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Continuous Quality Improvement

Fall Reduction and Injury Prevention Toolkit: Implementation on Two Medical-Surgical Units Shirley Ambutas Karen V. Lamb Patricia Quigley atient falls are one of the most commonly reported incidents, often resulting in significant injury, death, loss of independence, prolonged hospital length of stay, and increased hospital costs (Degelau et al., 2012). In the United States, between 700,000 and 1,000,000 patients fall in hospitals yearly (Agency for Healthcare Research and Quality [AHRQ], 2013). In 2013, direct medical costs of falls among older adults, adjusted for inflation, were over $34 billion (Centers for Disease Control and Prevention, 2015). A widely cited systematic review of falls and injuries in hospitals by Oliver, Healty, and Haines (2010) reported an injury range of 30%-51% among falls. Falls with injury are not only a patient safety concern, but also a financial concern for institutions. The Centers for Medicare & Medicaid Services does not reimburse hospital costs associated with an injury from a fall occurring in the hospital. National efforts are focused on reducing fall-related injuries (Degelau et al., 2012; Quigley & White, 2013; Williams, Szekendi, & Thomas, 2014). Normative data from medicalsurgical units in non-federal, shortterm hospitals in the United States were collected July 1, 2006September 30, 2008. The incidence of patients experiencing injury was 26.1% for 345,800 falls studied. The majority of injurious falls were determined to cause minor injury (85.6%). Approximately 1 in 10

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Falls and related injury are the most frequently reported adverse events in the hospital setting. A comprehensive Fall Reduction and Injury Prevention Toolkit was implemented on two medical-surgical units over 6 months. Results of this quality improvement project suggest infrastructure and capacity can be enhanced through structured program evaluation. injurious falls resulted in moderate injury (9.8%), fewer than 1 in 20 injurious falls were classified as causing major injury (4.3%), and 2 in 1,000 injurious falls resulted in death (0.2%) (Bouldin et al., 2013). This study supported the need to develop methods that decrease injuries due to falls. Higher falls rates occur among older patients with neurology conditions in the rehabilitation setting (Miake-Lye, Hempel, Ganz, & Shekelle, 2013). Approximately one-third to one-half of all patients who fall experience injury. These patients experience fear of falling, depression, anxiety, and decreased activity (Miake-Lye et al., 2013). The American Geriatrics Society (2017) clinical practice guidelines summarize evidence-based recommendation to avert incidence and decrease severity of falls. Some strongly recommended interven-

tions are to investigate fall history using a multifactorial assessment; offer exercise incorporating balance, gait, and strength training; ensure interventions are conducted by the healthcare team; assess the environment for safety; and provide vitamin D supplementation. Fall and injury prevention programs historically followed four key components: implement a safer environment of care for the whole patient cohort, identify specific modifiable fall factors, implement interventions targeting those modifiable risk factors to prevent falls, and intervene to reduce risk of injury for those patients who fall (Oliver et al., 2010). Based on the evidence in the literature, authors determined best practices in the form of a fall reduction toolkit would be the most effective method to address falls on the two study units at this medical center.

Shirley Ambutas, DNP, APN, CCNS, CCRN, is Clinical Nurse Specialist, Rush University Medical Center, Chicago, IL. Karen V. Lamb, DNP, RN, GCNS, is Associate Professor, Rush University College of Nursing, Chicago, IL. Patricia Quigley, PhD, ARNP, CRRN, FAAN, FAANP, is Nurse Consultant, St. Petersburg, FL. Acknowledgment: The first author acknowledges the support of Lou Fogg, statistician. Special thanks to Norma Vilutis, MSN, RN, and Barbara Bolek, MSN, RN.

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Continuous Quality Improvement Purpose The purpose of this project was to improve organizational infrastructure and capacity to identify and address solutions for patients at risk for fall and injury on two medical-surgical units at the medical center, ultimately reducing the incidence of falls and injury. The proposal for this project was reviewed by the Institutional Review Board at the project site and deemed to be a quality improvement (QI) project requiring no formal board approval.

