Patient safety is a major concern

Transcription

1 Continuous Quality Improvement Mobility/Activity Circles: A Quality Improvement Effort to Reduce Falls Brenda Murphy Patient safety is a major concern for hospital leaders. Falls are included among the list of hospital-acquired conditions offered by the Centers for Medicare & Medicaid Services (2012). The Joint Commission (2011) also has identified fall reduction and patient safety as a national priority for hospitals. National Patient Safety Goal requires hospitals to reduce the risk of harm resulting from falls. A health network located in the southeastern United States em - barked on a fall prevention journey in December One strategy from this initiative is described. Literature Review Hospital falls are among the most commonly reported adverse events in hospitals, second only to medication errors. Patient falls can cause an increase in length of hospitalization and result in increased utilization of resources. Falls and subsequent consequences cost approximately $20 billion annually (Kolin, Minnier, Hale, Martin, & Thompson, 2010). Falls can cause injuries for persons of all ages; however, older adults are more likely to be injured from a fall. A single fall can result in fear of falling and lead to a downward spiral of altered mobility contributing to subsequent falls (Dykes et al., 2010). According to Lloyd (2011) and Oliver, Healey, and Haines (2010), the most successful approaches to fall prevention in the hospital environment include multifactorial in - terventions with multidisciplinary professional input. A multifactorial fall prevention program has potential for positive impact on fall rates. No single strategy will be effective A health network in the southeastern United States piloted Mobility Circles as a strategy to help reduce falls on a medical renal department. Mobility Circles were used as visual cues to communicate the patient s mobility status, and promoted patient safety, teamwork, and satisfaction, and communication among disciplines, patients, and families. and staff adherence to the interventions is key to the success of the program (DiBardino, Cohen, & Didwania, 2012). Nurse-led safety strategies and interventions can be successful in improving fall rates (Tzeng & Yin, 2008). Spoelstra, Given, and Given (2012) identified many possible components for an evidence-based falls prevention program. The first steps are to develop a culture of safety within the organization and to use an evidence-based risk assessment tool predictive of falls. After patient risk factors are determined, appropriate interventions must be implemented to modify the identified risks. Essential interventions for a successful falls prevention program include: Environment/equipment interventions Armbands and room/door signs Communication/education Safety rounds Appropriate staff assignments Patient aids Multidisciplinary consultation and collaboration. (Degelau et al., 2012; Spoelstra et al., 2012) Inadequate caregiver communication is one of the five dimensions of causes of a fall identified by The Joint Commission (Tzeng & Yin, 2008). Dykes, Carroll, Hurley, Benoit, and Middleton (2009) re - ported a discussion by registered nurses (RNs) and nursing technicians (NTs) concerning the importance of receiving specific information in shift report to promote safe patient care. They identified verbal report as the most common method of relaying fall risk communication. Both groups acknowledged delays in giving and receiving report. Nurse technicians indicated that unless they worked the previous day, they knew very little about the patient s abilities, but they were accountable for answering call lights for all patients. The NTs reported they did not know how the patient slept at night, how to toilet him or her, or the patient s activity level. This often resulted in the patient attempting to get up without assistance. This lack of information was a deterrent in meeting the patient s immediate needs and could result in a fall. Brenda Murphy, GNP-BC, RN, is Geriatric/Medical-Surgical Clinical Nurse Specialist, Moses Cone Memorial Hospital Cone Health, Greensboro, NC. Acknowledgment: The author acknowledges the dedication and contributions of everyone involved in this project. Special thanks to the leaders and nursing staff in the medical-renal department who agreed to pilot this strategy; also the Stop All Fall Events (SAFE) team members. November-December 2013 Vol. 22/No

