F RO M T H E DATA B A S E Falls, a Hospital-Acquired Condition: The Pennsylvania Patient Safety Authority’s Enhanced Reporting Program Lea Anne Gardner, PhD, RN The Centers for Medicare and Medicaid Services (CMS) is addressing hospital-acquired Senior Patient Safety Analyst conditions (HACs) through the Partnership for Patients and the Affordable Care Edward Finley, BS Act.1,2 There are 10 different categories of HACs that were chosen because of their high Data Analyst occurrence and/or the high cost associated with treating them.3 Of the 10, the most Pennsylvania Patient Safety Authority frequently occurring class of HACs is falls and trauma, with a national rate of 0.564 per 1,000 patient discharges.4,* The Pennsylvania rate for falls and trauma, using CMS administrative data, is 0.581 per 1,000 patient discharges (95% CI: 0.531 to 0.632). Falls and trauma rates consist of falls that result in fractures, dislocations, and intra- cranial injuries and also traumas from other hospital causes, specifically harm from crushing injuries, burns, and electric shocks.5 Pennsylvania Patient Safety Authority analysts compared the CMS Pennsylvania falls and trauma rate with the Authority’s falls rate (other trauma events were excluded due to their low number of events).6 The Authority’s falls rate was calculated using falls events that resulted in fractures, dislocations, surgical interventions, intracranial inju- ries, and deaths that were reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS) along with discharge data reported through CMS for the same time period. The Pennsylvania rate based on PA-PSRS event reports for falls with harm was 0.332 per 1,000 patient discharges (95% CI: 0.294 to 0.370). The average additional cost of a fall with serious injury (e.g., fracture, subdural hema- toma, any injury resulting in surgical intervention, death) was $13,316.7 The average additional length of stay was 6.3 days longer than for patients who did not fall.7 Combining these averages with the number of falls with serious injury reported to the Authority in 2010 (215 falls with serious injury), Pennsylvania hospitals experienced an estimated additional average cost of $2.9 million and 1,355 additional days from fall injuries.✝ The Authority has developed a new falls-with-harm savings calculator for hospitals to calculate the average additional cost of falls with serious injury, additional days, and cost savings associated with 10%, 25%, 50%, 75%, and 90% reductions in falls with serious injury. This savings calculator is available on the Authority’s website (see http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2012/Jun;9(2)/ Pages/home.aspx). ENHANCED FALLS REPORTING PROGRAM In March 2012, the Authority launched a statewide initiative for reporting patient falls to provide real-time falls rate reports with benchmarking data for Pennsylvania hospitals. This new initiative is an expansion of a two-year Pennsylvania southeast region patient falls initiative that ended in 2010.8 The new statewide falls reporting initiative has two ways to participate. In one, hospitals can participate in the CMS Hospital Engagement Network (HEN) collaboration project among the Hospital and Healthsystem Association of Pennsylvania, the Authority, and hospitals statewide in Pennsylvania. The second is through the non-HEN statewide falls reporting program. Both programs require hospitals to use standardized definitions of falls and falls with harm to provide similar comparisons of falls rates and receive meaningful falls reports with comparative data. To accomplish this task, PA-PSRS has been enhanced to * For the purposes of this article, falls rates were calculated using discharge data for comparison with CMS, whereas other articles in this issue included falls rates calculated using patient days, which aligns with the new PA-PSRS enhancements. ✝ The average additional cost of a fall with serious injury and additional days were based on the study by Wong et al. Vol. 9, No. 2—June 2012 Pennsylvania Patient Safety Advisory Page 47 ©2012 Pennsylvania Patient Safety Authority F RO M T H E DATA B A S E provide unit-level and facility-level reports general medical/surgical units are com- Not all care areas will be measured in the on falls rates, detailed falls reports, and posed of medical units, surgical units, statewide falls reporting program. Care prevention strategies for participating and medical/surgical units in a hospital. areas for the falls reporting program were hospitals. Intermediary units include “intensive care chosen based on where the largest number Before March 2012, PA-PSRS did not have unit step-down units” and telemetry-type of falls and falls with harm occurred in the capacity to provide users with falls rates units. Specialty units are identified by Pennsylvania hospitals. To determine this and comparative data. Achieving this new medical conditions (e.g., orthopedic unit, information, the Authority conducted a level of functionality (i.e., providing falls cardiac unit, gynecology unit). PA-PSRS search, by care areas, of falls event reports rate reports with comparative data at the has 20 care areas that are used to identify submitted to PA-PSRS from January 1, facility and unit levels) required enhance- the location of a fall, including a category 2008, through December 31, 2010. The ments in the form of utilization data entry titled “Other,” which includes chemical Table shows the location of patient falls by (i.e., entering data for patient-days and dependency units, ancillary departments, care areas within Pennsylvania hospitals. patient encounters). To calculate unit-level diagnostic labs, administration, and falls rates—since falls rates will be based unspecified care areas. When the unit DISCUSSION on the location of the falls—the Authority location of a fall is unknown or unspeci- Nearly half (46.5%, n= 