Falls are a persistent and significant health care problem, considered a nurse-sensitive indicator because they depend on the quantity and quality of nursing care provided rather than medical interventions.1 Falls that affect patients and occur during a hospital or medical facility stay are defined as a hospital-acquired condition and adversely impact Medicare reimbursement. In 2014, our 245-bed Magnet- and Planetree-designated community hospital located in the northeastern United States established patient fall prevention as its top patient safety priority.
Three primary goals were established: (1) reduce the overall fall rate (number of falls/1000 patient days), (2) eliminate all falls with injury through an evidence-based fall prevention protocol, and (3) increase the percentage of patients who receive appropriate fall risk assessment and individualized fall prevention interventions.
Before the implementation of this evidence-based fall prevention protocol, the hospital's fall prevention program was inconsistent and not effective. Internal quality and risk management data showed an increase of inpatient falls, prompting a need for improvement. The internal fall data were compared with the National Database of Nursing Quality Indicators (NDNQI) for benchmarking.2 The benchmarking revealed the need for an innovative approach to improve fall prevention. In 2013, our baseline fall rate was 3.21, higher than the NDNQI median of 2.91. The baseline fall with injury rate, including minor falls and higher, was 0.77 compared with the NDNQI benchmark of 0.49.3
In addition to the NDNQI data, clinical nurses on the inpatient medical-surgical units identified that many patients on their units were not properly identified as a fall risk, and as a result, the number of falls increased. These missed opportunities during the fall risk assessment prompted an investigation as to the sensitivity of the current fall risk assessment method. The clinical nurses also identified that the implementation of the fall prevention interventions (eg, identification arm bands, door signage, bed/chair alarms, and patient sitters) did not prevent falls. Based on the NDNQI data and our internal observations, the hospital identified the need to improve the current fall prevention program.
In 2014, an interprofessional fall reduction team was commissioned by the chief nursing officer to evaluate the hospital's current fall prevention program. The evidence-based practice improvement (EBPI) model developed by Levin and colleagues4 was used as our method of using evidence-based practice (EBP) to improve patient care. The EBPI model combines the best of the EBP and performance improvement paradigms. The EBPI model gave direction to our methods for implementing the evidence-based practice change. Through small tests of change (STC) using Plan, Do, Study, Act cycles,5 we evaluated each aspect of a proposed improvement before a large pilot or organization-wide implementation. The EBPI model allowed for process refinement, paying attention to system issues or educational enhancements that needed to be addressed before full project implementation.4
As part of the EBPI methodology, we developed a PICO (patient, intervention, comparison, and outcome) practice question as the focus of our work. The PICO question was: In adult hospitalized medical-surgical patients, does an evidence-based fall prevention program that includes comprehensive assessment and individualized interventions based on patient-specific risks decrease the fall rate?
Search for evidence
Our priority was to identify evidence to inform the EBPI project. The team wanted to find the highest level of high-quality evidence and, thus, searched for a clinical practice guideline (CPG) that was relevant and applicable to the practice setting and clinical population. The CPG chosen was the Institute for Clinical Systems Improvement Health Care Protocol on Prevention of Falls in Acute Care Institutions. This CPG was chosen because it focused on an adult acute care setting and was appraised as high quality.6 The CPG identified 7 key practices for effective fall prevention:
- Organizational support for a fall prevention program
- A process for evaluation of the hospitalized patient on admission for risk of falling
- Risk assessments to identify risk factors
- Communication of risk factors
- Risk factor interventions
- Observation and surveillance
- Auditing, continuous learning, and im-provement6
The team completed a gap analysis to compare the 7 key practices identified in the CPG with the hospital's current fall prevention policy and current practice (see Supplemental Digital Content, Figure 1, available at: http://links.lww.com/JNCQ/A448). Using our quality monitoring event tracking system database, we evaluated whether our current policy contained the 7 key practices, whether staff were following the current policy, and whether the CPG practices would address the actual reasons patients fell. The 7 recommendations from the CPG were used to identify areas where there was a gap between current policy and practice and EBP for fall prevention.
Based on the gap analysis, we conducted a further literature review to find evidence-based interventions for each of the identified gaps. The team summarized and critically reviewed the literature and developed tables of evidence to summarize and compare recommendations to inform our new fall prevention program.
EBPI fall prevention program development
Based on the gap analysis and evidence review, the team incorporated the 7 key processes and interventions into the fall prevention program. To support consistent implementation of the program, we also developed an algorithm (Supplemental Digital Content, Figure 2, available at: http://links.lww.com/JNCQ/A449) of the prevention interventions as a resource for staff to follow. The algorithm outlined the evidence-based individualized interventions for fall prevention determined by the patient's assessed risk category. All patients identified as a fall risk, regardless of the category they belong to, were placed on Universal Safety Precautions. Based on each patient's assessed risk category, additional interventions were implemented for optimal patient safety. Staff education, which included in-depth algorithm protocol directions, was paramount in the implementation of the EBPI fall prevention program. We developed our implementation plan based on the integration of the 7 key practices of the CPG into our new fall prevention plan.