2 Continuous Quality Improvement Improvement Needs/Group Oversight Fall rates on this medical-renal department were above the targeted goal set by the health network. Information access was a concern and staff on the department identified communication issues as one of the contributing factors to patient falls. For example, when RNs and NTs answered call lights of unfamiliar patients, they had questions related to mobility and/or elimination, and as a result were unsure how to help the patient. According to Dykes and co-authors (2009), there is often no mechanism to communicate fall risk status systematically among health care providers. Neither staff nor patient/family had easy access to this vital information. Staff was confronted repeatedly with the following questions: Is a bedpan needed? How does the patient ambulate? Does the patient need a urinal? Staff members on the department discussed in this article faced the same problem. In light of these issues, defined processes would be required to communicate patient mobility and elimination information to all caregivers. The health network s multidisciplinary fall prevention team the SAFE (Stop All Fall Events) Team reviewed data and the current literature for fall prevention strategies. The team noted the medical renal department was consistently above the network target for falls. As a result, the SAFE Team approached department leaders to discuss fall rates and offer assistance with fall prevention efforts. Mobility Circles is a strategy recommended by VHA, Inc s., Leading Practice Blueprints. VHA is a national network of notfor-profit health care organizations. Laminated circles display visual cues related to mode of travel or activity for a patient, including the need for any assistive devices. Departmental leaders expressed interest in completing a pilot with the circles. The CQI Model The pilot process occurred over a 3-month period on a medical-renal department. This 3-month period included the time allotted for staff education as well as the administration of a pre and post pilot. Staff utilized the circles for 4-5 weeks. This quality improvement (QI) project was conducted using the PDCA (Plan, Do, Check, Act) process of QI. Quality improvement is defined as small-scale cycles of interventions to improve processes, outcomes, and efficiencies. It is an ongoing process (U.S. Department of Health and Human Services, n.d.) that Allows nurses to make changes. Focuses on making things better for patients. Provides data on how things are working. Generates questions about how to improve care. (Kring, 2008) The Iowa Model was the framework for this QI project and was adopted as the network s evidencebased practice model (Titler et al., 2001). The Iowa Model can be used to conduct nursing research, evidence-based practice projects, and quality improvement processes. It utilizes a multidisciplinary team ap - proach with feedback loops to allow for continuous monitoring, evaluation, and follow-up to im prove quality of care. Quality Indicators and Data Collection The project began with two clinical questions: 1. Will Mobility Circles Provide a visual cue to inform staff of the patient s mobility status? Decrease response time to patients personal needs? Improve staff and patient satisfaction? 2. What are staff s perceptions regarding the use of Mobility Circles? Project Objectives Goals of the project were to: Improve communication with team members regarding the patient s mobility status. Improve mobility status; patient assistance/needs. Improve communication with patients and families. Provide knowledge of the pa - tient s mobility to all staff. Improve patient satisfaction by decreasing response time to call and attention to patient needs. Because falls may occur when the patient s mobility limitations are unknown, nurse champions be - lieved the Mobility Circles could impact fall reduction. The indicators used for this quality improvement process were as follows: The number of falls obtained from the network s quality dashboard. Pre-perception surveys: Staff s perceptions of the patient s limitations related to mobility and/or activities of daily living. Post-perception surveys: Staff perceptions of the value of Mobility Circles. Patient satisfaction scores during the 3-month period from the Press Ganey Patient Satisfaction database (answers to question regarding response time to call and attention to patient needs ). Action Plan After discussion, the department director agreed to encourage staff participation with the Stop All Falls Events (SAFE) Team. Staff members were interested in a project that would promote patient safety and impact fall reduction. The department s nursing staff formed a team to determine the process for using the Mobility Circles. Prior to initiation of the pilot, staff surveys were administered to determine perceptions of a patient s limitations related to mobility and/or activities of daily living. In addition, patient satisfaction and number of falls were monitored during the pilot months. Staff members also were educated about the Mobility Circles. The pilot was conducted over a 3-month period and included 12 patient rooms. These 12 rooms were chosen due to renovations occurring on the department. Circles were cut and placed in individual sealable bags. These bags were placed beside the white boards 366 November-December 2013 Vol. 22/No. 6