Literature Review A review in CINAHL and PubMed was conducted using keywords fall reduction, falls with injury, and patient falls for years 20122015. Because many articles were found, limits were applied to include only adult inpatient populations. A meta-analysis of the effectiveness of interventions in prevention of falls over a 10-year period (20002009) analyzed falls and fall rates (Choi & Hector, 2012). The combined risk ratios for number of falls among 17 studies (N=5,501 participants) demonstrated fall prevention programs can reduce fall rates by 14%. Fall prevention interventions were related to the physical environment, care process and culture, and technology. Further research is needed regarding room design and flooring. Graham (2012) summarized current evidence regarding interventions to prevent inpatient falls. Four areas of fall prevention identified were medication review, environmental aids, fall teams, and technology. Further research was recommended regarding video surveillance monitoring. Godlock, Christiansen, and Feider (2016) used a FOCUS-PDCA model to establish a fall safety team that responded to falls, completed the post-fall assessment checklist, and made recommendations to frontline staff based on their findings. These processes provided consistency and confirmed day-to-day practice for fall prevention. This 176

project decreased the fall rate from 1.90 falls/1,000 patient days to 0.69 falls/1,000 patient days. Engagement of patients and families in patient safety measures, including fall reduction, has aligned with federal programs and initiatives (U.S. Department of Health & Human Services, 2014). Incorporating patient feedback into fall reduction practices and including the patient in rounds at the bedside are essential to achieve patient engagement in the fall reduction interventions (Hicks, 2015). A meta-analysis by the American Medical Directors Association for 2000-2009 examined effectiveness of interventions in preventing falls in older adults (Choi & Hector, 2012). Included in the analysis of 227 studies were 17 randomized controlled trials that researched interventions to reduce falls. These studies documented 14% reduction of falls but with substantial heterogeneity among multifactorial interventions. Three characteristics of fall prevention interventions were related to the physical environment, care process and culture, and technology. Recommendations were to identify risk for fall, determine predisposing factors for fall including fall history, provide interventions to increase balance and lower extremity strength, consider patient self-imposed restrictions on activity, and classify injuries based on the International Classification of Diseases. Fall toolkits have been used to implement comprehensive programs to reduce falls and injuries (AHRQ, 2013; Boushon et al., 2012; Degelau et al., 2012; U.S. Department of Veterans Affairs [VA], 2015). An analysis of existing fall toolkits was conducted for this project. Of particular note was the AHRQ (2013) toolkit that identifies 22 evidence-based practices. Ten practices were classified as having sufficient evidence for adoption: analysis of the causes of falls, universal fall precautions, standardized risk assessment, care plan development based on risk assessment, education of the patient and family, post-fall huddles, incorporation of

specific best practices from specialties, measurement of fall rates, identification of high-risk medications, and interprofessional involvement in the change with incorporation of specific best practices based on diagnostic categories. Identified best practices were one-to-one nursing on select patients with every-15minute rounding in geriatric-psychiatric units, interprofessional plan of care for rehabilitation, pharmacy review of medications, and physical therapy consult for medical patients. Based on the data analysis by AHRQ (2013), these practices were most effective in affecting change. The VA National Center for Patient Safety toolkit (VA, 2015) was designed to prevent injury due to falls, promote safe use of technology, and promote a culture of safety to support clinicians providing safe patient handling. Decades of research have focused on interventions to prevent falls. Most studies provided insufficient statistical review or expert opinion. As a result, strong empirical evidence is lacking to identify interventions demonstrating the greatest impact on falls. The literature supports continued research to reduce incidence of fall-related injuries through multifactorial interventions (Degelau et al., 2012; Graham, 2012; Trepanier & Hilsenbeck, 2014).

