Program inspires fall prevention project
Program inspires fall prevention project
Big topic at MPSC
It was a summer of crime in Washington, DC, and area police agencies collaborated to implement a crime prevention program called All Hands On Deck. Washington Hospital Center was having a problem with falls. Would a program based on the idea of putting everyone to work to prevent falls help keep patients safe?
It was what Leslie Smith, RN, AOCNS, an oncology clinical specialist at Washington Hospital Center and her nursing director Stefanie Lescallett hoped. They presented the program they came up with at the recent Eighth Annual Maryland Patient Safety Conference.
The fall rate at the hospital was as high as 3.4 per 1,000 patient days. The goal was to get down to 2.0. So Lescallett and a committee of staff nurses, transporters, and physical and occupational therapists looked at trending. They made an interesting discovery: Most falls were happening during change of shift, between 7:00 and 7:30 a.m., 3:00 and 3:30 p.m., and 11:00 and 11:30 p.m. The day of the week didn't matter, nor did the traditional risk factors of the patients. This trend was outside of that.
At the time, handoffs were done in a break or conference room. With no one in the hallways, the patients were using call bells that weren't heard. And if they did get up on their own, the bed alarms weren't heard. It was a situation that demanded all hands on deck — no one elsewhere, everyone there, everyone vigilant, Lescallett says.
At report, they required every nurse and patient care technician to be out of the break room. Report was done in the hallways or patient rooms where call lights could be seen and alarms heard, says Smith.
They did leadership forums and implemented the program on the units. Every unit leader explained why no one was allowed in break rooms during the change of shift. It worked. Fall rates came down dramatically, to 2.6 per 1,000 days and none with severe injury.
They also started doing rounding at least once an hour, says Smith. At each round the patients are asked if they need to go to the bathroom, if they want to sit, whether they have anything they would like the care provider to get for them. "We monitor them much more closely, regardless of the acuity of their fall risk score."
Each room has a rounding sheet, says Lescallett, and a nurse or patient care tech has to sign it after each round. Whoever enters a room looks to see when the patient was last questioned. If no nurse or tech has checked the rounding sheet, the caregiver goes through the list of questions.
Smith says it's unlikely they'll ever reach zero falls for any length of time. "You will always have patients who won't call out to ask for assistance, or someone who wants to get up without help. But our goal is to be lower. As we develop more processes — right now we are working to troubleshoot each incidence — we hope to get lower."
As an example of how they do that, Lescallett mentions a unit that took each occurrence and posted it in a break room with a form that listed why the patient fell and how it could be prevented. The next month, that unit had no falls. Another unit is doing a poster on scoring patients for fall risk. "It rethinks the issue," she says. Rather than asking for interventions only if there is a certain level of risk, this scores patients as high, medium, or low risk. High-risk patients get certain interventions, medium-risk fewer, low-risk maybe none. It makes nurses look at this in a different way.
Patients and families are also part of the effort. Each is given a brochure on the risk of falls and the importance for asking for help. The nurses then reeducate high-risk patients at every change of shift.
The patient safety conference highlighted the work of a number of other hospitals working to reduce falls. At the University of Maryland Medical System's 12 member hospitals, a fall prevention team worked to improve compliance with core measures related to falls by doing a literature review, reviewed fall prevention tools, and is working to come up with a customized education and patient awareness program for each of the hospitals.
The health system monitors progress with monthly reporting and quarterly report cards and shares results and best practices across the system. More on this effort is available at http://www.marylandpatientsafety.org/html/education/solutions/2012/documents/Using_System_Synergy_to_Achieve.pdf.
Sinai Hospital in Baltimore created the Call Don't Fall program to reduce its 1.53 falls per 1,000 patient days down to a benchmark of 1.00. To achieve the goal, they evaluated fall events to try to determine the reasons behind them. During one particular week, an interdisciplinary "SWAT team" investigated each event, interviewed the patient, and determined what happened. After that week, they analyzed trends and came up with a variety of interventions — from culture change to improved education. Administration made fall prevention an annual goal; they educated staff on everyone's role in fall prevention; and there was an element of accountability included for management-level employees. All frontline staff were required to take a fall prevention education module, and even providers were involved in the education efforts. Falls and their reasons were reported monthly. Any unit with too many falls was required to audit 10 charts for missed opportunities to implement fall prevention programs.
Over nearly two years, the fall rate declined from 1.03 at the start of the program to about 0.30 last fall. Sinai maintains a fall prevention team in place to continually review fall rates and interventions. More information on this project is available at http://www.marylandpatientsafety.org/html/education/solutions/2012/documents/Call_Dont_Fall_Initiative.pdf.
At the University of Maryland Medical Center, they were concerned with falls in the cardiac surgery step-down unit — particularly those related to getting up from chairs. Using the Morse Fall Risk tool to determine which patients needed intervention, UMMC made sure that patients who needed it received chair alarms. There were audits and rounding in which patients were reevaluated for alarm needs, and all shift changes began with a statement of when the last fall was and ended with the rallying cry, "Call, don't fall."
While fall rates in the step-down unit were stubborn, by the second quarter of 2012 they were running below benchmark. The team continues to evaluate opportunities for patient and family education, patient audits, and nurse and other staff training. More information on this project is available at http://www.marylandpatientsafety.org/html/education/solutions/2012/documents/Jacks_Crown_and_Jills_Hip_Revisited.pdf.
For more information on this topic, contact:
- Leslie D. Smith, RN, AOCNS, Oncology Clinical Specialist and Stefanie Lescallett, RN, MSN, Nursing Director, Washington Hospital Center, Washington, DC. Telephone: (202) 877-2221.
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