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Prevention of falls is an issue of concern for all hospitalized patients. Certain units, however, may be at higher risk for falls due to patient diagnosis, comorbidities, and other intrinsic factors. Creation of a unit-specific fall-prevention program may be more effective at reducing incidence of falls in the adult orthopaedic inpatient setting. It may also be better valued by staff according to a critical analysis of the literature and staff survey of perceptions. This information was used as a starting point to create a template for a unit-based fall program specifically for high-risk units. The evidence from this analysis could be used to identify high-risk units and adapt existing generic fall-prevention programs to this higher risk population.
Falls are not only of issue in the community setting but also of special concern for the acute setting. Hospitalized patients are at an increased risk for falls related to unfamiliar environment, diagnosis, procedures, and comorbidities. Falls can be frustrating for bedside nurses as they seek to keep patients safe while also accomplishing daily tasks and goals. Patients at risk for falls require more frequent observation and nurses often are liable when patients do fall. This can lead to decreased nursing satisfaction related to job performance and expectation (Tzeng & Yin, 2008). Falls in the acute care setting increase length of stay, increase patient care costs, and account for the majority of reported adverse incidents in hospitalized patients (Kerzman, Chetrit, Brin, & Torin, 2004). The incidence rate may range from 1.1 to 7 falls per 1000 patient days, depending on the literature reviewed (Cameron et al., 2005).
The Joint Commission has recognized the issue of fall assessment and prevention in its list of goals since 2005 and continues to focus on prevention (2007, 2008). The Centers for Medicare and Medicaid Services, in 2008, identified 10 conditions they called hospital-acquired conditions (HAC), falls, and trauma, and these were included on this list. The impact for hospitals was that they would not receive additional reimbursement for falls that occurred while hospitalized (Centers for Medicare and Medicaid Services, 2010). In response, hospitals have developed systems for risk assessment and fall tracking and implemented various prevention programs.
The tracking of falls is both an important and necessary task for nursing. It is sometimes difficult to compare fall rates because of the variation in tracking methods and the definition of a fall itself. Falls may be tracked per 1000 days, per 1000 admissions, fall risk, falls per bed, etc., with each institution determining how they will track and define a fall (Premier Inc, 2007). To remain accredited, hospitals are expected to implement some type of fall-prevention program (Hook & Winchel, 2006). Tracking falls along with fall risk may help to illustrate whether an intervention program has an effect. Researchers for one study concluded that "existing data collection and data storage systems enhance their ability to complement current fall-prevention strategies" (Kerzman et al., 2004, p. 10). Databases that can correlate and track falls along with risk can provide valuable input regarding prevention (Hannah, Ball, & Edwards, 2006). According to Hannah et al. (2006), data gathering should be used to make nursing decisions about patient care. By assessing patients at risk and not tracking these data, facilities lose an essential piece of the puzzle concerning in-patient falls. Many facilities, including the one examined, utilize the National Database of Nursing Quality Indicators. By using the information garnered from tracking falls, fall-prevention programs can be continually evaluated for effectiveness, improvements can be made, and information sharing can occur.
Assessing patients for risk of fall is the first step in reduction. A literature search showed that various tools are available for fall risk assessment and no one tool has been shown to have greater predictability or specificity (Dempsey, 2008). Usually hospitals adopt tools based on ease of use and appropriateness to setting (Hayes, 2004). All inpatients should be screened for fall risk; however, the effectiveness of prevention programs postassessment is also an important issue.
