1 Running head: OUTPATIENT FALLS Outpatient Falls Reduction Utilizing a Universal Fall Screening Tool Haley Hathaway & Irene Maiyo Michigan State University College of Nursing 4/19/2023 2 OUTPATIENT FALLS Table of Contents Abstract/Executive Summary…………………………………………………………………….4 Introduction……………………………………………………………………………………….5 Background/Significance…………………………………………………………………5 Problem Statement/Clinical Question…………………………………………………….7 Organizational Assessment “Gap Analysis” of Project Site……………………………...8 Purpose of the Project…………………………………………………………………….8 Theoretical Framework/Evidence Based Practice Model/QI Model…………………….8 Review of the Literature………………………………………………………………………….9 Goals/Objectives/Expected Outcomes………………………………………………………….11 Methods…………………………………………………………………………………………12 Project Site and Population…………………………………………………………….12 Ethical Considerations/Protection of Human Subjects………………………………….13 Setting Facilitators and Barriers…………………………………………………………14 The Intervention and Data Collection Procedure……………………………………….14 Timeline…………………………………………………………………………………15 Measurement Instrument(s)/Tool(s).................................................................................16 Analysis…………………………………………………………………………………………16 Sustainability Plan………………………………………………………………………………17 Discussion/Implications for Nursing……………………………………………………………18 Cost-Benefit Analysis/Budget………………………………………………………………….19 Conclusion………………………………………………………………………………………20 References………………………………………………………………………………………21 3 OUTPATIENT FALLS Appendices………………………………………………………………………………………… Appendix A………………………………………………………………………………26 Appendix B………………………………………………………………………………28 Appendix C………………………………………………………………………………49 Appendix D………………………………………………………………………………50 Appendix E………………………………………………………………………………52 Appendix F……………………………………………………………………………….53 Appendix G………………………………………………………………………………54 Appendix H………………………………………………………………………………58 Appendix I……………………………………………………………………………….59 Appendix J……………………………………………………………………………….60 4 OUTPATIENT FALLS Abstract Background: Outpatient falls result in injuries and hospitalizations that generate billions of dollars in medical costs annually. Adults aged 65 and older are the group most frequently affected by falls. Changes in healthcare status, decreasing eyesight, strength, and mobility issues can all contribute to issues for this patient population. One proven way to help decrease falls is identification and intervention with at-risk individuals. The use of a universal screening tool is an efficient and effective way to identify patients who are at-risk for falling or have already fallen and require interventions to avoid future falls. Purpose: The purpose of this quality improvement project is to identify older adults who are at risk for falls through utilization of a universal fall screening tool. Methods/Implementation/Plan/Procedure: The project was implemented at Michigan State University Health System Family Medicine Clinic. Clinic staff were educated on the CDC STEADI fall screening tool, flyers were used as reminders in the clinic, and an implementation staff ‘champion’ was identified and utilized. Older adults were screened for fall risk using the CDC STEADI fall screening tool and flagged within the electronic health record. Use of the STEADI fall screening tool in older adult patients and appropriate flagging of at- risk patients were evaluated as the primary outcomes. Fall incidence and fall-related injuries are among the secondary outcomes. Implications/Conclusion: Identification of at-risk older adults using a universal screening tool is an appropriate and cost-effective approach to prevention and reduction of falls and fall-related injuries in older adults. Keywords: Falls, older adults, elderly, seniors, geriatric, primary care, primary healthcare, general practice, GP 5 OUTPATIENT FALLS Outpatient Falls Reduction Utilizing a Universal Fall Screening Tool A fall is an unintended descent to the floor that may result in an injury to an individual (Phelan et al., 2015). What often comes to mind when one thinks about patient falls is a hospitalized patient made fragile and at-risk by illness, medications, or surgery. It may be surprising to learn that falls in the outpatient setting are all too common, with injuries and hospitalizations costing insurance companies billions of dollars annually (Centers for Disease Control and Prevention [CDC], 2021). Besides the financial cost, lives can be altered or lost due to injuries sustained like broken bones and head injuries (CDC, 2021). Older adults, age 65 and older, are the group most frequently subject to accidental fall-related hospitalizations and deaths (Injury and Violence Prevention Section, 2018). Falls in older adults can result in serious injuries affecting patients in several aspects such as decline in ability to perform daily living activities, increase in emergency room visits, institutionalization, or even death (Taylor-Piliae et al., 2017). There is an increase in incidence of falls in older adults, injuries related to the falls and the cost of treatment of injuries related to falls. Falls result from multiple factors such as individuals that are frail related to age, chronic diseases and environmental interactions and can lead to serious injuries such as fractures and brain trauma injuries (Berková & Berka, 2018). The purpose of this paper is to identify a usable tool to help reduce the incidence of falls and fall- related injuries in the outpatient setting. Background In 2014, there were 29 million falls in the United States, with 7 million of those falls requiring medical treatment (Lee, 2017). In 2018, there were approximately three million emergency room visits, over 950,000 hospitalizations, and about 32,000 deaths as a result of fall- related injuries (Moreland et al., 2020). In 2015, fall-related medical costs totaled more than $50 6 OUTPATIENT FALLS billion; Medicare and Medicaid paid for around 75% of this cost (CDC, 2021). The Centers for Medicare and Medicaid Services (CMS) have created a Merit-based Incentive Payment System (MIPS) that measures the quality of care given to patients and reimburses accordingly (Centers for Medicare and Medicaid Services [CMS], 2018). This measurement is based upon various categories, like quality, and this is measured based upon reports of appropriate care and screenings, like a fall-risk assessment, being completed (CMS, 2018). There are various extrinsic and intrinsic factors that may contribute to an individual’s risk of falling. Environmental factors like medications, alcohol and drug use, footwear, and assistive devices can contribute to fall issues (Phelan et al., 2015). Individual factors such as cognitive and/or sensory deficits, acute illness, behavior and choices, and deficits in strength, balance, and/or gait can also be fall risks (Phelan et al., 2015). The United States population is also aging, with 65 and older individuals projected to be one in five by 2030 (Lee, 2017). In Michigan, from 2006-2015, over 68% of the fall-related hospitalizations, and over 83% of the fall-related deaths, annually, were in individuals over the age of 65 (Injury and Violence Prevention Section, 2018). Older individuals frequently worry about falling, with 50% of older people having worrisome thoughts about falling at some point (Ellmers et al., 2022). Fear of falling can also lead to deconditioning of individuals, with muscle wasting and increased imbalance increasing fall risk (Ellmers et al., 2022). On the other side of the same coin, overconfidence often leads to falls as an individual believes themselves capable of more than they are physically able (de Clercq et al., 2021). In 2018, 63.7% of the population of the United States, aged 65 and older, had two or more chronic health conditions (Boersma et al., 2020). To manage these chronic conditions, patients frequently visit outpatient care centers including primary care and specialty offices. As 7 OUTPATIENT FALLS more than 90% of patients typically see a provider at least once per year, this presents an excellent opportunity to screen patients for the various risk factors, many of them modifiable, that place them at increased risk for falls (Dellinger, 2017). There are a variety of risk factors