In Our Unit Bedside Nurses Leading the Way for Falls Prevention: An Evidence-Based Approach Marty Cangany, RN, DNP, ACNS-BC Dawn Back, RN, BSN Tori Hamilton-Kelly, RN, BSN Marian Altman, RN, MS, CNS-BC, ANP Susan Lacey, RN, PhD
ncidence and characteristics of patient falls and fall prevention programs have been a topic of interest in the literature; however, few articles on fall reduction strategies written by staff nurses have been published. Falls in hospitalized patients are serious threats to patient safety.1 According to Morse,2 sequelae of falls are the second leading cause of death in the United States. Costs resulting from falls alone have been reported at between 0.85% and 1.5% of the total health care expenses within the United States, Australia, the European Union, and the United Kingdom.3 A fall is the most reported safety incident in inpatients and occurs in all adult clinical areas. Accidental falls are among the most common incidents reported in hospitals and occur in approximately 2% of all hospital stays.4 Growing evidence indicates that falls occurring in the hospital can be reduced with planning and intervention techniques.5
I
Authors Marty Cangany is a medical-surgical clinical nurse specialist at Franciscan St Francis Health, Indianapolis, Indiana. Dawn Back is a registered nurse in the cardiac critical care unit at Franciscan St Francis Health. Tori Hamilton-Kelly is a patient care coordinator and registered nurse in the progressive cardiac care unit at Franciscan St Francis Health. Marian Altman is a clinical practice specialist, American Association of Critical-Care Nurses, Aliso Viejo, California. Susan Lacey was program director of the American Association for Critical-Care Nurses Clinical Scene Investigator Academy when this project was done. Corresponding author: Marian Altman, RN, MSN, ACNS-BC, American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656 (e-mail: [email protected]). To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected]. ©2015 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2015414
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Our unit is a 30-bed, medical progressive care unit (PCU) in a 200bed Midwest hospital that primarily provides care for patients with heart disease. In 2011, 37 patients fell in our unit; these patients accounted for 46% of all falls on the hospital campus. Thirty-seven falls resulted in a 3.92% fall rate, which was higher than the 3.37% National Database for Nursing Quality Indicators (NDNQI) benchmark and resulted in a cost of $719 280. PCU staff selected to participate in the American Association for Critical-Care Nurses (AACN) Clinical Scene Investigator Academy (CSI) identified falls as their patient improvement project.
Purpose and Goal of the Project The purpose of our CSI project entitled “No Fall Zone” was to determine if improved education on the current falls policy, coupled with use of a falls contract and fall prevention signs above patients’ beds, decreased the overall total number of falls. The goal of this project was to decrease the total number of falls by 50% in 1 year to within NDNQI benchmarks. NDNQI defines a fall as www.ccnonline.org
an unplanned descent to the floor (or extension of the floor, eg, trash can or other equipment) with or without injury of the patient: this includes falls that are result of physiological as well as environmental reasons. Falls include both assisted falls (when a staff member attempts to minimize impact of the fall) and unassisted falls. A fall that is reported to have been assisted by a family member or visitor counts as a fall.6 Fall rates are calculated as the total number of falls multiplied by 1000 and divided by the total number of patient days.
Action Plan A 40-minute video was developed that reenacted a real-life fall of a patient that resulted in harm. The first part of the video reenacted the chain of events preceding the fall and the harmful consequences for the patient and the patient’s family. The second part of the video showed how the same scenario should have been handled. This video was shown to all of the staff on the unit through in-service training sessions during January 2013. The in-service training sessions also included staff education related to the falls policy, documentation requirements, and the Morse Fall Scale (MFS). A patient/family fall teaching contract was developed and implemented with all patients. New fall signage was designed and placed on the ceiling above the patients’ beds.
Results Audits of practice after education and implementation of the new
www.ccnonline.org
Table 1
Documentation audit results
Documentation
Audit result
Morse Fall Scale completed
95%
Mean fall risk score
56.7
Median fall risk score
55 (majority of patients at risk for falling)
Fall interventions match Morse score
90%
Bed alarm indicated and used properly
77% (23% of time not used and should have been)
Bed/chair alarm not indicated
33%
Fall care plan implemented appropriately
75%
Educational fall contract completed
45%
Table 2
Falls data
Year 2011
2012
2013
37
23
11
Progressive care unit fall rate
3.92
2.42
1.84
National Database for Nursing Quality Indicators benchmark
3.37
2.68
3.20
$719 280a
$447 130
$213 840
Variable Total No. of falls
Costs associated with fall a Mean
cost of a fall was $19 440.
program began in March 2013. A total of 246 audits were completed by staff nurses and nursing leaders on all shifts on the following items: accurate completion of the MFS and the total fall risk score. We also assessed the following: Did the interventions implemented match the MFS? Was a bed alarm indicated? If so, was it on? Was the fall care plan implemented? Was the educational teaching contract completed? (See Table 1 for audit results.) The total number of falls, the fall rate, and the cost of falls dramatically decreased after the implementation of these interventions (Table 2). The total number of falls decreased by more than 50%, and the fall rate is now below the NDNQI benchmark.
