecca: 16:57

Oh my goodness

Andy: 16:57

Of falls within the health care settings.

Rebecca: 17:00

So are you talking about financial cost or emotional cost?

Andy: 17:05

A little bit of everything

Rebecca: 17:06

So let's talk

Andy: 17:07

So I think about my own practice working with the elderly. I go to a couple of different facilities in the community. They again have different standardized practices within...

Rebecca: 17:22

Are they standardized throughout the facility?

Andy: 17:26

They're standardized just to that facility, this is the way we do things and period. That's it. End of story. We have to go to some kind of a committee to have it changed or manipulated which is good to some degree, but a lot of the facilities that I go to might have a population of only, you know, 30 or 20 people.

Rebecca: 17:46

Where I work there are over 700 beds

Andy: 17:50

Right. Whereas for a facility that's over 100 beds it's a little more difficult to insitute a standardized policy. Anyway I'm thinking in particular of one place I go to where if a patient has a fall even if it's just a scratch on their head or if they just fall to their knees and perhaps fall against a wall and it's witnessed and they hit their head and it merits the need for a C.T. scan. So it's not necessarily based on assessment, it's based on did this person hit their head.

Rebecca: 18:29

Right, and then they go to the hospital

Andy: 18:31

So they go to the E.R., right. And they had this big evaluation sometimes by ambulance. That's a monetary cost the ER's a monetary cost...

Rebecca: 18:40

Who pays for it?

Andy: 18:41

Well that's it. Who does pay for it?

Rebecca: 18:44

So does Medicare pay or do they get nicked themselves?

Andy: 18:47

So in most of the situations that I'm involved with insurance takes care of it. However, that contributes to the problem of the high cost of health care you know. You know in your heart and clinically speaking, you can look at this patient and say, this patients OK, assessment wise they are OK, but there's a policy that is buttoned up in this legal framework that says we need to protect ourselves and we put this patient through this...

Rebecca: 19:21

The trauma.

Andy: 19:22

Yeah the trauma of going through to the E.R. going into a C.T. scan

Rebecca: 19:29

Having to go sit in the E.R.

Andy: 19:30

Yes sit in the E.R. or even being medicated in the E.R. or perhaps before imaging takes place. Most people don't like to be drugged or anesthetized prior to.

Rebecca: 19:42

Why do they have to get drugged?

Andy: 19:44

Well if there is like an anxious event, if you have someone who has perhaps fallen or during an ER evaluation they're anxious they don't want to get a C.T. scan

Rebecca: 19:56

Putting your head inside that thing

Andy: 19:57

Right. Yeah, it's traumatic for some people, right? And so all of this adds up to just a huge financial cost and it's a burden to the medical system. All because we have a policy that says this needs to be done and it has its roots in a legal framework. So we don't get sued. That to me is a cost of falls. It's also the difference that we see in policies. Other places I go to might have more of a assessment based...we use nursing judgment, especially if it's a witnessed fall. Oh they hit their head against their mattress or something as they fell, but you know what? They're okay, their neck is more sore than anything else.

Rebecca: 20:48

If someones on coumadin, you might have a higher threshold or lower threshold for going to the ER for a head bump.

Andy: 20:56

Yes exactly and then also based on what clinical symptoms look like.

Rebecca: 21:00

Right, over time

Andy: 21:01

Yeah, over time. That time can be defined as a couple minutes or even like a couple hours because things change clinically

Rebecca: 21:09

Right, and a subdural can can pop up days later. So it's just everybody being aware. Wow. And then we look at, you know, costs to the medical system of a fall. I can't remember the numbers that I saw. But the whole system is got to be nearly a billion dollars.

Andy: 21:31

I wouldn't be surprised

Rebecca: 21:32

And then you look at if somebody injures themselves, breaks a bone, has had surgery and traumatizes a surgical site. They need sutures if they fall and cut themselves. And these are all huge trauma for them for patients and then their family. But can you imagine as a patient if you've fallen, just the psychological trauma and the fear of falling. Have you ever tripped over anything?

Andy: 22:10

Yeah, of course(laughs)

Rebecca: 22:11

And you know you feel yourself going down. Yesterday, I was out watering plants and I was pouring a hose out and I was in between two stones and I had on rubber clogs and I felt myself slipping and I just said a very bad word and grabbed a tree so that I wouldn't fall because I imagine cracking my head on the side of a stone. OK, you're going to be a fall risk for the rest of your life now because you cracked your head on a stone. But my neighbor, a young woman, fell and got stitches in her chin and she said,"wow you know it's really changed how I run, I'm really watching things now" That's a young person, but if you're sick or you are elderly and not very strong physically, the fear of falling and then the trauma of the fall must be huge.

Andy: 23:04

Yeah, of course. I think another aspect for nurses in particular, especially the newer nurses that are out there; if you see and and understand that a patient is at risk for a fall....think about your other health care colleagues like who else can help. So like physical therapy your occupational therapy

Rebecca: 23:23

You're nurse practitioner

Andy: 23:24

Yeah, you're nurse practitioner. You're restorative therapists that can maybe give some some movement exercises to your patients to help build muscle and get some range of motion exercises going to eventually help prevent that patient from falling in the future.