including polypharmacy, balance impairment, gait abnormalities, vitamin D deficiency, vision, impairment, and home/environmental factors (Dellinger, 2017). In 2012, a Cochrane Systematic Review showed that clinical assessment, referral if necessary, and follow up of risk factors helped reduce fall rates by 24% (Phelan et al., 2015). A fall risk assessment consists of 5 pieces: a physical assessment, review of medications, a fall history, and assessment of environment and function (Phelan et al., 2015). Use of an effective fall risk screening tool, utilized to gather initial information about patient health and risk factors, can allow for a more in-depth screen and identification of at-risk patients prior to falls occurring. Problem Statement/Clinical Question There is a worryingly high incidence of falls in adult patients within outpatient clinical settings. Older adults are at greater risk for falls and injuries related to the falls, and screening for this population for fall risk is key in prevention and reduction of falls and fall-related injuries. Annual fall risk screening in addition to individualized clinical evaluation and management can reduce fall incidence. Multifactorial and individualized fall risk interventions should be implemented to reduce falls and fall-related injuries of patients at risk and for patients with a history of falls. Reduction of falls using fall assessment and intervention can significantly impact public health and improve quality of life in older adults (Moreland et al., 2020; Taylor-Piliae et al., 2017; Berková & Berka, 2018). 8 OUTPATIENT FALLS Clinical question: PICOT - In adult patients, does the use of a universal fall assessment, identification of high-risk patients in the Athena Health System, and staff education on safe transfer techniques, compared to the current practice decrease fall incidence. Organizational Assessment “Gap Analysis” of Project Site When assessed in 2022, MSU Health Care had no universal fall screening tool. There was inconsistency in fall risk assessments and screening tools being used by providers. Fall risk assessment was consistently performed on patients during Medicare Wellness Visits, but other than that there was inconsistency in screening. In the fall occurrence report, 2020-2022, 50% of the fall occurrence patients were not assessed for fall risk (Appendix A). A universal fall risk assessment tool would be useful in identifying adult patients at risk for falls. A universal tool could also provide assessment and intervention, while ultimately reducing fall incidence and fall-related injuries, and hopefully improving patient quality of life. Purpose of the Project This project aimed to institute a universal screening tool for fall risk, to be utilized by all staff on all pre-identified patients. This project also sought to establish a method of identifying patients deemed at-risk and who necessitate fall risk screening. In identifying at-risk individuals and appropriately screening for fall risk, we hoped to reduce the frequency of outpatient falls. Evidence Based Practice Model/QI Model The evidence-based practice intervention we utilized to assist in outpatient fall reduction in the clinical setting was the use of a fall-risk assessment tool on patients ages 65 and up. As evidenced in the following literature review, fall-risk assessment tools do help to identify patients at risk. This identification can occur before a fall happens, allowing for targeted education and interventions to hopefully prevent any future falls. The Chronic Care Model 9 OUTPATIENT FALLS includes six areas that may help to improve health care (Institute for Healthcare Improvement, 2022). Our intervention utilized clinical information systems to assess fall risk, thereby affecting change in patients’ lives. Plan Do Study Act (PDSA) cycle is a tool that has been shown in evidence to facilitate quality improvement. The PDSA tool was used to guide in the planning, implementation, review, and analysis of the intervention (Institute for Healthcare Improvement, 2022). Review of the Literature Search Strategy A systematic literature search was conducted to determine available literature and data on older adult patient falls in outpatient clinics. Fall screenings and interventions in the older adult population was the focus of the literature search. The literature review search was conducted using the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the National Library of Medicine’s MEDLINE (PubMed) databases. Key search terms included “Falls” AND “Older adults or elderly or seniors or geriatric” AND “Primary care or primary healthcare or general practice or gp” which yielded 726 articles. “Older adults fall prevention in primary care” yielded 1021 articles. Selection Criteria Studies were selected based on the relevance to the quality improvement project on prevention or reduction of older adult’s outpatient clinic falls. Studies were selected based on abstract and title. Inclusion criteria included publication in the last five years, full text, study subjects greater than 65 years of age, demographic in the USA, English language, and human subjects. A total of 13 articles were reviewed based on the themes of intervention (Appendix B). The articles chosen encompassed various study types including randomized control trials (3), 10 OUTPATIENT FALLS cohort studies (3), systematic review and meta-analyses (4), cross sectional studies (1), observational case-control study (1), and systematic review (1). Literature Findings The literature reviewed demonstrated the importance of fall prevention in older adults and the different intervention strategies that can be implemented to avoid falls, fall-related injuries, hospitalizations, and even death. Fall Risk Screening Routine fall risk screening and provider and patient-involved interventions are associated with a reduction in fall frequency and severity (Mark et al., 2020; Mackenzie et al., 2020). Proper screening techniques and utilization of time with the patient for complete assessment of risk factors, many of which are modifiable, can help to minimize the risk of falls (Davenport et al., 2020). Fall Risk Assessment Assessing patients’ individual fall risk factors using a multifactorial approach to assess items such as age, gait, medications, comorbidities, home environment, visual acuity, history of falls, and fear of falling among others compared to a single intervention has been associated with a reduction in falls (Bhasi et al., 2020; Harper et al., 2017; Gomez et al., 2017; Tricco et al., 2017), fall-related injuries such as fractures (Lamb et al., 2020) and improved quality of life (Lamb et al., 2020). Fall risk assessment including high-risk medications assessment, mobility assessment, and intervention involving physical therapy evaluation or referral or exercise program intervention reduces fall incidences and emergency room visits for fall-related injuries and produces better outcomes with balance-related exercises (Goldberg et al., 2020; Sherrington et al., 2017). 11 OUTPATIENT FALLS Fall Risk Interventions Single fall risk interventions, like the use of exercise alone as a fall prevention strategy, were associated with lower risk of injurious falls compared to usual care (Tricco et al., 2017). Other interventions such as fall screening and the deprescribing of medications commonly related to falls such as antiarrhythmics, anticholinergics, sedatives, antipsychotics, antidepressants or antihypertensives as a fall prevention strategy has not been proven to reduce fall incidence as a sole intervention (Lee at al., 2021; Naharci & Tasci, 2020). Individualized and simple algorithm fall screening and intervention such as the STEADI initiative and grouping patients as at-risk or not at-risk with an individualized fall plan of care is a successful tool in reducing older adult falls, fear of falling, and fall-related hospitalizations (Gomez et al., 2017; Johnson et al., 2019). Literature Summary In summary, the literature pointed to the benefits of screening and intervention in the reduction of falls and fall risk in older adults. The above findings supported the need for a universal screening process and tool to be utilized within the outpatient setting. Routine universal fall screening, coupled with patient-provider involvement and individualized multifactorial intervention, as highlighted in the CDC STEADI fall screening tool (CDC, 2017) (Appendix G), can be an effective approach to reduce fall incidence in an outpatient clinical setting. Goals, Objectives, and Expected Outcomes The goal of this project was to identify an intervention to reduce the number of falls in the MSU Health Care system. The goal and objectives of the project were identified and set in a specific and measurable manner to achieve the expected outcome. Data was collected using record review to assess the effectiveness of the intervention in meeting the expected outcomes. 