Falls are focus of community hospital’s first EBP project
For reasons she can’t explain, Debbie Durant, RN, BSN, has seen a rise in the number
of patient falls occurring recently at North Adams (MA) Regional Hospital.
“Up until six months ago, our fall rate was pretty flat,” says Durant, director of the
medical surgical unit at the 120-bed hospital. “But about six months ago, they began to
jump, and we don’t know why. Was it that we weren’t assessing correctly, were we not
putting the right interventions in place, or was it that our patient population changed—or
a combination? That’s the question that started us down this road.”
North Adams had been using what Peg Daly, RN, BS, the hospital’s education specialist,
calls a hybrid version of several other falls risk assessments.
“It’s not the Morse Falls Scale, not the Hendrick Scale. It’s the North Adams Regional
Hospital Scale,” Daly says. It’s been in place for so long that no one remembers it being
implemented—or who decided it would be effective for preventing patient falls.
But with falls rising steadily and payer pressure on the hospital to eliminate hospitalrelated injuries, Daly says the old method simply wasn’t working anymore.
That’s why the hospital turned to its falls committee to research evidence and change
how nurses at North Adams assess patients’ risks for falls and how they intervene with
at-risk patients.
During the next several months, the committee has the following four goals:
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Decrease falls at North Adams by 10% 12 months after plan implementation
Review and revise falls policy and procedures based on evidence-based data
Recommend necessary education for staff members
Develop ongoing performance improvement monitoring
A few extra steps
Once the falls problem was identified and brought to the attention of the hospital’s patient
safety committee, Daly and Durant formed a falls subcommittee and recruited staff
nurses to participate.
The committee has representation from inpatient and outpatient areas of the hospital and
meets weekly to discuss current practice and published research on the subject. The
committee discussed various journal articles and literature found online and evaluated
models used by other healthcare organizations. In particular, Daly says, the committee
examined the assessment used by Department of Veterans Affairs hospitals and the
Morse and Hendrick models used by a handful of neighboring organizations.
“We compared risk assessment tools to the tool that we were already using and felt, after
looking at everything, our tool was basically a hybrid of several scales,” says Daly.
North Adams’ size and its previous success with a hybrid falls prevention model caused
the committee to decide that the hybrid model was once again the way to go—and North
Adams was the perfect place to test it.
“We decided that if we were going to do all this work, we should try to validate its use in
our facility,” Daly says, adding that instead of simply copying another organization’s best
practice, the hospital could better find the right solution by testing it.
“I suggested that we treat this as more of a research project so that we could gather the
data and really see if it impacted our fall rate,” she says.
The committee started by analyzing its current falls assessment process, including
interventions. Up until six months before, the procedure had been effective, and Daly
says many nurses believed that with a few simple additions, it could be so again.
Beginning in January 2009, North Adams will use a revised model for assessing a
patient’s risk and preventing falls based on the research and analysis done by the
committee. The model includes:
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Addition of IV criteria to the assessment tool
Institution of primary interventions for every patient who comes to the hospital
for care and additional interventions for patients scored at low or high risk for
falls
Required documentation of interventions and completion of a falls risk
assessment every eight hours and with any change in the patient’s condition
An increased focus on orienting patients to their surroundings and educating them
about falls prevention
Increased involvement by hospital ancillary staff members in assessing patients’
likelihood of falling
IV precautions
When the falls committee started discussing North Adams’ old assessment models, staff
nurses immediately identified one major flaw: Patients who were hooked up to IVs were
being assessed in the same manner as those who did not have IVs.
“When a patient has an IV, it is because of an event or a disease process that requires IV
fluids or medications, thus can lead to instability in the patient’s condition and increasing
the risk for a fall because they may be hemodynamically unstable,” Daly says. Add North
Adams’ cramped layout, IV poles, pumps, and tubing, and other technical equipment to
the equation, and you have conditions ripe for patient falls.
In the revised falls assessment and prevention model, nurses will make every attempt to
ensure patients’ IVs are inserted on a nondominant extremity, allowing patients to have
their dominant extremity available to assist with movement, Daly says.
Staff members will also place an increased focus on making sure that IV patient rooms
are uncluttered and work with physicians to reduce the length of time patients undergo IV
therapy when possible.
Assessment for all
Under the revised hybrid model, every patient that comes to North Adams will undergo a
falls assessment every eight hours, including those seeking outpatient care. “Anyone who
comes into the hospital, they’re coming in for a reason, not just because they thought it
would be a nice vacation spot,” says Daly. “No matter what is wrong with you, we’re
going to assess the possibility of you falling.”
Under the old model, North Adams assessed all patients for falls risk, but only patients
who were deemed high risk had fall interventions put in place. By revising the risk
assessment tool, North Adams will now have a mechanism to implement primary
interventions for all patients, with additional interventions for those deemed at risk.
Documentation required
Starting in January, nurses will be required to document not only the falls risk
assessment, but also the interventions put in place. This step alone will drastically
improve the old falls prevention model used at North Adams.
“Staff liked what we were using ... but we couldn’t really quantify or qualify any of it
unless we really monitored it during implementation,” Daly says.
Now, with documentation requirements in place, the hospital will have a way of knowing
which interventions were put in place and whether those interventions are working to
prevent falls, Daly says. Documentation will be on paper for the first few months of
2009, but the hospital expects to have an online documentation tool available through its
electronic medical record by summer, she says.
Patient involvement
Like most hospitals, North Adams recognizes that preventing falls isn’t solely the
responsibility of the nursing staff—patients and their families must be involved, says
Daly.
Previously, when patients were admitted at North Adams, nurses would give a quick
orientation of the hospital environment, pointing out the bathroom, the nurses’ station,
and how to use the call button. But today’s model goes much further, educating patients
and their families about precautions that can be taken to avoid falls.
Staff members go over these precautions in person, says Daly, but North Adams has also
created a one-page flyer that is left in each patient’s room. The flyer includes basic safety
information, including a reminder for patients to wear proper footwear and use canes or
walkers when getting out of bed and to sound the call bell when needed. This form can be
left at the bedside and reviewed with the patient, family, and visitors each time a staff
member is at the bedside.
Signs are also posted in the room to remind patients to ask for help. “We’ve developed a
sign that we’re going to put in every patient room on the wall facing the bed,” Daly says.
“It says ‘Call, don’t fall’ in a big font so they can see it, as a reminder to use their call
bell when they need to get up.”
Ancillary staff involvement
At presstime, Daly and Durant were working on the most important and hardest to
implement portion of the new falls risk assessment: getting staff members from other
hospital departments involved in the prevention of patient falls.
If North Adams is to see a reduction in falls, Daly says, more than just the nursing staff
will have to be part of the falls risk assessment team. Those working in food service,
pharmacy, environmental services, and other departments will have to be trained to
observe changes in patient status and situations that could increase the chances of a
patient fall.
For example, Daly says, the pharmacy currently does a quick assessment of a patient’s
medications when they are entered into the electronic medical record, but with the new
process, a pharmacist will perform a more careful analysis of the medications to check
for potential drug interactions that may cause a patient to become disoriented and fall.
“If they’re at high risk for a fall, we want them to look at medications and make sure that
the pharmacy review is a little more in-depth,” Daly says. “But we’re still figuring out
what that mechanism is. We have to work this out with the pharmacy.”
Working among the silos of a typical hospital will be a challenge, Daly and Durant say.
“When it comes down to it, patient safety isn’t just the responsibility of nursing,” Durant
says, “but all departments.”
Source: The Staff Educator, January 2009