In Our Unit Prevention of Falls: Applying AACN’s Healthy Work Environment Standards to a Fall Campaign Beth Bechdel, RN, MSN, CNN Christa Bowman, RN Charlene Haley, RN, MHA, MSN, CNS, CCRN
E
fforts leading to the reduction and elimination of falls within acute and long-term clinical care settings are one of the top priorities of health care organizations nationwide. Falls often lead to serious life-threatening conditions and long-term consequences for our patients, their families, and health systems, while also contributing to astonishing costs for health care facilities. In 2010, the direct medical cost related to falls (adjusted for inflation) was $30 billion, and by the year 2020, the annual direct cost related to falls is expected to be near $54.9 billion.1 With the 2008 change in payment rule by the Centers for Medicare and Medicaid Services (CMS), hospitals no longer receive payment for costs required to treating injuries that are acquired during hospitalizations as a result of falling.2 The latest recommendations from the guidelines for prevention of falls from the Institute of Clinical Systems Improvement (ICSI) provide health care organizations with evidence-based, best-practice interventions for the implementation of a successful program to reduce the number of falls.3 Our unit-based team used many of the interventions and practices identified within the guidelines. Second, by committing and applying the American Association of Critical-Care Nurses (AACN) healthy work environments standards, our team developed and implemented a unified approach in our strategy to reduce and eliminate falls within our progressive care unit (PCU).
Authors Beth Bechdel is a nurse manager, Christa Bowman is a fall resource nurse, and Charlene Haley is an advanced practice care coordinator in a progressive care unit at The Reading Hospital, Reading, Pennsylvania. Corresponding author: Charlene Haley, The Reading Hospital, Sixth Avenue and Spruce Street, West Reading, PA 19611 (e-mail: [email protected]). To purchase electronic and print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273; fax, (949) 362-2049; e-mail, [email protected]. ©2014 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2014987
www.ccnonline.org
Background Our PCU at the Reading Hospital in Reading, Pennsylvania, is a 25-bed unit classified as an adult step-down unit. This unit receives patients with various diagnoses, including complicated surgeries, traumatic injuries, cardiac concerns, respiratory injuries, and medical problems such as sepsis and diabetic ketoacidosis. In addition, many patients admitted to the unit have a primary or secondary diagnosis of alcohol withdrawal. These various challenging diagnoses lead to marked risks for patient safety. One of the patient safety concerns that were difficult for the staff in our PCU to achieve with any type of consistency was fall prevention. Other identifiable factors contributing to the high rate of falls were unit design and layout, staff inexperience and turnover, management turnover, various physician rotations, lack of staff awareness and ownership, and the absence of a dedicated fall resource unit team. Despite the organization’s concentrated efforts to reduce the occurrence of falls, our unit continued to achieve poor outcomes. The National Database
CriticalCareNurse
Vol 34, No. 5, OCTOBER 2014
75
of Nursing Quality Indicators provided our team with compelling data related to our unit’s fall statistics compared with other similar units nationally. From the fourth quarter 2011 through the second quarter of 2013, our PCU outperformed the median only twice, and on average our unit sustained a rate of 3.69 falls per 1000 patient days. The time for action was obvious, and with the commitment toward a common vision, our unit embarked on a fall campaign that has resulted in a remarkable reduction in the number of falls and a new sense of pride and accountability within the unit.