3 Mobility/Activity Circles: A Quality Improvement Effort to Reduce Falls in patient rooms, and the circles appropriate to each patient were selected and taped to the white board on patient admission. As each patient was discharged, circles were returned to the bag to be used for the next patient. Results and Limitations Number of Falls At the end of the 3-month period, falls decreased by 67% (from nine to three falls) (see Table 1). This reduction cannot be attributed solely to use of Mobility Circles. The usual fall risk identification process and implementation of other interventions also may have contributed to this decrease in falls. Awareness of fall prevention increased through discussion during department huddles, shared governance meetings, staff meetings, and patient hand-off/shift report. This heightened awareness could have had an impact as well. Pre-Perception Survey Responses Staff completed a survey prior to implementation of the Mobility Circles. Surveys were placed in an envelope in the staff lounge area for 2 weeks prior to beginning the pilot, and staff was invited to respond. Sixteen surveys were returned (see Table 2). TABLE 1. Falls by Month Number Month of Falls January (pilot began) 9 February (pilot continued and ended) 6 March (post-pilot pereception survey) 3 Survey Questions (N =16) If a co-worker is unavailable and one of his/her assigned patients needed toileting, what would you do? If you are walking by a room and an aphasic patient is trying to get out of bed without assistance, how do you determine his/her mobility status right there on the spot? If you have never worked with a patient before, how do you know what the patient can or cannot do? How would you determine an unfamiliar patient s mobility status? TABLE 2. Pre-Pilot Survey Responses Survey Responses 77% (n = 12) would assist the patient first. 23% (n = 4) would ask someone (patient, family, other nursing staff) before assisting. 46% (n = 7) would check for yellow armbands and red socks (indicating high risk for falls) before assisting. 23% (n = 4) would check their resources, including asking RNs/NTs and reviewing the patient medical record. 62% (n = 10) would ask the patient and/or family. 62% (n = 10) would ask the RN/NT or PT and review the chart, patient profiles, etc. Survey Questions Questions from the pre-perception survey included the following: What do you do to determine the patient s mobility status when it is unknown to you? How do you know the patient s limitations if you are unfamiliar with the patient? Sixtytwo percent of staff responded they would ask the RN/NT or physical therapists (PTs) and review the medical record, patient profiles, etc. They also indicated they would check with the RN, obtain the information during shift report, ask the patient, read the record, or ask someone else who previously cared for the patient. They noted a delay in meeting patients needs in a timely manner due to lack of knowledge about their activity status. After a 1-month pilot of the 100% 80% 60% 40% 20% 0 FIGURE 1. Patient Satisfaction Scores Jan Feb March April May Response to call Attention to needs November-December 2013 Vol. 22/No

4 Continuous Quality Improvement TABLE 3. Post-Pilot Perception Responses Survey Item (n=13) I used the mobility circles. The Mobility Circles were helpful. I was able to help the patient in a more timely manner by using the Mobility Circles. I felt like I was providing safer care by knowing how the patient got out of bed/mobilized. Changing the Mobility Circles took a lot of time. Percentage of Respondents Answering Yes 55% (n=7) 30% (n=4) 35% (n=5) 45% (n=6) 22% (n=3) TABLE 4. Action Plan Problem/Concern Need specific people designated to update circles each shift. How do we know the circles are up to date? The pilot needed to be longer to get other staff involved. There were times when the circles were lost or missing. Action Plan Prior to initiating the action plan, the NT or environmental services technician placed the circles on the white board. Action Plan: Designate a staff member during the shift to ensure the circles are updated appropriately. Identify a champion for each shift and on weekends. During walking rounds, ensure the correct circle is placed. Action Plan: During huddle times on each shift, remind staff the circles need to be displayed and are correct for each patient. Determine a designated place for the circles and ensure all staff is aware of this information. Hold peers accountable. Use in shift report. Mobility Circles, the staff was asked to complete a post survey to ascertain their perceptions of the value of the circles. Patient Satisfaction Patient satisfaction scores (see Figure 1) could not be linked directly to use of the Mobility Circles. The scores concerning response to call lights and attention to personal needs increased positively (86.6% and 90.9% respectively) during the pilot. Immediately after the pilot, however, the scores did not remain consistently high. Limitations One of the limitations of the study was staff turnover. Staff champions moved to other positions during the pilot, leading to a need to motivate and re-educate new staff to oversee the QI processes and monitor staff adherence to pilot procedures. Clearly, a plan was needed to address any such contingencies. Weekend staff also needed more coaching related to this process. When staff members were reassigned or floated to the department, they were oriented to the pilot process. In hindsight, they could have been assigned to those rooms that were not included in the pilot. Other areas for improvement were identified by staff comments in the post-perception survey, which was available in the staff lounge. Again, surveys were placed in an envelope in the staff lounge. Thirteen surveys were returned (see Table 3). Some comments from staff included the following: Circles need to be bigger and brighter in color. Have specific people designated to update circles each shift. Place Velcro or magnet on the circles. Use the circles in shift report. The pilot needed to be longer to get other staff involved. Sometimes the circles were lost or missing. These comments can be used to refine the QI process. See Table 4 for examples of action plans based on staff comments. Nursing Implications The purpose of a QI project is to improve a process and make change to obtain better patient outcomes (Kring, 2008). Quality improvement is a continuous process and includes rapid cycles of improvement. Fall prevention team members determined more specific action plans needed to be developed to demonstrate a greater success with the Mobility Circles. Suggestions from staff continue to stimulate process change post pilot. 368 November-December 2013 Vol. 22/No. 6

