With troubling data in hand about patient injuries and deaths, The Joint Commission (TJC) has issued a Sentinel Event Alert, notifying healthcare organizations that they need to up their game when it comes to preventing patient falls. Since 2009, the accrediting agency says it has received 465 reports of patient falls with injuries, with 63% of these falls resulting in death. Further, the agency reports that patient falls with serious injury are among the top 10 sentinel events that are reported to the agency. While some of these falls occur in non-hospital organizations, TJC says the majority occur in hospital settings.
Why are patients falling in healthcare settings? In reviewing five years of data collected on patient falls with injury, TJC reviewers note that the most common contributing factors are inadequate fall assessments, communication failures, and a lack of adherence to protocols and safety practices. TJC also cites deficiencies in staff orientation about patient falls, supervision, and problems with staffing levels or the skill mix. Other key contributing factors include deficiencies in the physical environment and a lack of leadership around this issue.
TJC makes clear that this is not just a matter of patient safety, although that is of prime importance. Falls also hit hospitals hard in the pocketbook. Studies suggest that patient falls with injury can add a number of days to a patient’s hospital stay. In fact, TJC reports that the average cost associated with a fall with injury is about $14,000. When you consider that hundreds of thousands of patients fall in hospitals every year, with 30% to 50% of these falls resulting in injury, it is easy to see how such costs can pile up.
Identify risk at triage
To prevent falls, TJC recommends that hospitals initiate several steps, starting with a high-profile effort to raise awareness of the need to address the issue. The agency also calls on healthcare organizations to establish an interdisciplinary falls injury prevention team, use a standardized, validated tool to identify fall risk factors, develop individualized care plans for identified fall and injury risks, standardize and apply best practices, including a standardized handoff communication process and one-to-one patient education, and conduct a series of post-fall management practices such as post-fall huddles and a system of reporting and analyzing falls. (See TJC’s recommendations and supporting information at www.jointcommission.org/sea_issue_55/.)
However, the fast-paced environment of a busy ED presents some unique challenges. For example, most of the existing fall risk assessments are really geared more to the inpatient setting, says Danette Alexander, the nurse director of the ED at Hartford Hospital, a level I trauma center in Hartford, CT, that sees more than 96,000 patients a year.
“It is not necessarily that they won’t work well, but you need to identify [patients at risk for a fall] quickly at triage, and the inpatient tools typically are done every four to six hours,” she explains.
Observing that triage nurses don’t have the time to go through all the elements on a standard fall risk assessment, Alexander teamed up with colleagues to develop a streamlined fall risk assessment tool that could be integrated easily into the triage process without slowing the workflow.
“I came from the inpatient side. I had never been in the ED. I sort of brought that inpatient mentality with me,” Alexander adds.
Terry Kinsley, RN, MSN, CEN, who is now director of the nursing learning lab and simulation at the University of St. Joseph in West Hartford, CT, worked with Alexander on developing and implementing the tool. At the time, Kinsley was the nurse educator in the ED at Hartford Hospital.
“We were not capturing our patients who were at risk of falling because all the risk assessment tools were just so cumbersome and long. So we broke it down into the basics,” Kinsley explains.
For example, the resulting instrument, which Alexander and Kinsley refer to as the Kinder 1 Fall Risk Assessment Tool, identifies five risk areas, any one of which will flag a patient as being at risk for a fall when they go through triage in the ED. The risk areas include:
patient presented to the ED because of a fall;
age older than 70;
altered mental status;
nursing judgement of fall risk.
A “yes” to any of the criteria denotes a patient as being at risk for a fall. Even if a patient does not have any of the first four risks, the triage nurse can flag that the patient is, indeed, a fall risk if he or she has any concerns.
“The other thing that is very different about this [tool] is that there is no scoring, there is no high fall risk, moderate fall risk, low fall risk,” Kinsley observes. “In our minds they are all the same. If you are a moderate or a low fall risk and you fall and hit your head, you are still going to get a bleed. If you are a high fall risk and you fall and hit your head, you are going to get a bleed, so it doesn’t really matter the amount of risk.”
Kinsley adds that a retrospective chart audit of all the patients who had fallen showed that the risk assessment tool would likely have captured 85% of these patients if it had been applied at triage.
The risk assessment questions have been embedded in the electronic medical record so that triage nurses can complete the process quickly as part of their regular workflow process, Kinsley explains. Further, once a patient has been flagged as a fall risk, he or she remains a fall risk for their entire stay in the ED. For patients who are not deemed a fall risk, they must be reassessed every two hours to see if their status has changed.
While many people may not think of the ED as a setting where falls typically occur, it is in fact a high-risk area, Alexander says.