New Common Vision As discussed previously, our PCU had little success with any type of approach to reduce the occurrence of falls. The unit management team realized that a new style and tactic were essential to foster staff allegiance, which would lead to a successful fall reduction campaign. The management team along with our advanced practice care coordinator (APCC) met and developed a plan that incorporated the recommendations from the ICSI while simultaneously applying the standards established within AACN’s initiative for healthy work environments. Researchers have reported that an increased awareness of the risk factors associated with falls among staff has been associated with improvement in fall rates.4 This “consciousness raising” was definitely something that was missing in our unit. Therefore, PCU nursing leaders concentrated their efforts on a new heightened sense of awareness campaign as one of the first steps to gain staff acceptance. We discussed in daily shift huddles
76
CriticalCareNurse
and staff meetings that the number 1 goal for our unit was to reduce our fall rate. We announced that we were going to be the unit that all other units in the hospital will look to for ideas to help improve fall ratings. A number of unit team members resisted the consistent verbal and nonverbal attention to fall prevention. They claimed they were “superstitious.” These resisters believed that drawing attention to the number of days without a fall would “jinx” the unit and a patient would experience a fall. These challengers did not thwart the nursing leaders from executing their original plan. A new fall team led by the unit APCC was organized. This team consisted of a registered nurse from each of the 3 shifts and included the weekend staff. With support from nursing managers to guide the team, our fall reduction campaign was underway. One of the first tools implemented was the creation of our new bright yellow unit “Fall” board. This visual alert that highlighted unit falls was placed in the main nurses’ station for all to see, including our patients and their families. The large black numbers designate how many days have passed since the last fall on our unit. This display provides transparency and awareness to all who come into our unit. At shift huddles, the number of days since the last fall is discussed, and when a new 24-hour period passes without a fall, a different staff member each day is asked to change the number of days on the board. When the number of days since the last fall is changed, staff in attendance applaud, which is always a positive reinforcement for the staff. The APCC and the nurse manager collaborated to help guide and
Vol 34, No. 5, OCTOBER 2014
support the team. These 2 nursing leaders were committed and energized for this journey to create a safe environment for patients and promote a sense of team ownership. The APCC referenced evidencebased guidelines and met daily with staff to identify patients at risk of falling. One of the first accomplishments by our APCC was to create a fall prevention model—another visual resource placed on our fall board illustrating unit council leaders who were additional resources for the staff. This model presents a cyclical team approach as to how the different unit-based council teams work together to reduce falls. Conducting a mini root-cause analysis revealed to the APCC that a common variable shared by our “fall patients” was being an “overestimator” as defined by the Morse Fall Scale. The APCC met with the newly formed fall resource team to review the hospital’s fall prevention policy, as all team members needed to be content experts. She assisted the fall resource nurses in conducting audits for the patients at high risk of falling. The team was charged with finding a method of discriminating the overestimators from other patients at high risk of falling. Universal fall signs were already placed outside patients’ rooms as a visual signal to alert the team that the patient was at high risk of a fall. When asked how we can identify these overestimators beyond the use of the universal fall sign, the assistant nurse manager on nights suggested using bright orange fluorescent paper to accompany the sign. This strategy was implemented to raise awareness that patients are at a higher risk of falling, because their
www.ccnonline.org
mobility is limited and they overestimate their ability to ambulate. Our hospital’s informatics system assisted the APCC to run daily reports identifying patients who were at high risk for falling and patients whose fall scores had not been assessed for the past 8 hours. The APCC reviewed the accuracy of the score on the Morse Fall Scale with each primary nurse and assisted them in creating a plan of care that was consistent with evidencebased practice. Real-time audits assisted primary nurses to understand the value of accurate assessments with respect to their patients’ risk of falling. Additionally, real-time audits allowed our nurses to see the influence they have with fall prevention while providing care to patients at risk. Previous monthly audit information was difficult for our staff to find significant because they often did not remember the occurrence. Finally, the APCC designed a simple graph with the unit layout, which was transformed into a tear-off tablet by our hospital’s duplicating services. After running fall reports, she quickly was able to place a check in the rooms of patients who were scored with impaired ambulation and patients who overestimate their ability to mobilize. This sheet of information was removed from the tablet and shared with the team. The unit facilitators also used this fall prevention schematic to communicate patients’ fall risk concerns to nursing supervisors and to allocate unit resources. This visual geographical tool allowed the team to locate the patients at high risk of a fall, and thus the entire team was empowered to increase their presence in these areas. Fall risk assessment and health information technology (HIT) have not been used enough in fall prevention
www.ccnonline.org
efforts. HIT improves communication and facilitates information and decision support.5 The nursing leadership team and fall resource nurses were committed to sharing information during shift huddles. Huddles promoted team responsibility and accountability. Patients at risk of falling were presented, with emphasis on the overestimators. Each staff member was reminded of the definition of an overestimator, and discussion revolved around the need for all staff to check on these patients frequently. Also, when passing by those patients’ rooms, staff took extra vigilance with looking in on these patients to see if the patient was attempting to get up on his or her own without pressing the call button. Because of the design of the unit, these patients often were moved to near the front nurse’s station for better oversight. Another potential problem that the leadership team identified was our unit design; nurses often sat and updated patients’ charts in a back nurse’s station. This area provided poor visualization of any patient along with the inability to see and adequately hear patients’ call bells. The unit management met with staff and a consensus was reached that this area would be avoided for patient documentation. Nurses and patient care assistants began recording patients’ assessments and care provided on portable computers just outside the rooms of patients at high risk of falling, and then in patients’ rooms once a computer was placed in each room.
