There's no getting around it, patients fall, even in the most progressive and watchful healthcare settings.

It is one of the great frustrations of the profession, noted Karlene Kerfoot, PhD, RN, NEA-BC, FAAN, vice president and chief clinical officer at Aurora Health Care, Milwaukee, and something the Centers for Medicare & Medicaid Services (CMS) are watching closely.

So, short of sitting with a patient 24 hours a day, where should nurses start to give their patients the best chance at avoiding a fall?

Simple, Kerfoot said. Start at the beginning.

Defining the Event

According to the Joint Commission, a fall is "an unplanned descent to the floor during the course of a patient's hospital stay with or without injury." The diagnosis "risk for falls," as defined by Taber's Medical Dictionary, is made when a patient has an "increased susceptibility to falling that may cause physical harm." According to CMS, not all falls are created equal, and it's possible to do a "good catch" of a patient to prevent a fall and injury.

Aurora Health Care, Milwaukee, recently implemented a knowledge-based nursing initiative seeking to prevent patient fall. Here, Laura Burke, PhD, RN, FAAN, director of nursing research and scientific support (left) discusses the initiative with Karlene Kerfoot, PhD, RN, NEA-BC, FAAN, vice president and chief clinical officer.

The Knowledge-Based Nursing Initiative (KBNI) was the result of that collaboration, led by Kerfoot, Sue Ela, MSN, RN, FAAN, Aurora senior vice president; Sally Lundeen, PhD, RN, FAAN, UWM dean and Ellen Harper, MBA, RN, healthcare executive from the IT company.

Norma Lang, PhD, RN, FAAN, FRCN, UWM distinguished professor of nursing and professor emeritus at the University of Pennsylvania School of Nursing was recruited to lead the project, while Laura Burke, PhD, RN, FAAN, Aurora director of nursing research and scientific support, and Mary Hook, PhD, RN, PHCNS-BC, Aurora research scientist, led an on-site clinical implementation team to ensure the successful launch of the evidence-based best practices and support the nurses' work flow.

Plan of Action

Instead of adding more steps to an already full assessment, KBNI uses the information gathered by the nurse to help inform the plan of care by providing evidence-based alerts back to the nurse who entered the data. The goal is to make clear, actionable recommendations based on the evidence gathered during the assessment.

KBNI currently contains alerts for six core nursing care issues, including risk for falls/injury, risk for and actual delirium, activity intolerance, risk for and actual venous thromboembolism, risk for and actual pressure ulcers and medication nonadherence, Hook said.

The system can help identify at-risk patients by integrating the nursing assessment with a list of risk factors. Most importantly, the system helps the nurse to use these assessments to select nursing interventions that will help the patient to achieve the best outcomes.

"We wanted to make the evidence come alive for nurses," Hook said. "KBNI provides clinical decision-making supports that provide direction to the nurse as they are interacting with the electronic health record (EHR). For instance, when the nurse conducts the admission interview with the patient and family, they complete the history and physical assessment forms.

"When the form is signed, more than 700 patient-specific variables are entered into the EHR, yet the nurse must remember what they documented and manually establish a plan for care," Hook continued. "When decision support is present, the nurse is alerted about potential problems based on the risks that were documented. Potential problems are suggested on the problem list and evidence-based planning forms provide them with information to select interventions appropriate to the patient's specific risks."