Volz, Tina M. PhD, RN; Swaim, T. Jane MS, RN
The Joint Commission mandates that fall reduction programs be implemented in order to address the alarming incidence of patient falls in healthcare systems (National Patient Safety Goal 9—09.02.01, Reduce the Risk of Patient Harm Resulting From Falls”).1 In addition, the American Nurses Credentialing Center Magnet Recognition Program® requires Magnet® hospitals to monitor nurse-sensitive indicators such as fall rates and to exceed the mean/median of national benchmarks for these indicators. According to the Institute of Medicine report, Crossing the Quality Chasm, “Patients should be safe from injury caused by the care system. Reducing risk and ensuring safety require greater attention to systems that help prevent and mitigate errors.”2(p62) The Centers for Medicare and Medicaid Services instituted a rule that for discharges occurring on or after October 1, 2008, hospitals would not receive additional payment for cases in which one of the selected conditions was not present on admission.3 That is, the case would be paid as though the secondary diagnosis was not present. One of those conditions is a patient fall that occurs during the hospital stay. Therefore, not only is it important to provide a safe, healing environment for our patients and keep them from falling, but also it might affect reimbursement if a patient falls and is injured.
In late 2009, the fall rate at one large healthcare system in the Midwest was 3.4 per 1000 patient-days despite many efforts to address this issue. In 2010, the healthcare system Board of Trustees and senior management made the fall rate a priority and set a reduction in the fall rates as an organizational goal. To further engage the staff around this initiative, the organization also made this a gainsharing or associate incentive goal. The organizational goal was to be below the national Midas® benchmark of 2.85 falls per 1000 patient-days. The fall rate became a priority not only to nursing but also to the entire organization.
Quality management reviewed all falls from the previous 2 years (2008 and 2009) to determine if the fall was truly a fall by national definitions. The baseline fall rate was then re-set, based on the National Database for Nursing Quality Indicators definition of a fall as “an unplanned descent to the floor (or extension of the floor, eg, trash can or other equipment) with or without injury to the patient.”4 A multidisciplinary committee was organized to address the fall issue by reviewing the entire fall prevention program and initiating new and innovative interventions with the end goal to decrease falls throughout the healthcare system. The team was composed of representatives from quality management, risk management, patient safety, nursing research, nursing performance improvement, pharmacy, clinical engineering, and the vice presidents (VPs) of nursing. The senior VP (SrVP)/chief nursing officer (CNO) chaired the meetings. As this project was a quality improvement project, no institutional review board (IRB) approval was needed. The chair of the IRB/risk management was part of the quality improvement project.
Review of the Literature
Falls among older adults cost the US healthcare system more than $19 billion in 2000.5 “Three to 20% of inpatients fall at least once during their hospital stay; these falls result in injuries, increased lengths of stay, malpractice lawsuits, and more than $4,000 in excess charges per hospitalization”5(p2391) More important than the monetary cost is the cost in terms of morbidity and mortality. With an aging population, both the number of falls and the cost to treat fall injuries are likely to increase. Fall rates in acute hospitals vary from almost 0 to more than 10 falls per 1000 bed-days, with an average of 4.8 falls reported for every 1000 bed-days.6 This rate can go even higher, depending on hospital type and patient populations. Falls result in significant consequences that add to the burden of care for patients, especially elderly patients in healthcare systems.
Articles on fall rates, assessment, and prevention are widespread in the healthcare literature. Clyburn and Heydemann7 reviewed the literature on fall prevention methods used in the home and the hospital. The review centered on existing evidence about the effectiveness of interventions in reducing falls in orthopedic patients. Their review found no conclusive evidence that fall prevention programs are effective in preventing falls. The only evidence they found was that addressing delirium can help decrease falls. In fact, they found similar falls rates in the home setting and the acute care setting, leading them to question the practice of making hospitals responsible financially for patient falls.