Success Applying AACN’s healthy work environment standards6 in congruence
with our fall campaign on our PCU produced history-making results (see Table). Little by little, day by day, staff engagement, dedication, pride, and ownership emerged. The APCC sent inspirational and motivational messages to the staff starting with the first week without a fall and on a regular basis counting the days until their unit goal was achieved. This electronic recognition was used to inspire the staff to work together for success. Thirty days passed without a fall, and a pizza party was provided for the unit by our division director. Sixty days passed without a fall, and an ice cream party was given by the management team per staff request. As 100 days passed, our chief nursing officer arrived on the unit with a banner congratulating us for all of our efforts as a unified team. Challenges of and barriers to implementing evidence-based guidelines for falls diminished as time passed. The “consciousness raising” over fall reductions and the creation of a unified team approach while using the AACN’s healthy work environment standards fostered this young inexperienced group of staff to achieve remarkable outcomes. The management team began to also have discussions with staff that eventually a fall would occur. We wanted our staff to know that no one would be punished or be made to feel that they had failed themselves or the team. We felt strongly that this principle was extremely important to foster the growth and development of our young team. The APCC and nurse manager’s plan was to focus on the patient’s outcome and learning for the entire unit team.
CriticalCareNurse
Vol 34, No. 5, OCTOBER 2014
77
Table Healthy work environment standard
Applying healthy work environment standards to a fall campaign
Nursing management/leadership
Clinician: advanced practice care coordinator (APCC)
Fall resource nurse/unit team
Skilled communication
Focus on solutions in staff meetings and daily huddles for fall prevention All staff perspectives sought in regard to fall prevention strategies Mutual respect for all team members: nurses, patient care assistants, environmental services staff, laboratory, dietary, and transport team by acknowledging importance and role in fall prevention
Provide coaching sessions; fall prevention policy, Morse fall scores, fall interventions Education of patients and families
Fall resource nurse/unit team Conducted fall prevention updates during weekend-shift huddles focusing on audit results Education of patients and families
True collaboration
Daily recognition of each team member’s role Aid in development of common purpose for all team members Assist in development of high level of personal integrity of all staff Competence demonstration oversight for all staff Support education for staff to attend organizational classes for unique patient population such as crisis intervention classes, facilitator class, certification classes, and other resources available for staff growth
Share at-risk patient fall scores and real-time audits with nursing management, facilitators, fall resource nurse, and unit team Creation of “Fall Prevention Unit Model” Competence demonstration oversight for all staff
Regular attendance at monthly hospital-wide fall resource meeting providing 2-way communication with unit team
Effective decision making
Review of daily patient acuity and assign appropriate staff to competence level Holding accountability for fall safety measures (bed alarms on and working, patient doors open, charting near patients, reduction in time to answer call bells) Providing time for resource nurses to attend organizational fall team, and time allotment for auditing and staff education
Daily patient safety rounding, relocating patients who are at high risk of falling closer to nursing station, sharing rationale with patient, family and staff
Advocate for interventions to prevent patients from falling such as high-low beds, bed alarms, and patient safety monitors when appropriate
Appropriate staffing
Support of staffing matrices for unit acuity Ensure support services are provided Support the changes made in the nurse/patient care assistant model of care for unit to prioritize patient care