Much research has been gathered related to risk factors and falls. According to the Joint Commission, falls may have either an intrinsic factor (related to patient condition) or an extrinsic factor (environment). Extrinsic factors such as flooring, furnishing, room layout, and location of nursing stations may not be as easily modifiable as ensuring that patients are wearing appropriate footwear and utilize assistive devices. Intrinsic factors such as age-related changes, chronic illness, mental status, and acute illness may be modified by screening as implementing direct interventions related to such factors (Tzeng & Yin, 2008). Risk factors that have been identified related to falls include mobility issues, reduced vision, medications, incontinence, previous fall, and impaired mental status (Hitcho et al., 2004; Lane, 1999). Hitcho and colleagues also suggest that modifiable risk factors, that is, mobility and elimination patterns, may contribute to falls more than other factors. Hitcho also states that age greater than 65 years (often highlighted as a risk factor for falls) should not be used to exclude patients younger than 65 years as being without risk (Hitcho et al., 2004). Studies have also focused on identifying and addressing intrinsic issues such as laboratory values, such as hemoglobin, international normalized ratio, albumin, white blood cell count, and urinalysis as a way to reduce fall risk (Frels, Williams, Narayanan, & Gariballa, 2002). Older patients with urinary tract infections may be prone to falls as they are linked to increased confusion. Abnormal laboratory values such as low hemoglobin may predispose a patient to dizziness. It is important to recognize and report abnormal values as prompt treatment will help to aid in reducing risk and also reduce injury if a fall does occur.
Some inconsistency exists in the literature regarding what risk factors predispose a patient to falling, but most institutions use some combination of those highlighted in the literature (O'Hagan & O'Connell, 2005). Even though it is imperfect, risk assessment still impacts patient safety. Risk assessment, however, is useful only if there is a feasible and appropriate prevention program in place (Williams et al., 2007).
Based on the available information regarding fall risk factors, certain units have been identified as being at increased risk for falls. Hospital units most frequently cited are oncology, medical-surgical, geriatric, and psychiatric (Jeske et al., 2006, Oliver, 2004). The use of modified prevention programs to address the needs of these high-risk units is supported by the literature and would seem prudent (Oliver, 2004).
A review of the literature revealed that multi-interventional, multifaceted, or multidisciplinary prevention programs show some difference in fall rate reduction (Oliver et al., 2007). One study that addressed the needs of orthopaedic patients and falls was related to femoral neck fractures and the postoperative period (Stenvall et al., 2007). The article focused on elderly postoperative hip fracture patients versus the needs of the general orthopaedic population. Specific emphasis on the reduction of postoperative complications was utilized as a method for fall reduction.
A study conducted in North Carolina indicated that multi-interventional approaches, along with interdisciplinary approaches, may affect outcomes favorably, but screening may be more easily modified (Colon-Emeric et al., 2006). The literature acknowledges that nursing may have the greatest impact on fall prevention. In a study by Healy, Monroe, Cockram, Adams, and Heseltine (2004), a nursing-led fall program resulted in a 22% reduction in falls. Coussement et al. (2008) conducted a systematic review and meta-analysis and findings appear to be consistent with the consensus that unifactorial programs may not be as effective as multifactorial programs. One interesting note was that although the interventions might have been nursing driven for many of the multifactorial programs, involvement of a multidisciplinary team approach seemed to be a common theme (Coussement et al.).
During the 2006-2007 time period, the orthopaedic surgical unit, in a 181-bed community hospital, had seen an increase in fall rates. The facility utilized the NDNQI database and for this time period the fall rate ranged between 3.67 and 5.18 for the four quarters, with the benchmark being 2.78. The 32-bed orthopaedic-surgical unit primarily handled scheduled postoperative joints and spinal patients. Patients with emergency fractures, intractable pain, and pain management may also be admitted to the unit along with stable progressive care and intensive care transfers. Patients' ages range from 18 to 100 years, and patient-to-nursing ratio was 6:1. Multiskilled technicians usually assist nursing with patient care, and their number is driven by unit census.
Orthopaedic patients may be at higher risk for falling due to factors identified in the literature, such as medications, mobility, and advanced age (Kerzman et al., 2004). Most patients on the unit have mobility issues and are on benzodiazepines, narcotics, possibly epidural, and intrathecal pain medication infusions, and some may have confusion or overestimate their ability. In the orthopaedic setting where early ambulation can decrease postoperative complications like ileus, thromboembolism, and deconditioning, nurses are often challenged with how to encourage ambulation while ensuring patient safety. A fall or history of frequent falls can create fear of falling, which can lead to anxiety for both patients and nurses leading to a decrease in their participation with mobility activities (Visschedijik, Achterberg, Van Balen, & Hertogh, 2010).