The fiscal impact associated with this project was $505 440 (cost of 2011 falls minus cost of 2013 falls).
Clinical Implications This project shows that focusing on 2 specific interventions, combined with the fall bundle, provides the tipping point to have an impact on fall reduction. Our plan to maintain momentum includes quarterly “No Fall Zone” days, keeping fall data and providing updates in monthly staff meetings, continued representation by our unit on our Hospital-Wide Falls Action Team, and involving staff council and the clinical nurse specialist from our unit in maintaining best-practice initiatives related to patients’ falls.
CriticalCareNurse
Vol 35, No. 2, APRIL 2015
83
Further work is needed to assist nurses in prioritizing fall interventions on the basis of patient-specific needs to identify clearly what will affect each patient in the most effective way. Because of the successful outcome of these strategies on this unit, the same process will be replicated and disseminated to other units within the hospital. For more information on this project, please visit the AACN CSI Database at www.aacn.org/csi. CCN Financial Disclosures None reported.
Now that you’ve read the article, create or contribute to an online discussion about this topic using eLetters. Just visit www.ccnonline.org and click “Submit a response” in either the full-text or PDF view of the article.
References 1. Oliver D, Connelly JB, Victor CR, et al. Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analysis. BMJ. 2007;334(3):82. 2. Morse JM. Preventing Patient Falls. Thousand Oaks, CA: Sage Publications Inc; 1997. 3. Heinrich S, Rapp K, Rissmann U, Becker C, Künig HH. Cost of falls in old age: a systematic review. Osteoporosis Int. 2010;21(6): 891-902. 4. Cameron ID, Gillespie LD, Robertson MC, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev. 2012;12:CD005465. 5. Oliver D, Healey F. Falls risk prediction tools for hospital inpatients: do they work? Nurs Times. 2009;105(7):18-21. 6. National Database for Nursing Quality Indicators. Definition of a fall, 2013. http://www .nursingquality.org/Content/Documents /NQF-Data-CollectionGuidelines.pdf. Accessed December 18, 2014.
In Our Unit
In Our Unit highlights unique practices, innovations, research, or resourceful solutions to commonly encountered problems in critical care areas and settings where critically ill patients are cared for. If you have an idea for an In Our Unit article, send it to Critical Care Nurse, 101 Columbia, Aliso Viejo, CA 92656; e-mail, [email protected].
84
CriticalCareNurse
Vol 35, No. 2, APRIL 2015
www.ccnonline.org
Copyright of Critical Care Nurse is the property of American Association of Critical-Care Nurses and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
ncidence and characteristics of patient falls and fall prevention programs have been a topic of interest in the literature; however, few articles on fall reduction strategies written by staff nurses have been published. Falls in hospitalized patients are serious threats to patient safety.1 According to Morse,2 sequelae of falls are the second leading cause of death in the United States. Costs resulting from falls alone have been reported at between 0.85% and 1.5% of the total health care expenses within the United States, Australia, the European Union, and the United Kingdom.3 A fall is the most reported safety incident in inpatients and occurs in all adult clinical areas. Accidental falls are among the most common incidents reported in hospitals and occur in approximately 2% of all hospital stays.4 Growing evidence indicates that falls occurring in the hospital can be reduced with planning and intervention techniques.5
I
Authors Marty Cangany is a medical-surgical clinical nurse specialist at Franciscan St Francis Health, Indianapolis, Indiana. Dawn Back is a registered nurse in the cardiac critical care unit at Franciscan St Francis Health. Tori Hamilton-Kelly is a patient care coordinator and registered nurse in the progressive cardiac care unit at Franciscan St Francis Health. Marian Altman is a clinical practice specialist, American Association of Critical-Care Nurses, Aliso Viejo, California. Susan Lacey was program director of the American Association for Critical-Care Nurses Clinical Scene Investigator Academy when this project was done. Corresponding author: Marian Altman, RN, MSN, ACNS-BC, American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656 (e-mail: [email protected]). To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected]. ©2015 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2015414
82
CriticalCareNurse
Vol 35, No. 2, APRIL 2015
Our unit is a 30-bed, medical progressive care unit (PCU) in a 200bed Midwest hospital that primarily provides care for patients with heart disease. In 2011, 37 patients fell in our unit; these patients accounted for 46% of all falls on the hospital campus. Thirty-seven falls resulted in a 3.92% fall rate, which was higher than the 3.37% National Database for Nursing Quality Indicators (NDNQI) benchmark and resulted in a cost of $719 280. PCU staff selected to participate in the American Association for Critical-Care Nurses (AACN) Clinical Scene Investigator Academy (CSI) identified falls as their patient improvement project.