Continuous Quality Improvement (CQI) Model The Rush Way CQI model used for this project is based on the Lean Six Sigma methodology as well as recognition CQI begins with a clear vision of the transformed environment, identification of necessary changes to achieve that vision, and input from engaged team members who understand the needs for the practice (Clark, Silvester, & Knowles, 2013). Steps in the model include becoming ready, understanding the process, determining opportunities for improvement, completing ongoing data collection, and holding the measurement of desired outcomes. Throughout the project, as improvement processes required modification, changes were based on

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Fall Reduction and Injury Prevention Toolkit: Implementation on Two Medical-Surgical Units

TABLE 1. Falls with Injury per 1,000 Patient Days Study Unit

1Q12

2Q12

3Q12

4Q12

1Q13

Year 2013

1

0.43

0.40

1.23

0.00

1.27

0.94

2

0.77

0.00

0.38

0.00

1.17

0.68

Q=Quarter

sound evidence from the data collected (National Learning Consortium, 2015). The Injurious Fall Prevention Organizational Self-Assessment Modified for Medical-Surgical Units was useful as a framework for quality improvement to identify areas for improvement within the organization (AHRQ, 2013; Quigley & White, 2013). The objective tool can guide the team to develop further process and outcome measures.

Improvement Needs/ Group Oversight In examining organizational fall data, the Quality Improvement Committee noted two medical-surgical units had fall rates greater than the National Database for Nursing Quality Indicators (NDNQI) mean for 2012-2013 (0.3/1000 patient days). These units were not meeting performance goals for falls, which were to be under the expected mean for like hospitals and within a lower percentile of similar hospitals (NDNQI, 2013). The rate of falls without injury per 1,000 patient days was consistently in the 90th percentile of similar hospitals, indicating 90% of reporting organizations with similar units had a lower fall rate than the project site. See Table 1 for 2013 means. Initial efforts for this project included a thorough analysis of previous falls to identify event trends. On unit 1, 81 falls were documented in 2013. Falls from bed had the highest frequency (40%, n=73), followed by falls related to toileting or commode usage (27%, n=22). Although staff members were educating patients to ask for help, patients did not always call and often fell. Four falls also occurred when family

members assisted patients with toileting instead of seeking staff assistance. On unit 2, 54 falls were documented. Of 38 falls related to toileting (70%), seven involved injuries (six minor, one major). The patients were attempting to toilet unobserved or had difficulty getting to or from the toilet. The goal for fiscal year 2014 for the institution was to implement an improvement plan to reduce falls with injury to meet the NDNQI benchmark (less than 0.14 falls/1,000 patient days) (NDNQI, 2013). Past practices on the patient care units included the use of the Schmid Fall Instrument for assessment of fall risk (Schmid, 1990). Universal fall prevention measures for all patients, a generic care plan through the electronic medical record (EMR) with interventions identified for patients at medium or high risk for falls, and use of bed alarms for patients at high risk for falls were the standard interventions. New practices included use of an interprofessional fall team, floor mats and low beds, teach-back of families and patients, and appropriate equipment with documentation of mobility on the communication board.

Setting The fall toolkit was implemented at a 664-bed academic medical center in Chicago, IL. The hospital serves adults and children, including persons requiring rehabilitative care for short-term or long-term disabilities. Unit 1 is a 32-bed neurology/neurosurgery medical-surgical unit. Unit 2 is a 32-bed general medical unit. The hospital opened a new patient care tower in 2012 based on an innovative architectural design

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to promote patient-centered care. While the design met the goal of providing patient-centered care, it seemed to impede use of best practices for fall reduction. For example, rooms are 50 feet apart and not visualized easily. After the new tower opened, an analysis was conducted to determine if any environmental variables contributed to the increase in falls; no statistically significant correlations were found.

Quality Indicators and Data Collection Major outcome indicators for this QI project were falls with and falls without injury per 1,000 patient days. The project objectives were to: • Implement a fall reduction toolkit to incorporate fall reduction strategies into practice. • Improve staff knowledge of fall reduction measures, particularly those to reduce injury, as evidenced by test score greater than 90%. • Reduce falls with injury to less than 0.3 per 1,000 patient days on study units. • Reduce falls without injury on study units to less than 3.4 per 1,000 patient days. Fall data were collected systematically by completing a handwritten Post-Fall Huddle Form with interprofessional participation; information was entered electronically into the safety event form by the clinical nurse who cared for the patient. Data on fall rates were extrapolated from the NDNQI registry, a requirement for Magnet® organizations. This process was continued during the toolkit implementation.