The hospital utilized a generic fall-prevention program on all of the inpatient units, regardless of patient type. The existing fall program involved handouts, patient identification by colored band, use of the Morse scale, frequent observation by nursing, and the use of beds with self-contained bed alarms. Handouts related to fall prevention were included in admission packets and no scripting existed in relation to informing patients or families about the handouts. There was no formalized language during hand-off in relation to patient fall risk and identification other than placing a magenta band on the patient's wrist.
To evaluate the effectiveness of the existing program and perception of problem from a staff perspective, a voluntary web survey was created. Fifteen questions focused on existing data, current program, and workflow improvement (Appendix A). The survey was distributed to staff members on the orthopaedic unit via a website after approval by the unit director. Staff logged in anonymously. Those who participated in the survey's identity were unknown to both the author and management staff and no incentive for participation was provided.
Twenty-one out of 34 staff members participated in the survey. The nursing staff was equally divided in terms of experience with 45% having 3 years or less experience and 50% having more than 10 years' experience, with only 5% stating that they had 3-5 years' experience. The majority of those surveyed reported that they were registered nurses, with 15% of the staff reporting that they were either multiskilled technicians or licensed practical nurses. Staff reported spending about 50% or more of their time involved in direct patient care.
Specific questions related to fall prevention and risk assessment revealed that 100% of the staff felt that falls were an issue of concern and that certain units might have more frequent falls. Survey respondents were asked to rate the orthopaedic unit in comparison with other units in order to determine whether the staff felt that certain units could be stratified according to risk. This stratification of staff perception in relation to unit is illustrated in Appendix B. The orthopaedic staff rated their unit high regarding the level of risk. According to the survey, staff felt that a unit-specific program might be more effective. A total of 63% of the nursing staff surveyed felt that the current program was inadequate, with 41% answering that they only felt they had an "adequate" level of knowledge regarding the existing program. This, however, may be attributed to the number of staff with less than 3 years' experience. A total of 86.7% of the nursing staff surveyed thought that a tool to highlight what steps to initiate would be useful and 100% of the staff that responded felt that a handout for patient's families was needed.
Based on the increase in the fall rate and the staff responses to the voluntary web survey, the question of whether there was valid evidence to support the creation and implementation of a unit-based fall-prevention program arose. The purpose of this fall-prevention program would be to provide a list of interventions, increase awareness of the issue, and stratify the program based on level of fall risk.
The current fall program involved handouts, patient identification by colored band, use of the Morse scale, and frequent observation by nursing. Although the program used was similar in some ways to those described by the literature, it could be improved. An individualized approach and improving identification regarding patients at risk would be more effective based on the research regarding difference in fall rate related to unit composition. The current method of identifying patients by wristband alone only alerts those ambulating the patient, and confused patients often remove bands. A falling star sign on the door was introduced to identify patients at risk. All the studies suggested that comprehensive staff education regarding falls was an important part of reducing incidence. The current fall-prevention program was discussed during initial orientation, but nursing was responsible only for banding the patient, putting a magenta dot on a handoff form, and checking on the initial admission form that the patient was given the fall-prevention packet. There was very little discussion about how fall rates can be improved and most staff members do not know the fall rate for the unit. By using the knowledge gained from current evidence and initiating a program tailored to the needs of high-risk units, it was theorized that the fall rate could be decreased.
Based on analysis of the literature and the results of the web-survey, a unit-specific nurse-driven program would appear to be more effective at fall prevention and may increase staff satisfaction. A checklist tool was developed to highlight what safety steps should be initiated to standardize interventions. Also, based on survey answers regarding improving patient and family education and collaboration regarding falls, the creation of a handout would be needed to specifically address family collaboration.
