HOSPITAL FALLS and injuries are one of the top 8 hospital acquired conditions that the Centers for Medicare & Medicaid Services indicate should not occur in hospitals.1 The hospital inpatient population is aging. In 2010, individuals 65 years and older accounted for 45% of the inpatient population; of those, 19% were 75 years and older and 9% were 85 years and older.2
Injurious falls are serious adverse events that should never happen and are associated with significant morbidity and mortality.3 Some 3% to 20% of inpatients fall at least once during their hospitalization.4 Around 80% to 90% of falls that occur in hospitals are unwitnessed, and 50% to 70% occur from the bed, bedside chair, or while transferring between them; 10% to 20% occur in toilets or bathrooms, a disproportionally large number, given the short amount of time patients spend there.5
Evidence supports multifactorial fall prevention programs for reducing falls and injuries in acute care settings.5–7 Despite increased research on strategies to reduce both the rate and risk of falls, the robustness of evidence for hospital-based interventions has not advanced.8,9 Hospital practice is still predominately reliant on a fall risk screening score to determine fall risk and universal fall prevention strategies based on a level of risk, managed by the nursing staff, which fails to address specific fall or injury risk factors.10 Recent fall prevention toolkits direct hospitals to build program infrastructure and capacity among nursing and interdisciplinary teams.11–15 This multihospital project focused on staff, organizational systems, and improvement of program infrastructure and capacity through program evaluation and implementation.
Medicine and surgery units present a challenging, multispecialty care setting for patients with multiple medical, surgical, and psychiatric diagnoses. Medical-surgical nurses and interdisciplinary team members rely on a vast set of clinical competencies and skills needed for comprehensive assessment, prioritized care management, and clinically and culturally relevant patient education.16 In addition to managing acute, urgent, and emergent health care needs, these professionals collaborate to provide safe, quality patient care, of which fall and fall injury reduction remains paramount. Yet, falls and injuries on these units remain the highest compared with other clinical units in hospitals17 and occur across all age groups, with the greatest number of falls occurring among adults 51 to 60 years of age.11 Over the years, we received numerous inquiries from multiple medical centers to implement a fall and fall injury prevention program for medical, surgical, and medical-surgical units, which built specifically on our prior multisite projects.18,19
All 6 medical centers were part of the Veterans Integrated Services Network 8 (VISN 8). All were academic teaching hospitals, 5 located in urban metropolitan locations and 1 in a rural community (hospital 2). All hospitals were tertiary care facilities, providing acute care services. Facilities are categorized according to complexity level, based on characteristics of the patient population, clinical services offered, educational and research missions, and administrative complexity. Hospital complexity, total number of available beds, total number of medicine and surgery beds, and number of units are displayed in Supplemental Digital Content, Table (available at: http://links.lww.com/JNCQ/A216). The intent of the complexity levels is to group similar organizations for operational reports, performance reviews, and comparisons. This project was approved as a quality improvement project by the lead site research committee.
Using the Injurious Fall Prevention Organizational Assessment,20 we surveyed the units before (January 2013) strategic plan development and implementation and after (February 2014). The results of the presurvey identified gaps in practices across units and were used to design and implement a Web-based learning program. Results for each unit were then reviewed with the associate chief nurses, nurse managers, peer leaders, and designated key nursing staff.
Common fall and injury prevention program components identified as requiring further implementation across all participating sites were as follows: multifactorial assessment to identify specific fall and injury risk factors and individualized plans of care; at-risk medications that contribute to fall risk; use of hip protectors and patient education to increase adherence, floor mats, and alarms; environmental redesign for safe exit sides for patient transfers from bed, bathroom safety (raised toilet seats and grab bars), and elimination of sharp edges in patient areas; and patient education for fall and injury prevention framed in the Ask Me 3 tool,21,22 with focus on teach-back strategies to ensure patient engagement and partnership in fall prevention programs.
Thus, a customized Fall Injury Prevention Program was designed for medical, surgical, and combined units. Specially designed tools were developed and presented to designated unit peer leaders on each unit for communicating patients' fall and injury risks and treatment plan. A series of webinars were implemented every 3 weeks for 4 months to enhance clinical expertise and implement population-specific fall and injury prevention practices. The webinars included the main content areas identified as needing further implementation in addition to content identified by the expert consensus (assessment of orthostasis, delirium prevention and detection, and postfall assessment). A brief description of each program component is provided.
