HOSPITAL FALL RATES are a nursing-sensitive indicator of quality patient care, and, as such, they're included as a nursing quality indicator for monitoring and reporting through the National Database for Nursing Quality Indicators (NDNQI).1 The NDNQI defines a fall as an unplanned descent to the floor with or without injury to the patient.2
According to the Agency for Healthcare Research and Quality, falls are the second most frequently reported adverse event within healthcare institutions, following medication errors.3 Inpatient fall rates range from 5.09 to 6.64 per 1,000 patient days across the nation. In patients over age 65, falls are the leading cause of injury-related death, estimated at 41 deaths per 100,000 people annually.2
Since sentinel event monitoring began in 1995, The Joint Commission has received 659 reports of fall-related events that resulted in death or permanent loss of function.4 It's noteworthy, however, that sentinel event reporting is voluntary, so rates may be higher than reported.
The patient population on our unit consisted of surgical and stroke patients, most of whom were scored at high risk for falls using the Braden Scale, for increased risk of injury after a fall. This article will review how our medical-surgical unit took a stand against falls by creating and sustaining a successful fall prevention program.
Creating the project
Late in 2009, our 34-bed orthopedic medical-surgical unit was chosen as a pilot unit for a systemwide falls prevention project. That was good news but the reason for our selection was bad news: During the previous 8 quarters, our unit had failed to reach our falls prevention target.
The falls prevention project leaders investigated falls data and interviewed staff for several months before the pilot was launched. They identified three areas for improvement: increased staff education around fall prevention, increased accountability by staff members for patient safety, and enhanced equipment to alert staff about impending unsafe actions by patients, which would allow a quick response. The pilot program, which started in April 2010, was designed to address these issues.
The first step is education
Although our unit was the pilot site, professional and unlicensed assistive personnel (UAP) from other units frequently supplemented our staffing. Additionally, ancillary employees from throughout the hospital were regularly on our unit or interacting with our patients in other departments. Therefore, members of all departments were educated on falls prevention.
Education was provided via online modules and during in-person classroom sessions. The online and classroom settings used the same module; however, the classroom session allowed time for question and answer sessions. Content included identifying high-risk patients, prevention strategies, and proper response to a patient fall. With the support of the clinical and operations managers, we successfully reached every active staff member by late 2010.
During this education phase, we identified some previously unknown barriers to fall prevention. For example, we learned that non-clinicians (such as maintenance and environmental staff) believed they weren't permitted to look into patient rooms because of patient privacy rights. In response, we adjusted our classroom presentation to include the expectation that all employees should look into any room that has a falling star attached to the doorframe. The star is a visual high fall risk indicator that's posted outside of a patient's room as needed.
Education for UAP focused on recognizing patients who were at risk for falls and identifying unsafe situations. To help them easily recognize patients at risk, we created magenta-colored wristbands for all high-risk patients, to be used in addition to the falling stars on patient doorways. Unsafe situations included environmental risks such as wet floors and patients ambulating without wearing skid-proof slippers.
Education for clinical staff focused on hourly rounding with a purpose. Our purposeful hourly rounding focused on the four Ps: patient possessions within reach, position and comfort of the patient ensured, pain assessed, and personal care needs met, such as toileting/bathing.5 All staff members received education about risk factors for falls, which include older age, medication use, confusion, incontinence, ambulation or balance difficulties, fall history, and medical condition.6
Real-time education took place during daily interdisciplinary rounds, when each nurse reported on the patient's fall risk assessment (we used the Morse Scale) and planned interventions to prevent falls based on his or her assessment findings.7 An advanced practice nurse and assistant nurse manager were present at rounds to support and reinforce the application of learned strategies.
Following the educational sessions and implementation of purposeful rounding, we realized that each staff member needed to feel accountable for the safety of his or her patient and actively engage in our unit's goal to decrease falls. This was accomplished in several ways. Because the care team was expected to complete purposeful hourly rounding on each patient, managers questioned patients during their rounds to determine staff adherence. Staff members who weren't rounding were then counseled, remediated, and disciplined as indicated.
We were fortunate that our staff embraced this plan and were eager to implement the strategy of frequent patient rounding.