The fall-prevention program currently in place on the orthopaedic unit is a general program that has been instituted throughout the hospital. According to the existing evidence, certain units have higher risk and for a fall program to have an effect on fall rates continuing education especially on high-risk units is imperative (Oliver, 2004). Research has shown that certain units, specifically psychiatric, oncology, orthopaedic, neurology, and geriatric units, have higher fall incidences (Kerzman et al., 2004). Based on the literature review, a program tailored to meet the needs of a high-risk unit would decrease falls on the adult orthopaedic unit. Implementation of a high-risk unit-specific program would entail that nurses on the orthopaedic unit continue to identify patients at risk for a fall using the Morse scale. However, the new fall-prevention program would involve stratification of patients and use of a checklist to guide nurses in selecting appropriate interventions.
A comprehensive educational program for staff regarding fall risk, prevention, and initiation of the new program via in-services for all shifts, web-based learning, and continuous feedback would be the most effective way to disseminate the information. Visual tools and cues for both staff and patients would have to be implemented. A checklist tool would highlight what specific safety steps staff should be initiating and improve compliance to the new program. Appendix C, Table 1 highlights the suggested objectives and methods for the new fall program fall-prevention program's details, and Appendix D shows tools that can be used to stratify patients at risk, along with a list of standardized interventions for each level of risk. The new program would also benefit from the creation of a database that tracked patients who were categorized at risk along with actual fall incidence. The effectiveness of the new program could then be evaluated by comparing these two data sets.
Success of the new program will involve utilizing the current assessment tool and using the new program to improve workflow, by providing guidance regarding specific safety interventions. However, the new process should not create a burdensome workload or it will not be sustainable (Dempsey, 2004). Key to implementation of the new practice will be the involvement of nursing in the change process. The web survey regarding fall prevention facilitated an atmosphere of open dialogue that allowed the nurses to reflect on their current practices. Myers and Meccariello (2006) state that the first step of implementation is having staff identify, discuss, and recognize clinical issues that may be improved through evidence-based practice. Strong leadership and the development of a facilitator or facilitators of information regarding the new program will be key to normalization of the process (Stetler, Ritchie, Rycroft-Malone, Schultz, & Charns, 2007).
The facilitator of the program should begin the implementation process through a series of educational in-services. These in-services should include all staff on all shifts and be divided into two different sessions. Initial sessions should focus on fall prevention and identifying patients at risk through stratification. Additional sessions should review the new program and solicit areas of improvement. The ideal time for educational sessions should occur during down periods in the shift and not be scheduled during medication rounds or peak discharge/admission times. These in-services should provide a background of information for nursing regarding the issue and facilitate acceptance of the new program.
The next step in the process should be the actual implementation of the new program. Use of visual tools, patient placement, and improving compliance regarding bed alarm use should be focused on. Bed alarms alone cannot prevent falls, but they have been shown to assist in fall reduction when used as a component of a multifactorial fall-prevention program (Emergency Care Research Institute, 2004). Currently the institution has beds in place that have bed alarms, and the use of the bed alarm might be facilitated by a visual tool for staff or a round table discussion regarding compliance. Focus on improving current workflow through existing resources will be the objective of this step in the process.
Implementation of a new practice in the institutional setting can be a difficult challenge. According to Lewin's theory regarding change, institutional behavior is based on equilibrium, of resisting and driving forces (Hannah et al., 2006). Driving forces regarding the proposed fall-prevention program are increased patient safety, and an institutional goal of increased use of evidence-based practice. Resisting forces that will need to be overcome are a fear of change. Increasing knowledge, addressing cultural attitude, and involving nursing in the implementation process will facilitate a smoother transition to the new program (Hannah et al., 2006).
Institutional support during the process will be critical to the program's success. If nursing evaluates and facilitates proposed changes, willingness to institute and sustain the new changes will increase (Carey, Buchan, & Sanson-Fisher, 2008). To accomplish this, a cyclical system of evaluation and reevaluation needs to take place on the basis of two conditions, patient safety and nursing satisfaction. Appendix E illustrates the flow of evaluation, feedback, and primary goals needed to make the new program sustainable.
