Mount Sinai St. Luke’s Hospital

Inpatient geriatric psychiatric unit’s “aha” moment leads to reducing falls by fifty percent

TEAM: Acute inpatient geriatric psychiatric unit nurses
ENTRY SUBMITTED BY: Michelle Dunn, RN, MSN, director, nursing quality improvement

Preventing falls in the inpatient setting is a challenge for any nurse-but even more so for the interdisciplinary team caring for patients in the acute inpatient geriatric psychiatric unit. The Acute inpatient geriatric psychiatric unit at Mount Sinai St. Luke’s Hospital services elderly patients who are admitted directly from the community or from nursing homes in the area. Many factors, including intrinsic, extrinsic or a combination of both, contribute to falls in the psychiatric inpatient.

Examples of intrinsic factors include impaired cognition resulting from a chronic condition (such as Alzheimer’s disease) or an acute condition (such as delirium). In addition, psychotropic medications and their adverse reactions may increase the likelihood of patient falls. Other intrinsic factors that may lead to falls include mobility, gait, vision, and balance disorders (Malik & Patterson, 2012). Extrinsic factors include lack of siderails to support getting into or out of bed, and the lack of a traditional call bell with a cord

In the first 3 months of 2015, there were 23 falls on the unit. This was a significant increase from the same time period in 2014. The hospital’s Skin Integrity and Falls Prevention Committee (SIFPC) convened a subcommittee consisting of members of the inpatient geriatric psychiatric interdisciplinary team (a nurse manager, staff nurses, nursing assistants, a physician, a nurse practitioner and a social worker). Together with the director of nursing QI, another physician, and a pharmacist, the subcommittee examined ways to reduce falls.

The subcommittee drilled down on the 23 falls and determined that the falls were evenly spread across the three traditional shifts (7-3, 3-11, 11-7). Furthermore, 3 patients fell twice; 7 falls were related to ambulating in the hallway; 4 falls were related to toileting; and 3 were accidental falls-patients slipped in urine on way to the bathroom.

Convening the subcommittee became the “aha” moment for the interdisciplinary team. The unit staff, led by their resilient nurse manager and with guidance of the SIFPC, continued to meet regularly to consider and develop opportunities for improvement. A risk assessment of the current environment and available resources was conducted.

One major thing that was immediately identified as a risk factor was the existence of a bathtub in one patient bathroom. The engineering staff was contacted to remove the bathtub. Anti-skid strips were placed in the shower rooms. The handrail in the hallways was painted a dark contrasting color to allow for better visualization.

Toilet seat risers were purchased, and the availability of wheelchairs and functioning walkers was assessed. A major factor for success in the therapeutic milieu depends upon the availability of a full-time physical therapist. Our unit did not have a PT dedicated to their patient population, but instead had one “available as consult.” Through meetings with nursing leadership and administration, a part-time PT position was approved in the fourth quarter of 2015. The team reached out to staff in other institutions to gain insights into their best practices. We visited nurse leaders at nearby nursing homes, and met with the nurse manager and staff on the geriatric psychiatric unit at another hospital within our own system.

We also met nursing representatives from similar units in nearby states when we joined The Joint Commission’s “Targeted Solutions Tool project” on falls prevention. To address the potential risk factor of orthostatic hypotension, nursing staff were instructed on appropriate assessment techniques.

Patients not having proper footwear was identified as a factor for falls. Although patients are provided with non-skid socks, this may not be an effective solution for patients who are accustomed to walking with shoes. A social worker initiated early calls to the facilities that would be transferring their patients to our unit as a planned admission; we requested that the patients’ shoes be sent along with them.

In December 2015, a shoe drive was initiated to ensure that every patient was appropriately provided with non-skid shoes. This successful initiative raised more than $600 for the purchase of sneakers.

Falls have decreased by approximately 50% in the fourth quarter of the year. In November, there were zero falls on the unit! Still, the interdisciplinary staff acknowledge that falls prevention is an ongoing challenge, with more work to be done. In March 2016, a falls prevention awareness program is being coordinated by our staff. The team realizes that their investment in this effort will further contribute to enhancing safety on the unit.

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