Advocate for synergy aligning patients’ fall prevention needs with nurses’ competencies Ensure support services are provided by attending daily care management rounds Support the changes made in nurse/patient care assistant model of care for unit to prioritize patient care
Communicate unit acuity in need for ancillary support to maintain patient safety
Meaningful recognition
Shift huddle recognition of team in efforts Daily celebration when number of days since last fall occurred is changed 30-, 60-, 100-day recognition Organizational recognition
Daily colorful e-mails with encouraging words illustrating number of days without a fall sent to entire unit team
Resource nurse provided positive reinforcement to unit team for complete and accurate documentation of falls
Authentic leadership
Embrace healthy work environment standards Ability to create enthusiasm for a common vision Lead unit in system changes to reduce falls: Implementing means to have patient supplies closer to point of service, attain proper equipment to provide care, changing location of stocked supplies in unit for better nurse accessibility, education on importance and holding accountability for meaningful rounding
Conduct root-cause analysis of falls, identify variables, and create tool to monitor patients at high risk for falling Embrace healthy work environment standards Ability to create enthusiasm for a common vision
Complete team engagement for successful fall prevention
78
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Vol 34, No. 5, OCTOBER 2014
www.ccnonline.org
6
No. of falls
5 4
Start of fall reduction campaign
3 2 1
Month
01 r2
r2 De
ce
m
be
be m ve
No
3
3 01
13 20 er
to b Oc
Se p
te m
be
us
r2
t2
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01
3
3
13 Au g
Ju
ly
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13
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ay M
il
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13
13 Ap r
ar M
br
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ch
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ar nu
em
c De
Ja
b
2 er
Fe
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ve
m
to b Oc
2
01
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er
20
12
0
Figure Total falls per month.
We made history in our hospital, 148 days without a fall in our unit— the team was ecstatic. The hospital’s chief nursing officer, chief operating officer, and chief executive officer all visited our unit to acknowledge all our efforts. A fall did occur, as warned, and we took that opportunity to debrief immediately with all staff. After our APCC and the fall resource team performed a mini root-cause analysis, we discussed opportunities for improvement with our staff. For 2 straight quarters, our PCU performed well below the national average for falls in an adult step-down unit (see Figure). We will continue on our journey by implementing new and innovative ideas from staff and evidence-based interventions, all while maintaining the standards of a healthy work environment. CCN Financial Disclosures None reported.
3.
4.
5. 6.
/Medicare-Fee-for-Service-Payment/HospitalAcqCond/downloads/HACFactSheet.pdf. Accessed July 16, 2014. Degelau J, Belz M, Bungum L, et al. Prevention of Falls (Acute Care): Health Care Protocol. Bloomington, MN: Institute for Clinical Systems Improvement (ICSI); 2012. Evans D, Hodgkinson B, Lambert L, Wood J, Kowanka I. Falls in Acute Hospitals—A Systematic Review. Adelaide, Australia: The Joanna Briggs Institute For Evidence-Based Nursing and Midwifery; 1998. http://www .joannabriggslibrary.org/index.php/jbisrir /article/view/399. Accessed July 16, 2014. Dykes PC, Carroll DL, Hurley A, et al. Fall prevention in acute care hospitals: a randomized trial. JAMA. 2010;304(17):1912. AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence. http://www.aacn.org/wd/hwe /docs/hwestandards.pdf. Accessed July 16, 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].
References 1. Centers for Disease Control and Prevention. Costs of Falls Among Older Adults. http:// www.cdc.gov/homeandrecreationalsafety /falls/fallcost.html. Accessed July 16, 2014. 2. Hospital-Acquired Conditions (HAC) in Acute Inpatient Prospective Payment System (IPPS) Hospitals. http://www.cms.gov/Medicare
www.ccnonline.org
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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.
