• Fall Prevention for Adult Patients in Perioperative Units

      Pruitt, Beth A.; Rowe, Gina; Hoffman, Ann G. (2019-05)
      Background: In the United States, patient falls have become a critical issue that negatively impacts our healthcare system. Even with continued emphasis on fall prevention, falls continue to occur frequently in hospitals across the United States. Falls are not benign events, and often lead to some level of patient harm or even death. Furthermore, since falls have been designated preventable hospital acquired conditions in acute care settings, they are no longer be reimbursed by insurance companies. The risk to patient safety as well as lack of reimbursement for falls are two major factors that support the need to prevent falls in acute care settings. In perioperative units, a highly vulnerable population exists, along with barriers to fall prevention. Local Problem: In a community-based hospital located in a Maryland suburban community, a comprehensive fall prevention plan was initiated to promote safety and prevent falls in this population. Interventions: Based on an extensive literature review, a fall prevention bundle was initiated on all adult patients in the perioperative units. This bundle included the following components: high fall risk wrist bands, non-skid socks, fall prevention signs, and fall education. Bundle compliance was tracked and measured using compliance audit tools. Additionally, falls were calculated as number of patient falls per 1,000 bed days. Results: After initiation of the comprehensive fall prevention bundle, staff had a high compliance rate with measures: wrist bands present, 97%; signs present, 100%; call bell within reach, 97%; education given, 89%; and non-skid socks on, 99%. Furthermore, no falls have occurred since bundle implementation. Therefore, the falls rate during this time is 0. Conclusions: Based on this data, the successful implementation of a fall prevention bundle has the potential to decrease the number of falls in a vulnerable population.
    • Falls in the Emergency Department

      Schultz O’Donovan, Laura; Rowe, Gina (2019-05)
      Background Patient falls in hospitals have been a long-standing issue for many inpatient units as well as emergency departments (ED). Studies have been conducted to find a reasonable solution to this issue. A literature review was conducted and found that bundled interventions that include multiple interventions, such as a falls wristband; supportive, non-skid footwear; patient education; and hourly rounding can be helpful to reduce falls numbers in the hospital setting. Overall, the literature supports a multi-pronged approach to reducing falls. Local Problem A local suburban hospital ED had experienced an increase in falls and requested a nurse practitioner student to assist them by implementing a falls prevention bundle for high falls risk patients. The student utilized information from the literature review and formulated a plan to implement a falls prevention bundle in the ED, including educating patients on their individual falls risk, providing the high falls risk patients with falls wristbands, non-skid footwear and auditing the use of hourly rounding. Interventions Over the course of two weeks, the project leader educated registered nurses and patient care technicians on the project, and how and where to locate the bundle items on the unit. After these two weeks, the bundle was officially implemented by the staff members and the project leader began auditing 5 randomly chosen high fall risk patients per week, to evaluate the usage of the bundle. After 14 weeks of implementation, monthly falls rates were evaluated, and electronic chart audits were completed by the project leader. Results In September, the project leader educated 51 nurses and patient care technicians out of 174 staff members, or 29.31% of the total ED staff. The unit had three falls noted on the incident report for the month of October. In October’s audits, 60% of high fall risk patients had received their non-skid socks upon entry to the ED. Seventy-six percent of nurses self-reported use of hourly rounding as well. In the month of November, there were zero falls, a great accomplishment. However, per the audit results, some of the bundle usage numbers had decreased. Of note, the project leader did not record any patients with the falls education handout in audits during the entire project. In the first week of December, data on patients who had fallen from 8/22/18-11/26/18 was collected. This data shows that zero of these patients had hourly rounding documented on them within the electronic chart. Conclusions Overall, it appeared that the falls numbers decreasing over the implementation period was not due to individual aspects of the intervention bundle, but perhaps due to the auditing process. The project leader’s presence on the unit every week, reminder emails sent to staff, and a poster with falls information were all incorporated once audits revealed that aspects of the bundle were not being consistently utilized. Perhaps re-education provided during the audits coupled with the presence of the project leader on the unit helped to increase falls awareness in order to decrease the falls rate for the unit.
    • Implementation of a Fall Prevention Bundle on a Pediatric Neurology Unit