“Even if you come in and you are not at risk for falling, but you have pain and we are giving you narcotics, we could make you at risk of falling,” she explains. “Actually you are pretty high risk the instant you cross the threshold of the ED because even if you are not at risk, we may do things to you that put you at risk.”
Implement post-fall huddles
However, identifying fall risk is only the first step in Hartford Hospital’s program to prevent falls in the ED. The second part is equally important, and involves a series of interventions aimed at making a patient’s stay in the ED safe and free from falls. For instance, patients identified as at risk for a fall in triage are provided green bracelets so that it is easy for clinicians to recognize their fall status.
Also, each of the rooms in the ED has been equipped with fall alarms so that nurses don’t have to search for the alarms when they have a patient wearing a green bracelet.
“That makes it very easy for each of the nurses to be successful,” Alexander says.
While nurses are key players in preventing falls in the ED, it is also important to involve physicians in the program, Alexander adds.
“All the attending and resident physicians are aware of [our fall prevention efforts], so they will put up the side rails after they have performed an exam of a patient,” Alexander says. “Involving them from the get-go is very, very important. It keeps the channels of communication open for feedback on how we can get better.”
Another key to the effort is performing a “fall huddle” every time a patient falls in the ED.
“That is where you find out about systems issues,” Alexander explains. “When someone has a fall and we perform a post-fall huddle, we try to make it as non-punitive as possible.”
In the past, nurses would never call the charge nurse to report a fall, but such calls are routine now, Alexander says.
“When a nurse calls and reports that they have had a fall, we all go and look at it, and if they did everything they possibly could to prevent the fall, then it is a non-punitive process,” she explains. “Obviously, you would have issues if someone was blatantly neglectful, but usually they are not. They just need support.”
Kinsley adds that one practice that goes hand-in-hand with the fall prevention interventions is hourly rounding.
“I wish we had implemented that even sooner,” she says. “It doesn’t have to necessarily just be nurses performing the rounding, as long as someone is going in and logging some face time with the patient every hour.”
Change the culture
While the fall prevention program is well-integrated into ED operations now, it took about a year for the nurses to buy into the approach, Kinsley recalls.
“We just kept plugging away. Danette and I were very visible on the unit, and we did lots of selling of the program,” she explains. “It was very labor-intensive on our part.”
However, Kinsley notes that a key turning point occurred after the fall prevention program had been in place for about eight months.
“We had a patient who had come into the ED in the very early morning because she had fallen,” Kinsley says. “She was an older lady from an Alzheimer’s unit.”
The day shift was just coming on board, and care of the patient was being transferred from a travel nurse to the oncoming day shift nurse.
“As they were finishing up report, they heard the sound that you hear when a head hits the floor,” Kinsley notes. “The patient had fallen out of bed and it turned out that no fall precautions had been put in place.”
The patient eventually passed away, although it is impossible to determine whether this was the result of her first fall or the fall that occurred in the ED, Kinsley explains. Nonetheless, the incident received everyone’s immediate attention.
“It just really shifted the whole culture,” Kinsley adds. “That is when we saw the tide turn.”
Since then, nurses have embraced the program.
“It is a matter of getting one person on the bandwagon, and then everybody else follows,” Kinsley notes.
In fact, while all of the interventions have made a difference in curbing serious injuries from falls, what has worked best is the way the program has focused awareness on the issue, Alexander explains.
“We will have a lot of falls for a variety of reasons. Sometimes they are [due to] behavioral health [reasons] where people will throw themselves on the floor. We also get a lot of intoxicated people, whether due to alcohol or other types of substances,” she says. “What we have tracked over the past two or three years on our dashboard unit is whether someone has experienced a serious injury from a fall, and … that has been relatively flat.”
Also, since first reporting on Hartford Hospital’s ED fall prevention efforts in the summer of 2013,1 Alexander says she has heard from other EDs that have adopted the Kinder 1 tool. She notes that now the EMS personnel who bring patients to the hospital will often put the green bracelets on patients even before they arrive.
Soon, the Kinder 1 tool will be shared with the other EDs in the hospital system, and Alexander is hoping this will provide an opportunity to conduct a formal observational study on the effectiveness of the tool.
Alexander D, et al. Journey to a safe environment: Fall prevention in an emergency department at a level I trauma center. J Emerg Nurs 2013;39:346-352.
Danette Alexander, Nurse Director, Emergency Department, Hartford Hospital, Hartford, CT. E-mail: [email protected]
Terry Kinsley, RN, MSN, CEN, Director, Nursing Learning Lab and Simulation, University of St. Joseph, West Hartford, CT. E-mail: [email protected]