strategies to implement in St. Joseph hospital targeting the reduction of falls and associated injuries

 strategies to implement in St. Joseph hospital targeting the reduction of falls and associated injuries

Falls and fall-associated injuries are a major health problem in inpatient settings in the United States. Fall-related injuries range from abrasions and minor bruises to head injuries, fractures, lacerations, and sometimes death. The Center for Medicare and Medicaid Services restrains from reimbursing services resulting from hospital-acquired conditions such as injuries from falls. Fall reduction and prevention interventions are an essential part of quality improvement. A third of falls in inpatient settings are preventable, and prevention strategies require multidisciplinary support program adoption and implementation. However, despite the years of efforts, there is a lack of concrete evidence on falls and fall-related injuries reduction. Nurses play a central role in falls and fall-related injury prevention efforts. The Agency for Healthcare Research and Quality identifies falls and fall-associated injuries as a nurse-sensitive measure. The incidence of inpatient fall varies depending on unit characteristics and individual patients. St. Joseph Hospital Orange is a healthcare provider whose patient-centered care is based on its strong Catholic-based values. The focus of this project is to develop strategies to implement in St. Joseph hospital targeting the reduction of falls and associated injuries in the observation unit to add to the already existing strategies such as standardized risk assessments. The proposed interventions include the use of bed exit alarms to alert the nursing staff when a patient leaves the bed without assistance and patient education for new clinicians and patients on fall prevention practices.

Keywords: falls and falls-related injuries, patient-centered care, interventions, inpatients, and patient education.

Introduction

Falls in the hospital settings is a major health problem with adverse effects that range from abrasions and minor bruises to more severe outcomes such as head injuries, fractures, lacerations, subdural hematomas, excessive bleeding, and in some cases death (Cuttler et al., 2017). The Center for Medicare and Medicaid Services stopped reimbursing services resulting from hospital-related events such as injuries from falls (Moskowitz et al., 2020). In the United States, falls account for 85% of all hospital-acquired conditions and affect more than one million patients annually. In inpatient settings, falls and associated injuries are the leading reported adverse event in the adult population (Moskowitz et al., 2020). Approximately 3-20% of inpatients fall one or more times during their hospital stay, with 30-52% of those falls resulting in injuries (Moskowitz et al., 2020). The additional costs of a fall without serious injury are $3,500, with more than two falls without serious injuries, increasing additional costs to $16,500. The most costly is a fall with a severe injury with additional costs of $27,000 (Moskowitz et al., 2020). In light of these facts, several organizations have identified falls measurement as important to patient outcomes. Although not all falls are preventable, a third of them are and hospitals design interventions to prevent falls and associated injuries (Moskowitz et al., 2020).

A majority of fall and fall-related injury prevention strategies require multidisciplinary support for the adoption of the program and implementation for particularly vulnerable subpopulations, for example, medical-surgical inpatients or the elderly at risk for fall-related injuries (Moskowitz et al., 2020). The incidence of inpatient falls and injuries varies depending on unit characteristics, with patients in the observation unit at a higher risk than intensive care patients. The increased risk of falls is associated with medication side effects, frequent toileting, history of previous falls, and altered mental status in an unfamiliar environment (Cuttler et al., 2017).

The Patient Protection and Affordable Care Act (ACA) of 2010 through Partnerships for Patients encouraged acute care hospitals to test prevention strategies aimed at decreasing patient falls and associated injuries by 40% (Cuttler et al., 2017). However, according to the Agency for Healthcare Research and Quality (AHRQ), there was relatively no change in the number of hospital falls and still equaled the 2010 levels. Stakeholders, including patients at risk, healthcare workers, and researchers, find it discouraging that despite the years of efforts, there is a lack of significant injury reduction (Cuttler et al., 2017). Furthermore, some research studies show that fall prevention efforts may not be cost-effective.

Nurses play a critical role in enhancing the quality and patient safety in healthcare. Since nurses spend a large proportion of their time with patients, they are in an excellent position to monitor and mitigate risks and improve patient outcomes. Falls and injury prevention measures that focus more on the role of nurses potentially lead to safer, high-quality care, and better outcomes for patients (Quigley, 2013). Adopting fall and injury prevention as a nurse-sensitive measure taps into the potential of nurses in ensuring safe and quality care both at the patient and organizational levels.

Project Overview

St. Joseph Hospital Orange is a healthcare provider whose patient-centered care is based on its strong Catholic-based values. The hospital believes in the intrinsic dignity of each person and encourages its staff to provide holistic healthcare encompassing body, mind, and spirit (Providence, 2020). Also, the hospital collaborates with its medical and other healthcare providers to optimize patients’ access to quality care.