Evaluation and Action Plan Action Plan The Injurious Fall Prevention Organizational Self-Assessment Modified for Medical-Surgical Units (Quigley, Barnett, Bulat, & Friedman, 2016; VA, 2015) was completed by key stakeholders (vice president of nursing, associate vice presidents of 177

Continuous Quality Improvement nursing, unit managers, fall team leaders) to determine organizational readiness for prevention of falls with injury. The purpose of the questionnaire was to determine key attributes of hospital fall injury programs. Findings helped identify strategies needed to build organizational infrastructure and capacity for meeting project objectives. Specific strategies included unit leader rounding to prevent falls and reduce injuries, and to generate more detailed analysis of fall events. Based on deficiencies in practice at the medical center, key elements were incorporated into toolkit development (Williams et al., 2014). Based on the meta-analysis by Trepanier and Hilsenbeck (2014) of success of other such toolkits over 50 acute care hospitals in 11 states, this toolkit came to fruition. Staff on project units first completed an analysis of strengths, weaknesses, opportunities, and threats related to falls. These analyses allowed managers and clinical nurses to determine actionable issues. The program toolkit used educational programs and leader support, and included fall team member audits to ensure implementation. The project director provided a fallspecific standard of care audit tool. The process for implementing the fall toolkit was planned over a year, and implemented within 6 months. Promotion included use of Call Don’t Fall signs in patient rooms, Fall No More buttons, and 10 Steps to Keep Your Patient Safe. Content validity for the fall knowledge test and audit tool was determined by educational and clinical nurse specialists with knowledge of fall prevention and with 10 years’ experience in nursing. Inter-rater reliability for the audit tool was established with members of the fall team. The project director and staff champions conducted concurrent audits of patients to determine inter-rater reliability at 0.95. The project director posted reminders to support adherence. Audits of staff adherence were completed by the fall team and results were shared with all staff. 178

Opportunities for interprofessional education were addressed by the project director at various department meetings. Staff from physical therapy, occupational therapy, pharmacy, electroencephalography, and transportation received information about the fall program and components of the toolkit. They were educated about their responsibility in helping to reduce falls by the project director. Ongoing education was provided to staff in quarters 1-4 through 30minute monthly programs. Educational program content included a fall fair with participant demonstration of gait belt and transfer techniques, review of fall reduction technology (e.g., rounding), and identification of medications that may contribute to falls in older adults. A staff-created video depicting effective patient rounding by assistive personnel and nurses was used for implementation of the rounding initiative. Completion of rounding was documented on forms near the doorway to communicate process completion as staff left the room. The interprofessional post-fall huddle included patients and families. Audit data were collected by unit fall team members and presented to staff to increase awareness of numbers and types of falls. The audit tool was similar to the audit tool within the AHRQ (2013) toolkit with some minor modifications for the organization.

receiving anticoagulants, interventions such as a patient education brochure adopted from the VA (2015) were instituted to reduce the risk of an injurious fall. Among methods to reduce injurious falls were using appropriate transfer method with gait belt, bedside commode, and floor mat with low bed. All patients and families were educated about fall risk and prevention using the teach-back method. Progress with the QI project was reported at the Fall Oversight Committee and staff meetings. Fall and injury events were tabulated by the NDNQI data collector from safety events. These safety events were filed electronically by staff, then added to the NDNQI registry as part of the usual process for fall data collection.

Evaluation

Limitations

Audits were performed monthly on the units to review consistent implementation of elements within the fall toolkit (AHRQ, 2013). If staff members were nonadherent to the standard of care on the audit, email or live feedback from fall team members was given to the staff. One component of the audit was determining if bleeding precaution signs were displayed on doors of patients receiving anticoagulants. In addition to a bleeding precaution door sign, an anticoagulation banner was added in the EMR for these patients so all staff were aware they were at risk for injury. For patients

Preventing Falls in Hospitals: A Toolkit for Improving Qua...