Rebecca: 23:42

Right, and educating the patient.

Andy: 23:43

Right, educating the patient's huge.

Rebecca: 23:44

What happens, do you think, when a patient falls to that trust relationship? With the family, with you and your patient. I would feel horrible if one of my patients fell.

Andy: 24:05

Sure, sure. I think particularly to the trust issue. I think that it would go down. I think it is the same thing for family members. I think they would lose confidence that a facility or the health care team, including nurses, would have the ability to take care of their loved one.

Rebecca: 24:23

Right

Andy: 24:24

And that in a sense is a cost too.

Rebecca: 24:26

So one of the ways to prevent this is to look at your fall prevention work that you do you in your unit and in your facility and to make sure that everybody including your patient understands that a risk for falling and that it's not just because you're old it's not just because you've had surgery, but you know you're in a different environment. There's equipment around. And what we're doing to help prevent that. So I would like to talk for a minute about what happens when you have to go to your bathroom and there's nobody around. What would you do? Well if it was you in bed and you had to pee...

Andy: 25:16

And I couldn't ambulate, is that what you're asking?

Rebecca: 25:18

What must that feel like?

Andy: 25:21

I think what you're speaking about is being able to empathize with your patient and preserving that sense of dignity

Rebecca: 25:31

That human dignity

Andy: 25:34

We're all human, we all have biological functions that need to be recognized especially when we're ill or in a in a setting that's not

Rebecca: 25:44

We're vulnerable and that thing about respecting human dignity is actually one of the very first statements in the nursing code of ethics is what we do to protect human dignity. And I think going to the bathroom preserves human dignity. The privacy of going to the bathroom preserves human dignity. I can't even imagine what it is to have to call for help to go to the bathroom. I mean you and I we can all get up and say, excuse me for a minute. And we don't even say where we're going. And you go to the loo and you come back. But now you have to ring a bell and announce it now over the intercom to everybody at the nursing station, I have to go to the bathroom. Well you were just there an hour ago what's this about.

Andy: 26:39

I imagine it'd be very difficult to be a patient. And I think it's my purview as a practicing nurse practitioner and no matter what initials I have behind my name which is DNP. And I get plenty of respect from my colleagues and including nursing facilities I visit. I would, I'm always making myself available to help the patients and their most basic needs even if it means to cover them up. So if they're in the OR for instance, if they're just laying on the bed and just completely stripped and naked we can preserve dignity by covering them up.

Rebecca: 27:22

Right

Andy: 27:22

Same thing in clinical practice in a primary care setting. If someone needs help to just simply stand up and maybe get a commode underneath them, humble yourself as a provider and as a human just to assist. I'm not saying all the time but I mean if you can it's not something that should matter what your credentials are. It's not just a nursing aides job it's not just a nurses job.

Rebecca: 27:52

It's a physician job it's a PA job

Andy: 27:54

Exactly

Rebecca: 27:54

I remember talking to a friend of mine because I was irritated that they did not help a patient go to the bathroom and they said to me,"well, I didn't know how to do that and that's what you do"

Andy: 28:08

See that's an inappropriate response I would say.

Rebecca: 28:11

So we had this little conversation about how would you feel if that was your mother or your sister or your brother or your child who needed to go to the bathroom and one of your physician colleagues said, oh just hold on I'll go find a nurse. And then you decide to go have a cup of coffee. Where is that coming from. Where does that come from? And again it's a culture thing.

Andy: 28:40

It's a culture thing yeah sure it is.

Rebecca: 28:41

So how it is that how we pattern, how we share and respect your human dignity.

Andy: 28:46

I would advise, especially the new nurses and advanced practice nurses out there, when they start their practice and don't forget that you're a nurse and you know you're also human and you should humble yourself to do those actions that are not so pleasurable at times in your line of clinical work. Be there to help out other nursing colleagues. It's a great way to earn respect. And plus it's a great way to earn your patients trust right. So that's some general advice I would give.

Rebecca: 29:28

Well I think we're about ready to wrap up here and I that...have a look at the article and see what you think. Send us your questions or thoughts and I challenge you to look at where you work and look at the cultural assumptions of who is responsible for fall prevention and how is that shared and should it be changed? So I think that's all we have today. It's been great talking with you Andrew.

Andy: 30:04

It's been so pleasurable talking with you too Rebecca.

Rebecca: 30:06

Take care everybody.

Andy: 30:08

All rightt. This is Friends of Flo saying innovate agitate and educate.

Rebecca: 30:12

And take care.

Narrator: 30:13

Here at NCLEX Mastery we love nurses and especially nursing students, but we need your feedback about this podcast. If you have ideas on topics or questions you want us to answer, shoot us a message, leave a comment, go to our Facebook page and just tell us what you think because we want to help you in the most specific way that you need that help. Thank you so much.