Whether it is due to age, illness or medication, falls in hospitals are inevitable. So facilities today focus not necessarily on preventing the fall itself, but rather the potential for resulting injuries.
"The mindset has changed and with that the overall goal. We expect patients to fall; therefore, our job is to anticipate when there is the greatest risk for a fall," said Josephine Moszynski, BSN, RN, clinical nursing director at Seton Healthcare Network, Austin, TX. "From there, we do all we can to reduce injuries. That is where we have seen the greatest impact in fall prevention."
Eight hospitals came together in 2006-07 with the Institute for Healthcare Improvement (IHI) to test a preliminary package of interventions. The Robert Wood Johnson Foundation provided grants to each facility. As a result of these case studies, an IHI team developed a package, "Transforming Care at the Bedside How-to Guide: Reducing Patient Injuries from Falls."
The guide has helped build the foundation to reduce patient injuries from falls using four main components: assessment, communication and education, standard intervention, and customized intervention, according to Suzanne Rita, MSN, RN, improvement learning network manager for the Iowa Health System, Des Moines, IA.
Assessment of Risk
Before injuries from falls can be reduced, facilities must determine the risk level of each patient and identify those in most danger of major injury or death were a fall to occur.
The guide states: "Ideally, nurses assess fall risk at critical times during a patient's hospital stay, not only on admission. When nurses switch at shift change, when patients transfer between departments, and when a patient's status or treatment changes, it is important to consider whether the patient's condition has changed and review fall risk."
Who is at the greatest risk of injury from falls? Nurses can turn to their ABCS to determine - Age or frailty; Bones; Coagulation; recent Surgery. This tool allows staff to assess patients' risk of injury from falls continually throughout the course of their hospital stay. Nurses agree it is critical for an understanding of who is in the most danger to be communicated to the entire healthcare team.
Communication & Education is Key
Staff must establish a dialogue to identify an individual's fall risk for the staff, as well as the patient and family. The TCAB guide offers an interdisciplinary approach that goes beyond simple nurse management. Every level of hospital staff, clinical and non-clinical alike, bear the responsibility of helping to prevent patient injury from falls.
For instance, at the Seton Healthcare Network, quarterly workshops bring all levels of staff together to communicate with and educate one another.
"A physical therapist was brought into the most recent workshop to demonstrate the correct body mechanics to use when lifting a patient, for their safety, but also that of the staff member," said Mary Viney, MSN, RN, NEA-BC, CPHQ, vice president for network services. "In past workshops, we have had individuals come in to help staff work on scripting, providing them with the most effective words to get patients to partner in their own safety."
Unlike many patient-safety issues, such as infection control or pressure ulcers, patient behavior largely determines falls during a hospital stay. "This is one patient-safety issue where the patient has most of the control. The patients have to be fully engaged and aware of their own risk because they are initiating it not the healthcare provider," Viney said.
The TCAB guide identifies the "Teach Back" program as an effective means of communication between staff and patient. After patients are educated on fall safety, they are asked to reiterate the information back to the nurse. This ensures there are no misunderstandings and helps staff members develop customized plans of care for patients who cannot understand.
"There are two things we want them to teach back," Rita said. "One is their understanding of our concern for their safety and why, and the other one is how to use the call light. What we found, even with some of our own patients, is they didn't how to use the call light because we did not teach them or they could not remember."
For those patients who cannot physically use the call light, other options are put into place. For those who cannot remember, due to medicines or their disease process, nurses must take an extra step. "If that's the case, we would ask the staff to go back in 30 minutes and have that conversation again," Rita added. If the patient still cannot teach back, the staff will develop a customized plan of care for the patient.
Hospitals nationwide employ multiple methods for the identification and protection of high-risk patients, such as bed and chair alarms, wristbands, color-coded socks or blankets, and signage. The TCAB guide and the participating hospitals continue to use such tools while building upon them.
"Reliable" or "intentional" rounding, which occurs every hour, helps to ensure every patient's needs are met and decreases the number of times a patient may attempt to get out of bed without assistance.
"Nurses are multitasking throughout their shift and there are often several alarms going off. It is easy to become desensitized," Moszynski said. "We had practices where they would set an alarm and help people identify the alarm and determine where to respond. This helped refresh and energize staff while improving quality of care."
Individuals with a high risk of injury through falls may be in need of more specialized care, the TCAB guide states.
This can be established through increased monitoring, a direct line of sight, or even one-on-one observation by a qualified staff member. These interventions can also be valuable when an incident occurs.
Despite every preventive measure, patients may fall. What's the best approach to take when that happens?
"When patients fall, the most important thing is to assess for injury. So the first thing we do is have a physician evaluate them. If they warrant a CT scan or X-ray, we immediately do that," said Kerri Scanlon, MSN, RN, chief nursing officer at Long Island Jewish Medical Center, New Hyde Park, NY. "Second, we put them in an environment where they may need additional observation. Then, we have a frontline staff nurse, a nurse clinician and a nursing representative from quality that come and debrief on the issue of the fall."
Future of Injury Prevention
As nurses continue to learn more about new strategies to prevent injuries from falls in the hospital, the TCAB guide will be revised to reflect these new strategies.
The TCAB guide and participating hospitals set the example for how prevention of this problem must be handled. Nurses cannot bear sole responsibility; a successful program includes every level of facility staff.
"It is not just a nursing responsibility; it is the responsibility of everyone in the hospital. We've learned other staff members are not sure what to do. In orientation they present the concept it is everyone's responsibility," Rita said. "We teach all staff their role in keeping patients safe including what to do to assist a high risk patient and how to call for help using the call light. Now they understand what their role is and how to execute the role."
The guide, "Transforming Care at the Bedside How-to Guide: Reducing Patient Injuries from Falls," can be found on the IHI website. Click here to go there now.
Catlin Nalley is editorial assistant at ADVANCE.