12 OUTPATIENT FALLS Primary outcome of this project was the utilization of the CDC STEADI fall screening tool in patients at MSU Health System and appropriate flagging of at-risk patients in the Athena electronic medical record. Secondary outcomes included fall incidence, injury from falls, hospitalizations, or death. Methods Project Site and Population The clinic targeted for this quality improvement project was Michigan State University Health Care. Michigan State University (MSU) Health Care is a non-profit academic medical center of Michigan State University. MSU Health Care is a clinical health system of MSU’s human health colleges, whose primary focus is to improve the health of Michigan through healing and caring, form joint ventures and partnerships, and leverage their expansive clinical research and expert educational strengths for their patients. The health system serves a population that includes students, faculty members and their families, and community members across the state of Michigan. MSU Health Care provides services such as diagnostic and support services (imaging and pharmacy), primary care (family medicine, internal medicine, and pediatrics) and specialty care including neurology, cardiology, endocrinology, sports medicine, surgery, physical medicine, and rehabilitation. MSU Health Care is a faculty practice of Michigan State University and is composed of health care professionals from the College of Human Medicine, Osteopathic Medicine, and Nursing who are actively involved in teaching, research, and direct patient care. Team members include physicians, nurse practitioners, physician assistants, pharmacist, nurses, psychologists, social workers, and therapists working together to improve the health of their patients. MSU Health Care operates six primary care 13 OUTPATIENT FALLS locations and provides an average of 234,918 patient visits annually in the primary care and specialty clinics (Michigan State University [MSU], n.d.). MSU Health Care uses Athena Health System electronic health record in collaboration with Epion health system. Epion health system is a digital system downloaded into a mobile device providing patient-provider partnership. A typical patient visit involves a pre-visit questionnaire screen form through EPION which includes a medical history, depression screening, anxiety screening, COVID-19 symptoms screening, and check-in. On the day of the visit, the patient is checked in at the front office by the front office staff. Once checked in, the system alerts intake staff (Medical Assistants [MAs]), and the patient is brought to the exam room by the MA and the intake process begins. Intake includes a vitals check, reason for the visit, and medical and medication history review. After intake, the patient is ready for the provider visit and examination. Providers are notified of “patient-ready” status after intake staff document in Athena. The provider (Physician, Nurse Practitioner, or Physician Assistant) meets with the patient for medical history and medication review and a physical assessment, and then works together with the patient to come up with a plan of disease management or prevention and follow up. After completion of the provider visit, the patient is ready for check out, and check out is provided by the front office staff. Nurses are team members in health and play a crucial role in patient education and follow up on patient cases. Ethical Considerations/Protection of Human Subjects Michigan State University Internal Review Board (IRB) approval was obtained prior to initiating the DNP Project. Once approval was received, the project began in practice. To protect patient confidentiality, an informed consent form was gathered from each patient eligible to be part of the data collection. Standards of Care are the level of skill, care, and treatment 14 OUTPATIENT FALLS demonstrated by one provider that would be recognized as appropriate by another similarly skilled provider (Bergé, 2021). These standards of care, along with HIPPA protection, offer patients assurance that their personal information is gathered only for research purposes and will not be shared unnecessarily. Setting Facilitators and Barriers MSU Health Care encompasses six locations that see an average of 234,918 patients annually (MSU, n.d.). Site interaction was minimal. As the intervention we were interested in studying involved the use of a tool already in place within the utilized EHR, there was very little required to begin use. A short orientation as to where to find the tool, how to chart it under identified patients, why it was being utilized, and what the goal was in using it was provided to staff prior to initiation of the intervention study timeframe. Our community partner facilitated the site orientation, as she is an employee of MSU Health Care, and familiar with the clinical site being utilized. Strength, weakness, opportunity, and threat (SWOT) analysis was completed (Appendix E) to identify factors that would strengthen or cause barriers to implementation of the universal fall screening tool in MSU Health Care. The Intervention and Data Collection Procedure The project intervention was the use of a universal fall screening tool in the MSU Health Care EHR system. The universal screening tool used was the CDC STEADI fall screening (Appendix G). CDC STEADI fall screening tool was already implemented in the Athena EHR and was the only tool used by the health system during the project timeframe. The MSU Health Care clinic that initiated the trial of the proposed project was the Family Practice Nurse Practitioner clinic. Clinic staff were educated on the intervention by our team, with reiteration from our partnership with a MA ‘champion’ on-site. Since the screening tool was already 15 OUTPATIENT FALLS available for use in the electronic health system, we expected and received minimal resistance or barriers to implementation. Plan Do Study and Analyze (PDSA) cycle tool was used in the implementation, analysis, and review of the intervention. Data was collected using a record review method. Electronic medical record charts of patients within the targeted population, and seen during the intervention time frame, were reviewed at the end of the implementation phase. All deidentified data was gathered by the project’s community partner, an employee of MSU Health Care with access to the Athena EHR. Data was provided through a secure email server from the community partner to project authors for analysis. All data has been kept secure in a password protected file. Chart review goal was to identify if the patient was screened for fall using the CDC STEADI fall screening tool, and if they did was the patient flagged appropriately in the electronic medical record chart. Flagging is a feature available in Athena electronic records where a patient is identified using a sticky note by staff. The “flag” feature is a bright color-coded note identifying fall risk status as red (high risk), yellow (at risk) or green (no risk) and is easily visible when a patient’s health record is accessed by any staff member. At the completion and data collection stage, it was discovered that sticky note flagging was not a data point that was collectible from patient charts. Baseline data was collected from the clinic identifying the need for an intervention (Appendix A). Timeline The proposal for this project was submitted for IRB approval September 22, 2022. Approval was received October 20, 2022, and the project was sent to our community health partner at MSU Health Care for implementation that began November 7, 2022, with continual evaluation and review. Data collection and analysis were completed February 2, 2023, with presentation of outcomes and results on April 19, 2023 (Appendix D). 