• 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 a Fall Prevention Toolkit on a Medical Surgical Unit

      Khandagale, Usha; Windemuth, Brenda (2021-05)
      Problem: In-hospital falls result in patient harm which includes minor injury, psychological distress and anxiety, and serious injuries like fractures, head trauma, and even death. The Joint Commission consistently ranks falls with serious injury as one of the top sentinel events. An acute care medical surgical unit in a community-based hospital experienced an increase in the number of falls with an overall fall rate higher than that of peer units. Purpose: The purpose of this Quality Improvement (QI) project was to implement and evaluate the benefits of, and staff adherence to, the use of Fall TIPS (Tailoring Intervention for Patient Safety) toolkit to reduce falls on a medical surgical unit. Methods: The Fall TIPS toolkit was designed to decrease the patient fall rate in hospitals and engage patients and their families in a 3-step fall prevention process including performing a fall risk assessment, creating a tailored fall prevention plan, and executing the plan regularly. Implementation of a Fall TIPS toolkit with auditing transpired weekly over 10 weeks on a medical surgical unit. Nurses’ adherence to the Fall TIPS protocol was measured weekly during implementation. Results: The results indicated that nurses’ adherence to use of the Fall TIPS toolkit averaged 78%. The run chart analysis of nurses’ adherence did not show any shifts or astronomical datapoints, and the number of runs was consistent with random variation. However, there was a 6-point upward trend in the data during weeks 2 to 7, indicating a special cause. Fall rates during the first two months of implementation were 3.39 and 2.41 per 1000 patient-days respectively, and dropped to zero during the third month. Conclusion: Nurses’ adherence to a Fall TIPS toolkit was demonstrated on a medical surgical unit, which likely resulted in a decreased patient fall rate during the final month of the project. Additional time will be needed to determine if the practice changes and outcomes are sustainable.
    • Implementation of Early Mobility Screening in the Surgical Intensive Care Unit

      Jones, Lindsay K.; Bundy, Elaine Y. (2021-05)
      Problem: A lack of early mobility screening in the adult critical care population may lead to adverse healthcare outcomes. In the past months preceding the practice change, a Surgical Intensive Care Unit (SICU) experienced seven hospital-acquired pressure injuries (HAPIs) and three inpatient falls. Purpose: The purpose of this quality improvement (QI) project was to implement and evaluate the effectiveness of early mobility screening via the Johns Hopkins Highest Level of Mobility (JH-HLM scale) in a 12-bed adult SICU in a community hospital setting. Methods: The JH-HLM scale was implemented over a 13-week period and was used to assess patient’s daily mobility level. Data on nursing compliance of use of mobility scale and improvement in mobility scores were collected via manual chart audits, and run charts were used to track and analyze results. Falls and HAPIs were also tracked. Results: Analysis of run charts for nursing compliance in use of the scale and improvement in mobility scores showed no shifts, trends, or non-random variation of runs, suggesting no effect due to the practice change. However, nursing compliance with use of the scale was consistently 85% to 100% and improvements in patient mobility occurred in 41 (35%) out of 116 patients screened. Although there was no decrease in patient falls, HAPIs decreased when compared to the previous eight months. Conclusion: The JH-HLM scale was found to be a safe and feasible screening tool useful by nurses in promoting early mobility in an acutely ill population. Additional QI projects are needed to determine if improved patient outcomes are associated with early mobility screening within 72 hours of ICU admission through discharge.
    • 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.
    • Reducing Falls Utilizing a Fall Prevention Toolkit, Tailored Interventions for Patient Safety

      Morales, Flor M.; Gourley, Bridgitte (2021-05)
      Problem: Despite the use of numerous evidence-based interventions, in 2019, a medical surgical unit at a community hospital had a higher fall rate than its peers. The average fall and fall with injury rates were 2.6 and 1.17 per 1,000 patient days. Purpose: To implement and evaluate the effectiveness of the Tailored Interventions for Patient Safety (TIPS) fall prevention toolkit (FPTK) in an inpatient medical-surgical unit. Methods: The intervention is a three-step evidence-based tool which provided individualized universal fall precautions. Nurses completed a fall risk assessment on every admission and transfer to the floor. Then, they completed a falls poster at the bedside with the patient, educating them on their individualized fall risks and fall prevention interventions. The poster was hung at the door as a reminder tool for staff and patients. Data collected during the project included staff education, poster completion audits, and the organizations reported monthly fall rates. The data was analyzed using run charts and bar graphs. Reminders, morning huddles, and staff education were used to promote compliance. Results: Nurses and patient care technicians (100%) were all educated prior to intervention implementation. The average compliance rate of completed TIPS posters was 67%. The fall rate increased during the intervention phase by 18% compared to the pre-interventions phase. There were no changes in fall with injury rates post intervention when compared to pre-intervention. Despite an increase in falls during the implementation phase, there was a positive trend that showed that as compliance rates increased from October to December, fall rates decreased. Conclusions: The compliance rate was not met and fall rates were higher post-intervention. Additional reminders, weekly huddles, and meetings could be held to re-educate staff and allow for discussion of barriers and facilitators. October and November’s low rate of poster completion may correlate with the higher fall rates. In December, there were less falls and compliance rates were higher. Strategies and tactics should be utilized in order to increase intervention compliance, increase sustainability, and decrease fall and fall with injury rates in the future. Limitations included a COVID pandemic and forgetfulness in completing the poster.
    • Reducing Falls with Tailored Intervention for Patient Safety on a Neuro Unit

      Lockard, Darlene; Gourley, Bridgitte (2021-05)
      Problem & Purpose: Falls on the neuro care unit at a suburban hospital in 2019 averaged 2.4 falls per month. This unit has the second highest fall rate at the medical center. Compared to the National Database of Nursing Quality Indicators for total falls in 2019, the neuro care unit was higher than the benchmark and averaged 2.98 falls per 1000 patient days with the benchmark at 2.95 falls per 1000 patient days. The purpose of this quality improvement project is to implement and evaluate the effectiveness of a Tailored Intervention for Patient Safety toolkit to reduce falls on an adult inpatient neuro care unit. The Tailored Intervention for Patient Safety is a 3 step fall prevention process that includes Universal Fall Precautions that apply to all patients admitted or transferred to the neuro care unit. Methods: Methods employed for assessing completeness and accuracy of data were done by spot checking audits twice weekly to make sure Tailored Intervention for Patient Safety poster at bedside and handout in admissions folders were properly filled out. This data was analyzed and graphed in a run chart to analyze for trends by looking for runs, shifts, and alternating points that suggest cause variation exists. The hospital provided monthly falls and falls with injury was and calculated using falls per 1000 patient days. This was plotted in a bar graph to compare pre-intervention and post-intervention to ensure completeness and accuracy of the data. Results: TIPS poster compliance was 90%, with 100% of staff trained. Falls decreased by 67% compared to pre/post-intervention data from 2019 to 2020. Falls with injury decreased by 14% compared to pre/post-intervention data from 2019 to 2020. TIPS handout compliance was 0%. Conclusions: TIPS adherence reduced falls and falls with injury. This reduces hospital cost and improves patient care.
    • 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.