Implementation of Falls Protocol to Improve Falls Rates in Confused Known Fallers

Abstract

Problem: Fall rates can decrease when standardized fall interventions and screening tools are used for confused patients who are known fallers (also known as repeat fallers). On an adult medical-surgical unit in an urban medical center, 40% of patients who were confused fell and falls increased from 4.19% in 2021 to 7.19% in 2022. Purpose: The purpose of this Quality Improvement (QI) project is implementation of fall prevention interventions to decrease the number of falls by placing new signage on the doorway for prompt identification of their fall status while hospitalized. Project goals include to reduce the falls rate in patients with a repeat history of falls and 2) to improve door sign accuracy and monitoring. Methods: A team of interdisciplinary stakeholders met and the creation of a new sign identifying “known fallers,” was implemented. Assessment and monitoring of routine metrics were carried out over 15 weeks in fall 2023. Education of nursing staff included new signage and fall prevention protocols. Weekly unit audits assessed the number of falls and initiation of the fall prevention protocol for the new signs. Results: The falls rate at the beginning of September was 13.2% and steadily decreased until December with a rate of 3.3% from 1000 bed days. Results show N=317 total (n=15, 3.3% patients who fell); 15 patients fell (4 known fallers, 11 patients fell who were not confused or had a history of falls). Door sign identification of high Morse fall risk = 42% accuracy; “known fallers” identification= 51.7% accuracy. Conclusion: The QI project revealed that the highest rates of falls were from patients who were cognitively intact and miscalculated their abilities and limitations when out of bed. This QI project emphasized the importance of stringent and consistent screening protocols for all hospitalized patients regardless of mental capacity.