16 OUTPATIENT FALLS Measurement Instrument/Tools Outcomes of this DNP project were measured using de-identified data collected from electronic chart review. The data collected and analyzed included incidences of fall screening using the CDC STEADI fall screening (Appendix G), age of patient screened, whether screening was completed on all patients based on targeted population, and other outcomes such as fall incidence or injuries from falls. Charts were audited for intervention outcomes as outlined above. Analysis Analysis of project success was twofold. The first piece involved analyzing how well the screening tool was utilized. The screening tool cannot be effective in identifying at-risk patients if it is not consistently used on the identified patient population. In addition, any falls recorded within the identified clinical setting being studied must be analyzed. As over 50% of the recorded outpatient falls occurring within the MSU Health Care system were in individuals 65 and older, the focus of screening tool use was targeted at the departments/specialty offices servicing that age group. The only way to effectively evaluate the intervention was to analyze the data to determine whether it was put into use (i.e. - screening of identified individuals at each visit). Once the intervention time frame concluded, data was retrieved from the site utilized for the intervention. Data gathered included numerical counts of total patients seen, number over age 65, number over age 65 screened using the screening tool, number identified as at-risk, and falls data for the same timeframe (Appendices H, I, & J). Success of the intervention was determined based upon the consistent use of the screening tool, use on the correct age group, and possibly a reduction in fall occurrence during the intervention time frame. 17 OUTPATIENT FALLS The project was completed based on the identified need for screening and intervention due to occurrence of outpatient falls. As shown in the data gathered between 2020-2022, there were 49 incidences of falls, 40 with injury (Appendix A). Further reiterating the need for intervention, was the fact that 63.2% of the 49 falls were in the 65 and older patient population (Appendix A). Project completion and data collection and analysis revealed multiple interesting points within the study. For example, of the 1,035 eligible patient encounters during the project timeframe, 71 were screened and 964 were not screened (Appendix H). Of the 71 patients screened, 14 were found to be low fall risk, 32 were moderate fall risk, 14 were high fall risk, and 11 were not scored due to missing components on the screening tool (Appendices G & I). There were no incidences of falls reported during the project timeframe. This is of clinical significance for the future use of a universal screening tool. If within the short project timeframe there was a reduction to no incidences of falls, the long-range outlook for the use of screening and fall reduction is positive. Sustainability Plan For the suggested intervention to become a regularly utilized tool, it must become a habit for staff to screen the appropriate patients during each visit. For something to become a habit, it must be practiced consistently for a period of time. The sustainability plan for this project intervention was to make it a required part of the check-in/rooming process for patient visits. Identified staff were responsible for administering the screening tool and interpreting the results. The thought in creating a habit was that if the screening tool is a necessary part of checking a patient in, much like gathering vitals, it will become second nature to make it a part of each visit. Unfortunately, upon analysis of the project data, it was discovered that of 1,035 encounters with patients eligible for screening only 71 were actually screened (Appendix H). Also, there were 18 OUTPATIENT FALLS multiple opportunities for screening with certain patients, as the 1,035 eligible encounters included patients who were seen more than once during the project timeframe. This inconsistency could be due to numerous factors including short staffing, new staff, and/or float staff within the clinic setting during the time of the project implementation. Whatever the explanation, if the screening is to be truly successful in the future, the inconsistencies will need to be ironed out and the tool utilized without fail with each patient 65 and older. Discussion/Implications for Nursing The MSU Health Care system is made up of various offices containing specialty and family care service providers. Patients seen in these clinics span the ages from birth to old age. As falls can be prevented, the institution and utilization of a universal fall-risk assessment tool could make a significant impact on the patient outcomes and clinical practice of the MSU Health Care providers. Identification of at-risk individuals allows for targeted care and education to hopefully prevent a fall from ever occurring. As there was no universally utilized tool or screening taking place, it was projected, with the data found in other studies, that screening and follow-up with those identified by the tool would result in a reduction of outpatient falls. As the screening tool already exists within the MSU Health Care Athena EHR, there was no cost related to implementation. Further, when looking at the long-term use of this fall-risk assessment tool, there could be various other pieces that could be examined down the road including narrowing the age range, refining the criteria for screening, and fine-tuning the educational practice with those patients identified as at-risk. Patient falls have an impact on patients and health care systems. Older adults are at a higher risk of injuries, hospitalization, or even death as a result of a fall (Taylor-Piliae et al., 2017). Falls were the leading cause of death in older adults in 2020, causing more than 36,000 19 OUTPATIENT FALLS deaths. Falls also resulted in injuries such as hip, wrist and arm fractures, and head injuries resulting in more than 3 million emergency room treatments (CDC, 2023). Injuries sustained from falls affect patients’ quality of life through the loss of ability to perform daily living activities, often ending up in rehabilitation facilities, long term care, or dependent on family. Furthermore, older adults are often afraid of falling again after a fall or near fall episodes. This affects their lifestyle, as their attempts to avoid falling leads to decreased physical activity, in turn making them weaker and prone to falls (CDC, 2021). Older adult falls are a huge financial burden to patients and the health care system. Approximately $50 billion is spent yearly on medical costs related to fall-related injuries, with three-quarters of that cost covered by Medicare and Medicaid services (CMS) (CDC, 2023). Fall screening is a proactive way to prevent falls in the older adult population. Fall prevention using universal screening tools will help to identify at-risk individuals. Identification of at-risk individuals will allow for education and follow up that will hopefully prevent falls and fall-related injuries. Prevention of falls can save the patient and the clinic from the financial costs associated with falls and demonstrate the provision of quality collaborative care between the patient and the provider. Cost-Benefit Analysis/Budget The budgetary constraints of this project were neutral to the organization (Appendix F). The screening software was already in place within the Athena EHR. Staff participating in the screening efforts were briefed on the use of the screening tool and its implementation process which was currently in place. A new feature, “flagging” of at-risk patients, in the electronic medical record, was implemented in the software and staff were educated on the new feature and universal STEADI screening tool through daily huddles and quality meetings. 