The new program should use a database that tracked patients at risk along with actual incidence and compare the two for evaluation purposes. The initial admission intake includes risk assessment for falls. The tracking and comparison of the two data sets would require no change in current admission practice since the information is already being collected. Along with comparing the two data sets, staff needs to have the ability to make suggestions regarding their perceived effectiveness of the program. This can be done two ways, via traditional suggestion box located in a secure staff area or through an ongoing anonymous web format. The web format would allow open-ended comments along with questions aimed at obtaining empirical data regarding the new program. The data related to falls should also be displayed in a common area so that staff is aware of current trends and the fall rate. Postfall huddles should occur so that staff can reflect on best practices and also have real-time education regarding falls.
The evidence in the literature indicates that programs tailored to the needs of patient population have more impact on fall incidence than general programs, this holds especially true for high-risk units. Staff awareness and ongoing education regarding falls appear to facilitate the most change. However, because falls are best addressed through a multifactorial approach, physical environment and physical status cannot be overlooked. Interventions must be created that encompass all facets of care and ways must be sought to overcome barriers to implementation (Oliver et al., 2007). Although a goal of zero falls may not be feasible, we can improve our existing systems through the use of evidence-based practice and improved workflow, so patients can have the safest stay obtainable.
Cameron I., Murray G., Gillespie L., Robertson M., Hill K., Cumming R., Kerse N. (2005). Interventions for preventing falls in older people in residential care facilities and hospitals (Protocol). Cochrane Database of Systematic Reviews, Issue 3. Art. No.: CD005465. DOI: 10.1002/14651858.CD005465, pp. 1-10. [Context Link]
Carey M., Buchan H., Sanson-Fisher R. (2008). Cycle of change: Implementing best-evidence clinical practice. International Journal for Quality in Health Care, 21(1), 37-43. [Context Link]
Centers for Medicare and Medicaid services. (2010). Hospital acquired conditions (present on admission indicator) (Inpatient prospective payment provision). Washington, DC: U.S. Department of Health & Human Services. [Context Link]
Colon-Emeric C., Schenk A., Gorospe J., McArdle J., Dobson L., DePorter C., McConnell E. (2006). Translating evidence-based falls prevention into clinical practice in nursing facilities: Results and lessons learned from a quality improvement collaborative. Journal of American Geriatrics Society, 54(9), 1414-1418. [Context Link]
Coussement J., De Paepe L., Schwendimann R., Denhaerynck K., Dejaeger E., Milisen K. (2008). Interventions for preventing falls in acute and chronic care hospitals: A systematic review and meta-analysis. Journal of the American Geriatrics Society, 56(1), 29-36. [Context Link]
Dempsey J. (2004). Care of older people falls prevention revisited: A call for a new approach. Journal of Clinical Nursing, 13(4), 479-485. [Context Link]
Dempsey J. (2008). Risk assessment and fall prevention: Practice development in action. Contemporary Nurse, 29(2). Retrieved June 29, 2008, from http://www.contemporarynurse.com/archives/vol29/issue2/article/2370[Context Link]
Emergency Care Research Institute. (2004). Bed exit alarms: A component (but only a component) of fall prevention. Health Devices, 33(5), 157-168. [Context Link]
Frels C., Williams P., Narayanan S., Gariballa S. (2002). Iatrogenic causes of falls in hospitalised elderly patients: A case control study. Postgraduate Medicine Journal, 78, 487-489. [Context Link]
Hannah K., Ball M., Edwards M. (2006). Health informatics (3rd ed.). New York, NY: Springer-Verlag. [Context Link]
Hayes N. (2004). Prevention of falls among older patients in the hospital environment. British Journal of Nursing, 13(15), 896-901. [Context Link]
Healy F., Monroe A., Cockram A., Adams V., Heseltine D. (2004). Using targeted risk factor reduction to prevent falls in older in-patients: A randomised controlled trial. Age and Aging, 33, 390-395. [Context Link]
