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Service Delivery Innovation Profile

Bundle of Interventions Targeting High-Risk Patients Reduces Falls and Fall-Related Injuries on Medical-Surgical Units


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Snapshot

Summary

As part of a year-long collaborative, James A. Haley Veterans Hospital implemented a bundle of interventions on two medical-surgical units aimed at preventing falls and physical injury from falls by improving patient education, identifying and intervening with high-risk patients, promoting patient comfort and safety, and holding safety huddles whenever a fall or near fall occurs. The program reduced falls and fall-related injuries on both units, with one unit eliminating falls that resulted in moderate or major injury or death.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of falls and fall-related injuries on the two units that implemented the program.
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Developing Organizations

James A. Haley Veterans Hospital
Tampa, FLend do

Use By Other Organizations

  • Information provided in April 2012 indicates this innovation has been adopted by the Minnesota Hospital Association to help reduce falls and fall-injuries in their hospitals.

Date First Implemented

2006

Problem Addressed

Falls in the inpatient setting occur frequently and can lead to devastating consequences, including serious injury and death. Traditional hospital-based fall prevention strategies, which have focused on universal precautions and risk assessments, have yielded mixed results and do not often include interventions to reduce injury when falls occur.
  • A significant problem: Falls are the second most common adverse event within health care institutions following medication errors,1 and an estimated 30 percent of hospital-based falls result in serious injury.2 The severity of this problem led the Joint Commission to make reducing the risk of patient injuries from falls a national patient safety goal for hospitals in 2009.3 In 2003, falls represented nearly 47 percent of all safety reports and aggregated events within the Veterans Affairs National Center for Patient Safety's database.4
  • Limited success from traditional hospital-based approach: Traditional hospital-based fall prevention programs, which tend to focus on standardized risk assessments, universal precautionary measures, and systematic reporting of falls when they occur have yielded mixed results.5,6 Relatively few hospitals have implemented more comprehensive programs that focus not only on preventing falls, but also on reducing fall-related injuries.7

What They Did

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Description of the Innovative Activity

As part of a year-long collaborative, James A. Haley Veterans Hospital implemented a bundle of interventions on two medical-surgical units aimed at preventing falls and physical injury from falls by improving patient education, identifying and intervening with high-risk patients, promoting patient comfort and safety, and holding safety huddles whenever a fall or near fall occurs. Key elements of the bundle include the following:
  • Patient education through teach-back: Using the teach-back approach, unit staff educate patients on fall prevention strategies and then ask them to repeat what instructions they understand and how they will apply the information. Patients with a history of falls learn about their increased risk for falling and the likelihood of being injured due to a fall. Patients on anticoagulants learn that they face an increased risk for bleeding if they fall. Educators ask high-risk patients to commit to calling for help when they need to get out of bed or walk to a different location, even if they believe such assistance is not necessary.
  • Targeted interventions for high-risk patients: High-risk patients, including those with osteoporosis or a history of falling, those on anticoagulant therapy, and those with a low platelet count, receive a series of interventions designed to reduce the risk for falls and fall-related injuries, as outlined below:
    • Precautions to reduce risk for falls: These precautions include putting the patient in a room close to the nurses' station, using a chair and/or bed alarm, conducting toileting and comfort rounds every hour, having the patient wear yellow nonskid socks, and using visual identifiers, such as yellow wrist bands, to indicate the patient's heightened risk for a fall and/or fall-related injury. Also, because pain medication can increase the risk for a fall, patients receive assistance with toileting before the administration of any high-risk pain medication.
    • Interventions to prevent injury from a fall: These strategies include placing a mat on the floor at the side of the bed (unless contraindicated), using adjustable-height beds or placing beds in a low position, having patients at risk for a head injury wear a helmet, and having those at risk for a hip fracture wear hip protectors.
  • Rounds to promote comfort and safety: Unit staff perform hourly "Comfort Care and Safety Rounds" in which they do the following: ask patients about any discomfort or pain they may be experiencing; ensure that patients are clean and have water at the bedside; check the bed and room for hazards; make sure the call light, urinal, and phone are within the patient's reach; check room lighting and temperature to ensure patient comfort; turn the patient; and change dressings as needed.
  • Safety huddles after fall or near fall: Unit staff engage in "safety huddles" at the patient's bedside whenever a fall or near fall occurs. Based on a model used in the military, staff focus the discussion on the following issues: what threatened the patient's safety, what should have happened differently, what accounted for the difference, how the same outcome can be avoided in the future, and the followup plan going forward.

Context of the Innovation

The James A. Haley Veterans Affairs Medical Center, a 327-bed tertiary care teaching hospital that also operates 300 nursing home care beds, provides comprehensive inpatient and outpatient care to more than 116,000 veterans living in a four-county area of Florida. Beginning in 2004, the Tampa Veterans Affairs Nursing Service developed an interdisciplinary fall prevention program to improve risk assessment, standardize interventions, expand signage, and integrate technology to prevent hip fractures. After receiving funding from the Robert Wood Johnson Foundation, the medical center joined the Institute for Healthcare Improvement (IHI) collaborative focusing on the causes of falls that result in harm and the design and testing of strategies to reduce adverse events from falls on medical-surgical units. The hospital participated in the IHI collaborative from June 2006 to May 2007.