62,992 of 135,221) standardized the locations or units within fied, the choice “Other” can be selected. of all falls reported by Pennsylvania a hospital. These units are referred to as However, falls reported in the “Other” hospitals from 2008 through 2010 care areas and are identified and grouped category do not appear in a unit-level falls occurred in medical/surgical units or by type of services provided. For example, rate report, which reduces the validity of intermediate units (e.g., telemetry unit, these reports. Table. Patient Falls by Care Area (Based on Reports Submitted to the Pennsylvania Patient Safety Reporting System by Hospitals Only, 2008 to 2010) PERCENTAGE AS SERIOUS EVENTS PERCENTAGE PERCENTAGE SERIOUS (SHADED CELLS ARE OF TOTAL CARE AREA INCIDENTS AS INCIDENTS EVENTS ABOVE CATEGORY MEAN) TOTAL FALLS General medical/ 42,928 96.7% 1,472 3.3% 44,400 32.8% surgical units Intermediate unit* 17,941 96.5 651 3.5 18,592 13.7 Inpatient psychiatric 14,360 95.8 622 4.2 14,982 11.1 Inpatient rehabilitation 13,901 97.3 392 2.7 14,293 10.6 Specialty units† 11,874 96.5 427 3.5 12,301 9.1 Critical care 6,037 96.6 211 3.4 6,248 4.6 Emergency department 5,408 95.3 265 4.7 5,673 4.2 Rehabilitation services 3,037 97.7 71 2.3 3,108 2.3 Pediatric care 2,682 96.6 94 3.4 2,776 2.1 Radiology services 2,023 94.8 111 5.2 2,134 1.6 Outpatient clinics 1,775 97.3 49 2.7 1,824 1.3 Extended care 1,207 97.7 28 2.3 1,235 0.9 Obstetrical care 1,038 98.2 19 1.8 1,057 0.8 Surgical services 769 96.2 30 3.8 799 0.6 Other‡ 5,559 95.9 240 4.1 5,799 4.3 Total 130,539 96.5 § 4,682 3.5 § 135,221 100.0 * Includes telemetry and step-down units † Includes units designated as single specialty units, such as oncology units and orthopedic units ‡ Includes chemical dependency, ancillary departments, diagnostic labs, administration, and unspecified care areas. Each care area in this category, except for unspecified care areas, accounted for less than 1% of the total percent of falls. Unspecified care areas accounted for 2% of total falls. § Average percentage Page 48 Pennsylvania Patient Safety Advisory Vol. 9, No. 2—June 2012 ©2012 Pennsylvania Patient Safety Authority step-down unit). The majority (85.7%, (2%, n = 2,900 of 5,799) were falls where CONCLUSIONS n = 115,884 of 135,221) of all falls the location of the fall was unknown Standardized reporting of falls requires occurred in inpatient care areas (e.g., or unspecified. A detailed review of the more than a standardized definition and medical/surgical units, critical care units, reports submitted indicates that many measure specifications. Accuracy of data inpatient psychiatric units), 10.0% of the falls in this category occurred on and fall characteristics (e.g., location of a (n = 13,538 of 135,221) occurred in care a hospital unit or in a diagnostic setting; fall) is equally important to understand- areas that provide services to outpatients however, the exact location was not identi- ing trends and reducing incidents of falls. and inpatients (e.g., emergency depart- fied. For hospitals participating in the The care areas defined by the Authority ment, radiology), and 4.3% (n = 5,799 of falls reporting program at the unit level, provide insight about the location and 135,221) were assigned to the care area providing the exact location of a fall is type of fall that will allow for meaningful titled “Other.” Half of the falls identi- necessary to provide accurate unit-level comparisons of falls rates and identifica- fied in the “Other” care area category falls rate reports. tion of trends across units. NOTES 1. Centers for Medicare and Medicaid hospitalacqcond/06_hospital-acquired_ Available from Internet: http://www. Services. The Affordable Care Act: help- conditions.asp. rti.org/reports/cms/FY2010-Data/ ing providers help patients. A menu of 4. Centers for Medicare and Medicaid 2010-Detailed-Analysis-Selected-HACs_ options for improving care [online]. [cited Services. Hospital Compare [website]. 080311.zip. 2012 Mar 14]. Available from Internet: [cited 2011 Dec 22]. Washington (DC): 7. Wong CA, Recktenwald AJ, Jones ML, et https://www.cms.gov/ACO/Downloads/ U.S. Department of Health and Human al. The cost of serious fall-related injuries ACO-Menu-Of-Options.pdf. Services. Available from Internet: http:// at three Midwestern hospitals. Jt Comm J 2. Centers for Medicare and Medicaid hospitalcompare.hhs.gov. Qual Patient Saf 2011 Feb;37(2):81-7. Services. Strengthening Medicare: better 5. Centers for Medicare and Medicaid Ser- 8. Arnold TV, Barger DM. Falls rates health, better care, lower costs. Efforts will vices. Hospital-acquired conditions (HAC) improved in southeastern Pennsylvania: save nearly $120 billion for Medicare over in acute inpatient prospective payment the impact of a regional initiative to five years [online]. [cited 2012 Mar 14]. system (IPPS) hospitals [fact sheet online]. standardize falls reporting. Pa Patient Available from Internet: http://www.cms. ICN 901045. 2011 Oct [cited 2012 Apr Saf Advis [online] 2012 Jun [cited 2012 gov/apps/files/medicare-savings-report. 3]. Available from Internet: https://www. Jun 6]. Available from Internet: http:// pdf. cms.gov/HospitalAcqCond/downloads/ patientsafetyauthority.org/ADVISORIES/ 3. Centers for Medicare and Medicaid HACFactsheet.pdf. AdvisoryLibrary/Pages/Home.aspx. Services. Hospital-acquired conditions 6. Research Triangle Institute. CMS reports: [online]. [cited 2012 Mar 14]. Available 2010 detailed analysis of selected HACs from Internet: https://www.cms.gov/ [online]. 2011 Aug 3 [cited 2012 Apr 3]. Vol. 9, No. 2—June 2012 Pennsylvania Patient Safety Advisory Page 49 ©2012 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 9, No. 2—June 2012. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2012 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. 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