Concerned about a 3.2 per 1,000 patient days fall rate, Broward Health Imperial Point nurses recognized an opportunity to improve care, made fall prevention a top priority and reduced the fall rate by 40% to 1.97 per 1,000 in one year, according to a presentation at the 2015 Annual Nurses Improving Care for Healthsystem Elders Conference in Orlando, Fla.
“It was huge and amazing, and it’s the staff nurses who were open to the intervention, understood there was a gap and wanted to bring it forward,” said Kimberly Cerri, MSN, RN, CPHQ, CMSRN, a quality management specialist at the 200-bed hospital in Fort Lauderdale, Fla. With full support from the C-level executives, an interdisciplinary team used Six Sigma, conducted a root cause analysis, surveyed nurses on all shifts, created a process map, analyzed incident reports and developed a plan. They found half of the patients fell during bathroom or toileting activities and 20% of the patients who fell were not identified as being at risk. Incorrect assessments, lack of determining at-risk patients, inconsistent nursing judgment about when to initiate the fall prevention protocol, insufficient education, lack of patient and family participation in prevention efforts, inconsistent supervision of patients in the bathroom and variable bed alarm functionality contributed to the high fall rate.
The team then set out to address and improve each issue by enhancing nurses’ and patients’ understanding of fall risk. The hospital instituted unit and facility safety huddles; immediate evaluation about what happened if a fall occurs; scripted teach back, with patients explaining to the nurse why they are a fall risk; scripted rounding; always staying with at-risk patients in the bathroom; and enhanced bed alarm connectivity with call bell system.
“We had success,” Cerri said. “We brought the issue to the forefront, talked to the team and refocused.”
Keynote on fall prevention
Cerri’s presentation immediately followed a keynote address on the same topic by Pat Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP, associate director of the VISN 8 Patient Safety Center in Tampa, Fla.
“To be effective in fall prevention, you have to reduce risk,” Quigley said. “And you have to make [patients] better off, because they came into your care.”
Quigley encouraged nurses to assess all patients for postural hypertension, create a safe environment, identify risk factors and then link interventions to the risk assessment. Nurses also can protect patients from injury if a fall occurs. Her suggestions include using floor mats and hip protectors.
“There were a lot of good ideas, things I can take back and try at our facility,” said Elizabeth Sposito, MSN, RN-BC, ONC, an RN supervisor with Scottsdale Healthcare in Arizona. “We’re a NICHE facility, but we could do a better job of executing.” [accordions]
[accordion title=”NICHE conference realizes growth” load=”hide”]More than 830 people from 320 facilities in 44 states and five countries attended the annual Nurses Improving Care for Healthsystem Elders conference in Orlando, Fla., an increase from 230 attendees in 2009, the last time the meeting was held at Walt Disney World.