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Fall prevention takes 'constant attention,' comprehensive interventions
Hospital keeps fall rate low with continuous reinforcement
Preventing patient falls is a constant struggle for hospitals. And as Medicare has cut reimbursement for falls as a "never event" and patients are getting increasingly older and sicker, it will continue to be a challenge. According to Joint Commission statistics, in 2008 patient falls ranked as the fifth highest sentinel event; reported falls have become increasingly more frequent since 2000, when The Joint Commission first labeled them as sentinel events.
Falls represent not only a significant cost to hospitals, but a greater length of stay for patients. In a 2009 study, "Medicare nonpayment, hospital falls, and unintended consequences," the authors write: Falls are "high-cost and high-volume, and they result in the assignment of a case to a higher-paying DRG. Some 3 to 20% of inpatients fall at least once during their hospital stay; these falls result in injuries, increased lengths of stay, malpractice lawsuits, and more than $4,000 in excess charges per hospitalization."1
Sentara Healthcare began working on its fall prevention program in 2000, when it added falls as a quality indicator on its executive quality report. It began its initiative by reviewing the literature available at the time and selecting a fall risk assessment scale, the Conley scale, published in MedSurg Nursing in 1999.2 Stephanie S. Jackson, DNP(c), RN, ACNS-BC, manager, patient care services, education department, diabetes program & enterostomal therapy services at Sentara Norfolk General Hospital, says the system also participated in a number of collaboratives. In a collaborative with the Institute for Healthcare Improvement, the system became one of the top 10% national performers in the area of falls with injuries in 2006.
"I can tell you that falls is certainly something that takes constant attention. When you take your eyes off of it for a little while, it begins to slip. We're always looking at our program to see what can we do different. What can we enhance? What have we done in the past that maybe we're not doing now?" Jackson says.
The hospital's comprehensive program has seen success over the years. In 2009, Sentara Norfolk General Hospital had 0.12 overall serious injuries per 1,000 patient days. The overall system rate is 0.10.
Besides the risk assessment procedure, Sentara's fall prevention program also includes what it calls "job aids," designed to help nurses, with interventions for "all the patients who come into our hospital" as well as high-risk and special patient populations, Jackson says.
Universal, patient-specific interventions
The risk assessment is completed for every patient every 12 hours. The hospital also has what it calls universal fall prevention interventions that can be used for every patient:
Then there are patient-specific precautions. Perhaps a patient has already fallen. Should that patient be moved closer to the nursing station so he or she is more visible? Does the patient need an assistive device or a consult with a physical therapist? Does the patient need a bedside commode? In some cases, the hospital places what it calls safety partners, or sitters, in rooms to monitor the patient's risks. Or a pharmacology review is done with a pharmacist if the patient is on a combination of high-risk medications, is overly sedated, or is new to narcotics.
If a patient is known to be at risk for a fall or injury, a low bed can be ordered from the equipment room with a floor mat. Jackson says it's important to make sure the hospital is always equipped with things you may need for patients. For instance, "a few patients have required helmets. And we stock those on our rehab unit." If a patient is on an anticoagulant or had some sort of surgery where a part of the skull was removed "and we think they're at risk for falls, we have a helmet we can put on them," she says.
Interventions for high-risk patients
In 2006, the focus shifted to patients at high risk for harm, Jackson says. Sentara uses the Institute for Healthcare Improvement's ABCs High Risk To Harm assessment tool to identify those patients. For that population, five interventions are in place, and staff are expected to follow these if a patient rates as high risk based on the Conley scale.
• Identify high-risk patients with a colored armband.
Each high-risk patient is identified with a pink armband. And all staff — from environmental services to catering — are educated on what the armband signals. The armband is used, Jackson says, because it identifies the patient throughout the hospital stay. A pink sign also is placed outside the patient's room with a symbol of a patient falling. The hospital now is looking at changing that to align with the national and statewide color of yellow.
• EMR system also identifies patients at high risk.
"There is a precaution in the documentation system that travels with the patient," Jackson says. For instance, if the patient is scheduled for an X-ray, the radiology department will get a transmittal prior to the procedure alerting clinicians there that they are getting an at-risk patient; they know they can't leave the patient unattended and extra caution needs to be used getting the patient on and off the table.
• Beds are equipped with alarm devices.
Beds are outfitted with alarm devices. When patients are in the ED on a stretcher for an extended amount of time, a portable alarm device is used.