E
fforts leading to the reduction and elimination of falls within acute and long-term clinical care settings are one of the top priorities of health care organizations nationwide. Falls often lead to serious life-threatening conditions and long-term consequences for our patients, their families, and health systems, while also contributing to astonishing costs for health care facilities. In 2010, the direct medical cost related to falls (adjusted for inflation) was $30 billion, and by the year 2020, the annual direct cost related to falls is expected to be near $54.9 billion.1 With the 2008 change in payment rule by the Centers for Medicare and Medicaid Services (CMS), hospitals no longer receive payment for costs required to treating injuries that are acquired during hospitalizations as a result of falling.2 The latest recommendations from the guidelines for prevention of falls from the Institute of Clinical Systems Improvement (ICSI) provide health care organizations with evidence-based, best-practice interventions for the implementation of a successful program to reduce the number of falls.3 Our unit-based team used many of the interventions and practices identified within the guidelines. Second, by committing and applying the American Association of Critical-Care Nurses (AACN) healthy work environments standards, our team developed and implemented a unified approach in our strategy to reduce and eliminate falls within our progressive care unit (PCU).
Authors Beth Bechdel is a nurse manager, Christa Bowman is a fall resource nurse, and Charlene Haley is an advanced practice care coordinator in a progressive care unit at The Reading Hospital, Reading, Pennsylvania. Corresponding author: Charlene Haley, The Reading Hospital, Sixth Avenue and Spruce Street, West Reading, PA 19611 (e-mail: [email protected]). To purchase electronic and print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273; fax, (949) 362-2049; e-mail, [email protected]. ©2014 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2014987
www.ccnonline.org
Background Our PCU at the Reading Hospital in Reading, Pennsylvania, is a 25-bed unit classified as an adult step-down unit. This unit receives patients with various diagnoses, including complicated surgeries, traumatic injuries, cardiac concerns, respiratory injuries, and medical problems such as sepsis and diabetic ketoacidosis. In addition, many patients admitted to the unit have a primary or secondary diagnosis of alcohol withdrawal. These various challenging diagnoses lead to marked risks for patient safety. One of the patient safety concerns that were difficult for the staff in our PCU to achieve with any type of consistency was fall prevention. Other identifiable factors contributing to the high rate of falls were unit design and layout, staff inexperience and turnover, management turnover, various physician rotations, lack of staff awareness and ownership, and the absence of a dedicated fall resource unit team. Despite the organization’s concentrated efforts to reduce the occurrence of falls, our unit continued to achieve poor outcomes. The National Database
CriticalCareNurse
Vol 34, No. 5, OCTOBER 2014
75
of Nursing Quality Indicators provided our team with compelling data related to our unit’s fall statistics compared with other similar units nationally. From the fourth quarter 2011 through the second quarter of 2013, our PCU outperformed the median only twice, and on average our unit sustained a rate of 3.69 falls per 1000 patient days. The time for action was obvious, and with the commitment toward a common vision, our unit embarked on a fall campaign that has resulted in a remarkable reduction in the number of falls and a new sense of pride and accountability within the unit.
