Fall prevention is a challenge in any healthcare facility, but none more so than the acute psychiatric hospital setting.
This article describes the successes and challenges of our fall prevention program in a psychiatric hospital embedded within the campus of a large urban medical center. Our inpatient program encompasses 117 beds across 6 units, servicing children, adolescents, adults and older adults.
Falls have traditionally been recognized as an inherent risk for patients with psychiatric illness. Since these patients are encouraged to remain ambulatory within the milieu and independent in self-care activities during the acute care stay, interventions that limit mobility, such as exit alarms or close supervision, may have adverse physical and psychological effects and may be poorly tolerated by the patient. Independent mobilization coupled with the side effect profiles of the medications given to these patients for their psychiatric conditions increases fall risk.
Many psychiatric medications can cause positional vital sign changes, often resulting in dizziness or an unsteady gait. Blood sugar regulation, electrolyte balance and muscle strength are commonly altered by psychiatric medications, increasing the complexity of managing patients with co-existing medical conditions such as heart disease, hypertension and diabetes.
Traditional fall prevention devices may not be safe in a setting with patients who may potentially use the device to inflict harm upon themselves or others. Therefore, emphasis on creative fall and injury prevention strategies is critical to this vulnerable patient population.
Planning & Implementing Interventions
In 2008, our hospital system convened a multidisciplinary fall prevention committee to examine falls across our inpatient units and make recommendations for fall and injury reduction. A nurse manager from psychiatry attended the monthly meetings to further explore opportunities to decrease falls in patients admitted for acute psychiatric care.
A process change implemented hospital wide by the fall committee was the “post fall huddle” generating a “mini root cause analysis” of each fall. When a fall occurs, staff gathers for a short discussion of the event to identify reasons for the fall and opportunities to improve safety at the individual, unit and system level.
We identified nursing staff particularly interested in fall prevention to befall prevention champions for their unit. Their role was to help create, implement and promote fall prevention initiatives.
A Fall Rounding Tool was developed to trigger discussion of existing and modifiable fall risks for each patient on the unit. It gave structure to the rounding done by the staff twice per shift to focus on fall prevention plans for each patient.
Environmental fall risks emerged from our mini root cause analyses and we responded with interventions to minimize each risk. To prevent patients from slipping in the shower, we installed rubber non-skid mats and provided shower shoes.
Patients were tripping on pajamas that were too long in the leg or too large at the waist. Therefore, “Capri” length pajama pants with a Velcro waist were made available.
Clogs, crocks, flip flops and other backless shoes were discouraged. We purchased lids for cups, spill proof water pitchers, and water bottles to encourage drinking but minimizing spills. Housekeeping staff were reminded to limit the amount of water used during floor maintenance. Nightlights were installed in all patient rooms.
Exit alarms can be an effective fall prevention intervention for patients with impulsivity and poor balance and/or weakness. However, strict restrictions surrounding devices with cords and wires exist on psychiatric units, due to the risk of suicidal patients using these items to hurt or kill themselves via hanging.
We created a protocol addressing life safety concerns when exit alarms are recommended. We shortened the electric bed cords to a length deemed safe and acceptable by our regulatory agencies and secured them to the wall for added safety.
Functional & Physiological Attributes of Patients
An occupational therapy or physical therapy consult is performed on selected patients whose fall risk score identifies physical risk factors impacting safe mobilization. The therapist identifies issues and makes recommendations to improve the patient’s mobilization and engagement in activities of daily living in a safe manner.
Mini root cause analysis revealed tachycardia, hypotension and orthostatic vital sign changes to be present prior to and/or following many falls. We suspected medications and co-existing medical conditions as the cause. In 2010, we implemented orthostatic blood pressure monitoring twice per day as our standard of care on all inpatient psychiatric units.
Staff notifies the physician immediately of systolic blood pressures below 100 (if this is different from patient’s baseline), pulse rates above 100 or positional blood pressure changes of 20 mm/Hg systolic or 10 MM/hg diastolic.
Patients are notified of their increased fall risk and are given a bright green laminated card reminding them to change position slowly, recognize the potential for dizziness or weakness and call for assistance with mobilization until the issue is resolved.
Some patients have required a higher level of medical care to resolve the underlying issue. Appendix A shows the impact of this intervention on reducing falls involving vital sign changes.
Other Fall Prevention Strategies
We noted that many falls occurred while patients wait in line for their medications. We placed chairs in the hall and posted signs in common areas reminding patients to sit down and notify staff immediately should they feel dizzy, weak or off balance. Patients receiving ECT have supervised mobilization for the four hours immediately following their treatment in order to keep them safe.
We recognized that some patients engaged in risky behavior prior to a fall. These behaviors include standing on furniture, rushing down the hall, exaggerated dance movements or jumping on beds. Although some of these behaviors may be inherent to the patient’s psychiatric diagnosis and out of their control, we wanted to include patients in fall prevention whenever possible.
A Fall Prevention Teaching Sheet is reviewed with each patient upon admission and as needed. Fall prevention is a daily topic of discussion among staff and patients in community meetings as part of the therapeutic milieu. If a fall does occur, the patient is asked what could have been done to prevent that fall.
Outcomes & Future Implications
The establishment and refinement of an administrative review process was necessary to change our hospital’s culture from “falls are inevitable” to” falls are preventable.”
Each nurse manager was held accountable for discussing the plan for each fall risk patient on their unit with the nursing director on a daily basis. In turn, each staff member was responsible for designing and carrying out the fall prevention plan for each patient on their unit.
shows our fall data from 2007 to 2012 with noticeable improvement. Although there continued to be fluctuation over the quarters, the overall quantity of falls, and falls with injury, decreased by 25%.
Fall prevention efforts in the inpatient psychiatric population continues to evolve. Real time analysis of each fall by unit staff identifies issues and potential interventions.
Engaging our patients in fall prevention has proven to be a pivotal strategy to empower them to keep themselves healthy and secure. The multidisciplinary workgroup has proven to be a valuable vehicle for change.
Preventing falls must be a top priority in creating a safe environment for inpatients with psychiatric illness.
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Ellen W. Blair is director of nursing at The Institute of Living, a division of Hartford Hospital, Hartford, Conn. Christine M. Waszynski is a geriatric nurse practitioner, geriatric clinical nurse specialist and chairperson of the Fall Prevention Committee at Hartford Hospital.