As part of the Transforming Care at the Bedside (TCAB) initiative's "framework for change," participating units focus on improving care in four specific areas: patient-centered care, value-added processes, safe and reliable care, and vitality and teamwork. In the last two articles (see Transforming Care at the Bedside, May and June) I outlined changes we made in the first two categories on White 10, a 20-bed general medical unit at Massachusetts General Hospital. Here, I describe changes we instituted to prevent falls.
FREQUENT ROUNDS: A HIT
White 10's average fall rate was similar to that of other general medical inpatient units throughout the country—6 per 1,000 patient days—but we knew there was room for improvement. To improve our understanding of why patients fall on our unit, in early 2008 I gathered White 10's safety reports and brought them to one of our "TCAB Tuesday" meetings, which include our unit's clinical nurse specialist (CNS), four staff nurses, and one patient care associate (PCA, a nurse's aide). We found that falls frequently occur when patients get out of bed to go to the bathroom, walk to or from the bathroom, or experience an episode of incontinence.
The CNS and I agreed that frequent, "structured" nursing rounds—in which PCAs would perform specific tasks at set intervals—could help to reduce the incidence of falls. The benefits of having structured, frequent nursing rounds have been related in the literature, reported by other hospitals participating in the TCAB initiative, and demonstrated in trials conducted on a few inpatient units at Mass General. One study found that performing specific nursing actions, such as asking whether the patient needed anything and assisting with toileting, at set intervals was associated with statistically significant reductions in patients' use of the call light and the incidence of falls, and with an increase in patient satisfaction.1 We also discussed a significant financial consequence of falls: As of October 2008, the Centers for Medicare and Medicaid Services no longer reimburses hospitals for treating medical conditions not present when the patient was admitted—including injuries associated with falls.
We decided to create structured nursing rounds that would improve patients' safety and satisfaction by anticipating their needs. Nurses and PCAs were frequently in patients' rooms, but the new rounds would emphasize structure and foster partnership between PCAs and nurses by having the PCAs ask the patients specific questions and report back to the nurse, if needed. In keeping with the TCAB practice of beginning with small changes, we devised a rounding schedule that had PCAs visiting patients every two hours (within six months, the rounds were hourly).
The planning for and communication of the new rounds policy took approximately three weeks. The planning group developed a model in which the PCAs ask patients three questions during each visit:
- Do you need to use the bathroom?
- Are you comfortable?
- Can I do anything for you?
Over a four-day training period, the resource (charge) nurses, who oversee the unit during their shifts, and I met with the PCAs to discuss and demonstrate the rounding process. We also distributed laminated cards detailing the actions they should take and the questions they should ask during the rounds.
We gauged the success of the rounds by the change in our unit's fall rate, anecdotal comments from patients, and patient satisfaction scores. We found that over two years our unit's average fall rate per 1,000 patient days decreased from 6 to 4.5. In this same period, patient satisfaction scores increased by 10 points. One patient who wrote to me after her discharge said, "Everyone [who] cared for me [was] caring and prompt in providing whatever I needed." Another said, "The nursing care has been wonderful; they are very attentive to my needs." In TCAB meetings, the staff commented that they noticed fewer call lights during their shifts, which meant that both nurses and PCAs had more time to provide direct care.
As with previous changes, it had seemed that implementing structured nursing rounds should be simple, but it actually required a larger cultural change. The PCAs were accustomed to their established routine of performing certain tasks, and shifting their focus to actively anticipating and meeting patients' needs required much prompting and cueing by nurses. By the same token, the nurses had to learn to manage the PCAs, ensuring that they completed the rounds and made them a part of their routine, so that no prompting was needed.
We've been conducting the nursing rounds for 14 months and reminders and cueing are still necessary. We hope to ensure the change's success by further educating staff on ways in which frequent nursing rounds benefit patients. We'll do this at our next retreat with the PCA staff, which we hold on-site a couple of times each year, and by frequently emphasizing the fall and patient satisfaction data that we post on the unit. Both clearly show trends toward greater patient satisfaction and fewer falls.
DAILY TRACKING OF FALLS: A HIT
At a national TCAB meeting, we learned about another change that would complement our new nursing rounds: daily tracking of falls. Representatives of one unit described their practice of posting the total number of days the unit had been "free from falls." I had been posting White 10's monthly fall report in the nurses' break room, but the information was relatively dated by the time it was posted. The idea of updating this number every day offered a new way to examine and report this news to the staff.
In the break room, I posted a sign that stated, "As of [date], it has been [number] days since our last fall." Each day, I change the sign to reflect our total number of days free from falls. This tracking method keeps the issue current, and it frames the information in a more positive way. At first we hoped to go 14 days without a fall, and then 28 days. At one point we went 36 days without a fall! We noticed that a stretch of fall-free days subtly inspired, motivated, and empowered all staff members to prevent falls. In one very telling example, a housekeeper encountered an unsteady patient whom she'd never seen out of bed trying to walk to the bathroom. She quickly intervened and called a nurse to assist the patient, most likely preventing a fall.
LEARNING FROM EXPERIENCE
On the whole, the changes we made to prevent patient falls were some of the most successful of the TCAB initiative. We're continuing to challenge ourselves to surpass our record of fall-free days.
Next month, in the final column of this series, I'll discuss our experience with another TCAB focus area: vitality and teamwork.