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In the national reports on patient harm, many indicators have seen marked improvement in the last decade. Several hospital infections have become much rarer, with many hospital units going years without seeing a single case. You can see the graphs in those national reports trending downward. But fall rate graphs seem to squiggle along in a fairly even fashion, neither rising much, nor falling much.
Until maybe now. A three-year collaborative through the Joint Commission Center for Transforming Healthcare finished up with seven hospitals reducing their falls by a total of 35%, and falls with injury by 62%. The extrapolation of those figures if they were national could be significant, given that a third of falls usually result in injury, which result in an extra six days in the hospital, and lead to some 11,000 deaths annually, according to the Center. In a 200-bed hospital, the figures would work out to a reduction of falls from 117 to 45, with a savings of about $1 million.
The participating hospitals included the following:
• Barnes-Jewish Hospital in St. Louis;
• Baylor Health System in Texas;
• Fairview Health Services in Minnesota;
• Kaiser Permanente in California;
• Memorial Hermann Healthcare System in Texas;
• Wake Forest Baptist Medical Center in North Carolina;
• Wentworth-Douglass Hospital in New Hampshire.
The collaboration used a process improvement process that incorporates elements of Lean, Six Sigma, and change management.
Erin DuPree, MD, vice president and chief medical office for the center, says that each of the ideas brought forth by participants was tested. In the end, some 21 targeted solutions were validated. In the next six months or so, an online Targeted Solutions Tool Kit for fall prevention will be available to Joint Commission members. The tool offers step-by-step guides to determining your organization’s issues related to falls, barriers to implementing change, and suggested solutions.
Not every solution will work for every patient or even every unit, says Becky Beauchamp, MSN, RN, CENP, director of nursing at Wake Forest Baptist Medical Center in Winston-Salem, NC. Oncology units have to deal with patients on chemotherapy; geriatric patients often forget that they should ring for help if they want to get up; patients with brain injuries can be very impulsive. "There are generic things you can do for every patient, but there are also cases you can’t foresee, like a first-time seizure or a massive heart attack."
Each kind of fall has a different potential intervention, she says. And each of those falls can take place at any time. It makes prevention exhausting but, because falls are considered healthcare-acquired conditions, all the more imperative.
A fall committee had some success at Wake Forest before the collaborative started, Beauchamp notes. Falls, and falls with injuries were tracked by unit. There was a strategy in place for trying to figure out just what was going wrong when someone fell. But what was missing was the element of working with other hospitals, she says. "We could learn from them, in a very structured way, using the robust process improvement methodology. Even if our interventions differed, the way we collected data would be the same. We used the same failure mode analysis to see gaps and test theories of what contributed to the risk of falling."
Those tools helped all the participants see toileting as a red flag. Patients who were otherwise compliant and anxious not to fall would get out of bed in the middle of the night to use the toilet, or would need to go to the bathroom, but after ringing a call bell, would be waiting too long and try to go themselves. Some patients might be on medications that made them need to go to the bathroom more often; others were not getting enough opportunity to use the toilet. While it seems like an obvious thing, to the participants, finding out how prevalent toileting issues were to fall risk was a big aha moment, she says.
"We found that we were giving diuretics to some patients at 10 p.m. They were needing to use the bathroom well after our tuck in’ time of midnight," Beauchamp says. That was something that could be easily changed to ensure that the patients were done diuresing well before it was time for bed.
The data gathered was much more in depth than anything they had seen before, she says. While before they had information on falls and falls with injury, translated to a rate of falls per 1,000 patient days, the collaborative included more refined data for the two units involved — geriatric and oncology. They had demographic data, medication data, call bell response times, and more. This enabled them to find problem areas — such as call response times — and focus efforts around them.
The data collection was done with help from graduate students and the performance excellence department, and it ended with the collaborative. Beauchamp says it would be nice to have that level of data available all the time, but it’s too resource intensive. For now, they have a nurse manager do additional data grabs monthly on some of the data points they used in the collaborative, but it’s not an everyday all-the-time thing on any unit.
