Improving Quality by Reducing Harm From Falls: Success Stories From the Field
One of the safety hazards facing patients, families, providers and hospital administrators is the possibility of patients falling while receiving care on medical/surgical units in hospitals. Thankfully, few falls in hospitals result in harm, defined by the National Quality Forum as minimal, moderate, major injury or resulting in death.
Falls that cause moderate or major injury do, however, have the potential to reduce a patient's mobility, decrease independence, extend hospitalization and increase the reliance on long-term inpatient care.
The Robert Wood Johnson Foundation (RWJF) and the Institute for Healthcare Improvement (IHI) are collaborating with multidisciplinary teams at nine hospitals to understand what causes falls resulting in harm, and to design and test strategies to reduce such adverse events.
According to Rosemary Gibson, RWJF senior program officer, "Patients can suffer significant harm from falls that occur while they are hospitalized. RWJF's work in this area is helping nurses at the bedside reach new levels of harm reduction, which is good for everyone-patients and their families, nurses and hospitals."
Currently, most hospitals in the United States have a system in place to screen a patient's risk for falling at the time of admission. Many of the hospital teams participating in the project are adding a new level to that assessment, to screen for patients at risk for injury if they were to fall.
Barbara Boushon, R.N., B.S.N., IHI's director of the Reducing Harm From Falls project, explains that this work is an addition to existing falls-prevention programs and should not replace current assessments. "We hope this added component of injury risk assessment will help the entire care team identify patients that need supplemental interventions to prevent harm from a fall. In addition to identifying patients at risk and implementing appropriate harm-reduction interventions," says Boushon, "it is important to communicate this information between shifts and between departments.
Furthermore, this cycle of assessing, intervening and communicating is required continuously throughout the length of the patient's stay."
In the first six months of the project, teams and faculty identified populations most at risk for harm because of a fall—elderly patients (85 and older), patients with brittle bones (as a result of cancer, chemotherapy or osteoporosis), and patients with blood that is anti-coagulated. Having identified what is called the ABC patient populations (age, bones, blood-coagulation), the teams are now in the process of monitoring the rate of falls with harm.
In addition, the participating hospitals are implementing interventions that have demonstrated reductions in severe harm from falls when used in long-term care and rehabilitation inpatient settings. Each hospital also is encouraged to test emerging ideas generated by their review of past falls with harm, such as implementing toileting and comfort rounds to proactively assist patients with toileting needs.
The James Haley VA hospital in Tampa, Fla., is one of the hospitals on target to reach the project's goal of reducing harm from falls to less than one fall resulting in moderate or major injury, or death per 10,000 patient days. Patricia Quigley, Ph.D., M.P.H., is deputy director for the VISN 8 Patient Safety Center, which includes the James Haley VA. Quigley says leadership commitment is a major contributor to helping Haley reach the project goal.
"Once administrators realized that these efforts make a difference, they began prioritizing the resources staff need to prevent falls altogether," she says. For example, the James Haley VA now uses hip protectors to distribute the impact of a fall for patients with osteoporosis. They also use height-adjustable beds to lessen the distance to the floor, and floor mats to soften the impact should a patient fall from the bed to the floor. These interventions are used in combination, an example of a multifaceted approach to preventing serious injury.
"We recognize the importance of providing our care team with the resources necessary to modify and eliminate those variables that can be changed," says Quigley. "We have to help frontline providers recognize who is at risk for fall-related injuries and make sure they have the ability to prevent a fall when possible, but most importantly, use proven interventions to lessen the impact of any potential falls."
With this level of commitment from leadership, the James Haley VA is launching a health literacy program to educate patients on their risks while staying at the hospital. After the provider describes how the patient can help the care team prevent and protect against falls, they ask the patient to communicate back to the provider what they heard. Since beginning the use of this "teach back" method, teams are finding that patients and families are more engaged and empowered to be part of their own care.
Iowa Health System, another team on track to reach the project's harm-from-falls reduction goal, also is using the "teach back" method. The system's clinical performance improvement education administrator, Gail A. Nielsen, B.S.H.C.A., who also serves as project director, agrees that including the family in these discussions about risk is essential.
She also highlights the importance of reliable, direct patient care procedures. "When we all do these things in the very same way every time, the entire team and each individual provider gets better at it, making our care processes more reliable." Nielsen provides an example:
Before a system was put in place to identify patients at risk and prevent them from falling, individual nurses would be responsible for recognizing at-risk patients. That nurse would then have to run around looking for the appropriate prevention resources. Because of the tremendous workload of nurses, sometimes not all of the available falls interventions for high-risk patients were put into place.
Now when a patient is admitted to the hospital, they are screened for fall risk factors using a standard, reliable and validated assessment tool. As soon as the assessment is completed, the nurse has access to a packet that contains prevention information and visual markers, such as an alert coded wristband, a tag to put on the patient's door, bed and chart, and a personal alarm. Nurses no longer worry about being interrupted while locating all of the prevention materials or depending solely on their memory to ensure a safe environment for at-risk patients. They have a reliable system in place to support their safety efforts.
As part of the Iowa system's prevention strategy, teams are developing procedures that help nurses intervene before an adverse event occurs. For example, communicating a patient's risk for injury is becoming an integral part of the standard handoff between shifts, and between the unit and other areas where patients may have diagnostic or treatment procedures. Expecting everyone on the care team throughout the hospital to be responsible for reducing risks creates a culture of safety and highlights the importance of multidisciplinary solutions to quality improvement challenges.
The Reducing Harm From Falls project continues to evaluate the success of falls prevention interventions. Hospitals are finding that components of a harm-reduction program-such as focusing on identifying patients at risk for harm upon falling, engaging leadership and creating a culture of safety- work together to prevent patients from getting hurt while being cared for in a hospital.