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Pharmacists help develop nationally recognized fall prevention program
Falls decrease by nearly half
Pharmacists involved in a falls prevention program at Mercy Health Center in Oklahoma City, OK, have developed a falls risk assessment tool that is being used by hospitals around the country.
The program has resulted in a 48% reduction in falls injuries, and a 30% reduction in overall falls, says Burl Beasley, RPh, MPH, medication safety coordinator at Mercy Health Center. Beasley and the health system have received several national awards for the program, including a medication use safety award in 2007 from the American Society of Health-System Pharmacists (ASHP), a 2007 CHEERS award from the Institute for Safe Medication Practices, and a 2008 ASHP best practice award.
In an economic analysis, Beasley found that the program has saved $516,000 in health care spending on patients at risk for falls over a 2-year period. This estimate is based on research showing that each patient fall adds $25,000 or more to the cost of the patient's hospital stay, he says.
Some falls are even more costly. A patient who falls in the bathroom of the hospital has an average of $87,000 more in medical claims, he adds.
For hospitals, including a clinical pharmacist in a falls prevention strategy is an economical and easy decision to make.
Beasley estimates that such a program might add one-half full-time equivalent (FTE) pharmacist position, although this work can be incorporated into pharmacists' existing workflow, which is how Mercy Health has handled it.
The 300-bed hospital has an average of 45 patients who are targeted as at-risk for falls. Four pharmacists take about 10-15 minutes to review this list each day. Also, the hospital recently has given this task to pharmacy students as part of their work rotation, Beasley says.
"The students do a lot of the legwork, looking at lab results and reviewing patient profiles," Beasley says.
The key to a hospital pharmacy achieving these results is to be involved in the falls prevention process from the beginning.
Mercy Health had asked that pharmacy be represented on a new, multidisciplinary falls prevention committee five years ago. (See pharmacist policy, below.)
"The committee talked about whether there was a way to look at patients' medications and identify those who were at risk for falls," Beasley recalls. "I did a literature search and couldn't find anything about a way to score patients based on their medications."
So Beasley developed a tool, using an online literature review, the American Hospital Formulary System, and other data.
Common themes emerged. For example, Beasley found that analgesics, antipsychotics, anticonvulsants, and benzodiazepines were the classes of drugs most commonly associated with falls.
Classes of drugs in a medium-risk category are antihypertensives, cardiac medications, antiarrhythmic agents, and antidepressants. And diuretics place patients at a low risk for falls.
The tool assigns risk values to the nine different classes on a 3-point scale. Drugs that have no associated risk for falls receive a score of 0.
The health system's electronic system has incorporated the tool so that all drugs that fall within the nine classes are given the falls risk score associated with each class. When the system has new drugs added, the scores automatically are determined.
Beasley has shared this tool with hospitals around the country.
"We also developed a policy for the pharmacist to follow, and I have a rounding tool that I use and train students how to use," Beasley says. "That checks for patients who are 65 years old or older and are new admissions."
Pharmacists check for medications that should be discontinued based on Beers Criteria and check for medications that need to be monitored. Also, they make certain that sleep agents are at the lowest possible dose, and they look for medication duplications or conflicts between home prescriptions and hospital medications, he says.
The short checklist, titled "Fall Risk Medication Evaluation," has 13 check boxes and leaves space for the pharmacist to sign and date. It is printed four to a page and can be attached to charts.
The checklist leaves space to list drugs that are discontinued or where dosages are decreased. It also has a check box for when a pain medication is duplicated and discontinued and when a specific drug is changed to reduce the fall risk.
Other check boxes are for discontinuing propoxyphene (Darvocet®), discontinuing meperidine (Demerol®), and monitoring labs for digoxin level, INR, Hg/Hct, and dilantin (Phenytoin®) level.
The rounding guide is a tip sheet that can be used in training pharmacy students.
Each medication on a patient's list contributes to the patient's overall medication falls risk. So if a patient has two drugs that are scored 3 points each, then the patient's overall score is 6. The same is true with a patient who has three drugs that are scored 2 points each. Six is the cutoff score, Beasley says.
The screening tool also weeds out patients who, despite their medication scores, are not at a high risk for falls.
Any patient whose medication risk is 6 points or greater is placed on the pharmacist's daily review list, and an intervention is initiated.
Typically about 15% of the hospital's patients are included on the falls risk each day. If all 300 beds are full, then this means 45 patients will be monitored as part of the intervention.
The intervention includes a closer medication review to see if specific drugs or dosages could be omitted or adjusted. Pharmacists also review the patient's lab results to check renal function.
Nurses assess each patient for the potential of falling based on a nursing assessment tool, and pharmacists also might take this into account as they make recommendations.
"We use the medication score in conjunction with the nursing falls score," Beasley says.
Pharmacists communicate the medication falls score and interventions on the patient's chart. Physicians have the option of accepting the pharmacist's recommended changes or making some other change.
"Most of the time physicians accept our recommendations, and we keep track of that too," Beasley says.
Then pharmacists will meet with patients to discuss their potential risk of falling and to offer them counseling.
"We say, 'You're at risk of falling because of your medication, and I just wanted to let you know that you need to be careful when you get up to go to the bathroom,'" Beasley says. "Then we give them a booklet on preventing falls for patients from the University of Pittsburgh."
Another intervention strategy might include asking patients to call nurses when they need to get out of bed.
There have been additional benefits to the program. For instance, pharmacists have discovered potential adverse events and drug-drug interactions as they've reviewed these at-risk patients' charts. Also, the program's emphasis on pharmacist involvement has raised pharmacy's profile in the hospital, Beasley says.
"As we do the rounds, nurses will say, 'What are you looking at this chart for?' and pharmacists say the patient is on their list because the patient is at high risk for falls," Beasley explains.
Nurses then realize that their own falls risk assessment, which may include a previous fall as a chief risk category, didn't include these patients. So they see the benefit of the pharmacy risk assessment in finding patients before falls occur.