"We know that alarms don't prevent falls, but we know that if a patient were to fall that that alarm would be an indication to us and we could get to the patient right away. And technology has improved a lot with alarms over time so they do send off a lot more quickly than they did say five or 10 years ago. So we're having a lot of success with those as well," she says.
• Toileting schedules are prepared.
A major risk for patient falls is when the patient goes to and from the bathroom, Jackson says, pointing to literature and what she's seen at the hospital. Patients have unique toileting schedules per unit. For example, in the rehab unit, it may be every two hours. The surgical unit may use an every four hour schedule. Nursing assistants round on the patients and take patients to the bathroom vs. asking them if they need to go. "It's more of an encouragement," Jackson says, and it's been quite successful.
• Beware the three Ps — pain, potty, and position.
"We try to focus on that type of rounding, especially in some of our units. We have an orthopedic trauma neuro unit that had a lot of falls in the past... we've encouraged a lot of rounding, frequent rounding on that unit. And that's really helped with that population," Jackson says.
One of the biggest challenges, Jackson says, was encouraging awareness among staff — "from the person who waxes the floor who sees that a patient with a pink armband is trying to get out of bed unassisted and they can request the nurse, all the way through to our physicians. And so we have the full gamut, the full spectrum of our employees is involved. That overcomes a big hurdle."
Each of the eight hospitals in the system has its own fall prevention task force in addition to a systemwide group. Representatives from the task forces come together for a monthly phone call in which they discuss interventions that are and are not working.
"The other thing that has been so important for us is our administrative support. Really keeping them in the loop. We have a quality department that tracks our data for us monthly," Jackson says.
But she prefers using a weekly report, so the data are more up to date. "If you're six weeks downstream, you can't huddle with your staff on your unit and say we've got to do something different. That's 10 falls ago. But if you know, 'Oh my gosh, we had a fall every day on our unit last week. We really have to buckle down. We've got to have some more frequent rounding.'"
Every Monday morning, all the inpatient nurse managers, the clinical nurse specialists, the nursing directors, the nurse executive, and the vice president of medical affairs get this report. The report is unit-specific, with goals for each.
"So if your unit goal was to have only two falls with injury for the year and you've already had one, then you know your staff have to be really focused on that. And tied to those goals is a performance plus incentive program that all the staff participate in. So that works really well to keep it in the forefront," she says.
She also receives all of the incident reports. "So if I see anything in those that I have a question about, I have a really quick timely follow up with the manager. So if it happens today, I get the report around midnight and so tomorrow morning first thing I'll do is follow up on all those, and if I need to follow up with any of the managers I'll do that if I have any questions or if I think something may have been coded wrong or it's just not clear."
Another important element is timeliness of intervention if a fall does occur. Patient care supervisors are available 24/7 and function as leaders. They are called if a patient has fallen and immediately respond. They complete a "mini-debriefing," which goes out to all leadership to let them know a fall has happened.
Jackson tries to round weekly with staff to ask questions such as: What are the barriers? What don't you have available for fall prevention? Someone may answer with a very specific need. For example, one nurse said she needs activity aprons, which are not regularly stocked on her unit.
A physical environment assessment of all patient rooms is done annually. "All the beds are built in with night lights under the beds, but sometimes they go out and the staff might not know the correct mechanism for reporting that. So we help with that. We look at all the IV poles and do they still roll well? Do they need to be lubed, or do they need to go out of service? So things like that; and when we do that, we always send staff from a different unit so that you have some really objective eyes looking at the physical environment," she says.
Falls are categorized at Sentara as no harm, minimal, moderate, major, and death. "So we track moderate harm and above," she says.
Jackson reports actual numbers rather than fall rates to staff, as they seem to understand those better. So in 2009, Sentara Norfolk General Hospital had 0.12 overall serious injuries per 1,000 patient days. She would explain that to staff as the hospital has 12 falls for every 100,000 patient days. "We had some hospitals that were as low as three falls for every 100,000 patient days. So definitely some admirable statistics," she says.
"What we find is we need constant reinforcement back to those interventions that will prevent patients from falling," she says.
[For more information, contact:
Stephanie S. Jackson, DNP(c), RN, CNS, ACNS-BC, manager, patient care services, education department, diabetes program & enterostomal therapy services, Sentara Norfolk General Hospital. Phone: (757) 388-2484. Pager: (757) 475-2874. Fax: (757) 388-3152. E-mail: email@example.com.]