When it comes to identifying patients at risk for a fall, a visual aid may be worth 1,000 words.
Steps taken to prevent falls included:
That's the premise behind a new fall prevention program at Provena Saint Joseph Medical Center (PSJMC), Joliet, IL, developed by Lynn Watson, MSN, RN, CMSRN, and Monica Nance, RN. In addition to other changes, the multidisciplinary team outfitted patients in yellow gowns who have a potential for falling. Staff training took on a spirited twist when the medical center produced a YouTube video hit Spot, Spot, Spot, parodying the Calypso tune Hot, Hot, Hot, reminding staff to shepherd patients by addressing fall hazards. (see video below)
At the 1-year anniversary of the Awareness-Responsibility-Commitment (ARC) pilot program, fall rates on the hospital's med/surg and rehab units dropped 40 percent and 54 percent respectively. In a banner year, participating units at Provena Saint Joseph Medical Center reported no falls with injury in 2010. Ultimately, the initiative will be rolled out housewide, with the neuroscience step-down and general med/surg units in the early stages of implementation right now.
- clinical team "huddling" to identify those at risk of falling;
- reinvigoration of patient rounding;
- routine safety/wellness checks;
- text page and overhead music to remind staff to complete checks;
- assertive toileting;
- patient and family education;
- technology enhancements, including bed alarms routed directly to the ASCOM phones and gait belts to assist with transfers and ambulation;
- magnet placed in nurse alcoves to alert team members to keep the blinds open on patient doors; and
- falls forums - open, multidisciplinary weekly meetings for continued learning.
Recognizing Risk Factors
Looking back to the summer of 2009, Watson said it was painful to realize the facility was following all the fall prevention recommendations - hourly rounding, screening for fall risk and incorporating Hendrich II fall risk model, yet averaging one fall every day.
The pilot group, including the vice president of nursing, nurse managers and director of quality, decided to borrow a page from Johns Hopkins Medical Center's unit-based safety programs for central line infections.
"It was a great concept because it featured bedside caregivers recognizing issues and making suggestions," said Watson.
|ENGAGED EMPLOYEES:Keith Hall, endoscopy scope technician (left); Lynn Watson, MSN, RN, CMSRN, and Sarode Pundaleeka, MD, medical staff president; illustrate the enthusiasm for the ARC program that's spread among 2,000 employees. courtesy of Provena Saint Joseph Medical Center
In the two units studied, med/surg/telemetry and physical medicine and rehabilitation, nurses quickly distinguished different sets of risk factors. Gait issues and muscular weakness were expected in rehab, said Watson, but the hospital's growing neurological program included more patients without the cognitive ability to make good safety decisions. In med/surg, many falls could be traced back to medication issues. In particular, Ambien prescribing practices and the time of day patients were taking medicine were studied extensively.
Armed with the right risk factors, nurses tweaked their rounding processes.
"We implemented hourly rounding years ago, but always knew toileting was an issue in fall prevention," said Watson. "Through this pilot, we discovered rounding could mitigate the toileting risk, but we were talking about it the wrong way. Prior to the ARC program, I'd go in and say 'Do you need to use the toilet?' Patients would say no, but later think about it and then try to go by themselves. Now we walk in and say 'It's been 2 hours and I'm here to help you use the toilet.'"
Watson thinks the multidisciplinary aspect of ARC may be the secret ingredient. When the pilot was introduced, they asked all staff to act as "ARC angels" and help with the commitment to a safe environment. After all, the idea of having patients at a high risk for falling don the yellow gowns was the brainchild of a housekeeping staff member. Even though there would be a sign on the door and an ID badge signifying a fall risk, one enterprising housekeeper noted that his eyes don't always notice the door signs every day and wondered if there could be a more obvious marker.
"The yellow gown concept engaged absolutely everybody," said Watson. "In the past, I'd send a patient to radiology who would then ask the patient if he could move. Patients always overestimate what they can do. Now, if they're wearing a yellow gown, nobody asks if they can walk."
As far the most important buy-in, Watson reported that patients love the special gowns because of the feeling that staff created a safety plan for them by first recognizing the risk.
"They could really see we're going the extra mile to keep them safe," she said.
Robin Hocevar is senior regional editor at ADVANCE.