Enlist organizational support for a fall prevention program
We identified key stakeholders. The key stakeholders identified for project success included the entire patient care team (ie, nursing staff and leadership, unlicensed patient care assistants [PCAs], physical therapists, pharmacists, physicians [hospitalists], advanced practice nurses, support staff [housekeeping, dietary], and the patient and family advisory council). Our philosophy was that everyone who sees a patient is part of the fall prevention team. Fall prevention became an organizational culture.
Incorporate an injury assessment
Since our prior fall risk assessment did not include an injury risk assessment, we needed to find an evidence-based tool that did so. The team found a comparative review of 4 valid and reliable fall risk assessment tools that incorporated injury risk assessment.7 The team compared the injury assessment components of the 4 tools with our internal quality data. This internal validation evaluated whether any of the 4 tools would be adequately sensitive to identify patients at risk for falls in our clinical setting.7 Based on our internal data, the 4 tools were not comprehensive. This finding led to the development of our individualized assessment criteria based on the gap analysis, CPG, and additional evidence search (ie, evidence-based assessment for injury risk [age, anticoagulation therapy], mobility, medications, and behaviors).
Incorporate assessment of medications that increase fall risk
The CPG recommended an assessment of medications that increase a patient's fall risk. The American Geriatric Society's Beers Criteria identify medications or medication classes that are potentially inappropriate medications and classes to avoid in older adults and that contribute to fall risk.8 The Beers Criteria were used to develop specific guidelines for medications in targeted drug classes. Medications in the anticholinergic, antihistamine, benzodiazepine, and nonbenzodiazepine hypnotic drug classes were reviewed for dose reduction and drug avoidance in patients older than 65 years.8 The guidelines were accepted by the Pharmacy and Therapeutics Committee and incorporated in the computerized physician order entry system, prompting appropriate drug and dose prescribing.
Incorporate mobility assessment
The CPG recommended a systematic method of mobility assessment. Our prior practice was to identify whether the patient's mobility needs were 1- or 2-person assistance or up ad lib without any specific guidelines to determine when a patient was placed in either category. The literature search identified multiple functional assessments (eg, self-dressing) and PT-focused mobility assessments, but only one nursing-driven mobility assessment was identified. The Banner Mobility Assessment Tool (BMAT) is a nurse-driven mobility assessment that identifies a patient's ability to stand and safely ambulate. In addition, the BMAT can guide the choice of mobility assistance equipment.8,9
Consistent communication of risk factors
While communication of risk factors was not an identified gap, internal data presented a compelling reason to review the evidence on the use of alarms as a fall prevention communication strategy. In addition, the internal data identified that alarms were the consistent intervention used to prevent falls at our hospital, yet our fall rate was increasing. We had been using the alarms as our principal mode of fall prevention, not as part of an integrated framework of safety.10 Through an inpatient care unit process evaluation, we identified that the bed and chair alarms were placed on all fall-risk patients, and the settings were not standardized. The lack of standardization caused frequent false alarms when they were set at a sensitive level. In addition, it was identified that the devices alarmed after the patient fell if the alarm was not set based on patient size and movement. We identified the need to standardize bed and chair alarm settings throughout the hospital.
Purposeful hourly rounding
Hourly rounds are an opportunity to ensure that universal fall precautions are implemented and that patients' needs are being met. These rounds integrate fall prevention activities with the rest of the patient's care. While hourly rounding had been in place before this EBPI project, we needed to define clearly rounding responsibilities and processes that focused on fall prevention interventions and that proactively anticipated patient needs. We revised our hourly rounding process to anticipate patient needs and ensure patients were safely in their bed or chair. Daily patient care leadership rounding was also revised to focus on fall prevention interventions, and evaluate the process of the protocol implementation and adherence. All levels of leadership, from the chief nursing officer through assistant unit managers, were incorporated in leadership rounds to communicate the fall prevention program, acknowledge when the processes were followed, and hold stakeholders accountable when the processes were not followed.
Conduct auditing, continuous learning, and improvement
A key issue for the team was to develop a learning culture related to fall prevention, to promote a culture of sustainability where we continue to learn from our internal data and build our individualized assessment. The team identified a process similar to a critical incident debrief, where real-time analysis of the fall would help us learn what was working.10 A new debriefing tool was mapped to coincide with the fall prevention program algorithm. By reviewing falls in real time, the patient care staff could identify any patterns and make decisions on new improvements needed to prevent falls. In the event of a fall, a postfall debrief was conducted immediately in the patient's room in the presence of the patient and family. The debrief leader is the nursing supervisor or nurse manager. Other team members included clinical nurses, PCAs, nursing education, quality, pharmacy, physicians, and physical therapy. The debrief allowed for a more thorough root cause analysis to identify causative factors in the recent fall, assess adherence to the algorithm, and provide on-the-spot education and solutions.
Fall prevention program education
We needed to educate the stakeholders about the importance of the fall prevention program and how to use the intervention algorithm to prevent patient falls. We emphasized that the program was based on our internal data and evidence to improve safety. The education built a team focus that fall prevention is everyone's responsibility and that through teamwork we would successfully improve patient safety.