Established in 1929, St. Joseph Hospital serves residents of Orange County. It has 446 total staffed beds discharging approximately 19000 patients annually (American Hospital Directory, 2020)The hospital strives to provide high-quality care by the integration of best practices, investment in the latest technology, best available research, and responsiveness to community needs. St. Joseph Hospital operates under Providence; the ranked third among not-for-profit health systems in the U.S. Inline with the mission of Providence, the hospital serves the needs of the community guided by five core values: compassion, dignity, justice, excellence, and integrity (Providence, 2020). The values shape the interaction between staff and patients. The Joint Commission accredits the hospital.

As per the requirements of the Joint Commission, accredited hospitals must undertake fall risk assessments for inpatients to identify their risks for falls to implement prevention strategies into the care plan. Chart audits data on falls in St Joseph Hospital’s Observation Unit four months between November 2019, and February 2020 showed 20 total falls; 6/20 NOT bathroom-related; 14/20 bathroom-related; 4/14 bathroom falls patient had been given narcotics before they fell; 3/6 non-bathroom falls patients had been given narcotics; RN witnessed 5/14 bathroom falls; 2/6 non-bathroom falls witnessed by RN; 7/14 bathroom-related falls patients were close to nursing station; 1/6 non-bathroom related falls patients were close to nursing station; 7/14 bathroom-related falls patients older than 65; 4/6 non-bathroom falls patient older than 65.

In light of the data presented, the focus of this project is to develop strategies to implement in the future that include the use of bed exit alarms to alert the nursing staff when a patient leaves their bed without assistance and patient education for new clinicians and patient on fall prevention practices in addition to standardized risk assessments, surveillance via hourly rounds, rounding, buddy system(using each other to help answer call lights and assist patients) and in-service on new toilet sensors to know when patient getting up from the toilet.

Review of Literature

There is limited published research on fall prevention programs utilizing randomized control trials in acute care settings. A meta-analysis of falls prevention reveals a small decrease in falls (DiBardino, Cohen & Didwania, 2012). Even more elusive is evidence of injury reduction, with only a small number of studies showing a considerable reduction in fall-related injuries (Lohse et al., 2012). Patient screening with standardized risk assessment, implementing risk interventions including patient education, fall risk warning signs (icons), and exit alarms indicating when a patient is leaving their without assistance are some of the fall prevention programs implemented in hospital settings (Cuttler et al., 2017).

Several factors may impede the process of fall reduction such as patient failure to activate the call light, failure of communication at the time of nursing shifts as well as with other units to include a patient’s fall risk regularly, and other priorities for quality and performance improvement such as pressure injury reduction and physical restraint (Cuttler et al., 2017). Inconsistent communication of fall risks among staff and patients being unaware of risks was a common occurrence in similar interventions.

A study by Cuttler et al. (2017) showed that the use of brief education and three-mode bed alarms to be both effective and feasible in reducing falls among medical-surgical inpatients. The researchers noted that although the use of standardized reporting methods elevates confidence, it is the interventions that were responsible for the observed improvement.

Summary of Project Implementation

Patient education and the use of bed exit alarms are some of the most effective interventions in reducing the number of falls in inpatient settings (Cuttler et al., 2017). Alarms will be introduced that alert nursing staff when a patient is getting out of bed. It will allow a nurse to come to the bedside before the patient has exited. Nurses will be responsible for training their peers on how to use bed alarms; this training is crucial in the reduction of falls and injuries. The bed alarms have the potential of freeing up nurses from close observation for only one patient at a time. Further analysis of the reported falls in chart audits showed that patients who fell during the night shift had a higher likelihood of injury. Therefore, it is essential to focus on encouraging nurses to pay more attention to the exit alarm for patients at risk, particularly in the night.

Nurses and other healthcare professionals will submit images matching the various fall risk factors used in screening patients for admission routinely. A specially formulated falls task force will then evaluate the images. An illustrator will then develop icons for presentation to hospital staff. The icons will be printed and mounted over the head of the bed. The spiral binding allows hospital staff to flip to the appropriate risk factor matching the applicable risk status or to a neutral position depending on the screening results.

The hospital staff will produce and film a 5 min video in a patient room, giving suggestions on fall risk mitigation. There will be no use of brochures owing to low literacy and some patients speaking several non-English languages. The video will be produced in English and Spanish. It will feature various healthcare professionals in the hospital, including nurses and physicians. Nurses will undergo training to show the video to patients. New clinical staff will receive education on exit alarms and also view the video. The video will describe some of the risk factors such as new medications, temporary weakness and dizziness, and unfamiliar environment, especially at night. It will demonstrate a patient and a nurse placing belongings within reach, requesting bedside commode, and accepting staff presence while using the bathroom or toileting. The nursing staff will present the video to patients and their families at any point during their hospitalization. The video will contain at least ten patient teaching points but less than twenty that will be demonstrated. By including bed exit alarms to alert nurses for immediate response and a video to educate both new clinicians and patients, the proposed intervention aligns with the requirement by the AHRQ for fall prevention programs to consist of several interventions to reduce falls (Quigley, 2013).