20 OUTPATIENT FALLS Conclusion Outpatient falls present a very real health risk to patients. Patients over the age of 65 are even more at risk due to a variety of issues including, but not limited to, reduced visual acuity, balance and coordination issues, polypharmacy, and home issues. Luckily, there are a variety of interventions that have proven useful in helping to identify patients at risk and offer interventions to hopefully reduce or eliminate falls. One such intervention is the use of a fall risk assessment tool within the outpatient clinical setting to identify at-risk patients. This tool is easily administered, quick to score, and quite useful in starting the conversation about fall risk and risk reduction. Currently, within the MSU Health Care setting, there is no universally administered fall risk assessment, and no parameters as to whom should be screened. This quality improvement project sought to change that by utilizing a tool already in place and easily accessible for clinic staff. Outpatient falls have statistically occurred more frequently in the 65 and older population, thus these patients were the target of the new screening process. The goal of this project was to ensure the routine use of the universal screening tool, specifically on patients 65 and older, and to hopefully see a reduction in fall rates during the project timeline. With the use of the universal screening tool (STEADI) there was an increase in screening of 65 and older individuals from zero to 71. There was a fall reduction in the 65 and older patient population from 63.2% of outpatient falls prior to screening initiation, to zero after project completion. This project has shown that screening is necessary and may be easy to implement into the admission process for each clinic patient. With consistent application and use, the beneficial reduction in fall risk and outpatient falls could be spread throughout the MSU Health Care system. Systemic use of screening would provide quality care, and in turn would reduce medical costs, prevent injury, and allow for patient and provider health collaboration. 21 OUTPATIENT FALLS References Bergé, P. I. (2021). The medical standard of care: A pot of gold at the end of the rainbow and other myths. Journal of Legal Nurse Consulting, 32(4), 20-24. Berková, M., & Berka, Z. (2018). Falls: a significant cause of morbidity and mortality in elderly people. Pády: významná příčina morbidity a mortality seniorů. Vnitrni lekarstvi, 64(11), 1076–1083. Boersma, P., Black, L. I., & Ward, B. W. (2020). Prevalence of multiple chronic conditions among US adults, 2018. Preventing Chronic Disease 2020. 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Enhancing patient care: Transitioning from the Physician Quality Reporting System (PQRS) to the Merit-based Incentive Payment System (MIPS). Retrieved from https://www.cms.gov/Medicare/Quality-Initiatives -Patient-Assessment-Instruments/PQRS/Downloads/TransitionResources_Landscape.pdf 22 OUTPATIENT FALLS Davenport, K., Alazemi, M., Sri-On, J., & Liu, S. (2020). Missed Opportunities to Diagnose and Intervene in Modifiable Risk Factors for Older Emergency Department Patients Presenting After a Fall. Annals of Emergency Medicine, 76(6), 730–738. https://doi- org.proxy2.cl.msu.edu/10.1016/j.annemergmed.2020.06.020 de Clercq, H., Naudé, A., & Bornman, J. (2021). Older adults’ perspectives on fall risk: Linking results to the ICF. Journal of Applied Gerontology, 40(3), 328-338. https://doi- org.proxy1.cl.msu.edu/10.1177/0733464820929863 Dellinger, A. (2017). Older adult falls: Effective approaches to prevention. Current Trauma Reports, 3(2), 118-123. https://doi.org/10.1007/s40719-017-0087-x Ellmers, T. J., Wilson, M. R., Norris, M., & Young, W. R. (2022). Protective or harmful? A qualitative exploration of older people’s perceptions of worries about falling. Age and Ageing, 51(4). https://doi-org.proxy1.cl.msu.edu/10.1093/ageing/afac067 Goldberg, E. M., Marks, S. J., Ilegbusi, A., Resnik, L., Strauss, D. H., & Merchant, R. C. (2020). GAPcare: The Geriatric Acute and Post‐Acute Fall Prevention Intervention in the Emergency Department: Preliminary Data. Journal of the American Geriatrics Society, 68(1), 198–206. https://doi-org.proxy2.cl.msu.edu/10.1111/jgs.16210 Gomez, F., Wu, Y. Y., Auais, M., Vafaei, A., & Zunzunegui, M.-V. (2017). A Simple Algorithm to Predict Falls in Primary Care Patients Aged 65 to 74 Years: The International Mobility in Aging Study. Journal of the American Medical Directors Association, 18(9), 774–779. https://doi- org.proxy2.cl.msu.edu/10.1016/j.jamda.2017.03.021 Harper, K. J., Arendts, G., Barton, A. D., & Celenza, A. (2021). Providing fall prevention services in the emergency department: Is it effective? A systematic review and meta- 23 OUTPATIENT FALLS analysis. Australasian Journal on Aging, 40(2), 116–128. https://doi- org.proxy2.cl.msu.edu/10.1111/ajag.12914 Injury and Violence Prevention Section. (2018). Injury and violence in Michigan: Michigan’s core violence and injury prevention program burden report - 2018. Michigan Department of Health and Human Services. https://www.michigan.gov/mdhhs/-/media/Project/ Websites/mdhhs/Folder2/Folder26/Folder1/Folder126/Injury_Violence_Michigan_ Burden_Report.pdf?rev=8d617d99628e44beb8d6fc700f1630ec Institute for Healthcare Improvement. (2022). Changes to improve chronic care. Retrieved from https://www.ihi.org/resources/Pages/Changes/ChangestoImproveChronicCare.aspx Institute for Healthcare Improvement. (2022). Plan-Do-Study-Act worksheet. Tools. Retrieved from https://www.ihi.org/resources/Pages/Tools/Quality-Improvement-Essentials- Toolkit.aspx Johnston, Y. A., Bergen, G., Bauer, M., Parker, E. M., Wentworth, L., McFadden, M., Reome, C., & Garnett, M. (2019). Implementation of the Stopping Elderly Accidents, Deaths, and Injuries Initiative in Primary Care: An Outcome Evaluation. Gerontologist, 59(6), 1182– 1191. https://doi-org.proxy2.cl.msu.edu/10.1093/geront/gny101 Lamb, S. E., Bruce, J., Hossain, A., Ji, C., Longo, R., Lall, R., Bojke, C., Hulme, C., Withers, E., Finnegan, S., Sheridan, R., Willett, K., Underwood, M., & Prevention of Fall Injury Trial Study Group (2020). Screening and intervention to prevent falls and fractures in older people. The New England Journal of Medicine, 383(19), 1848–1859. https://doi.org/10.1056/NEJMoa2001500 Lee, J., Negm, A., Peters, R., Wong, E., & Holbrook, A. (2021). Deprescribing fall-risk increasing drugs (FRIDs) for the prevention of falls and fall-related complications: A 24 OUTPATIENT FALLS systematic review and meta-analysis. BMJ Open, 11(2), e035978. https://doi.org/10.1136/bmjopen-2019-035978 Lee, R. (2017). The CDC’s STEADI initiative: Promoting older adult health and independence through fall prevention. American Family Physician, 96(4), 220-221. Mackenzie, L., Beavis, A.-M., Tan, A. C. W., & Clemson, L. (2020). Systematic Review and Meta-Analysis of Intervention Studies with General Practitioner Involvement Focused on Falls Prevention for Community-Dwelling Older People. Journal of Aging & Health, 32(10), 1562–1578. https://doi-org.proxy2.cl.msu.edu/10.1177/0898264320945168 Mark, J. A., Haddad, Y. K., & Burns, E. R. (2020). Differences in Evaluating Fall Risk by Primary Care Provider Type. Journal for Nurse Practitioners, 16(7), 528–532. https://doi-org.proxy2.cl.msu.edu/10.1016/j.nurpra.2020.04.014 Michigan State University [MSU]. n.d. MSU Health Care. https://healthcare.msu.edu/ about/index.aspx Moreland, B., Kakara, R., & Henry, A. (2020). Trends in nonfatal falls and fall-related injuries among adults aged ≥65 years - United States, 2012-2018. MMWR. Morbidity and Mortality Weekly Report, 69(27), 875–881. https://doi.org/10.15585/mmwr.mm6927a5 Naharci, M. I., & Tasci, I. (2020). Frailty status and increased risk for falls: The role of anticholinergic burden. Archives of Gerontology & Geriatrics, 90, N.PAG. https://doi- org.proxy2.cl.msu.edu/10.1016/j.archger.2020.104136 Phelan, E. A., Mahoney, J. E., Voit, J. C., & Stevens, J. A. (2015). Assessment and management of fall risk in primary care settings. The Medical Clinics of North America, 99(2), 281- 293. https://doi.org/10.1016/j.mcna.2014.11.004 25 OUTPATIENT FALLS