Reducing Patient Falls Quality Improvement Plan

Patient falls and the injuries related to them account for one of the most prevalent safety issues facing the healthcare system today. Falls not only have the potential of negatively affecting patient health, but due to recent changes in insurance reimbursement policies, can cost the hospital thousands of dollars as well. Literature surrounding the topic shows that there are multiple interventions that can be instated to effectively reduce the amount of patient falls. These may include, but are not limited to, hourly rounding, pressure sensitive pads, fall-risk signage, and patient/family education. Empowering nurses to participate in a shared governance structure and come up with new solutions to the problem has also been shown to help to eliminate falls and improve patient safety.

Reducing Patient Falls Quality Improvement Plan

According to the Agency for Healthcare Research and Quality, about 700,000 to 1,000,000 patients each year fall during the course of their hospital stay (“Preventing Falls in Hospitals,” 2018). With such a staggering statistic, it comes as no shock that patient falls are one of the main safety issues regarding inpatient stays in the hospital. Approximately 30% of patient falls result in physical injury, including fractures, subdural hematomas, excessive bleeding, and even death. Inpatient falls also have the potential of increased hospitalization costs to both the patient and healthcare system. In a study conducted by Anderson, Postler, and Dam, patients who reported a fall during their hospital stay were charged more than $4200 compared to patients who did not fall. Additionally, inpatient falls are now considered to be a hospital-acquired condition for which hospitals are no longer receiving reimbursement from insurance companies for. For these reasons, patient falls continues to be one of the most researched and prioritized issue faced in the healthcare system today.

Quality Improvement Structure of Geisinger Wyoming Valley

After questioning multiple staff members and managers at Geisinger Wyoming Valley, it is clear to see that the quality improvement structure is not well defined or understood. According to the Geisinger Nursing Department Shared Governance Structure policy (“2016 Nursing Annual Report,” 2016), the shared governance council is made up of a number of staff nurses and nurse managers from every unit. The specific number of staff nurses per unit varies, as units like the Emergency Department and Intensive Care Unit have more nurses participating. Twice per month, usually Tuesdays and Wednesdays, the members from each floor join together with management to go over various safety and patient-care issues. Each day, different topics are discussed, with occasional in-services by Respiratory Therapy, Physical/Occupational therapy, etc.

On the fifth floor (east side), there are three nurses that partake in the bi-monthly shared governance meetings. The unit has identified patient falls as the main patient safety issue on the floor, and as of the end of June, the floor reported zero patient falls. According to Kristine Hilstolsky, December of 2017 was the last month there were zero reported falls. Between January of 2018 through May, there were 12 patient falls total, over the course of 2,693 patient days. To combat the problem, the nursing staff and management have enforced already existing policies. Hourly rounding is taken very seriously, focusing specifically on the “4 P’s” (pain, potty, positioning, and possessions). Within the past month, management has implemented additional policies to decrease the occurrence of patient falls. With every shift change, employee on the floor is required to participate in a safety huddle. The safety huddle begins with the unit manager addressing any critical events that occurred over the last shift, how many new admissions took place, and how many patients are suspected to be discharged within the next shift. Afterwards, the current nurses on duty read through their list of patients, reporting every patients’ Morse Fall Score, whether they have a pressure pad, and how compliant they are with using their call bell. Utilizing the floor’s budget, the unit manager also purchased cords that connect from the Posey pressure pads to the call bell system. With this, any time a patient attempts to get up out of their bed or chair, the call bell alerts the staff and the phone rings at the nurses’ station. Lastly, about three weeks ago, the unit secretary assembled a brand-new whiteboard system at the nurses’ station. The whiteboard is extensive and lists patient fall scores, how many staff members are required to ambulate the patient, if the patient is incontinent or has a Foley catheter, any other safety concern relevant to each patient.

Evidence Based Protocol for Reducing Patient Falls

After conducting a thorough literature review, it is clear that there are specific interventions that have been proven to significantly reduce patient falls in the hospital. These include hourly rounding, improved communication among the staff, medication reviews, and patient/family education.

Among these interventions, hourly rounding by the nursing staff is perhaps the most effective way to prevent patient falls. Not only does hourly rounding involve patients in their own care by addressing the four most common needs (pain, toileting, positioning, and possessions nearby), but it is also shown to make patients feel safer and easy anxiety and apprehension. An integrative research review conducted by Hicks (2015), examined 14 independent studies regarding patient falls and the interventions carried out in each. Although the specific type of rounding varied by study (i.e. what times the rounds were completed, how long the nurses spent in each room, etc.), the results were conclusive. Every study but one, which stated neither an increase or decrease in patient falls, reported either no falls or a significant decrease in patient falls over the time surveyed. The studies examined ranged from three weeks to six years. Another year-long study conducted on the effect of hourly rounding was carried out on a 75-bed neuroscience floor. In comparing the pre- and post-intervention data, researchers noted a 50% decrease in the incidence of falls on the floor from 44 falls per 1,000 patient days to 22. Lastly, after only one month of implementing hourly rounding in a UK hospital, researchers discovered a 36% decrease in patient falls.