Other studies, however, have shown that fall prevention plans have resulted in decreased fall rates. Weinberg et al8 discussed a quality improvement project to decrease falls focusing on safety awareness, accountability, critical thinking, and staff accountability. Senior leaders assigned accountability to the fall committee cochairs who were the chairman of rehabilitation medicine and the CNO. An education blitz, mandatory compliance with fall protocols, monthly discussions of falls, and transforming the culture of the system were successful in decreasing their fall rate from 3.9 falls per 1000 patient-days in November 2005 to 1.1 falls per 1000 patient-days in March 2010.
Walker et al9(p2497) found that the use of nonsteroidal anti-inflammatory drugs as well as drugs that can cause sedation, postural hypotension, or other central nervous effects were associated with a higher fall rate, P < .001. Beasley and Patatanian10 developed and implemented a pharmacy fall prevention program to supplement the existing nursing fall prevention efforts. Medications implicated in higher fall rates were assigned a numerical score (3 = high risk, 2 = medium risk, and 1 = low risk). Examples of high-risk mediations included analgesics and long-acting benzodiazepines. Medium-risk drugs included antihypertensive and antidepressant drugs, and an example of a low-risk drug was a diuretic. A list of high-risk patients (score ≥6) was reviewed daily by pharmacists, and when applicable, recommendations for changes to the medications were sent to the physician. The fall rate decreased at the facility after implementation of this program from 5.59 per 1000 patient-days to 1.75 per 1000 patient-days .
Numerous publications currently address fall prevention. The escalating interest in this topic by hospitals and researchers has been fueled by multiple variables including impact on reimbursement, transparency of public reporting of patient outcomes, and a focus on decreasing falls as a component of patient safety. Research supports that a multifactorial approach works best at reducing fall rates.11 Cameron et al11 advocated that interventions in hospitals “targeting multiple risk factors seem more likely to be effective than those targeting single risk factors.”11(p14) Our current study addresses the sustained decrease in falls in our organization after a multidisciplinary group implemented targeted, consistent, multimodal interventions.
At the direction of the SrVP/CNO, a multidisciplinary integrative fall committee (IFC) was initiated to reduce the fall rate. Key to the success of the IFC was high-level administrative involvement. The goals of the IFC were to review the current fall reduction program and to review and initiate a program based on the Institute for Healthcare Improvement (IHI) Fall Toolkit.12 At the IFC, issues were identified and placed on a priority list.
One high-priority issue emphasized from the onset was that prevention of falls needed to be the primary focus. The IFC members agreed with the overarching premise that, in the hospital environment, all patients are at risk for a fall. Issues identified included (a) inconsistency with reporting and the potential for underreporting falls and (b) the misperception by allied health and ancillary departments that this is only a nursing issue and that they cannot impact the fall rate. Transportation, nutrition, physical therapy, occupational therapy, pharmacy, environmental services, and all other disciplines were involved in addressing the fall issue. Each staff member was perceived to be able to contribute to the maintenance of a safe hospital environment. Education of allied health and ancillary departments was identified as a need in order to engage these groups. Toolkits for allied health and ancillary departments would need to be developed to provide these departments with necessary materials for implementation of the program in their departments considering their scope of services and opportunities to contribute. The existing computer-based leaning (CBL) modules of the organization were reviewed, and it was determined that the CBL modules could be supplementary to other educational methods and could support documentation of fall prevention competency education. The CBL module was completed by all employees (associates) during annual mandatory in-service days (MIDs). It was voiced that other methods of education would also be needed to maximize the engagement of the workforce. It was also noted that there was a need for a more consistent fall assessment and evaluation by nursing while completing hourly rounds, especially related to the room environment. Scripting was initiated on the units as a way to deliver a consistent message about ambulating patients for routine toileting. An “I Stop for Lights” button was distributed and worn by all associates. This further served to validate the organizational responsibility of all staff to support this safety goal. In addition, associates from all departments were instructed to assist the patient or call for assistance if they saw a patient’s light on or if they saw a patient trying to get out of bed or up from a chair unassisted.