Sherrington, C., Michaleff, Z. A., Fairhall, N., Paul, S. S., Tiedemann, A., Whitney, J., Cumming, R. G., Herbert, R. D., Close, J., & Lord, S. R. (2017). Exercise to prevent falls in older adults: an updated systematic review and meta-analysis. British Journal of Sports Medicine, 51(24), 1750–1758. https://doi.org/10.1136/bjsports-2016-096547 Taylor-Piliae, R. E., Peterson, R., & Mohler, M. J. (2017). Clinical and community strategies to prevent falls and fall-related injuries among community-dwelling older adults. The Nursing Clinics of North America, 52(3), 489–497. https://doi.org/10.1016/j.cnur.2017.04.004 Tricco, A. C., Thomas, S. M., Veroniki, A. A., Hamid, J. S., Cogo, E., Strifler, L., Khan, P. A., Robson, R., Sibley, K. M., MacDonald, H., Riva, J. J., Thavorn, K., Wilson, C., Holroyd- Leduc, J., Kerr, G. D., Feldman, F., Majumdar, S. R., Jaglal, S. B., Hui, W., & Straus, S. E. (2017). Comparisons of Interventions for Preventing Falls in Older Adults: A Systematic Review and Meta-analysis. JAMA, 318(17), 1687–1699. https://doi.org/10.1001/jama.2017.15006 26 OUTPATIENT FALLS Appendices Appendix A Organizational Data: Falls/Slips 2020-2022 Table 1: Fall Incidence Patient Population (Age) Fall Incidence Percentage of Fall Incidences Pediatrics (0-21 years) 4 8.2 Adults (22-64 years) 14 28.6 Older Adults (Over 65 years) 31 63.2 Total 49 100 Table2: Fall Incidence Categories Injury Category Injury Incidence No injury 9 Injury 40 Total 49 Table 3: Fall Risk Assessment Status Assessment Status Number of Incidence Not Assessed 25 No Data 22 Not Applicable 1 No Documentation 1 Total 49 Table 4: Fall Incidence Causes Cause Number of incidences Accidental 34 Physiological 2 27 OUTPATIENT FALLS Developmental 2 No Information 2 Others 9 Total 49 28 OUTPATIENT FALLS Appendix B: Outpatient Falls Sample Literature Table Citation Design Sampl Interventio Measureme Findings Limitations Purpose e n nt: Variables and Instruments Bhasin, S., Gill, T. M., Reuben, D. B., Latham, Randomized N= Multifactor First serious Rate of first Lack of N. K., Ganz, D. A., Greene, E. J., Dziura, J., control trial 5451 ial fall injury serious fall process Basaria, S., Gurwitz, J. H., Dykes, P. C., Aim: interventio Rate of injury was measures. McMahon, S., Storer, T. W., Gazarian, P., evaluate n includes hospitalizati 4.9 (event Lack of Miller, M. E., Travison, T. G., Esserman, D., effectiveness risk on per 100 health care Carnie, M. B., Goehring, L., Fagan, M., of a assessment Death person resource Greenspan, S. L., … STRIDE Trial multifactorial and years) in the utilization. Investigators (2020). A Randomized Trial of a intervention individuali intervention Multifactorial Strategy to Prevent Serious Fall in prevention zed plans group and Injuries. The New England journal of of falls. administere 5.3 in the medicine, 383(2), 129–140. d by control https://doi.org/10.1056/NEJMoa2002183 trained group (No nurses. significant difference). Rate of reported injury was 25.6 in the intervention group and 28.6 in the control group. The rate of hospitalizati on or death were similar 29 OUTPATIENT FALLS in both groups. The intervention was associated with a lower rate of first participant reported fall injury than usual care. 30 OUTPATIENT FALLS Davenport, K., Alazemi, M., Sri-On, J., & Liu, Cohort study N=40 Review Percentage 349 out of Small S. (2020). Missed Opportunities to Diagnose 0 chart for of missed 400 patients sample size. and Intervene in Modifiable Risk Factors for Aim: to modifiable opportunitie had Bias Older Emergency Department Patients quantify the fall risk s to identify modifiable potential Presenting After a Fall. Annals of Emergency number of factors. risk factors risk factors. since it was Medicine, 76(6), 730–738. https://doi- missed in older The ED not a blind org.proxy2.cl.msu.edu/10.1016/j.annemergmed. opportunities adults. team missed study. 2020.06.020 to identify Modifiable identifiable Variability and reduce risk factors factors in in providers. fall-risk such as 335 factors in visual patients. older adult acuity, use 96% Visual ED patients of high-risk acuity, 95% presenting medication high risk after a fall. and gait medication abnormalitie and 56% s. gait abnormaliti es. Providers fail to identify and intervene in modifiable fall risk factors in older adults presenting to the clinic. 31 OUTPATIENT FALLS Goldberg, E. M., Marks, S. J., Ilegbusi, A., Randomized N=11 Usual Care Fall- related Intervention Role of Resnik, L., Strauss, D. H., & Merchant, R. C. control trial 0 group injuries participants skilled care (2020). GAPcare: The Geriatric Acute and Post‐ Aim: (compariso Ed visits were half as facilities Acute Fall Prevention Intervention in the Describe a n group) hospitalizati likely to was not Emergency Department: Preliminary new Interventio on experience a accounted Data. Journal of the American Geriatrics multidiscipli n group subsequent for in the Society, 68(1), 198–206. https://doi- nary team (INT). ED visit study. org.proxy2.cl.msu.edu/10.1111/jgs.16210 fall Brief (RR 0.47) Small prevention medication and one sample size. for older therapy third as High adults who manageme likely to number of seek care in nt session have a fall- declined the by related ED participants emergency pharmacist, visits (RR (n=174) department fall risk 0.34) within hence after fall, assessment 6 months reduction in assess by a compared to generality of feasibility physical the usual results. and review therapist care lessons learnt and referral participants. during to The INT initiation. outpatient group services experienced such as half the rate home of all safety hospitalizati evaluation ons and and there was physical no therapy. difference in fall- related hospitalizati 32 OUTPATIENT FALLS ons between the two groups. 33 OUTPATIENT FALLS Gomez, F., Wu, Y. Y., Auais, M., Vafaei, A., & Prospective N= Risk factors There was Exploratory Zunzunegui, M.-V. (2017). A Simple Algorithm Cohort study 1718 for no tree analysis to Predict Falls in Primary Care Patients Aged Aim: occurrence significant used and 65 to 74 Years: The International Mobility in Primary care of falling; difference thus need Aging Study. Journal of the American Medical providers age, sex, between for further Directors Association, 18(9), 774–779. need simple BMI, incidence of testing. https://doi- algorithms to Multimorbid falls and Algorithms org.proxy2.cl.msu.edu/10.1016/j.jamda.2017.03 identify older ity, age group. specific for .021 adults at cognitive Fall the age higher risk of deficit, happened group 65-75 falling. depression, more years of age number falls frequently and might in the past in women not be 12-month, than men applicable fear of (P=0.01). for other age falling, History of groups. timed chair- falling and rises, fear of balance, and falling were gait. significantly associated with occurrence of falls (P<0.01). Reduction on rate of hospitalizati on for fall related injuries. Depression and chronic 34 OUTPATIENT FALLS diseases were significantly associated with subsequent falls. 35 OUTPATIENT FALLS Harper, K. J., Arendts, G., Barton, A. D., & Systematic N=40 Single: one Number and There was Majority of Celenza, A. (2021). Providing fall prevention review and 18 type of proportion significant studies used services in the emergency department: Is it meta- interventio of older (P=0.01) multifactoria effective? A systematic review and meta‐ analysis n strategy adults who reduction in l analysis. Australasian Journal on Ageing, 40(2), Level I only. fell. the monthly intervention 116–128. https://doi- To assess the Multiple Monthly rate of impacting org.proxy2.cl.msu.edu/10.1111/ajag.12914 effects of fall component rate of falls. falling, fall- ability to prevention : a set of Number of related compare services combinatio fall-related injuries, and with single initiated in ns of injuries. hospital or multiple the interventio Number of admissions. components emergency n provided hospital Multifactori intervention. department to each admissions al Availability (ED) to patient. ED intervention of original support Multifactor presentation s studies. patients after ial: s significantly Patient discharge. interventio Death. reduce fall- assessments n is related such as matched to injuries and cognitive a patient; s admissions. ability and fall risk impairments factors that were may excluded in receive information different on living combinatio conditions ns was depending excluded in on need. some studies. 