Know patient fall trends before attempting to fix
Know patient fall trends before attempting to fix
Education combats unwitnessed falls
It was a little notation during a Joint Commission survey: one unwitnessed fall of a patient at Clarion Forest Visiting Nurse Association (VNA) in Knox, PA, had no documented follow-up.
According to Jonette Smerker, RN, CQI coordinator for the agency, there was no fallout from the surveyor because of the notation. "It was just one chart out of many they looked at," she recalls. "But it made us think."
Since that survey in the fall of 1995, Smerker and a team of caregivers and administrators have worked to change their policies and procedures on patient falls. In the year the new policies have been in place, Smerker says reports of unwitnessed falls have actually increased something she attributes to greater awareness.
And Smerker says there may be another benefit. Improved training of both staff and patients on fall prevention and how to break falls may have reduced the severity of injury caused when they do occur.
Smerker says that after the survey, she and a team that included three nurses, a home health aide, a physical therapist, a private-pay companion, and one clerical person looked at three months of unwitnessed fall reports. "We had 45 of them, and that surprised us a lot," she says. "We tried to see if there were any trends."
There were. Among them:
• There were more unwitnessed falls than witnessed falls.
• More falls occurred with patients who used the private-pay companion service (an extended care service staffed by people with less training than other caregivers).
• More falls happened in the bathroom than in any other room.
• Many falls were the result of improper or total lack of use of equipment such as walkers, hand rails, shower chairs, and wheelchair locks.
• Falls were more likely to happen during transfers.
After determining when the problems were occurring, Smerker and her team devised a three-pronged attack to reduce the number of falls.
The first component was to better educate patients and caregivers. "We were using a booklet on home safety that covered fire, electricity, food, medication, and bathrooms," she says. "We revised it to include a whole section on what to do when falls occur, fall prevention, and breaking a fall."
The last section was particularly important, says Smerker, because there are some occasions when a fall can’t be avoided. The section emphasizes that trying to stop a fall can be the worst course of action in some cases. "This can cause injury to both you and the person you are helping," states the booklet.
Instead, it offers a seven-step procedure:
1. Stand with your feet apart, one foot slightly in front of the other.
2. Bring the person close to you as fast as you can.
3. Let the falling person’s buttocks rest on your front leg.
4. Lower the person to the floor, allowing him or her to slide down your leg.
5. Call for help if someone else is in the house.
6. Check for injuries.
7. Call for medical help if necessary.
The patient handbook was given a color front page and drawings were added throughout so as to better focus the patient’s or caregiver’s attention on safety, says Smerker.
The second approach was to improve staff education. Most of this effort focused on the companions, not only because they seemed to have the greatest fall rates among staff, but prior to the new program they also had the least training, she explains. The staff were taken through the same safety booklet as patients, and were also shown videos on preventing falls and on moving, lifting, and positioning patients. The additional training added about 30 minutes onto existing training time.
Last, Smerker and her team initiated a fall risk assessment on all VNA patients (see sample assessment form, p. 79). "The extended care private-pay patients were already known to be high risk," explains Smerker. "We knew they were unsafe in the home alone. That’s why we were there, and we didn’t feel a need to use this part of the assessment on those patients."
The assessment is part of every admission and readmission, and is done for each patient on a yearly basis. Smerker also wrote a new policy and procedure to go with the new form. (See policy and procedure, p. 80.) Part of that procedure is that a yellow fall alert sticker must be placed on patient folders and care plans of high-risk patients to make any team member dealing with that patient aware that there is a fall risk.
The whole program was initiated in May 1996. Since then, Smerker has struggled with how to measure her success. "We know that there are more unwitnessed fall reports coming in," she says. "We think that means there is greater awareness." She also knows each unwitnessed fall will have documented follow-up, thanks to a fall report form that was revamped to provide greater detail. (See fall report form, p. 81.) "It doesn’t just ask the patient’s name and date anymore, but includes sections on what action was taken after a fall and what plan is being made to address the fall risk in the future."
Earlier this spring, the team regrouped to look at the number of incident reports. Smerker says there were fewer in 1996, but not significantly fewer. The team is looking further at the reports to see if any of the falls could have been prevented. "We want to concentrate this year on how to avoid the falls altogether," says Smerker. Already a plan is taking shape.
Included is an emphasis on "frequent fallers" those who have more than two falls in a given month. Smerker has created a frequent fall alert form. (See alert form, above.) When one is filled out it goes first to Smerker. She lets the nursing supervisor know, and a team conference is called. At the meeting, the staff discusses whether the patient needs more equipment or more education, or whether all has been done that can be done. "We document whatever we do," Smerker says.
The agency also is looking at whether the companions in the extended care program need more training. If there are falls for those patients, a nurse supervisor goes into the home with the companion to give on-the-job education for that caregiver and that patient.
Smerker will look at the data again toward the end of the year, but she says she knows measuring success will be hard. "We really thought that looking at the number of falls would be a good enough indicator," she says. "It’s not. We have to look at awareness and maybe severity of injury to really tell how we are doing."
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