JCAHO will look for evidence of reduced risks
To comply with the Joint Commission on Accreditation of Healthcare Organizations’ new National Patient Safety Goal to reduce the risk of patient harm resulting from falls, you must assess and periodically reassess each patient’s risk of falling — including the potential risk associated with the patient’s medication regimen — and take action to address any identified risks.
However, even if your organization has a falls prevention program in place, it doesn’t mean you’re getting significant results. At St. Marys Hospital Medical Center in Madison, WI, a program had been in place for years to prevent falls, but the organization wasn’t seeing a reduction in the fall rate.
"Our population was getting older, sicker, and more acute," says Christine Baker, RN, PhD, APRN, BC, CEN, clinical nurse specialist and director of clinical outcomes management and decision support. "So it was difficult to know if we were actually making gains, when our population was more prone to falls."
The organization’s nursing research council began by researching existing fall prevention programs and grading scales. "We decided to borrow from the best of them and then incorporate our own twist," she explains.
All of the existing grading scales ask questions such as whether patients are on a certain medication or if they have fallen in the past year, Baker notes.
"That really takes away that aspect of nursing judgment. You could have healthy people on Lasix who aren’t at increased risk of falling; or a patient may have fallen twice on the ice, but that doesn’t mean that they are at risk for falling in the hospital," she says.
An algorithm was developed that identified all patients as being at universal risk of falling because of factors such as being sick, sleep-deprived, and in an unfamiliar environment.
"We borrowed that element from universal precautions — something that exists for all patients just because they are in the hospital," Baker says.
A second category of patient is put at higher risk for falls because of specific risk factors such as disorientation. "The last question on the algorithm asks the nurse to put all of that together and make a nursing assessment, as to whether this patient is at high risk for falls," Baker says.
Even after the algorithm was implemented, the fall rate didn’t drop significantly, so the organization trialed two interventions. The first was a protocol that reduced the use of sleeping pills, particularly those that had long half-lives and would make patients drowsy the following day. Instead, patients were offered comfort measures such as a backrub, warm milk, or herbal teas.
"Although physicians did adopt the protocols and use of sleeping pills dropped markedly, we still didn’t see significant reductions," Baker says. "Where we saw our payoff was in our Safe Room’ setup — we cut our fall rate by half."
This intervention involved making the patient’s room safer, by placing intravenous poles on the same side where the patient would exit the bed and removing physical barriers so patients were less likely to trip on the way to the bathroom.
As a result, the number of patient injuries related to falls fell sharply. "By having the beds in a low position, the patient didn’t have far to fall," she says. "We’d like to prevent the fall, but if it happens, to have no injury result is the best outcome."
Posters placed in every room reminded family and visitors to call a staff member to assist the patient with getting to the bathroom, as opposed to trying to help the patient themselves. "So we involved another pair of hands and eyes in watching the patients," Baker explains. "We also teach patients who are cognitively intact about how to prevent falls, such as using their call light, and not trying to exit when there’s a side rail up."
As a result, the severity of injuries has dropped significantly, she says. "It’s been a long time since we had more than a minor bump or bruise from a fall," reports Baker. "The nurses are pleased as well. It was frustrating to put a patient on fall precautions when they knew the patient wasn’t really at risk. Also, this gives them license to use the protocol when the nurse has a gut feeling that a patient is at risk, even if they don’t screen in."
The organization uses comparative data from the Maryland Hospital Association database and the National Database of Nursing Quality Indicators to set fall rate goals for the year, which are incorporated into the annual nursing QI plan. "Each unit reports fall rates at a monthly QI council. If they exceed the fall rate goals, the unit has to have a plan in place to bring the fall rates down," says Baker.
The organization’s fall prevention program recently was revised by its falls workgroup to reflect the most current research. "What we needed to do was clarify things that should trigger a reassessment, such as the patient coming back from surgery and a new medication added," Baker says. "Typically, patients are reassessed after a shift, but something could happen mid-shift to increase a patient’s risk of falling. Every time you have patient contact, the caregiver should be thinking: Has anything been done to put this patient at risk for falling?"