In the first project, using an expert consensus model, we developed a Unit Peer Leader Program for Fall Prevention that included a training session and manual and coaching calls. Two nurses considered fall experts drafted the manual specific to fall and injury prevention, sent the manual to other fall experts for review and comment, and made final revisions. The final manual was disseminated to designated inpatient peer leaders for review, comment, trial use, and revisions during a 2-month period. On the basis of peer leader feedback, final changes were made to the toolkit and it was then distributed to each unit. We subsequently developed a functional statement for an inpatient medical-surgical Unit Peer Leader for Fall Prevention and selection criteria. During the initial 3 months of the program, designated unit peer leaders were encouraged to individualize the manual (eg, by adding their own unit fall policies and procedures). All peer leaders found this manual to be helpful and each reported use of the peer leader criteria to further expand this role to other nursing shifts.
Orthostatic blood pressure evaluation and delirium assessment and prevention were rarely mentioned as part of fall prevention among medical-surgical nurses and nurse managers during project planning calls. They requested focused clinical reviews of orthostasis and delirium—the causes and frequency, assessment, differential diagnosis, and management with interdisciplinary team members—linked to fall occurrence. As a result, in project 2, nursing and medical specialists presented 3 separate webinars for each topic.
As patients with multiple, complex, medical comorbidities are admitted to acute care units, the staff is faced with the need to reduce injurious falls (fall protection). Two technologies are useful for fall protection: hip protectors and floor mats (project 3). While the evidence of hip protector effectiveness has been mixed, the most recent conclusion is that hip protectors are protective when used in patient populations at risk for hip fracture.23,24 We educated all sites about hip protector products, implementation methods, and strategies to increase patient adherence, referring the staff to our Hip Protector Toolkit (http://www.visn8.va.gov/patientsafetycenter). This toolkit includes prescriptive guidelines, patient adherence interventions, laundering guidelines,25 and replacement protocols.
Although hip fractures in the older adults can result from falls from a standing height, falls from bed account for the majority of falls and injurious falls in institutional settings. Floor mats are considered an essential component of any comprehensive injury-reduction program where injurious falls are a concern.26 Prior research described the relationship between bed height and injury risk and protectiveness of floor mats in a laboratory setting using a Hybrid III mannequin.27 Older inpatients are at higher risk for fall-related injury than the general older adult population, yet floor mats are not used consistently in inpatient settings to reduce injury risk. We educated all sites about floor mat products, implementation methods, and strategies for acceptance, referring the staff to our Floor Mat Selection Guide (http://www.visn8.va.gov/patientsafetycenter).
Engaging patients as full partners in their fall and fall injury prevention requires that education be dynamic, interactive, and individualized. Teach Back is one such tool, grounded in health literacy that focused on the cognitive and psychomotor skills of learning.28 Recognizing that teaching is not a 1-way process of information giving, rather it requires evaluation of learning through knowledge tests and skills test,29 a specialized teach-back tool was made available to the nursing staff for patient and family education on admission to the medical-surgical unit.7,30
In project 4, during a 5-month period, the expert faculty provided monthly lectures based on previously identified needs, with additional coaching and mentoring through triweekly conference calls and e-mail exchange. To enhance adoption and spread of program components, we subsequently used small tests of change, audit, and feedback of results to all participants and shared lessons learned across sites. Finally, we repeated organizational assessment several months after the webinars ended.
We identified unit peer leaders for each participating units. Orientation sessions were held with these leaders both to provide an overview of the project and their role and to provide them with tools to support their role (Unit Peer Leader Manual for Medical-Surgical Units and Handoff Communication Tool for shift report of patients' fall and fall injury risk and their plan of care, and schedule for the 4-month curriculum).
We analyzed changes in organizational fall injury program components and fall and injury data over time, before, and after the program implementation. Four hundred five responses were received from the 6 participating hospitals: 208 staff members participated in the presurvey and 197 (−5%) in the postsurvey. Only 2 sites (hospital 4 [+17%] and hospital 5 [+32%]) increased their participation rates in the postsurvey; all other sites averaged a 28% decrease.
For both pre- and postsurveys, the nursing staff comprised 75% (n = 305) of the total sample. The remaining 100 participants were interdisciplinary team (n = 24), other (n = 49), prescribing providers (n = 25), and support staff (n = 2). Participants were mainly day shift (8 hours; n = 145; 36%); day/evening (10-12 hours; n = 107) and evening shifts (8 hours; n = 35); evening/night (10-12 hours; n = 18) and night shifts (n = 25); or missing (n = 57). Shift distribution was nearly identical across pre- and posttesting.