5 Mobility/Activity Circles: A Quality Improvement Effort to Reduce Falls The Mobility Circle pilot was a strategy that promoted patient safety, teamwork, patient satisfaction, and communication among disciplines, patients, and families. To impact patient safety, staff must consider creative methods that promote participation and easy implementation. Mobility Circles is a project nurses can use in conjunction with other strategies to improve patient satisfaction. Fall prevention is an ever-changing quality indicator. Fall prevention strategies do not require costly interventions, but a multi-faceted approach is essential. Mobility Circles, used in conjunction with other evidence-based interventions, have the potential to decrease falls and increase staff awareness of patient safety and patient mobility. Signage or visual cues are used frequently as a fall prevention strategy. In a study by Dykes and co-authors (2009), staff frequently identified visual cues as methods of preventing falls. Mobility Circles also can promote teamwork and eliminate a delay in meeting a patient s needs because staff lack knowledge of his or her ambulatory status. Re - sponding to another staff member s patient can be done more confidently if the patient s mobility status is known by all. Members of the fall prevention team realized more specific processes were needed to ensure greater success with the Mobility Circles in future trials. Communication was key to the success of this project. Although improvements could not be related directly to the Mobility Circles pilot, the participating department experienced a 67% reduction in falls over the quarters during and directly after the pilot. An improvement in patient satisfaction scores also was noted during the pilot. Heightened awareness of staff during the pilot or an increase in communication among staff also may have contributed to these results. In addition, patients and families were more involved and were asking questions about the Mobility Circles. Conclusion All care providers, patients, and families must be invested in the fall prevention process. Mobility Circles were displayed for the staff, patients, and families to see and discuss. Improved communication was ac - complished through their use. Transporters and care staff from other departments also were able to identify the patient s mobilization method. The Mobility Circle pilot was a strategy that promoted patient safety, teamwork, patient satisfaction, and communication among disciplines, patients, and families. REFERENCES Centers for Medicare & Medicaid Services. (2012). Hospital-acquired conditions (present on admission indicator). 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Critical Care Nursing Clinics of North America, 13, Tzeng, H., & Yin, C. (2008). Nurses solutions to prevent inpatient falls in hospital patient rooms. Nursing Economic$, 26(3), 179. U.S. Department of Health and Human Services. (n.d.). What is quality improvement? Retrieved from TAdoptiontoolbox/QualityImprovement /whatisqi.html Letters Welcome MEDSURG Nursing wel comes readers comments and invites readers to share information with their colleagues through Letters to the Editor. Submission of a letter constitutes permission for its copy right and publication in MEDSURG Nursing. Letters are subject to editing. Please address your corres pondence to: MEDSURG Nursing, East Holly Avenue Box 56, Pitman, NJ 08071; msjrnl@ajj.com. November-December 2013 Vol. 22/No

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