Major fall injuries are nonexistent
At the VA Medical Center in Lexington, KY, patient falls have been incorporated in the incident reporting system for many years, says Linda Cranfill, quality manager. "But with the evolution in patient safety approaches in recent years, we have taken fall analysis, assessment, and prevention to new levels," she says.
One effective strategy involved the use of hip protectors, which provide padding so fractures can be prevented if a fall does occur, Cranfill says. The implementation of hip protectors resulted in a projected cost savings of $16,065 to $44,415.
Another major change was the implementation of a falls collaborative group. "Nationally, the VA requires its facilities to do aggregate root-cause analyses on patient falls," Cranfill notes. "Our falls collaborative group does those, and much more, here. They are the core group for aggregating and analyzing data as well as for developing and implementing improvement strategies."
A combination of facilitywide and patient- specific interventions has resulted in dramatic improvement in both fall and major injury rates, says Mary Ann Ford, RN, MSN, CRRN-A, the VA’s director of utilization management. "The acute medical-surgical units have had a 20% reduction in the fall rate and no major injuries for 2½ years," she reports.
Some of the interventions include:
- education of interdisciplinary staff on fall risk assessment and fall prevention interventions;
- integration of the fall risk assessment into the electronic initial nursing assessment and reassessment;
- implementation of tools for more in-depth patient assessment to identify factors that could be modified to decrease fall risk, such as gait and balance assessment in nursing home care units, revised drug regimen review, delirium management guidelines, and orthostatic blood pressure guidelines;
- use of hip protectors, low beds, signs posted in patient rooms as reminders to call for assistance, bed alarms, exercise programs, and toileting programs;
- initiation of the use of flip charts or fall communication boards on the units to improve communication among staff;
- ongoing feedback to staff about results of their efforts.
"We measure the success of our fall prevention program with the outcome measures of fall rate and major injury rate, using national and internal benchmarks," says Ford. "A rate is used in order to take into consideration fluctuation in patient census."
The fall rate is the number of falls per 1,000 days of care, and the major injury rate is the number of major injuries per 100 falls. Additionally, to aid the review team and target interventions, fall data aggregation also includes tracking circumstances surrounding the falls, such as history of falls, where and what time falls occurred, and patient cognitive and functional abilities, Ford says.
Data are collected via incident reporting and analyzed quarterly by an interdisciplinary team that includes the patient safety officer. Analysis of fall and major injury rates is done through the use of run charts, noting when interventions were implemented, and circumstances of falls are analyzed with bar graphs and run charts.
Staff education efforts have focused on assessment of patients for risk of falls, and identification and implementation of strategies to reduce risk of falling, or risk of serious injury should a fall occur, Ford says. "The education focuses on basic fall prevention interventions and individualized patient care," she says. "I recommend that a valid, reliable tool be used to provide a basic assessment and periodic reassessment of risk of falling, to guide staff toward taking actions to reduce the risk of falling."
[For more on fall prevention programs, contact:
• Christine Baker, RN, PhD, APRN,BC, CEN, Clinical Nurse Specialist, Director, Clinical Outcomes Management and Decision Support, St. Marys Hospital Medical Center, 707 S. Mills St., Madison, WI 53715. Phone: (608) 259-5855. E-mail: Christine_Baker@ssmhc.com.
• Linda Cranfill, Quality Manager, VA Medical Center, 1101 Veterans Drive, Lexington, KY 40502. Phone: (859) 233-4511. E-mail: firstname.lastname@example.org.
• Mary Ann Ford, RN, MSN, CRRN-A, Director, Utilization Management, VA Medical Center, 1101 Veterans Drive, Lexington, KY 40502. Phone: (859) 233-4511. Fax: (859) 381-5973. E-mail: Mary.Ford@med.va.gov.]