Organization: Sinai Hospital of Maryland Solution Title: Sustaining Fall Prevention Over Time, Is It Possible? Focus rea: Preventing Falls with Injury Program/Project Description, Including Goals: In 2010, Sinai s Falls Program was recognized by the Maryland Patient Safety Center (MPSC) and received the Distinguished chievement in Patient Safety Innovation ward. t the time of our award, Sinai s fall with injury rate in March was 0.4/per 1000 inpatient days. In an effort to further enhance patient safety, the Falls Committee and Sinai Leadership lowered the falls with injury rate from 0.8 to 0.5/per 1000 inpatient days. The purpose of our project was to utilize the Maryland Falls Initiatives best practice to sustain Sinai s (2013) falls with injury rate benchmark of 0.5/per 1000 inpatient days. Process: The interdisciplinary falls team determined that in order to further reduce the rate to the 2013 benchmark, additional evidence based interventions and institutional changes would be required. Sinai s collaborative falls team partnered with the Maryland Patient Safety Center (MPSC) Safe from Falls Initiative. The purpose of this Maryland collaborative is to reduce the incidence and severity of patient falls, by supporting and coordinating communications and outreach through a statewide initiative. Sinai has been a part of this program for five years and they provide us with data analysis, best evidence and solutions in fall prevention. The MPSC practice recommendations were integrated with the current Sinai Falls Program. The combined recommendations are described in the solutions section. Solution: ssessment of the present program: Per the MPSC fall initiative, an evaluation of the current program was required and included: ssessment of Units were falls occurred Occurrence reports related to falls, Discussions with patient and staff involved in falls Implementation of the best practices recommendations received from the Maryland SFE from Falls initiative: signage, toileting, bed alarms. The group looked for patterns related to the time of the incident, the patient activity at the time of the fall, and interventions implemented prior to the fall. Several surprising trends existed. higher number of falls were occurring during the day and most were related to toileting either trying to go to or return from or in the bathroom. ll the patients had some form of fall precautions in place, but the patient still managed to fall. The patient falling during the day was a
surprising finding to the committee members. This was when the greatest amount of help existed, but patients still fell. more in-depth review of the reports revealed that sometimes the patients family were trying to help the patient, and the patient fell. The MPSC recommendations recommended fall signs usage as a helpful tool in falls prevention. The signs were in place but could be more descriptive regarding asking for staff assistance. The next problem was related to toileting. If the staff are rounding every hour and offering toileting, why were the patients still falling? lso, were we using bed pans, urinals and bedside commodes? How many units had the new toilet alarms and were they using them? nd finally, many patients were cognitively impaired, but some were not. So, it was clear that not all confused patients fall, so why were the ones that did fall doing this? lthough we felt like we had many tools available to the staff, we were still having falls and falls with injury; and knew that these questions must be answered throughout the evaluation. The Falls Committee decided to implement additional strategies based on the MPSC and the findings from the Sinai assessment of the program. It was important to integrate: 1) interventions that were appropriate for staff usage, 2) New tools to enhance assessment of falls, 3) Re-educate staff on the program requirements, 4) methods to ensure ongoing monitoring of adherence and compliance. Measureable Outcomes: Compliance: The falls committee decided to create an evidence based practice table that outlined the best practices in fall prevention, and to look at the number and the degree of adoption of the interventions implemented throughout the hospital. The Nurse Managers on every unit were asked to rate on a scale of,, or C, ( being fully implemented and C meaning poorly implemented or not implemented at all), the interventions listed. This data was then collated and presented back to the Nurse Managers at one of the large nursing department meetings. The data revealed that overall compliance was highly variable, and the committee agreed to gain hospital wide compliance in 3 areas. The areas of focus were: Fall signs posted in all rooms and bathrooms, ed alarm usage on all high risk patients. Implementation of new interventions for toileting. Compliance of fall signage: smaller group of individuals from the falls committee performed a hospital wide walking audit looking for the fall signs in the bathroom and in the patient room. This provided the first true assessment of compliance regarding the signs. This information was reported back to the Nurse Managers and their Directors who then went about getting the signs up in the areas where compliance was lower. These assessments will continue over time until compliance with the signs is at 90% or higher. Compliance of bed alarms: Compliance with the bed alarms was much more difficult, because not all patients have to have the bed alarm on. However, as we listened to why the alarms