For the administrative part of the survey, we found a statistically significant increase of 12.0% in leadership involvement in a fall and injury score (pre: 29.05 ± 9.56 vs post: 32.53 ± 9.03; P < .001). Similar results were observed for program evaluation with a significant increase of 13.6% (pre: 18.13 ± 8.94 vs post: 22.55 ± 8.68; P < .001).
Survey results for direct care providers were as follows: for Fall Injury Risk Assessment items, there was a significant increase of 5.0% (P < .01) (13.07 ± 2.89 vs 13.75 ± 2.42). For Screen for Likelihood of Fall items, there was a similar statistically significant increase of 5.3% (P < .01) (18.17 ± 4.14 vs 19.13 ± 3.37). For Environmental Safety items, scores increased from 21.99 ± 6.78 to 23.80 ± 6.82, a significant increase of 8.3% (P < .01). For Post-Fall Injury Assessment items, there was a significant increase of 6.0% (P < .004), and finally, for Discharge Patient Education items, scores increased from 9.37 ± 4.65 to 11.88 ± 4.12, a significant increase of 13.5% (P < .001) (Table).
Fall and fall injury rates
We obtained the baseline fall rates for the participating VISN 8 units from the In Patient Evaluation Center database to use as comparison of fall rates at project end. The VISN 8 fall rate per 1000 bed-days of care remained low compared with the national fall rate for all 3 types of units. Acute medical units' fall rate in VISN 8 stayed relatively stable through fiscal year (FY) 12, increased slightly at the end of FY13, and then decreased during the first 2 quarters of FY14 (Figure, A).
Similarly, the VISN 8 fall rate for acute medical-surgical units remained stable through FY12 but had unstable rates during FY13 and FY14, which were still below the national rates (see Figure, B). The fall rate in VISN 8 acute surgery units decreased through the first 3 quarters of FY12, before spiking in the fourth quarter and then decreasing in the first quarter of FY13. Furthermore, the fall rate in acute surgery units in VISN 8 steadily increased in FY13, before decreasing to national levels in quarter 2 of FY14 (see Figure, C). Major injuries due to falls were rare among all the 6 medical centers based on In Patient Evaluation Center data. The total number of major injuries for all units was 7 and 5 for 2012 and 2013, respectively.
Hospital administrators, clinicians, patient safety officers, and researchers continually reassess and build on current fall and injury-reduction strategies. Despite this, falls and fall-related injuries occur and remain a priority for prevention. Successful fall prevention programs that exist in health care settings typically display a combination of medical and rehabilitation interventions along with environmental adaptations such as assessing patients before and after a fall to identify and address risk factors and underlying medical conditions (eg, orthostasis, delirium, incontinence, mobility problems); implementing unit-based champions for peer learning; educating staff about fall and injury risk factors and prevention strategies; educating patients about their fall and injury risk factors; enabling patients to move safely in their environment (eg, installing good lighting, safe handrails, nonslip floor mats, bed alarms); and providing patients with hip protectors and floor mats that may prevent a hip fracture if a fall occurs.
Given the aging population, it is important to disseminate and build on the preventive work presented in this article with continued implementation of effective fall prevention programs that focus on increased program infrastructure and capacity, determination of individualized fall and injury risk factors, and protection from injury should a fall occur. While progress is being made, we believe that the percentage of falls resulting in serious injuries can continue to decrease. Equipment use specifically designed to reduce trauma during a fall, such as hip protectors and floor mats, should be integrated into patient care as emphasis should shift to prevention of injuries rather than falls per se. Acute care units have diverse patients with varying acuity and complexity that are known fall and injury risk factors. Focused programs can be effective in changing practices that are measurable but require strategic planning and implementation. Our implementation program consisted of organizational assessment at baseline, which informed the areas in need of improvement to reduce fall-related injuries. Through Web-based education, use of unit peer leaders, small PDSA (Plan-Do-Study-Act) cycles, and expert coaching, we were able to document the change in fall injury prevention processes and practices in all participating units. We were unable to show a decrease in fall-related injuries because those injuries were rare, making our sample too small to detect any change in the ultimate outcome of interest, which was fall-related injuries.
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