895 / Decision support tool to assess and prevent risk of falling/pressure ulcers

Type of Patient Safety Practice Safe
Clinical Practice (CP)
Related practices from PaSQ database
“Best fit” category of the reported practice


Decubitus ulcers
Patient falls
Topic of the reported practice
Patient safety system
Aim and the benefit of the Patient Safety Practice
Patients treated as inpatients in the hospital have a high decubitus and fall risk. Demographic changes and rising prevalence of multimorbidity/polymorbidity among elder patients increases the risk to incur a decubitus or a fall. In Germany, approximately 10 % of all inpatients develop pressure ulcers during their hospital stay, resulting in an estimated number of 190.000 patients per year suffering from the effects of pressure ulcers. Besides causing pain, distress, injuries, post-fall syndromes, infected wounds etc., falls and pressure ulcers may significantly prolong the hospitalization period and/or present unwanted and excessive expenses of resources. Severe pressure ulcers (i.e. decubitus with high grades according to the known classification scheme of the European Pressure Ulcer Advisory Panel, which ranges from 1 to 4) also correlate with lethal developments of inpatient therapy regimes. As an example, a sepsis may occur due to persisting wound infections around the pressure ulcer area of a patient.
Reducing the incidence of pressure ulcers and falls is an urgent and most relevant topic for inpatient treatments, taking into account both views of the individual affected patient, society in general and health insurance companies.
Description of the Patient Safety Practice
National and international scientific developments in nursing science nowadays provide numerous scales and methods to assess the risk of pressure ulcers (e.g. Norton scale, Braden scale or Waterlow scale) and falls (e.g. Morse scale, Hendrich scale). Unfortunately, their power to predict the risk of incurring a pressure ulcer is poor. In consequence, Charité – Universitätsmedizin Berlin developed a unique risk assessment tool for pressure ulcers and falls, based both on the rather unclear scientific evidences and the newly revised German expert standards on decubitus and fall prophylaxis issued by the German Network on Quality in Nursing (Deutsches Netzwerk für Qualität in der Pflege – DNQP) in 2010 and 2011.Purpose and aims of patient safety practice
The developed risk assessment tool focuses on the following goals:
• Early identification of risk patients and application of appropriate and evidence-based prevention measures.
• Consistent, institution-wide and simplified risk assessments and codes of practice for both decubitus and fall prevention.
• Integration of risk assessment as a computerized decision support tool into the existing IT-landscape of all general and intensive care units
• Reduction of necessary documentation effort by combining decubitus and fall risk assessment in in one tool (in total 10 items)
• Enhancing visibility of existing patient risks regarding decubitus and fall for all medical staff involved in the treatment of a specific patient (ubiquitous access on risk data from all possible access points inside the hospital information system)
• Safe and effective diagnosis of pressure ulcers and correct assignment of resulting category (I to IV)
• Empowerment of nurses via training modules (training modules focus on application and usability of the developed risk assessment tool)Implementation/Use in inpatient setting
The assessment of decubitus and fall risk is a mandatory part for determining the inpatient’s nursing status (= anamnestic evaluation of necessary patient care actions according to the care status). As such, nurses have to run through the risk assessment tool in order to automatically detect possible pressure ulcer or fall risks. Access to the risk assessment tool is granted from the general hospital information system; the risk assessment is executed inside the hospital information system and decision support with standard operating procedures (SOP).

Assessing the decubitus risk is carried out by judging 4 specific risk factors:
• Existing decubitus prior to inpatient hospital admission
• Patient mobility/ Jones index
• Transferability of patient
• Existence of “medical devices” close to the patient’s body

Assessing the fall risk is carried out by judging 7 specific risk factors:
• Fall incidents in the past within the last 12 months (existence and amount)
• Transferability of patient
• Walking ability of patient
• Excretion status of patient (urine)
• Patient orientation/ cognition
• Existing psychotropic or sedative therapies
• Known diagnoses such as syncope, epilepsy, transient ischemic attack, Chorea Huntington

As a result, the risk assessment tool automatically “calculates” the current risk for incurring pressure ulcers and/or falls and displays the corresponding risk both in a written and verbal way as well as with short risk indicators inside the hospital information system. Risk indication follows a simple threefold categorization:
• 0 = no risk
• + = risk
• ++ = high risk
• +++ = very high risk

The developed risk assessment tool is effectively used at Charité – Universitätsmedizin Berlin since the end of 2012. It possesses a high accordance between the PU/Falls prevalence and the PU/Falls risk and categorizes inpatients correctly and robustly in specific risk categories. The risk assessment tool has been evaluated internally, please see attached files for evaluation details.
Summing up the most striking evaluation results:
• The already low incidence of pressure ulcers at the Charité – Universitätsmedizin Berlin was further reduced by 10 %, taking into account the evaluation data/ delta between 2012 and 2013.
• The proportion of applied prophylactic counter-measures (e.g. support systems) increased substantially within the last two years and already shows ceiling effects on intensive care units.

Attachment of relevant written information and/or photos, as appropriate
Effectiveness of the Patient Safety Practice
Degree of implementation of reported practice
Yes, fully
Level of implementation of reported practice
Institution level
Specific and measurable outcome for the reported practice were defined
A baseline measurement before implementation of the reported practice was obtained
A measurement after full implementation of the reported practice was obtained
Evaluation of a “positive” effect of the reported practice on Patient Safety
The evaluation showed improvements in Patient Safety outcomes
Type of before-and after evaluation
Enclosure of a reference or attachment in case of published evaluation’s results

Health care context where the Patient Safety Practices was implemented
Successful implementation of this Patient Safety Practice in other health care settings than above stated
Specification of implementation in another health care setting(s)
There is no specified text here
Successful implementation’s level  of this Patient Safety Practice across settings
There is no specified text here
Involved health care staff
Patient Involvement
Direct service user’s involvement as integral part of this Patient Safety Practice
Specification of the service users or their representatives’ involvement in the implementation of this Patient Safety Practice
Point of time in which service user or their reprasentatives’ involvement takes place
During the application of the Patient Safety Practice
Active seeking of service users’ opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
Short description of the service users’ level of involvement
Consultation, such as asking for information
Public accessibility of information regarding this Patient Safety Practice to patients and citizens/service users
List of sources where public information is accessible
A brochure (3-pager) on recommendations for avoiding inpatient falls is distributed to both patients and their respective relatives if the computerized risk assessment shows a risk. Available in German language only.
Implementation of the Patient Safety Practice
Existing collaboration with other countries or international organisations related to implementation of this Patient Safety Practice
Problems encountering in the implememntation course of this Patient Safety Practice like lack of motivation, no management support, etc.
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
There is no specified text here
List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
Specially trained staff
Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
Description of used incentives, if any.
There is no specified text here
Existence of support or approval by the clinical or hospital management or any other hihg level authority in the implementation process of this Patient Safety Practice
Costs of the Patient Safety Practices
Completion of cost calculation related to this Patient Safety Practice
Total number of person days required to implement this Patient Safety Practice
Clinical staff:
External consultants:
Support staff:
Managerial staff:
Not relevant:
Total number of person days required for training as preparation for implementation of this Patient Safety Practice
Clinical staff: 282
External consultants: 0
Support staff: 50
Managerial staff: 20
Others: 0
Not relevant: 0
Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice
There is no specified text here
Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
There is no specified text here