New Common Vision As discussed previously, our PCU had little success with any type of approach to reduce the occurrence of falls. The unit management team realized that a new style and tactic were essential to foster staff allegiance, which would lead to a successful fall reduction campaign. The management team along with our advanced practice care coordinator (APCC) met and developed a plan that incorporated the recommendations from the ICSI while simultaneously applying the standards established within AACN’s initiative for healthy work environments. Researchers have reported that an increased awareness of the risk factors associated with falls among staff has been associated with improvement in fall rates.4 This “consciousness raising” was definitely something that was missing in our unit. Therefore, PCU nursing leaders concentrated their efforts on a new heightened sense of awareness campaign as one of the first steps to gain staff acceptance. We discussed in daily shift huddles
76
CriticalCareNurse
and staff meetings that the number 1 goal for our unit was to reduce our fall rate. We announced that we were going to be the unit that all other units in the hospital will look to for ideas to help improve fall ratings. A number of unit team members resisted the consistent verbal and nonverbal attention to fall prevention. They claimed they were “superstitious.” These resisters believed that drawing attention to the number of days without a fall would “jinx” the unit and a patient would experience a fall. These challengers did not thwart the nursing leaders from executing their original plan. A new fall team led by the unit APCC was organized. This team consisted of a registered nurse from each of the 3 shifts and included the weekend staff. With support from nursing managers to guide the team, our fall reduction campaign was underway. One of the first tools implemented was the creation of our new bright yellow unit “Fall” board. This visual alert that highlighted unit falls was placed in the main nurses’ station for all to see, including our patients and their families. The large black numbers designate how many days have passed since the last fall on our unit. This display provides transparency and awareness to all who come into our unit. At shift huddles, the number of days since the last fall is discussed, and when a new 24-hour period passes without a fall, a different staff member each day is asked to change the number of days on the board. When the number of days since the last fall is changed, staff in attendance applaud, which is always a positive reinforcement for the staff. The APCC and the nurse manager collaborated to help guide and
Vol 34, No. 5, OCTOBER 2014
support the team. These 2 nursing leaders were committed and energized for this journey to create a safe environment for patients and promote a sense of team ownership. The APCC referenced evidencebased guidelines and met daily with staff to identify patients at risk of falling. One of the first accomplishments by our APCC was to create a fall prevention model—another visual resource placed on our fall board illustrating unit council leaders who were additional resources for the staff. This model presents a cyclical team approach as to how the different unit-based council teams work together to reduce falls. Conducting a mini root-cause analysis revealed to the APCC that a common variable shared by our “fall patients” was being an “overestimator” as defined by the Morse Fall Scale. The APCC met with the newly formed fall resource team to review the hospital’s fall prevention policy, as all team members needed to be content experts. She assisted the fall resource nurses in conducting audits for the patients at high risk of falling. The team was charged with finding a method of discriminating the overestimators from other patients at high risk of falling. Universal fall signs were already placed outside patients’ rooms as a visual signal to alert the team that the patient was at high risk of a fall. When asked how we can identify these overestimators beyond the use of the universal fall sign, the assistant nurse manager on nights suggested using bright orange fluorescent paper to accompany the sign. This strategy was implemented to raise awareness that patients are at a higher risk of falling, because their
www.ccnonline.org
mobility is limited and they overestimate their ability to ambulate. Our hospital’s informatics system assisted the APCC to run daily reports identifying patients who were at high risk for falling and patients whose fall scores had not been assessed for the past 8 hours. The APCC reviewed the accuracy of the score on the Morse Fall Scale with each primary nurse and assisted them in creating a plan of care that was consistent with evidencebased practice. Real-time audits assisted primary nurses to understand the value of accurate assessments with respect to their patients’ risk of falling. Additionally, real-time audits allowed our nurses to see the influence they have with fall prevention while providing care to patients at risk. Previous monthly audit information was difficult for our staff to find significant because they often did not remember the occurrence. Finally, the APCC designed a simple graph with the unit layout, which was transformed into a tear-off tablet by our hospital’s duplicating services. After running fall reports, she quickly was able to place a check in the rooms of patients who were scored with impaired ambulation and patients who overestimate their ability to mobilize. This sheet of information was removed from the tablet and shared with the team. The unit facilitators also used this fall prevention schematic to communicate patients’ fall risk concerns to nursing supervisors and to allocate unit resources. This visual geographical tool allowed the team to locate the patients at high risk of a fall, and thus the entire team was empowered to increase their presence in these areas. Fall risk assessment and health information technology (HIT) have not been used enough in fall prevention
www.ccnonline.org
efforts. HIT improves communication and facilitates information and decision support.5 The nursing leadership team and fall resource nurses were committed to sharing information during shift huddles. Huddles promoted team responsibility and accountability. Patients at risk of falling were presented, with emphasis on the overestimators. Each staff member was reminded of the definition of an overestimator, and discussion revolved around the need for all staff to check on these patients frequently. Also, when passing by those patients’ rooms, staff took extra vigilance with looking in on these patients to see if the patient was attempting to get up on his or her own without pressing the call button. Because of the design of the unit, these patients often were moved to near the front nurse’s station for better oversight. Another potential problem that the leadership team identified was our unit design; nurses often sat and updated patients’ charts in a back nurse’s station. This area provided poor visualization of any patient along with the inability to see and adequately hear patients’ call bells. The unit management met with staff and a consensus was reached that this area would be avoided for patient documentation. Nurses and patient care assistants began recording patients’ assessments and care provided on portable computers just outside the rooms of patients at high risk of falling, and then in patients’ rooms once a computer was placed in each room.