continue to not be activated, it was clear that multidisciplinary training was critical. Education of staff was in place, but again, it was not always specific to the job/role of the employee. Training was developed on how to correctly engage and disengage the bed alarm system at the bed side. We also recommended posting signs of how the bed alarm should look when it is connected so that anyone in the room could look at the cables and determine if they were set. This enabled everyone including patients and visitors, to know how to help in with the bed alarm system. Structural support on or around the toilet: The falls committee re-looked at ways to reduce falls related to toileting. Several options were explored and we discovered that toilet alarms were being used in only a few areas. The goal was to implement the use of the alarm more widely as a best practice for patient requiring toileting assistance. gain the occurrence reports were reviewed and several committee members reported that the equipment structure of the toilets is lacking, and in the bathrooms there is only one bar to assist the patient to sit or stand while on the toilet. It was realized that bedside commodes could also be used both at the bedside and in the bathroom over the toilet. This revelation supports the family member with providing the patient assistance. Since some of our falls also included the family or a visitor helping, we thought providing them with additional assistance in addition to a nurse being there should be a an additional strategy that reduces the patients likelihood of a fall. Patients and family members are educated to call for the nurse even when they are helping the patient to the bathroom. Falls Rate Outcome: See attachment #1. Since 2011, the falls with injury rate has continuously reduced, excluding 1-2 month upward surges, but overall the rate is within the range of lower than 0.5/per 1000 inpatient days. Sustainability: In an effort to support sustainability of changes to the program the Falls Committee also developed strategies for education, patient and family involvement. Education: the decision was made to implement an annual PCS Falls education that includes a new module every year highlighting the issues, and solutions that had arisen in the previous year. This keeps the content fresh and relevant to issues the staff faces on a regular basis. Patient and family involvement: nd finally, we looked at how we could better work with the patients and families to increase their involvement and engagement in our falls prevention program. gain, the MPSC included the idea of a patient/family contract. Previously a falls contract was created for patients that refused to follow our program due to their overriding need to smoke and leave the unit independently. The contract was limited to smoking and high falls risk patients, and the clearly the need was to revise the form to address all patients. form was created to include: a falls safety plan that described more thoroughly a specific falls plan that provided the patient/family the option to accept or refuse certain components. Currently, there is no data as of yet as to correlate to a reduction in falls, but the committee is hopeful.
Role of Collaboration and Leadership: The Falls Committee is comprised of direct care Nurses, rehabilitation therapists (PT and OT), mid-level providers, nurse managers, Clinical Nurse Specialist, safety officer, physician, pharmacy representative, and ad hoc departments as needed. Liferidge Health facilities were also a part of the collaboration, Northwest Hospital and Levindale. Innovation: The innovation of this work lies in the measurement of accountability and incorporation of MPSC recommendations into a current Falls Program. The evidence provided a sound base for development and selection of tools utilized at Sinai. Key aspects of sustainability related to ensuring accountability of staff by holding people accountable to adherence to the program requirements. Sinai s implementation of the following strategies supports accountability: random audits, and manipulation of the electronic system to constantly support correct decision making. Related Tools and Resources: Dykes, P., Carroll, D., Hurley,., enoit,., and Middleton,. (2009) Why do patients in acute care hospitals fall? Can falls be prevented? Journal of Nursing dministration, 39 (6), 299-304. Miake-Lye, I., Hempel, S., Ganz, D., and Shekelle, P. (2013). Inpatient fall prevention programs as a patient safety strategy. nnals of Internal Medicine, 158 (5), 390-397. Padula, C., DiSano, C., Ruggiero, C., Carpentier, M., Reppucci, M., Forloney,., and Hughes, C. (2011). Impact of lower extremity strengthening exercises and mobility on fall rates in hospitalized adults. Journal of Nursing Care and Quality, 1-7. Summary of the updated merican Geriatric Society/ritish Geriatric Society Clinical Practice Guideline for Prevention of Falls in Older Persons. (2011). Journal of merican Geriatrics Society, 59: 148-157. See attached University of Maryland CNL student audit tool. ttachment #2. Contact Person: Sue Pugh Title: Clinical Nurse Specialist Email: spugh@lifebridgehealth.org Phone: 410-601-7241
ttachment #1
ttachment #2 est Practices in Fall Prevention for Patients EST PRCTICE INTERVENTIONS Fall risk assessment tool Clear identification of high fall risk (magnets, bracelets, blankets, etc.) Hourly rounding Leadership rounds* Team huddles Culture of safety* Patient safety contracts* Sitters ctivity specialists* Clearing environmental hazards Sufficient lighting ed and chair alarms Toilet alarms Low beds Timed toileting Non-skid socks ssist in, assist out Patient education Restraints Medication specific interventions Patient self-perception of fall risk* Use of language cards INTERVENTION GRDE C C C IMPLEMENTTION GRDE * = Suggested interventions in the presentation Intervention Grading Scale = Recommended by the Institute for Healthcare Improvement = Commonly used interventions C = Novel suggested interventions Implementation Grading Scale = Fully implemented = Partially or inconsistently implemented C= Not implemented at all