      Habib, Olimatu I.; Hoffman, Ann G. (2019-05)
      Evidence/Background: Many times the nursing staff may not be readily available at the bedside to prevent falls. Falls continue to place a tremendous burden on patients and financial burden on the institution. A multifaceted approach to decrease falls in a pediatric hospital setting was implemented with a fall bundle. Included in this fall bundle is the Humpty Dumpty Fall Scale, a validated and reliable tool that is specifically sensitive to neurology patients and an education plan focused on families and staff. The Humpty Dumpty Fall Scale included a wide variety of medications and anesthesia/sedation influences to assess the risk of falls. Education to families has been identified as important in preventing falls. Local Problem: Pediatric patients are at an increased risk for falls in the hospital setting. Nursing staff and caregivers play an important role in preventing falls yet little is known on how to best prevent falls rates in the pediatric acute care setting through evidence- based interventions. The Joint Commission, the certifying body for health organization, now requires that a fall prevention program be implemented to prevent falls in all hospital setting. The purpose of this quality improvement project is to decrease the pediatric fall rate through the implementation of a pediatric fall bundle. Intervention: This quality improvement project took place on an 18-bed pediatric acute care unit at a large freestanding pediatric facility on the East Coast. The Neurosurgical unit pediatric patients were included in this quality improvement project. The pediatric fall bundle included implementation of education on fall prevention in children to staff and caregivers, the introduction of a new pediatric fall risk assessment scale, the Humpty Dumpty Fall Scale, and fall risk bracelet/band identifiers. Results: Quantitative data comparing fall risk and occurrence of falls was collected to assess the effectiveness of the fall bundle on the neurosurgical unit. Sixty patients met the inclusion criteria and were included in this quality improvement project. All sixty patients risk for a fall was assessed using the Humpty Dumpty Fall Scale. In 2018 there were a total of seven falls reported on the neurosurgical unit. Prior to implementation of the fall bundle, four falls were reported on the neurosurgical unit. During the implementation of the fall bundle, there was a decrease in fall rates with only one reported unwitnessed fall resulting in no injuries. Two additional falls occurred post implementation of the fall bundle on the unit. Conclusions: This DNP project was intended to improve the quality of patient care and promote fall safety to pediatric patients admitted to the neurosurgical unit. There was a decrease in rate of falls on the unit during implementation. This QI project increased awareness of neurological assessments pertaining to patient falls. Nursing staff reported including fall prevention in their daily plan of care after receiving fall prevention education. This QI project promoted a change in practice that heightened fall risk awareness and included fall risk education, a pediatric-specific fall scale, and patient identifiers in an effort to decrease the fall rate of patients on the neurosurgical unit.
    • Implementation of the Fall Round Checklist in Hospitalized Adult Patients

      EBONGUE, JULIENNE; Clark, Karen, Ph.D., R.N. (2019-05)
      Background: One million inpatient falls occurs in U.S hospitals annually, with medical units incurring the highest fall rates. In fiscal year 2018, 325 falls occurred in patients at high risk for falls at a local academic hospital. One hundred and forty-eight or 46% were found to have gaps in fall prevention practices at the time of fall. As costs associated with falls are no longer reimbursed by the Centers for Medicare and Medicaid, the organization’s goal was to improve fall prevention practices in low performing units. Clinical audits on falls have been found to directly measure fall prevention practices by assessing nursing compliance. Methods: This Doctorate of Nursing Practice project was implemented over a 14 week period. Data was collected while conducting an electronic health record audit and direct bedside observations using the “Fall Round Checklist” by the project leader and resource nurse participants. Percentages were used to evaluate nursing compliance with each item on the checklist from data entered into Excel. Results: Eleven medical-surgical units were audited. Two hundred and fifty- five patients were identified as high risk for falls. Consistent fall prevention interventions were observed in fall risk assessment documentation (87%). Environmental measures (call bell in sight and within reach, bed in low position, table and personal items within reach, clutter free room) averaged 96% compliance. Lack of consistency was noted with documentation of fall interventions (41%), turning the bed alarm on (46%), yellow armbands (50%), or supervision with toileting (41%). Conclusion: Successful implementation of the “Fall Round Checklist” identified gaps in practice that will assist the organization in improving fall prevention practices in low performing units through corrective actions of care processes, thus ensuring safe and quality care.
    • A Quality Improvement Project Using Fall Management Algorithms in Long-Term Care