Success Applying AACN’s healthy work environment standards6 in congruence
with our fall campaign on our PCU produced history-making results (see Table). Little by little, day by day, staff engagement, dedication, pride, and ownership emerged. The APCC sent inspirational and motivational messages to the staff starting with the first week without a fall and on a regular basis counting the days until their unit goal was achieved. This electronic recognition was used to inspire the staff to work together for success. Thirty days passed without a fall, and a pizza party was provided for the unit by our division director. Sixty days passed without a fall, and an ice cream party was given by the management team per staff request. As 100 days passed, our chief nursing officer arrived on the unit with a banner congratulating us for all of our efforts as a unified team. Challenges of and barriers to implementing evidence-based guidelines for falls diminished as time passed. The “consciousness raising” over fall reductions and the creation of a unified team approach while using the AACN’s healthy work environment standards fostered this young inexperienced group of staff to achieve remarkable outcomes. The management team began to also have discussions with staff that eventually a fall would occur. We wanted our staff to know that no one would be punished or be made to feel that they had failed themselves or the team. We felt strongly that this principle was extremely important to foster the growth and development of our young team. The APCC and nurse manager’s plan was to focus on the patient’s outcome and learning for the entire unit team.
CriticalCareNurse
Vol 34, No. 5, OCTOBER 2014
77
Table Healthy work environment standard
Applying healthy work environment standards to a fall campaign
Nursing management/leadership
Clinician: advanced practice care coordinator (APCC)
Fall resource nurse/unit team
Skilled communication
Focus on solutions in staff meetings and daily huddles for fall prevention All staff perspectives sought in regard to fall prevention strategies Mutual respect for all team members: nurses, patient care assistants, environmental services staff, laboratory, dietary, and transport team by acknowledging importance and role in fall prevention
Provide coaching sessions; fall prevention policy, Morse fall scores, fall interventions Education of patients and families
Fall resource nurse/unit team Conducted fall prevention updates during weekend-shift huddles focusing on audit results Education of patients and families
True collaboration
Daily recognition of each team member’s role Aid in development of common purpose for all team members Assist in development of high level of personal integrity of all staff Competence demonstration oversight for all staff Support education for staff to attend organizational classes for unique patient population such as crisis intervention classes, facilitator class, certification classes, and other resources available for staff growth
Share at-risk patient fall scores and real-time audits with nursing management, facilitators, fall resource nurse, and unit team Creation of “Fall Prevention Unit Model” Competence demonstration oversight for all staff
Regular attendance at monthly hospital-wide fall resource meeting providing 2-way communication with unit team
Effective decision making
Review of daily patient acuity and assign appropriate staff to competence level Holding accountability for fall safety measures (bed alarms on and working, patient doors open, charting near patients, reduction in time to answer call bells) Providing time for resource nurses to attend organizational fall team, and time allotment for auditing and staff education
Daily patient safety rounding, relocating patients who are at high risk of falling closer to nursing station, sharing rationale with patient, family and staff
Advocate for interventions to prevent patients from falling such as high-low beds, bed alarms, and patient safety monitors when appropriate
Appropriate staffing
Support of staffing matrices for unit acuity Ensure support services are provided Support the changes made in the nurse/patient care assistant model of care for unit to prioritize patient care