Hitcho E., Krauss M., Birge S., Dunagan W., Fischer I., Johnson S., Nash P., Costantinou E., Fraser V. J. (2004). Characteristics and circumstances of falls in a hospital setting. Journal of General Internal Medicine, 19, 732-739. [Context Link]
Hook M., Winchel S. (2006). Fall related injuries in acute care: Reducing the risk of harm. Medsurg Nursing, 15(6), 370-377. [Context Link]
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The Joint Commission (2007). National Patient Safety Goal 2008 [Data File]. Retrieved from http://jointcommision.org
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Kerzman H., Chetrit A., Brin L., Torin O. (2004). Characteristics of falls in hospitalized patients. Journal of Advanced Nursing, 47(2), 223-229. [Context Link]
Myers G., Meccariello M. (2006). From pet rock to rock-solid: Implementing unit-based research. Nursing Management, 31(1), 24-29. [Context Link]
O'Hagan C., O'Connell B. (2005). The relationship between patient blood pathology values and patient falls in an acute-care setting: A retrospective analysis. International Journal of Nursing Practice, 11, 161-168. [Context Link]
Oliver D. (2004). Prevention of falls in hospital inpatients. Agendas for research and practice. Age and Aging, 33(4), 328-330. [Context Link]
Oliver D., Connelly J., Victor C., Shaw F. E., Whitehead A., Genc Y., Vanoli A., Martin F., Gosney M. A. (2007). Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: Systematic review and meta-analysis. British Medical Journal, 334(7584), 82-87. [Context Link]
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Stetler C., Ritchie J., Rycroft-Malone J., Schultz A., Charns M. (2007). Improving quality of care through routine, successful implementation of evidence-based practice at the bedside: An organizational case study protocol using the Pettigrew and Whip model of strategic change. Implementation Science, 2(3). [Context Link]
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For more than 30 additional continuing education articles on geriatric topics, go to http://nursingcenter.com/ce.
1. How many years have you worked in the hospital setting?
0-3 years, 3-5 years, 5-10 years, more than 10 years
2. Select your job title.
MST/support staff, LPN, RN, Management, Other
3. How much of your time is spent providing direct patient care?
None, 25%, 50%, 75%, 100%
4. Do you feel falls are an important concern in the hospital setting?
5. Part 2 If yes: Do you feel falls occur more frequently on certain units?
6. Based on the previous question, what do you feel is the level of risk regarding falls per unit listed below. Use the following: No Risk, Low Risk, Moderate Risk, High Risk
Emergency Room, ICU, PCU, Trauma, Pulmonary, Cardiac, General Med/Surg, Oncology, Orthopaedic, Pediatric, Obstetrics, NICU, Mental Health
7. Do you feel that a unit-specific fall-prevention program might be more effective than a generalized fall program?
8. Do you think that tracking patients at risk for a fall in a database would be helpful?
9. Do you feel the current program for assessing risk for a fall and prevention strategies are adequate?
10. How would you rate your level of knowledge regarding the hospital's fall risk assessment and prevention program?
I am an expert, I feel comfortable, Adequate, I would like to know more, No knowledge
11. When a patient is identified as being at risk for a fall, which of the following do you do? Check all that apply.
Color band/ID chart and patient
Give fall precaution packet or handouts
Verbal patient/family teaching
Involve patient's family in safety planning
Place near nursing station
Set bed alarm
Identify patient to staff
Other (please specify)
12. Do you feel the fall-prevention program should incorporate more teaching and collaboration with patient's family?
13. If you answered yes to the above question, which is your preferred method of teaching for family?
14. Would a stratified identification system for fall prevention be more effective? Example: low risk, moderate risk, high risk
15. Would a tool that highlighted what steps to initiate on the basis of the above categories be helpful?
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