36 OUTPATIENT FALLS Johnston, Y. A., Bergen, G., Bauer, M., Parker, Cohort Study N= Three Fall related Older adults FPOC was E. M., Wentworth, L., McFadden, M., Reome, Aim: 12346 cohort treat and at risk for not C., & Garnett, M. (2019). Implementation of the Determine groups release at fall with randomized. Stopping Elderly Accidents, Deaths, and the impact of -At risk the FPOC were Potential for Injuries Initiative in Primary Care: An Outcome a STEADI and no fall emergency 0.6 times selection Evaluation. Gerontologist, 59(6), 1182–1191. initiative on plane of department. less likely bias. https://doi- medically care Hospitalizati to have a Difficult to org.proxy2.cl.msu.edu/10.1093/geront/gny101 treated falls (FPOC) on. fall-related determine within a -At risk hospitalizati which large health with a on than FPOC was system in FPOC those followed. Upstate New - Not at without Different York. risk. FPOC elements of (P=0.041). FPOC were Fall implemente intervention d. odds were similar for those who were not at risk. 37 OUTPATIENT FALLS 38 OUTPATIENT FALLS Lamb, S. E., Bruce, J., Hossain, A., Ji, C., Randomized N= Advice Incidence of Screening Methods of Longo, R., Lall, R., Bojke, C., Hulme, C., control Trial 9803 sent by Fractures and targeted measuring Withers, E., Finnegan, S., Sheridan, R., Willett, Level II mail, risk Use of population and K., Underwood, M., & Prevention of Fall Injury screening Health did not reporting Trial Study Group (2020). Screening and for falls resources result in falls were Intervention to Prevent Falls and Fractures in and lower rates retrospective Older People. The New England journal of targeted of fractures. . medicine, 383(19), 1848–1859. interventio There was Maybe https://doi.org/10.1056/NEJMoa2001500 n( (Rate Ratio) underestimat Multifactor RR 1.20 of ion of ial fall fractures in results from prevention the exercise restriction of or exercise group access by for people compared to one of the at advice by practices. increased mail group. risk for RR 1.30 of falls). multifactori The effect al fall of prevention community compared to screening advice by and mail group. therapeutic Exercise prevention strategy was strategies associated with improved quality of life and lowest overall costs. 39 OUTPATIENT FALLS Lee, J., Negm, A., Peters, R., Wong, E., & Systematic n=130 Fall risk Rate of Little to no Additional Holbrook, A. (2021). Deprescribing fall-risk review and 5 increasing Falls, Fall- difference studies increasing drugs (FRIDs) for the prevention of meta- drugs related in the rate needed to falls and fall-related complications: a systematic analysis (FRIDS) injuries, or risk of optimize review and meta-analysis. BMJ open, 11(2), Level I deprescribi fall-related falls as a information e035978. https://doi.org/10.1136/bmjopen- Determine ng fractures, or sole and reduce 2019-035978 the efficacy compared fall-related reduction uncertainty for the to usual hospitalizati strategy of the prevention of care ons intervention. falls and fall- related complication s 40 OUTPATIENT FALLS Mackenzie, L., Beavis, A.-M., Tan, A. C. W., & Meta N=27 Systematic Fall incident Overall Risk of bias. Clemson, L. (2020). Systematic Review and Analysis- 36 review of at least one studies were Limited to Meta-Analysis of Intervention Studies with Systematic Randomize fall. not effective geographical General Practitioner Involvement Focused on review. d control Multiple in reducing location of Falls Prevention for Community-Dwelling Level I trials falls (two or falls English- Older People. Journal of Aging & Aim: Identify more) (P=0.10), speaking Health, 32(10), 1562–1578. https://doi- effective falls Injurious Reducing countries. org.proxy2.cl.msu.edu/10.1177/0898264320945 prevention fall multiple High 168 interventions falls heterogeneit with (p=0.08) but y between involvement were studies of general effective in hence practitioners reducing difficulty in (GP) injurious interpretatio falls n. (P=0.001) Active role of GP was effective in reducing falls. 41 OUTPATIENT FALLS Mark, J. A., Haddad, Y. K., & Burns, E. R. Cross- N=11 Survey Events of Almost half Potential for (2020). Differences in Evaluating Fall Risk by sectional 28 questions fall of the bias. Primary Care Provider Type. Journal for Nurse study “Under screening providers Participants Practitioners, 16(7), 528–532. https://doi- Level IV what during a indicated to were org.proxy2.cl.msu.edu/10.1016/j.nurpra.2020.04 Aim: circumstan healthcare routinely younger .014 Differences ces do you encounter. screening hence in clinical screen your for falls at shorter time fall risk patients 65 each visit. in practice assessment and older Internal (lack of of older for fall medicine experience). adults and risk?” providers Response clinical PCPs could (IMs) had rate of NPs resources select all lower odds was less used by the of screening than 50% primary care following at each hence providers answers wellness potential for (PCP). that visit nonresponsi applied: (1) compared to ve bias. I rarely Nurse screen Practitioner older s (NPs). adults for There is an fall risk, unmet need (2) I screen for fall if the screening patient among older presents adults’ with a fall patients injury, (3) I during screen if healthcare the patient visits. has concerns 42 OUTPATIENT FALLS about falling, or (4) I screen at each wellness visit. The next “select all that apply question” was “What standardize d approach do you most commonly use when assessing gait and balance in older adults?” Options included (1) Timed Up and Go (TUG), (2) the 30- Second Chair Stand Test (30-SCST), (3) the 4- 43 OUTPATIENT FALLS Stage Balance Test (4- SBT), (4) I only observe patient walking, and (5) I do not assess patient 44 OUTPATIENT FALLS Naharci, M. I., & Tasci, I. (2020). Frailty status Observationa N=52 Using a Fall risk ACB was Patients and increased risk for falls: The role of l Case- 0 statistical (geriatric significantly with anticholinergic burden. Archives of Control analysis to assessment), associated cognitive Gerontology & Geriatrics, 90, N.PAG. Study identify Fall-related with the impairment https://doi- Level association injuries, frailty were not org.proxy2.cl.msu.edu/10.1016/j.archger.2020.1 Aim: to between fall-induced components included in 04136 examine the ACB and fractures. . the study. potential falls based Frailty (fried Duration of association on frailty Frailty exposure of of and its Index) target drugs anticholinerg component Anticholiner was not ic burden s. gic burden assessed. (ACB) with Patients (anticholiner Study the risk of were gic design falls among grouped cognitive shows frail older into burden) correlation adults. “Fallers” Mini- between patients Mental State anticholiner who Examination gics with reported . falls but not one or Physical causation. more fall in assessment. the last 12 months and “non fallers” were patients who did not report falls. 45 OUTPATIENT FALLS Sherrington, C., Michaleff, Z. A., Fairhall, N., Systematic n- Exercise Incidence of There was Small Paul, S. S., Tiedemann, A., Whitney, J., Review 19478 program Falls 21% sample size Cumming, R. G., Herbert, R. D., Close, J., & Aim: To test interventio reduction in on Lord, S. R. (2017). Exercise to prevent falls in whether n falls after Parkinson’s older adults: an updated systematic review and exercise exercise and meta-analysis. British journal of sports prevents falls intervention cognitive medicine, 51(24), 1750–1758. in older . impaired https://doi.org/10.1136/bjsports-2016-096547 adults. Exercise studies activities hence small that study challenged effects. balance and frequency more than 3 hours a week had greater effects in fall reduction 39%. There was fall reduction rates in patients with Parkinson’s or other cognitive diseases who exercised. 46 OUTPATIENT FALLS There was no evidence of fall reduction in patients at residential care, stroke survivors or people recently hospitalized . 