The fall prevention procedure was revised to incorporate the relevant elements of the IHI Fall Toolkit.12 The 1st element was to assess risk. The facility continued to utilize the Morse scale13 on admission and ensured that the same version of the scale was utilized throughout the system. Approximately half of the falls occurred in patients in their mid-60s years of age, a subset of patients who were alert and oriented. Intense data analyses revealed that more falls occurred around or in the bathroom and on no particular shift. Falls occurred more frequently when otherwise healthy people had surgery or a procedure. Patients who were accustomed to being independent in ambulation often did not accept the restrictions placed on them by the surgery; therefore, they would try to get out of bed without asking for assistance. Because falls in our organization were occurring in other populations in addition to the elderly, confused patient, all patients were assessed and treated as at high fall risks. Hourly rounds provided an opportunity to reassess patients and to reinforce education and instructions to the patient and family to call for help prior to getting out of bed.
The 2nd IHI element incorporated in the plan was to communicate and educate.12 Nurses in staff development were engaged to assist with an education plan regarding the process and procedure revisions. Corporate marketing staff was instrumental in designing flyers and posters. As mentioned previously, there was a large campaign to educate and involve associates in departments outside nursing. It was emphasized that falls were everyone’s concern, not just a nursing issue. There was also a concerted effort to educate families and patients about the risk of falls and the need to call for assistance with ambulation, especially to the bathroom. An educational brochure called “It Takes a Team” was developed and incorporated into the admission process to ensure that patients and families understood the patient’s fall risk and measures they could take to prevent a fall. Patients and families were asked to teach back to the nurse what they learned at all points to confirm their understanding of fall risk and preventive measures. This process and outcome were then documented in the patient’s education record by the care provider.
Interventions were standardized throughout the healthcare system. Available tools such as bed alarms, chair alarms, and self-release belts were trialed and implemented house-wide. Gait belts were made available in every patient room and used for initial ambulation or transferring. Staff were reeducated in the use, and the education was incorporated in the MID annual competency. Clinical associates were instructed to zero the beds to ensure that the patient’s weight triggered the bed alarm if they attempted to get out of bed. Postfall huddles were started on all units after every fall. All personnel available were involved in these huddles to review the fall and determine what measures could have been implemented to prevent the fall. The practices of “no call-light goes unanswered” and the wearing of “I Stop for Lights” were integrated throughout the system as best practices. Lastly, customized interventions were designed for high-risk patients. Specifically, yellow wrist bands were placed on patients’ wrists when they had a history of a fall or if they had experienced a fall while in the hospital.
Friday Fall Reviews
Perhaps the most effective strategy initiated was the Friday fall review (FFR). The SrVP/CNO started the FFR by meeting every Friday at 7 am. Nurse managers (NMs) from every unit who had patients who had fallen were requested to attend. Each fall was presented by the NM or assistant NM the unit. The NM could bring a staff nurse or anyone involved in the fall episode to the FFR. The meetings were collegial, nonthreatening, and educational, and the tone was set by the SrVP/CNO. While the institution embraces a culture of accountability, we also strive to be nonpunitive and view issues from a process perspective versus an individual mistake. Each fall was discussed in depth to drill down into the cause and contributing factors of the fall and what could have been done to prevent it. Also in attendance were representatives from quality management, risk management, patient safety, nursing research, nursing performance improvement, pharmacy, clinical engineering, and the vice presidents of nursing from the entities in the system. The SrVP/CNO chaired the meetings. Themes were identified that contributed to falls. Interventions to address these issues were implemented, and “Humpty-Dumpty fall tips and pointers” information sheets were sent out by the SrVP/CNO to all staff (Figure 1).
Frequently, discussion centered around the issue of sleeping aids. It was found that some physician order sheets had a sleeping pill, usually zolpidem or temazepam, included in routine orders. In addition, the dosage of these medications was often not reviewed or adjusted for the elderly population. With the cooperation of medical staff leaders and pharmacy, orders for these sleeping pills were changed to the lowest dosage for those older than 65 years on all order sets. Lastly, all order sets that had orders for zolpidem or temazepam were changed to require the physician place a check in the box next to the medication to specifically order the sleeping pill.
Because patient falls often occur in the bathroom, the use of diuretics compounded this problem as patients are getting out of bed more frequently. Lee et al14 reported that diuretics were a significant predictor of falls. Hill et al15 found that sleep disturbances were more highly associated with falls (P = .0 56) than diuretics in a group of people living in a residential aged care facilities. In recognition of this evidence, every-12-hour diuretic administration was changed from 9 am and 9 pm to 6 am and 6 pm in order to avoid patients getting out of bed at night to use the bathroom.
