SOS: Morse code does not predict well

Expanding on last week's post on falls, Marsha Maurer, our chief nursing officer, reports:

We've achieved fall rates at BIDMC on par with those noted in the JAMA article by using an algorithm, fine tuned over the past few years based on root cause analysis of each fall. The algorithm guides nurses to an individualized safety plan for each patient identified as "at risk" on the Morse falls tool. Of note, delirium has its own leg on the tool. It was a series of root cause analyses which identified the upstream impact of delirium on a subsequent fall that led both to this leg in the tool and the GRACE work.

We have found, however, that the Morse is a blunt tool. It over-predicts who will fall, and entirely misses some people at fall risk; for example otherwise alert, oriented and ambulatory oncology patients who become weakened over the course of chemotherapy and who overestimate their own strength. Given this, our departments of Nursing and Health Care Quality are working with the Institute for Healthcare Improvement on the next frontier of assessment and intervention -- a falls bundle. It is in pilot use now. The bundle dictates three interventions for all patients regardless of fall risk status: 1) Bed in low position -- with a clear visual cue that this is so; 2) the infusion pump on the side of the bed where the patient will exit; and 3) the call light in reach.

Concurrent with this is the use of a more clinician-friendly simple risk question: "Is this patient willing and able to RELIABLY use the call light to get help?" If the answer is "no" this puts the patient in a high risk category for falls, and additional falls prevention strategies will be implemented.

We are hopeful that this will provide a more specific and meaningful risk identification process and ultimately a reduction in the overall fall rate.

Epilogue

This work at BIDMC and the work cited in the previous post from Brigham and Women's Hospital are exemplary and clearly complimentary. But what is striking is the lack of coordination between the two efforts. Two Harvard teaching hospitals, separated by only a few blocks (see map), both concerned about patient safety, have had virtually no contact on this topic.

I hope I am misinterpreting, but I am concerned that this may be one of those instances in which the competitiveness among the Boston hospitals has spilt over into the safety arena. For sure, there are other areas in which information about quality of care is shared and protocols are examined together. But wherever there is a lack of discourse, opportunities for collaboration are lost. In contrast, remember our colleagues in Ohio, where the rule is, "We compete on everything, but we don't compete on safety." We owe it to our patients to adopt the same approach.