Other considerations in addition to the bed exit alarms include documenting and analyzing fall occurrences such as ‘post-fall huddle,’ and collaborating with inpatient pharmacy in identifying common medications that increase the risk of falls. Additionally, nursing staff should request a nursing assistant to observe patients at risk of falls when necessary carefully. Implementing a patient safety education program for staff will enhance the fall reduction efforts. Also, the nurse manager has the responsibility to ensure that nurses continue surveilling patients at risk through standardized safety rounds. Occasionally, physical restraints will be in use to prevent a patient from getting out of bed.

Nursing Implications

Fall reduction and prevention interventions are essential in the hospital, and nurses play a central role as falls are a nurse-sensitive measure (Jones 2016). The role of nurses in fall and injury prevention programs include, first, team training through educating new clinical nurses and patients on the fall prevention program and nursing interventions aimed at reducing the patient falls (Nuckols et al., 2017). Second, designing care processes to reduce risk and harm. The proposed program on fall and injury prevention enhances other nursing interventions integrated into the nursing process such as routine, standardized risk assessment, and patient monitoring. The program mainly focuses on bathroom related-falls. In this case, the program is a nurse-led intervention where nurses contribute significantly from the design of the program, implementation, to evaluation. Thirdly, understanding the core process; there are measurements to ensure that nurses understand the core process, which is reflected in the outcome measures (Nuckols et al., 2017). The program is excellent in theory, but its effectiveness lies in its implementation. Potential changes in the number of patent falls will give an indication of how well it is implemented, which relies partly on nurses having a good understanding of specific interventions.

The American Nurses Association (ANA) quality indicators associate nursing care with patient outcomes. A nurse-sensitive indicator is a quality measure that connects patient outcomes with the availability and quality of professional nursing services (Jones, 2016). According to the ANA, nurses have a responsibility to assess patient’s risk for falls and injury, formulate and implement risk reduction interventions, and evaluate the effectiveness of clinical fall prevention interventions. The ANA recommends nurses to be consistent in data reporting, measurement, and analysis. As such, to ensure that the hospital participates in the National Database of Nursing Quality Indicators (NDNQI), the nurse manager will document all the processes of the proposed intervention. The NDNQI evaluates the use of standardized fall risk assessment tools (Jones, 2016). Additionally, available standardized post-fall analysis and falls offer a platform for the analysis of patient safety programs and their clinical effectiveness.

The implementation of the fall prevention program involves nurses at all levels in the hospital. Nurse leaders have the responsibility to set a supportive culture, provide resources, and set expectations about measures. Nurse leaders are the “powerhouse ” to get things done and unless they ensure full compliance with the set measures, without which flawless execution of the proposed interventions is impossible (Nuckols et al., 2017). Direct care nurses have the role of implementing the interventions, which determines its effectiveness on improving patient outcomes by reducing falls and fall-related injuries for inpatients at risk.

The risk of falls varies from one patient to another, making patient-centered care the recommended approach. Patient-centeredness is an approach that is gaining popularity in the nursing profession and healthcare industry as the focus shifts from a fee-for-service model to a value-based model (Tseng & Hicks, 2016). The result is an increase in the patient expectation that nurses and other healthcare professionals use the principles of patient-centered care in practice and for healthcare providers to respect the values of patients (Tzeng, 2011).

Good practices in fall prevention efforts in inpatient settings involve clinicians applying practical knowledge in doing what is right. That is, using the appropriate fall prevention interventions to patients on an individual level based on their unique needs and risk factors for falls. An example of this in the proposed intervention is for nurses to select an icon that corresponds to the particular risk for falls that a specific patient has. Patient-centered care aligns with St. Joseph hospital’s belief in the intrinsic dignity of each person and the provision of care holistic healthcare encompassing body, mind, and spirit.

Apart from choosing the appropriate intervention, good practices also involve nurses having a caring attitude towards their patients (Tzeng, 2011). In implementing falls and injury prevention programs particularly in inpatient settings, nurse education should not only focus on promoting their professional knowledge and skills for program implementation but also nurture their caring attitudes of treating a patient in the same way they would treat their loved ones (Tzeng, 2011). By doing so, nurse education promotes the provision of patient-centered care and value-based care.

Conclusion

Falls and fall-related injuries in hospital settings are undesired occurrences. Hospitals design prevention strategies that aim to reduce falls and their associated injuries. A proposed prevention program targeting to reduce falls and injury at St. Joseph Hospital ‘s observation unit includes patient education and the use of bed exit alarms, which are some of the most effective interventions in reducing the number of falls in hospital settings. Nurses play a critical role in enhancing the quality and patient safety in healthcare by engaging in prevention efforts. The implementation of the fall prevention program involves nurses at all levels in the hospital and requires multidisciplinary support. Since the risk of falls varies from one patient to another, patient-centered care becomes a preferred approach. In addition to professional knowledge and skills in program implementation, nurses should have a caring attitude towards their patients.