The nurse educators on the team led the development of the education for each step of the program. We used the intervention algorithm as the framework for the education. Members of the team identified additional unit champions for the project who would be subject matter experts (SMEs). In-person training was completed, and demonstrations of equipment (if indicated as necessary by the algorithm) were mandatory for all staff from physicians through support staff. A competency was developed to support sustainability.
Small tests of change
Essential to our success were STCs that ensured each step of the fall prevention program was consistently implemented and that the process worked before we could evaluate outcomes. A staged implementation plan evaluated the effectiveness of each intervention and built on each success with additional interventions. STCs were completed as each component of the program was implemented. We used the SMEs on each unit for 2 consecutive weeks at each STC to validate and support the use of each component of the interventions before implementation on the next unit.
Evaluating program implementation
Before evaluating the effectiveness of the fall prevention program to decrease our fall rate, we first had to evaluate understanding and adherence with each of the steps of the program. The unit SMEs and team leaders rounded on the unit to assess the process of each STC. They assessed qualitatively whether the staff were following the process being implemented, asked for feedback, and reeducated if needed. If an implementation process problem was identified, the SMEs brought the feedback to the team where the process was reviewed and either affirmed or adapted. The SMEs then returned to the unit and communicated the team's review. With the addition of each intervention, reeducation of the prior steps was completed, and teach-back methodology was used to ensure the stakeholders understood how the individual interventions fit together for a comprehensive fall prevention program. After each step of the fall prevention program was fully and consistently implemented, we compared our fall rates with the baseline data from the quality department to determine whether our program was effective.
Addition of video monitoring into the fall prevention program
Following the successful implementation of the fall prevention program, the fall rate was decreasing. However, the team identified that a subset of patients, patients who exhibited impulsive behavior, were still falling. Before the implementation of our EBPI fall prevention program, we were using an adapted sitter model. We placed confused or impulsive patients in our geriatric cluster, a dedicated 4-bed cluster where a PCA would watch the patients for movement toward a fall. We evaluated the geriatric cluster process and determined it was not consistently effective, because the PCA could be intervening to prevent a fall with one patient while another patient needed safety interventions. In addition to the geriatric cluster, we also used 1:1 sitters for patient safety.
Since the geriatric cluster was not an effective part of our fall prevention program, we again searched for evidence of effective interventions. We found that video monitoring was a cost-effective safety promotion technology for confused and impulsive patients to replace sitters.11,12 In April 2016, we implemented a video monitoring system and trained PCAs as safety technicians (STs) to watch up to 12 patients at a time. The ST can verbally redirect patients via an intercom to wait for assistance and can notify a care team member to go in to help the patients before they get up and fall. Using the video monitor, the ST has seen patients starting to get out of the bed, used the intercom to redirect the patient, and prevented falls. These “good catches” would not have happened without video monitoring.
With full implementation of the fall prevention program and the addition of video monitoring, we had a 54% reduction in falls from 2.51 falls per 1000 patient days for the fiscal year 2014 to 1.15 falls per 1000 patient days for the last half of 2016 and first half of 2017 on the inpatient medical-surgical units (Figure). In addition, a 72% reduction in sitter usage equating to $84 000 in annual savings was noted (this would be higher in a larger hospital and in a hospital that did not have an existing geriatric cluster).
Debriefing is a key component of sustainability. Our real-time debrief promotes a culture of learning and sustainability by keeping fall prevention at the forefront of safe patient care. To communicate the essential nature of the real-time debrief, a fall alert call is broadcasted over the hospital's communication device to alert the team to attend the fall debrief. The fall alert creates an efficient mechanism for the debrief leader to gather the key staff caring for the patient who fell. In addition, after the debriefing takes place, the staff huddle to discuss what happened. During the huddle, all the staff on the unit caring for the patient discuss what interventions from the program may have been missed, and identify care plan modifications to prevent a subsequent fall for that specific patient. The huddle provides an opportunity for staff to learn from the experience.
In January 2016, a fall-free calendar was implemented on each unit to track fall events. A sign was posted, which records the number of days since the last fall. When a fall occurs, the sign is updated to raise awareness that a fall has occurred in the department and prompts staff to ask what happened. The debrief and the fall-free calendar maintain awareness of the fall prevention program and assist with increasing sustainability. In addition, as part of our shared governance framework, the debrief data are discussed at the Nursing Quality Council to identify opportunities for improvement and develop action plans to move forward and sustain results.
The interprofessional fall reduction team remains intact and meets monthly to review the debrief data. We have added the SMEs who are now the fall champions from each unit. The team also compares the results of any falls that occurred with the debrief data in an iterative process to ensure the process is still followed and to maintain the positive outcomes. Together with the Nursing Quality Council, the team conducts peer review audits and provides just-in-time education to colleagues to continuously reinforce the importance of accurate assessment and application of interventions based on the individualized patient assessment.
Fall prevention is an interprofessional patient priority. A multidisciplinary team approach that focuses on implementing evidence to individualize fall prevention and improve patient safety can decrease fall rates. This EBPI project demonstrated that focusing on the implementation process, feedback from staff, and learning from real-time debriefs reinforces learning and sustainability.