Effective communication among the staff members on the floor is another tool that can be utilized to prevent patient falls. Providing detailed, written information to the patient’s families and visitors should stress the importance of the call bell should the patient need assistance. In the room, a whiteboard should be displayed within the patient’s view noting their fall score and alerting all who enter their risk for falls. The whiteboard should also include an hourly rounding section that is initialed by the nurse every hour. If a fall should occur, an “after-fall” huddle is an efficient method to discuss the event and how the fall could have been prevented.

Lastly, patient/family education is pivotal in reducing the risk for patient falls. In elderly patients especially, polypharmacy greatly increases the risk for falls by affecting cognition, balance, frequent urination, confusion, and dizziness. Reviewing medications and their side effects with the patient and their family can reinforce the importance of using the call bell to prevent a fall. Additional patient and family education may be provided centering around the facility’s specific fall prevention interventions. These may include fall risk signs outside the patient’s room, bed alarms or pressure-sensitive pads, and fall risk bands placed on the patient’s wrist.

Implementing a New Plan

After evaluating the current data provided from the past six months, it is clear that the current interventions in place on 5E are effective in decreasing the occurrence of patient falls and working towards the goal of 0 patient falls. Rather than implementing a new plan, improvements to the current strategies in place can help to sustain the down-trend and improve patient safety.

Patient and Family Education

Unit staff should continue to educate patients and their families about proper fall precautions. This can be achieved during hourly rounding through constant re-orientation, especially for confused or disoriented patients, and the reinforcement of proper call bell use. Chu (2017) suggests the use of internal TV channels in the patient rooms to help educate patients and families about fall prevention during their hospital stay.

Nursing and Ancillary Staff

Although the cords that connect the Posey pressure pads to the call bell system work well in alerting the staff to a patient attempting to get out of bed, there is not an urgent response to the alarm by the staff. Providing the staff with an in-service on the importance of responding to this alarm could help improve compliance. Although the current policy is to only place a pressure sensitive pad under the patient with a Morse Fall Score of over 50, patients who are unstable or impulsive with a lower fall score should also be considered. As mentioned above, the use of a whiteboard to document hourly rounding may also be beneficial. Currently, the only documentation required is via the patient’s chart on the computer. Adding a section to the whiteboards already used is both cost effective and can help improve patient satisfaction scores on post-discharge surveys. Unit managers should continue to perform management rounds each day and ensure patients are reporting continuous hourly rounding being performed by their nurse.

Medical Staff

Like nursing and ancillary staff, medical staff are also responsible for ensuring patients remain free of falls. During bedside rounding, doctors should ensure the patient’s bed is in the lowest position possible and the call bell within reach before leaving the room. Physical and occupational therapy should continue to ambulate their patients safely and effectively, paying close attention to those at a high risk for falls.

Economic Considerations

Chu (2017) suggests creating a “fall prevention toolkit,” consisting of a yellow fall risk wristband, yellow socks, and a yellow magnet at the door. To implement this toolkit on 5E, yellow socks and fall risk magnets would need to be purchased. Considering non-skid socks are already included in the hospital’s budget, changing the color of the socks ordered should not have a large impact on the budget.

Evaluation

To evaluate the success of the fall precautions and patient/family education, falls on the unit will be measured monthly (per 1,000 patient days) and plotted on a graph to better visualize the trend. At the beginning of each new month, the unit manager and charge nurse will assess the floor’s success for the month past and provide any additional staff education if needed. The unit manager will be responsible for ensuring that the goal of zero patient falls per 1,000 patient days was met. The staff will continue to look at evidence-based practice for any additional improvements to current fall prevention measures to ensure the best patient safety possible.

Disseminating the Implementation

Disseminating the implementation plan for fall precautions will be relatively simple. Many hospitals engage in a “Fall Prevention Week” in which posters, presentations, lectures, and activities are made available to their employees. This event can inform clinicians about various fall-risk factors (i.e. polypharmacy) and ways to manage them. Hospital newsletters can be used to distribute information to hospital staff in addition to creating a specific channel dedicated to safety on the patients’ TV. Unit managers may also display floor specific information in the employee breakroom. This may include a sign displaying the number of days since the last fall, current prevention strategies in place, and any additional relevant information.

Barriers to Change

Assessing staff readiness to learn and adapt to change is a necessary step in implementing new policies and procedures. In trying to enforce change, unit managers may experience barriers and challenges. These can include (but are not limited to) restricted budgets, high turnover rates, resistance or criticism from current employees, lack of trust in the evidence-based research presented, and lack of time to educate staff members. In order for the change to be effective, all employees need to be made aware of the importance of maintaining patient safety and preventing falls. Enthusiasm towards improving patient safety and satisfaction should be used as momentum to encourage staff members to participate. To implement the fall prevention toolkit, there may be the need for a slight budget adjustment to change the color of socks worn by patients. However, this change would be necessary as the socks would serve as an easily identifiable indicator of a patient’s risk for falls for every employee.

Conclusion

Patient falls continue to be one of the largest problems in the healthcare industry today, despite multiple varying interventions. Nurses especially are responsible for properly assessing and documenting every patient’s unique fall risk and taking the proper precautions to ensure their safety through intentional hourly rounding, pressure sensitive pads, fall risk wristbands, signage, color-coded socks, and patient/family education. By using enthusiasm to help implement changes, unit managers can empower nurses to take charge of their patients’ safety and decrease the amount of patient falls during their hospital stays, while saving the hospital thousands of dollars that are normally lost due to changing reimbursement policies.