      Lopez, Bianca E.; Windemuth, Brenda (2019-05)
      Background: Falls have been an ongoing and reportable problem in long-term care facilities. Moreover, falls can lead to serious physical, psychological and financial consequences for residents, their families and the staff. Each resident has individual risk factors that may lead to falling. Multifactorial interventions, or strategies that target multiple risk factors for falls, have been shown to reduce the number of falls and are recommended for fall prevention and management. The initial step in fall prevention and management includes identifying each resident’s risk factors upon admission into the facility, and after each fall. Local Problem: The medical administrators from a Mid-Atlantic facility expressed a need for a fall prevention and management intervention because of the increased number of falls, despite frequent changes to the facility’s fall management protocol. The latest protocol included fall risk assessment upon admission and fall incident documentation by nurses after each fall. The purpose of this project was to improve fall management in a long-term care unit through implementing the Post Fall Algorithm and reinforcing the Fall Assessment Algorithm with the goals of improving identification of fall risk factors, compliance on post-fall algorithms and overall reducing the number of falls. Interventions: The quality improvement project occurred over a 10-week period in a 33-bed long-term care unit located in a Mid-Atlantic facility. Participants included the certified nursing assistants, certified medicine assistants, registered nurses, nursing administration and providers. The first two weeks included collecting baseline data, recruiting of champions, and training of participants on the algorithms and the fall forms. The Fall Assessment Algorithm provided the staff with a list of intrinsic and extrinsic fall risk factors. The Post Fall Algorithm listed the process to complete forms and assessments within 72 hours after a resident fall. The algorithms were implemented during weeks three through ten, and the impact was monitored by tracking fall rates and compliance with the process of the post-fall algorithm. Descriptive statistics were used to analyze the completion of the Post Fall Algorithm, and determination of trends on fall incidences through the data on the forms. The generated report on fall incidence was analyzed to determine the relationship between the implementation of the algorithm and the fall incidence in the long-term care unit. Results: There was an overall decrease in the average number of falls in the unit from before (𝑥̅=3.33) to after (𝑥̅=2.63) implementation of the Post Fall Algorithm, accompanied by more than 75% staff compliance on documentation of the post fall forms. An inverse relationship was noted between staff compliance and the number of falls. Incidental finding included that the majority of the falls happened in the resident’s room (90%) and during a change in position (86%). Conclusion: Identifying each individual’s risk factors for falls and performing comprehensive evaluation by a proactive multidisciplinary team after a fall are important in developing individualized plans of care and may potentially reduce the number of falls.
    • Stopping Elderly Accidents, Deaths and Injuries: Fall Prevention for Community-Dwelling Older Adults

      Neser, Sarah B.; Rowe, Gina C. (2020-05)
      Problem & Purpose: Falls are the leading cause of death due to injury among older adults, yet most older adults who fall fail to report falling to their provider. Lack of routine fall screening and management among community-dwelling older adults places them at risk for future falls and injuries. The purpose of this 12-week quality improvement project was to implement the Centers for Disease Control and Prevention’s Stopping Elderly Accidents, Deaths, and Injuries protocol in a primary care office to screen older adults for falls and address modifiable risk factors for those at increased risk. Methods: A literature review supported the protocol in reducing falls among older adults. Publicly available resources were adapted into training presentations and case scenarios for providers and staff. Staff screened eligible older adults during their office visit. Providers assessed gait and balance for those with a positive screen and identified fall risk (low, moderate or high). Moderate- and high-risk patients received a risk assessment and fall plan of care. Protocol steps were recorded on checklists reviewed weekly by the project leader to evaluate protocol adherence. Ongoing chart reviews, case scenarios, and a mid-project training session reinforced the protocol. Data was analyzed in three four-week time intervals with a goal of 80% adherence to all protocol steps. Results: The majority of protocol steps remained above goal over all time intervals or improved with training. All moderate- and high-risk patients received a fall care plan, despite risk assessments dropping below goal in the final interval. Moderate-risk patients were difficult to correctly identify. Overall protocol adherence was highest for low-risk patients (97%) and lowest for high-risk patients (80%) compared to moderate-risk (81%). Conclusion: With continued staff education and protocol reinforcement, the Stopping Elderly Accidents Deaths and Injuries protocol can be successfully implemented in the primary care daily workflow. Protocol adherence may be complicated by fall risk level. This project’s results support the 2019 modified protocol in removing stratified risk levels. Barriers to implementation include lack of protocol reimbursement and time to complete the protocol. Future studies should assess effectiveness of the protocol in reducing falls at one-year follow-up.