In an effort to keep staff focused on our goal, each staff member took on the personal goal of decreasing falls during his or her yearly evaluation in mid-2010. We were able to trace each fall to the accountable staff member and recognize those staff members with no patient falls for their outstanding care.
We also developed a postfall assessment for nurses to complete after his or her patient fell. This included a review of interventions in place and a patient interview to determine the cause of the fall. RNs were expected to complete this if any of their patients fell, and had to share the findings and any recommendations for improvement with management. This process encouraged clinical nurses to own their patients' safety successes and breakdowns.
The postfall assessments also helped us determine at-risk patients whom we hadn't previously considered. For example, we expected older and disoriented patients to be at highest risk, but we learned through the postfalls assessments that most falls occurred in our middle-aged surgical population (ages 45 to 65). Further investigation found that after elective joint and spine procedures, patients who were relatively young and used to independent mobility frequently overestimated their ability to ambulate alone or with family members, even after they were educated about the need to have a staff member present.
Fifty to seventy percent of hospital falls occur from the bed or chair, or while transferring between the two.6 We kept this in mind as we continued our pilot program and decided that implementing alarms may be a useful tool to alert nurses when patients were attempting to ambulate without supervision. Through interviews, however, the project leaders found that staff members were frustrated by the difficulty of quickly locating a source of the bed alarms that were already in place. The team met with the bed manufacturer and learned that the bed-based alarm could be wired to the existing call bell system, providing a blinking light cue above the patient door to accompany the auditory alarm.
In 2011, minor construction was completed that allowed us to wire our rooms, but the system still had shortcomings. Unfortunately, we had the ability to visually alarm only 18 beds at any one time, and maneuvering the equipment so that all patients in need of a bed alarm had one was difficult.
We quickly realized that we didn't want bed alarms to be a limited resource because we needed every bed on our unit to have this capability. We lobbied our organizational leaders for financial help, and our organization supported us. By early 2012, every bed on our unit had a bed alarm.
During this pilot, the project team was discussing its progress with our sister long-term-care facility and discovered that they used chair alarms along with bed alarms. We initially purchased a few of these, and quickly found that they benefited both staff and patients. Staff members benefited from the early detection of patient movement, and patients benefited from the staff's quick response. Both bed and chair alarms were instrumental in decreasing our unit's fall rate.
Guilty unless proven innocent
At the start of 2012, when the pilot was over, our unit was fully wired for bed alarms with a visual cue. We then decided to institute a new rule, which we termed “guilty unless proven innocent.” Unlike other alarm systems that may sound a false alarm for unwarranted reasons, we found that the bed alarms sounded reliably only when a patient was attempting to move from the bed. The sensitivity of our bed alarms allowed for repositioning. The alarm is triggered by sensing the patient's weight moving from the bed, so it doesn't alarm when patients are repositioning. With this process in place we didn't get false alarms, only alarms that were a true indication of a patient attempting to leave his or her bed.
Patients “proven innocent” are those who've been assessed by their nurse and can safely ambulate independently. Bed and chair alarms weren't engaged for these patients. However, our usual safety mechanisms for fall prevention, such as purposeful rounding considering the 4 P's, providing a clutter-free environment, and the use of non-skid footwear, stay in place for these low-risk patients.
The staff has supported this process, and UAP who work on our unit have also eagerly adopted it. Our physical therapists were initially skeptical, but they soon came on board after seeing results such as several fall-free months. The physical therapists also became frequent users of the chair alarms for patients at high risk for falls.
Standing tall against falls
We compared preintervention (called pre-2010) fall rates with postintervention (or post-2010) fall rates. Our preintervention fall rate for 8 quarters showed a mean of 5.42/1,000 patient days with a standard deviation of 1.38. Our postintervention fall rate for 8 quarters showed a mean of 3.94 with a standard deviation of 1.22. An independent-samples t-test of these data provided a P-value of 0.04, demonstrating a significant improvement in our falls rate. (See Pre- and postintervention fall rates by quarter.)
Staff members worked extremely hard to prevent falls on the unit, and the results show it. We're especially proud that this improvement translates to more patients who are discharged from our unit after a safe stay.
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