Different bed alarms/chair alarms were trialed. Every patient room was supplied with both a chair alarm as well as a bed alarm. Gait belts were ordered for all patient rooms and stored in the same place in the room so it could be easily located and used by all caregivers. Patients and family members would sometimes turn off the alarms, so alarms were checked during hourly rounds, and patients and families were reminded to leave the alarm on. When necessary, gait belt training was provided to families, and the gait belts were sent home with the patient at discharge if indicated as a need. The purpose of this intervention was to ensure that families could safely help the patient to ambulate at home after discharge to prevent a fall and readmission to the hospital.
It was discovered that many of the falls occurred in the bathroom. Even when patients were escorted to the bathroom and the staff person was waiting outside the bathroom, patients would still fall. Our data demonstrated that patients were not consistently calling for assistance even if instructed to call for assistance prior to getting out of bed or standing up from the commode. It was decided that “safety trumped privacy,” and staff were instructed to keep the door open enough to see the patient when toileting. Patients were never to be left unobserved and thus unattended in bathrooms.
Staff outside the nursing department was invested in protecting the patients. Physical therapy ensured that they had the chair alarm on after they ambulated a patient. Nutrition aides who delivered and retrieved meal trays would put on the call light and stay with patients if they noticed them trying to get out of bed. Respiratory, pharmacy, and transportation staff members were all trained to be alert and assist with patients. One unit started a “hero of the day” award for those who prevented a potential fall. Flyers were posted on their unit that described allied health workers who helped prevent a fall (see Figure, Supplemental Digital Content 1, http://links.lww.com/JONA/A225).
The use of a multidisciplinary, multimodal approach in our organization to decrease fall rates proved to be very successful. The fall rate was below the MIDAS benchmark starting 2nd quarter of 2010, and it has been sustained through the 3rd quarter of 2012 (1.8 falls/1000 patient-days) (Figure 2). Pharmacists review all medications on patients who have fallen, and there is heightened awareness of polypharmacy. Physician involvement was enlisted for decreasing zolpidem to the lowest effective dose on orders. Careful attention is given to patients on pain medications, when getting them out of bed and when ambulating them. When possible, patients who have fallen are placed closer to the nurses’ station. Nonskid socks are available for all patients. Hourly rounds include assessments of the environment for fall risks such as ensuring the pathway for the patient is free of clutter including obstacles/equipment and keeping personal use items close to patients so that they are within reach. Patients are asked on hourly rounds about toileting needs, and bed alarms are turned back on after every time the patient is returned to bed.
Decreasing the fall rate remains an organizational goal but not a gainsharing goal because it has been achieved. To sustain our outcomes, however, leaders and staff are still focused on this issue. The fall rate is reported at the nursing performance improvement council meetings, the quality coordinating council, and the patient care committee of the Board of Trustees. The multidisciplinary committee continues to meet monthly, and the FFR continues to meet biweekly at 7 am. The process was so successful that quality management leaders have adopted it to review any core measure indicators that were missed or are off the benchmark.
The authors thank Wendy Bauer, MSN, RN, NHA, NEA-BC, Fall Committee Cochair; Ruth Henthorn, MSN, RN, NEA-BC, VP of Post-Acute Clinical Services; Bobbie Lehmkuhl, PhD, RN, CPHQ, AVP Quality Management; Sabrina Long, BSN, RN, Fall Committee Cochair; Susan McDonald, DNP, RN, CENP, NEA-BC, VP of Nursing; Donna Prather, MBA, RN, CPHQ, Quality Management; Joseph Rectenwald, JD, Risk Management; David Roth, MBA, RPh, Pharmacy; Tracie Shelton, BSN, RN, Director, Patient Safety and Accreditation; Jeannie Smith, BS, RN, CPHQ, Quality Management; Benita Utz, MSN, NEA-BC, VP of Nursing; and all of the nurse managers, assistant nurse managers, and all department directors.
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