JCAHO will look for evidence of falls prevention

Is your patient falls reduction program up to par? If not, you could have problems during your next survey by the Joint Commission on Accreditation of Healthcare Organizations. One of the new National Patient Safety Goals for 2005 requires you to reduce the risk of patient harm resulting from falls by assessing and periodically reassessing each patient’s risk for falling and taking action to address any identified risks.

"For instance, you wouldn’t want an intoxicated patient to walk to the X-ray room," says Kim Colonnelli, RN, BSN, MA, district director for emergency and trauma services at Palomar Pomerado Health in Escondido, CA. "That patient should go by wheelchair or preferably gurney."

To reduce risk of patient falls in your ED, you can do the following:

  • Assess patients for fall risk.

At Bronson Methodist Hospital in Kalamazoo, MI, ED nurses use the Hendrich II Fall Risk Model to assess confusion, depression, altered elimination, dizziness, and mobility, says Glenn Carlson, RN, MSN, CCRN, clinical nurse specialist for the ED. (See resources, below, for more information.)

If the patient’s score indicates a risk of falling, the patient is placed on fall precautions, with a sign placed outside the door. "Our computer system lists choices for interventions for someone on fall precautions," he explains.

If your ED doesn’t have an electronic system, then your assessment form should have interventions listed for all the areas assessed by the Hendrich scale, he recommends. Possible interventions include use of a bed alarm, presence of family members at bedside, continued assessment of medications that could be causing a patient to be at risk, and offering toileting at more frequent intervals, says Carlson.

Assessment and interventions are documented so that all staff will know if someone is at risk, why they are at risk, and what interventions have been attempted, says Carlson. "In addition, if the Hendrich tool is used and interventions are not applied, then you have done only half of the prevention, and someone looking at the chart would pick up on this," he adds.

  • Use color to identify patients at risk.

Patients on fall precautions have a purple dot placed on their identification bands. "Even ancillary staff can quickly identify those at risk, as the identification band is looked at by everyone when the patient is asked their name and birth date as patient identifiers," says Carlson.

At Cape Canaveral Hospital in Cocoa Beach, FL, ED nurses place an orange bracelet on any patient at risk for falling, to alert staff that the patient needs additional precautions and assistance, says Stacey Westphal, RN, MS, CEN, clinical educator for emergency services. "If a patient asks to go to the bathroom, and I see an orange bracelet, I will get a wheelchair and assist them instead of sending them down the hall," she says.

  • Re-assess patients at risk.

If patients are confused or continue with unsafe practices after continued reinforcement, they are placed on a "fall watch," says Carlson. Once on Fall Watch, a red eye is placed outside the patient’s room to increase awareness that the patient is at risk, which is especially important for areas that don’t have as much traffic and visibility, he explains. "Everyone that walks by that room is supposed to check and make sure the patient and the environment are safe, such as having a call light or bedside table within reach," says Carlson.

  • Make changes in the ED environment.

Consider the need for call lights, the proximity of commodes, height of the bed, and hydration needs, says Carlson. "A good percentage of patients are trying to get to the bathroom 20 minutes after a meal or 20 minutes after their diuretic or laxative," he says. "Raising awareness of these issues is as essential as assessment for risk."

For elderly or medicated patients, use diversion techniques such as providing videotapes or televisions in rooms or enlisting the help of family members to help keep agitated patients calm, Colonnelli suggests.

  • Address visitor falls.

At Palomar’s ED, several falls occurred because of visitors sitting on the rolling stools that doctors use for exams, reports Colonnelli. "So we added visiting chairs to every room and stenciled the rolling chairs Staff only’ to help decrease the risk of falls." No visitor falls have occurred since, she says.

  • Increase sitter use.

By clustering patients in together in one "pod" who require close watching, you can use one sitter for the group to reduce the cost, suggests Colonnelli. Using a single sitter instead of two saves about $150 per shift, she adds.

  • Educate staff on the new patient safety goal.

Nursing assistants at Bronson attended a mandatory one-hour interactive lecture and completed a post-test, says Carlson. "The nursing staff was educated via a self-learning pack, with informal education at the bedside and formally at a skills fair," he says. "The nurses were required to return the post-test to the clinical nurse specialist."


For more information on falls prevention in the ED, contact:

  • Glenn Carlson, RN, MSN, CCRN, Clinical Nurse Specialist, Emergency Department, Bronson Methodist Hospital, 601 John St., Kalamazoo, MI 49007. Telephone: (269) 341-8424. E-mail: carlsong@bronsonhg.org.
  • Kim Colonnelli, RN, BSN, MA, District Director, Emergency and Trauma Services, Palomar Pomerado Health, 555 E. Valley Parkway, Escondido, CA 92025. Telephone: (760) 739-3320. Fax: (760) 739-3121. E-mail: kace@pph.org.
  • Stacey Westphal, RN, MS, CEN, Clinical Educator, Emergency Services, Cape Canaveral Hospital, 701 W. Cocoa Beach Causeway, Cocoa Beach, FL 32931. Telephone: (321) 868-7651. E-mail: Stacey.Westphal@health-first.org.

A comprehensive fall prevention, risk management and intervention program featuring the Hendrich II Fall Risk Model is available on the Internet, CD-ROM, and intranet system applications. The cost varies according to platform, individual content requests, and other custom features. For more information, contact: A. Hendrich, P.O. Box 5036, Clayton, MO 63105. Telephone: (866) 653-6660. E-mail: info@ahendrichinc.com. Web: www.ahendrichinc.com.

A free Falls Tool Kit with information on implementing a falls prevention program, effective interventions for high-risk fall patients, and educating staff on fall injury prevention is available on the VA National Center for Patient Safety web site (www.patientsafety.gov/fallstoolkit).