47 OUTPATIENT FALLS Tricco, A. C., Thomas, S. M., Veroniki, A. A., Systematic N= Examining Number of Number of Some Hamid, J. S., Cogo, E., Strifler, L., Khan, P. A., review and 15991 fall- injurious falls (158 groups' Robson, R., Sibley, K. M., MacDonald, H., meta- 0 prevention falls and RCTS analysis and Riva, J. J., Thavorn, K., Wilson, C., Holroyd- analysis. interventio fall-related 107300 sensitivity Leduc, J., Kerr, G. D., Feldman, F., Majumdar, n (single or hospitalizati participants were not S. R., Jaglal, S. B., Hui, W., & Straus, S. E. Level I multifactor on. and 77 conducted (2017). Comparisons of Interventions for To assess the ial) and Rate of falls, intervention due to Preventing Falls in Older Adults: A Systematic potential comparison cost, s. Event rate insufficient Review and Meta-analysis. JAMA, 318(17), effectiveness between number of of falls in data. 1687–1699. of usual care, intervention the usual Unclear risk https://doi.org/10.1001/jama.2017.15006 interventions fall s related to group was biases. for prevention harms and 0.38 across Network preventing interventio quality of all meta- Meta- falls. ns and life. analysis analysis placebo. comparison included 6.7% were numerous statistically intervention significant. s with sparse Five data for intervention treatment s were comparisons associated , additional with a lower analysis is risk of recommende patients d for the experiencin future. g a fall relative to usual care. Fractures: 86491 participants and 43 48 OUTPATIENT FALLS intervention s in addition to usual care. The event rate for fractures in the usual group was 0.07. across 946 network meta- analysis comparison 4.8% were statistically significant. One intervention was associated with lower risk of fractures compared to usual care. 49 OUTPATIENT FALLS Appendix C Outpatient Fall Fishbone diagram People Processes Equipment Transfer Techniques Wheelchair Patient Support Team Fall risk identification Walker Treatment team, RN Fall protocol Exam Table Problem Statement Outpatient Fall Fall prevention effectiveness Treatment team communication Visit process Fall Prevention committee Fall Prevention protocol Leadership Easy accessibility of location Regulation Management Environment 50 OUTPATIENT FALLS Appendix D: Timeline M J J A S O N D J F M A M a u u u e c o e a e a p a Task Task Description y n l g p t v c n b r r y - - y - - - - - - - - - - 2 2 - 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 2 1. Faculty Advisor Meetings x x x x x x x x x 2. Community Liaison Meetings x x x x x x x x x 3. Literature Review x x 4. Complete Proposal x 5. College of Nursing Quality Review Approval x 6. IRB Approval x 7. Facility Approval for project implementation x 8. Implementation of the Universal Fall Screening Tool x 9. Collect Outcome Data x x x 10. Evaluate Outcome Data x 11. Evaluate and Analyze Outcome Data x x 51 OUTPATIENT FALLS 12. Complete final report x 13. Presentation of final report x 52 OUTPATIENT FALLS Appendix E SWOT Analysis Strengths ● Quality Improvement committee ● Knowledgeable staff ● Screening tool already a part of EHR Weaknesses ● No standardized fall screening ● Inconsistent fall screening ● Lack of fall protocol Opportunities ● Chance to assess and avoid falls in individuals 65+ ● Large healthcare system serving many patients annually ● Increasing number of individuals 65+ as population ages Threats ● Staff turnover ● Short staffing ● Staff resistance to new practice ● COVID-19 pandemic-related clinic constraints 53 OUTPATIENT FALLS Appendix F Project Budget Project Financial Plan September 2022 - May 2023 Personnel Pay Total Haley Hathaway $35/hour x180 hours $6,300 Irene Maiyo $35/hour x 180 hours $6,300 Other Expenses Educational Supplies $200 Total Expenses 12,800 54 OUTPATIENT FALLS Appendix G STEADI Fall Risk Assessment Tool Have you fallen in the past year? o Yes o No Do you use or have you been advised to use a cane or walker to get around safely? o Yes o No Do you sometimes feel unsteady while walking? o Yes o No Do you steady yourself by holding onto furniture when walking at home? o Yes o No Do you worry about falling? o Yes o No Do you need to push with your hands to stand up from a chair? o Yes o No Do you have trouble stepping up onto a curb? o Yes o No Do you often have to rush to the toilet? o Yes o No Have you lost some feeling in your feet? o Yes 55 OUTPATIENT FALLS o No Do you take medicine that sometimes makes you light-headed or more tired than usual? o Yes o No Do you take medicine to help you sleep or improve your mood? o Yes o No Do you often feel sad or depressed? o Yes o No STEADI Fall Risk Scoring Guidelines Check your risk of falling Please circle "Yes" or "No" for each (Why it matters) statement below Yes No (0) I have fallen in the past year. (People (2) who have fallen once are likely to fall again.) Yes No (0) I use or have been advised to use a cane (2) or walker to get around safely. (People who have been advised to use a cane or walker may already be more likely to fall.) Yes No (0) Sometimes I feel unsteady when I am (1) walking. (Unsteadiness or needing support while walking are signs of poor balance.) 56 OUTPATIENT FALLS Yes No (0) I steady myself by holding onto (1) furniture when walking at home. (This is also a sign of poor balance.) Yes No (0) I am worried about falling. (People who (1) are worried about falling are more likely to fall.) Yes No (0) I need to push with my hands to stand (1) up from a chair. (This is a sign of weak leg muscles, a major reason for falling.) Yes No (0) I have some trouble stepping up onto a (1) curb. (This is also a sign of weak leg muscles.) Yes No (0) I often have to rush to the toilet. (1) (Rushing to the bathroom, especially at night, increases your chance of falling.) Yes No (0) I have lost some feeling in my feet. (1) (Numbness in your feet can cause stumbles and lead to falls.) Yes No (0) I take medicine that sometimes makes (1) me feel light-headed or more tired than usual. (Side effects from medicines can sometimes increase your chance of falling.) Yes No (0) I take medicine to help me sleep or (1) improve my mood. (These medicines can sometimes increase your chance of falling.) 57 OUTPATIENT FALLS Yes No (0) I often feel sad or depressed. (1) (Symptoms of depression, such as not feeling well or feeling slowed down, are linked to falls.) Total Add up the number of points for _ each "yes" answer. If you scored 4 points or more, you may be at risk for falling. Discuss this brochure with your doctor. * Low Fall Risk - score less than 4 *Moderate Fall Risk - score greater than 4, or patient has gait, strength, or balance problem(s) *High Fall Risk - score greater than 4 with a history of falls with/without injury, or patient has and of the following: postural dizziness/hypotension, mobility aids and vision problems, or cognitive issues 58 OUTPATIENT FALLS Appendix H STEADI Fall Risk Screening Status Screening Status Number of Older Adult Percentage (%) Encounters Screened 71 6.9 Not Screened 964 93.1 Total 1035 100 59 OUTPATIENT FALLS Appendix I Fall Risk Assessment by Risk Category Percentage (%) Risk Category Number of Individuals Low Fall Risk 14 19.7 Moderate Fall Risk 32 45.1 High Fall Risk 14 19.7 Missing Scoring 11 15.5 components Total 71 100 60 OUTPATIENT FALLS Appendix J STEADI Fall Screening Results Demographics Table 1: Older Adult Individuals Screened for Falls by Race Race Number of Individuals Percentage (%) Caucasian/White 59 83.1 Black/African American 6 8.5 Native Hawaiian/Other 1 1.4 Pacific Islander Asian 3 4.2 Race not identified 2 2.8 Total 71 100 Table 2: Older Adults Individuals Screened for Falls by Gender Gender Number of Individuals Percentage (%) Male 18 25 Female 49 69 Gender not identified 4 6 Total 71 100 Table 3: Older Adults Individuals Not screened For Falls Race Number of Individuals (not Percentage (%) of total screened) patients not screened Caucasian/White 936 97.1 Black/African American 11 1.2 Native Hawaiian/Other 3 0.3 Pacific Islander Asian 8 0.8 Race not identified 6 0.6 61 OUTPATIENT FALLS Total 964 100 Table 4: Percentages Based on 1,035 Screening-Eligible Patients Race Screened Patients Not Screened Patients Percentage (%) Percentage (%) Caucasian/White 5.7 90.4 Black/African American 0.6 1.1 Native Hawaiian/Other 0.1 0.3 Pacific Islander Asian 0.3 0.7 Race not identified 0.2 0.6 Total 6.9 93.1