Is preventing patient falls tripping you up? Get a grip

Prevention efforts must be tailored to environment

Patient falls — with the resulting injuries and lawsuits — are a fact of life in any health care facility. Yet pinpointing the causes and correcting them is a challenge to any risk manager.

At Gratiot Community Hospital in Alma, MI, falls were on the increase two years ago, so something had to be done. When monitoring falls through the hospital’s occurrence reporting process, Quality and Risk Manager Jill Goodell, MS, CPHQ, noticed an overall increase in the number of patient falls. Since there was no easy way to determine what was causing the increase or where falls were happening, Goodell gathered all the recent fall reports and divided them according to which nursing units they involved. That analysis showed the highest number of falls were occurring on the geriatric psychiatry unit and the medical rehabilitation unit.

"That wasn’t a real surprise, but we weren’t sure how much to attribute the falls to those units until we actually analyzed the reports," Goodell recalls. "Then it was clear that those two units needed a lot of our attention."

After conducting a literature review on patient falls and how to prevent them, Goodell met with the manager of the two units to review the cases and find ways to reduce patient falls. A key part of their analysis was examining each fall and looking for information such as where it happened, what time of day it occurred, and what type of staff were present. Patients were not injured in most cases, but Goodell points out that the risk of serious injury is high with any patient fall. And patient falls can be difficult to defend when a lawsuit is brought, especially if a serious injury resulted.

Goodell’s research showed that patient falls often can be traced to problems unique to the particular nursing unit where they happen. For that reason, she devised separate solutions for the geriatric psychiatry and medical rehabilitation units. In the psychiatric geriatric unit, many of the falls could be traced to the fact that patients are more disoriented there than patients on other units and often are unaware of what they are doing. With that in mind, Goodell worked with the unit manager to come up with these solutions:

• Staffing was adjusted so more staff were available at the times of day when most falls occurred. The type of staffing — the mix of nurses and assistants — also can make a substantial difference in whether staff have enough time to properly aid patients at risk for falls. Unfortunately, staff who are stretched too thin can find it impossible to devote enough attention to individual patients, leaving them unattended.

• Staff increased the use of "pillow buddies," which are heavy pillows that lay on patients’ laps while they’re in a wheelchair. The pillow helps stabilize patients so they don’t lean forward and fall, or slip out of the chair. Most patients can lift the pillow out of the way if they choose, but it also serves as a reminder not to get up without asking for help. The pillow buddy is not considered a restraint, so it can help the facility reduce its restraint use, an added benefit.

In the medical rehab unit, Goodell and the unit manager had to find a way to decrease falls without hindering patients’ independence. In rehab, it is crucial that patients be encouraged to gain independence and not rely entirely on staff or family members. The hard part was finding a compromise between leaving patients alone — and at risk of falling — and taking away all independence.

The solution was educating the staff and family members, not the patients. "We didn’t want to tell the patient not to do risky things because, in rehab, they really have to be willing to do risky things," Goodell explains. "But we found that some family and some staff were not cognizant of the risks from falling. They might visit the patient or bring him back from X-ray, then just leave him alone in the room and not realize that’s a risk."

To counter those problems, Goodell and the unit manager implemented these solutions:

• An inservice is held for all staff who transport patients throughout the hospital. Staff members are about the risk of falls, how they happen, and common preventive steps. In particular, they are told why it is risky to wheel patients to their rooms on the medical rehabilitation unit and then leave them there. Unlike many other units, staff are told, these patients are very likely to try to get up and walk on their own.

• Similar information is now provided to family members when they are oriented to the unit. The risk of falls is explained, and they are urged to contact a staff member before leaving the patient alone.

• A special notice is posted on the inside of every patient door, cautioning both staff and visitors not to leave the patient unprotected in the room. (See sample of the notice, above.)

The facility’s fall reports are analyzed on a quarterly basis, and Goodell watches for trends that suggest room for improvement. A recent analysis showed that one unit had a higher number of patients who were falling as they tried to get up to go to the bathroom. The information was relayed to the unit manager, who then met with staff to help them understand how such falls could be anticipated and prevented.

Falls are analyzed quarterly because the 141-bed hospital does not have enough falls for a more frequent analysis to be reliable or significant. Larger hospitals might benefit from a monthly analysis, Goodell says.

What defines a fall?

She also suggests first establishing a facilitywide definition of what constitutes a fall. Her facility’s staff previously had different definitions, which got in the way of gathering reliable statistics. "There were times in the past when staff didn’t consider it a fall if they lowered the patient to the floor, or if the patient said he didn’t fall," Goodell says. "We wanted to include anything that might be considered a fall, so we came up with a broad definition that includes everything."

Now the hospital’s definition of a fall is "any time a patient is found on the floor, and we don’t know how he got there; an unplanned lowering of the patient to the floor; or actually observing the patient falling."

All hospital units use the same form to record data about patient falls. Those forms can be important if Goodell and the unit manager have to figure out why the number of falls has increased. (See p. 75 for a sample of the form.)

To arrive at the fall rate, Goodell calculates the number of falls per 1,000 patient days. From the finance department, she gets the number of patients and how many days they were in the hospital during the quarter. Multiplying the number of patients by the number of days gives her the total number of patient days for the quarter. That number is divided by 1,000.

For example, if there were 1,192 patient days for the quarter, dividing that number by 1,000 results in 1.192. If there were 10 falls during that quarter, 10 is divided by 1.192. That would result in a rate of 8.4 falls per thousand patient days.

"Our last measurement was 1.5 falls per thousand patient days for the overall facility," Goodell notes. "We’ve seen an increase in the number of patient days and the census since we started this program, but there’s been no increase in falls. We haven’t eliminated falls, but we’re keeping them down, and we now have a way to keep track and step in when necessary."