"We think this was a great way for us to find out things about our particular population that we might not otherwise have found," she says. For instance, the oncology patients were not traditionally gotten up and moving during weeks-long chemotherapy stints in the same way a surgical patient would be once the anesthesia wears off. If the patient didn’t feel well, they were left in bed. But being active helps preserve muscle and prevent future falls, so nurses now assess oncology patients daily, and if they are able, they are walking daily. For the geriatric unit, they implemented a video monitoring system, which other hospitals in the collaborative used with success. "They forget to use the call button, so if we see them moving to get out of bed, we can call into the room and tell them to hold on, someone is coming, and then send an alert out for all caregivers so that someone will get there quickly."
The fall rates at the hospital dropped 42% and injury rates dropped 11% over the course of the collaborative. The things they do now are an amalgamation of items from the solutions kits of the other participants: Some beds have piercing alarms that alert caregivers if patients leave them or if they move beyond a prescribed boundary on the bed. There are "do not pass" zones that require anyone walking by who sees a call light on to step in, engage the patient, and wait for the caregiver with them, no matter who it is, CEO or food service worker. The mobility training from the oncology unit has expanded pretty much hospitalwide: If a patient can move, the patient is up and moving. No more lingering in bed where muscles can atrophy. And all patients get a timed up and go test in which a nurse will determine if they have the stamina, strength and cognitive skills to walk.
Beauchamp suggests that after every fall, you drill down to the contributing factors. Have a debriefing that looks for the reasons why the fall happened, then change the plan of care for that patient. "Even if you don’t have the Six Sigma resources, you can look at the information from fall debriefings and see contributing factors," she says. "We found early that we were being inconsistent with our hourly rounding and our handoff communications."
When you figure out your issues, communicate them to others through use of whiteboards in the rooms or interdisciplinary rounds, she says.
At Barnes-Jewish in St. Louis, fall prevention projects in the past had covered most of the usual improvements, such as yellow blankets on the bed, no-skid socks, and video-monitoring. Laurie Wolf, MS, CPE, ASQ-CSSBB, performance improvement engineer, says they were looking to dig deeper and find some of the root causes of falls. "We wanted to push further."
There was a lot of buzz about Kaiser Permanente’s program out of its San Diego hospital, No One Walks Alone, which treats every patient as a potential fall, and ensures every single patient is accompanied when walking. "It has great results, and that’s just the culture of the place," says Eileen Constantinou, MSN, RN-BC, practice specialist at Barnes-Jewish. They may implement that, but it calls for a commitment in staffing that many organizations would find daunting. "But what validates it is that we all have the same contributing factors: unassisted toileting, not calling for help. The data is pretty similar," she says.
The project allowed Barnes-Jewish to dig into the data and find something out they didn’t know before — that when someone is assisted when they fall, they are less likely to be injured, says Wolf. Unfortunately, assisting a patient to the ground and preventing an injury still counts as a fall — a healthcare-acquired condition.
Many nurses get burned out working on falls. It’s often considered a depressing subject, a problem so intransigent that no one wants to work on it. But Costantinou says it is much easier to put the time in to preventing a fall than the two or three hours it is estimated to take filling out paperwork and doing reports after a fall. "There is no single answer," says Cathie Limbaugh, MSN, RN, ACNS-BC, OCN, oncology staff nurse at Barnes-Jewish. It is patient by patient and you have to engage each person, assessing his or her risk. Not one of them thinks they will fall, and not one of them realizes the devastating consequences of a fall if they do.
That makes it even more important to do this deep digging to see what your falls have in common, Costantinou notes. Figuring out where you have issues and room to improve will mean less of the demoralizing post-fall work in the future. "Ask yourself what you do to prevent falls and what you have to do after a fall," she says. "Which would you rather do? But don’t think this is something you will ever fix completely. You can’t fix it and move on. You can’t ever let down your guard on this. Keep paying attention."
For more information on this topic, contact:
• Becky Beauchamp, MSN, RN, CENP, Director of Nursing, Wake Forest Baptist Medical Center, Winston-Salem, NC. Telephone: (336) 716-2011.
• Erin DuPree, MD, Vice President and Chief Medical Officer, Joint Commission Center for Transforming Healthcare, Oakbrook Terrace, IL. Email: email@example.com.
• Cathie Limbaugh, MSN, RN, ACNS-BC, OCN, oncology staff nurse, Eileen Costantinou, MSN RN-BC, Practice Specialist, and Laurie Wolf, MS, CPE, ASQ-CSSBB, Performance Improvement Engineer, Barnes-Jewish Hospital, St. Louis, MO. Telephone: (314) 747-3000.