Advocate for synergy aligning patients’ fall prevention needs with nurses’ competencies Ensure support services are provided by attending daily care management rounds Support the changes made in nurse/patient care assistant model of care for unit to prioritize patient care
Communicate unit acuity in need for ancillary support to maintain patient safety
Meaningful recognition
Shift huddle recognition of team in efforts Daily celebration when number of days since last fall occurred is changed 30-, 60-, 100-day recognition Organizational recognition
Daily colorful e-mails with encouraging words illustrating number of days without a fall sent to entire unit team
Resource nurse provided positive reinforcement to unit team for complete and accurate documentation of falls
Authentic leadership
Embrace healthy work environment standards Ability to create enthusiasm for a common vision Lead unit in system changes to reduce falls: Implementing means to have patient supplies closer to point of service, attain proper equipment to provide care, changing location of stocked supplies in unit for better nurse accessibility, education on importance and holding accountability for meaningful rounding
Conduct root-cause analysis of falls, identify variables, and create tool to monitor patients at high risk for falling Embrace healthy work environment standards Ability to create enthusiasm for a common vision
Complete team engagement for successful fall prevention
78
CriticalCareNurse
Vol 34, No. 5, OCTOBER 2014
www.ccnonline.org
6
No. of falls
5 4
Start of fall reduction campaign
3 2 1
Month
01 r2
r2 De
ce
m
be
be m ve
No
3
3 01
13 20 er
to b Oc
Se p
te m
be
us
r2
t2
01
01
3
3
13 Au g
Ju
ly
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ay M
il
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13 Ap r
ar M
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c De
Ja
b
2 er
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2 01 r2
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er
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0
Figure Total falls per month.
We made history in our hospital, 148 days without a fall in our unit— the team was ecstatic. The hospital’s chief nursing officer, chief operating officer, and chief executive officer all visited our unit to acknowledge all our efforts. A fall did occur, as warned, and we took that opportunity to debrief immediately with all staff. After our APCC and the fall resource team performed a mini root-cause analysis, we discussed opportunities for improvement with our staff. For 2 straight quarters, our PCU performed well below the national average for falls in an adult step-down unit (see Figure). We will continue on our journey by implementing new and innovative ideas from staff and evidence-based interventions, all while maintaining the standards of a healthy work environment. CCN Financial Disclosures None reported.
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/Medicare-Fee-for-Service-Payment/HospitalAcqCond/downloads/HACFactSheet.pdf. Accessed July 16, 2014. Degelau J, Belz M, Bungum L, et al. Prevention of Falls (Acute Care): Health Care Protocol. Bloomington, MN: Institute for Clinical Systems Improvement (ICSI); 2012. Evans D, Hodgkinson B, Lambert L, Wood J, Kowanka I. Falls in Acute Hospitals—A Systematic Review. Adelaide, Australia: The Joanna Briggs Institute For Evidence-Based Nursing and Midwifery; 1998. http://www .joannabriggslibrary.org/index.php/jbisrir /article/view/399. Accessed July 16, 2014. Dykes PC, Carroll DL, Hurley A, et al. Fall prevention in acute care hospitals: a randomized trial. JAMA. 2010;304(17):1912. AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence. http://www.aacn.org/wd/hwe /docs/hwestandards.pdf. Accessed July 16, 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].
References 1. Centers for Disease Control and Prevention. Costs of Falls Among Older Adults. http:// www.cdc.gov/homeandrecreationalsafety /falls/fallcost.html. Accessed July 16, 2014. 2. Hospital-Acquired Conditions (HAC) in Acute Inpatient Prospective Payment System (IPPS) Hospitals. http://www.cms.gov/Medicare
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Vol 34, No. 5, OCTOBER 2014
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