Purpose and Goal of the Project The purpose of our CSI project entitled “No Fall Zone” was to determine if improved education on the current falls policy, coupled with use of a falls contract and fall prevention signs above patients’ beds, decreased the overall total number of falls. The goal of this project was to decrease the total number of falls by 50% in 1 year to within NDNQI benchmarks. NDNQI defines a fall as www.ccnonline.org
an unplanned descent to the floor (or extension of the floor, eg, trash can or other equipment) with or without injury of the patient: this includes falls that are result of physiological as well as environmental reasons. Falls include both assisted falls (when a staff member attempts to minimize impact of the fall) and unassisted falls. A fall that is reported to have been assisted by a family member or visitor counts as a fall.6 Fall rates are calculated as the total number of falls multiplied by 1000 and divided by the total number of patient days.
Action Plan A 40-minute video was developed that reenacted a real-life fall of a patient that resulted in harm. The first part of the video reenacted the chain of events preceding the fall and the harmful consequences for the patient and the patient’s family. The second part of the video showed how the same scenario should have been handled. This video was shown to all of the staff on the unit through in-service training sessions during January 2013. The in-service training sessions also included staff education related to the falls policy, documentation requirements, and the Morse Fall Scale (MFS). A patient/family fall teaching contract was developed and implemented with all patients. New fall signage was designed and placed on the ceiling above the patients’ beds.
Results Audits of practice after education and implementation of the new
www.ccnonline.org
Table 1
Documentation audit results
Documentation
Audit result
Morse Fall Scale completed
95%
Mean fall risk score
56.7
Median fall risk score
55 (majority of patients at risk for falling)
Fall interventions match Morse score
90%
Bed alarm indicated and used properly
77% (23% of time not used and should have been)
Bed/chair alarm not indicated
33%
Fall care plan implemented appropriately
75%
Educational fall contract completed
45%
Table 2
Falls data
Year 2011
2012
2013
37
23
11
Progressive care unit fall rate
3.92
2.42
1.84
National Database for Nursing Quality Indicators benchmark
3.37
2.68
3.20
$719 280a
$447 130
$213 840
Variable Total No. of falls
Costs associated with fall a Mean
cost of a fall was $19 440.
program began in March 2013. A total of 246 audits were completed by staff nurses and nursing leaders on all shifts on the following items: accurate completion of the MFS and the total fall risk score. We also assessed the following: Did the interventions implemented match the MFS? Was a bed alarm indicated? If so, was it on? Was the fall care plan implemented? Was the educational teaching contract completed? (See Table 1 for audit results.) The total number of falls, the fall rate, and the cost of falls dramatically decreased after the implementation of these interventions (Table 2). The total number of falls decreased by more than 50%, and the fall rate is now below the NDNQI benchmark.
The fiscal impact associated with this project was $505 440 (cost of 2011 falls minus cost of 2013 falls).
Clinical Implications This project shows that focusing on 2 specific interventions, combined with the fall bundle, provides the tipping point to have an impact on fall reduction. Our plan to maintain momentum includes quarterly “No Fall Zone” days, keeping fall data and providing updates in monthly staff meetings, continued representation by our unit on our Hospital-Wide Falls Action Team, and involving staff council and the clinical nurse specialist from our unit in maintaining best-practice initiatives related to patients’ falls.
CriticalCareNurse
Vol 35, No. 2, APRIL 2015
83
Further work is needed to assist nurses in prioritizing fall interventions on the basis of patient-specific needs to identify clearly what will affect each patient in the most effective way. Because of the successful outcome of these strategies on this unit, the same process will be replicated and disseminated to other units within the hospital. For more information on this project, please visit the AACN CSI Database at www.aacn.org/csi. CCN Financial Disclosures None reported.
Now that you’ve read the article, create or contribute to an online discussion about this topic using eLetters. Just visit www.ccnonline.org and click “Submit a response” in either the full-text or PDF view of the article.
References 1. Oliver D, Connelly JB, Victor CR, et al. Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analysis. BMJ. 2007;334(3):82. 2. Morse JM. Preventing Patient Falls. Thousand Oaks, CA: Sage Publications Inc; 1997. 3. Heinrich S, Rapp K, Rissmann U, Becker C, Künig HH. Cost of falls in old age: a systematic review. Osteoporosis Int. 2010;21(6): 891-902. 4. Cameron ID, Gillespie LD, Robertson MC, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev. 2012;12:CD005465. 5. Oliver D, Healey F. Falls risk prediction tools for hospital inpatients: do they work? Nurs Times. 2009;105(7):18-21. 6. National Database for Nursing Quality Indicators. Definition of a fall, 2013. http://www .nursingquality.org/Content/Documents /NQF-Data-CollectionGuidelines.pdf. Accessed December 18, 2014.
In Our Unit
In Our Unit highlights unique practices, innovations, research, or resourceful solutions to commonly encountered problems in critical care areas and settings where critically ill patients are cared for. If you have an idea for an In Our Unit article, send it to Critical Care Nurse, 101 Columbia, Aliso Viejo, CA 92656; e-mail, [email protected].
84
CriticalCareNurse
Vol 35, No. 2, APRIL 2015
www.ccnonline.org
Copyright of Critical Care Nurse is the property of American Association of Critical-Care Nurses and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