Did It Work?

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Results

The program reduced falls and fall-related injuries on both units, with one unit eliminating falls that resulted in moderate or major injury or death.
  • Fewer falls: Both units experienced a reduction in total falls after program implementation in 2007 when compared to baseline aggregated data from 2003 to 2005, with rates on one unit decreasing from 4.55 to 4.11 falls per 1,000 patient days, and rates on the second unit decreasing even more significantly, from 3.71 to 1.18 falls per 1,000 patient days. Both units achieved a fall rate below the average (mean) for comparably sized units, as reported in the National Database of Quality Indicators.2
  • Fewer fall-related injuries: During the same time period, one unit eliminated fall-related injuries, with the rate of moderate or major injury or death due to falls decreasing from 1.16 to 0 per 10,000 patient days (below the collaborative's target rate of 1 or less for this indicator). The second unit experienced a more moderate decline, from 2.1 to 1.7 per 10,000 patient days.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of falls and fall-related injuries on the two units that implemented the program.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Forming multidisciplinary team: The hospital enlisted a variety of staff, including the falls committee chairperson, nurses managers, quality improvement specialists, epidemiologists, risk managers, patient safety managers, and informatics specialists, to develop a strategic plan for the program.
  • Selecting pilot units: Program developers approached nurse managers throughout the hospital about the program, and two managers volunteered their units to participate in a pilot test. The majority of patients on these units required significant physical assistance, placing them at higher risk of falling.
  • Collecting data to guide development: Staff conducted a descriptive, retrospective review of 22 injurious falls that occurred over a 5-year period to identify risk factors for falls and fall-related injuries, and then developed the various interventions with these risk factors in mind.
  • Adopting injury rating scale: Program leaders decided to adopt a standardized scale to assess the level of injury from a fall, thus allowing the hospital's data to be compared to that from nine other sites participating in the IHI collaborative.
  • Hiring data manager: The hospital hired a data manager to create and manage a program database, complete statistical analyses, and draft reports documenting program impact.
  • Training frontline staff: The training of frontline staff was a dynamic and ongoing process but involved direct patient care rounds, unit inservice and staff meetings, biweekly IHI collaborative community conference calls across sites, and involvement in tests of change.

Resources Used and Skills Needed

  • Staffing: As noted above, the program requires a data manager. The amount of time allocated for this part-time position varies depending on the phase of program rollout and evaluation. Unit-based staff participate as part of their regular duties.
  • Costs: Specific program costs are not available but are largely limited to salary and benefits for the data manager.
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Funding Sources

Robert Wood Johnson Foundation
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Tools and Other Resources

The Institute for Healthcare Improvement prepared a Toolkit in 2008 specific to reducing serious injuries from falls in medical surgical units. Available at: http://www.safetyandquality.health.wa.gov.au/docs/squire
/IHI%20Guide_Reducing_Patient_Injuries_from_Falls.pdf
(If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software External Web Site Policy.)

Adoption Considerations

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Getting Started with This Innovation

  • Leverage nurse leaders to engage frontline staff: The pilot unit nurse managers proved pivotal in securing staff buy-in, as their leadership inspired frontline caregivers to engage in the program.
  • Listen to frontline staff, recognize unit differences: Solicit staff feedback from each unit during the development phase, and incorporate their ideas into program design. Because staff dynamics and patient populations vary across units, program developers should recognize and accept these differences.
  • Plan for data collection: Make someone responsible and accountable for data collection and reporting at the onset of the program, and allocate adequate resources to these tasks.

Sustaining This Innovation

  • Continue listening: Periodically solicit and address staff concerns as necessary after implementation.
  • Incorporate proven interventions into policies and procedures: Once interventions have been tested and proven effective, incorporate them into formal hospital policies and procedures.
  • Expand focus to fall-related injuries: Think beyond traditional risk assessment by focusing on reducing not only falls, but fall-related injuries as well.

Use By Other Organizations

  • Information provided in April 2012 indicates this innovation has been adopted by the Minnesota Hospital Association to help reduce falls and fall-injuries in their hospitals.

More Information

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Contact the Innovator

Pat Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP
Associate Director, VISN 8 Patient Safety Center - James A. Haley VAMC (151R)
Associate Chief of Nursing for Research
HSR&D/RRD Center of Excellence: Maximizing Rehabilitation Outcomes
Patient Safety Center of Inquiry
8900 Grand Oak Circle
Tampa, FL 33637-1022
Phone: (813) 558-3912
Fax: (813) 558-3992
E-mail: Patricia.Quigley@va.gov

Innovator Disclosures

Dr. Quigley reported having no financial interests or business/professional affiliations relevant to the work described in this profile other than the funders listed in the Funding Sources section.

References/Related Articles

Boushon B, Nielsen G, Quigley P, et al. Transforming Care at the Bedside How-to Guide: Reducing Patient Injuries from Falls. Cambridge, MA: Institute for Healthcare Improvement; 2008. Available at: http://www.ihi.org/knowledge/Pages/Tools/TCABHowToGuideReducingPatientInjuriesfromFalls.aspx

Quigley P, Hahm B, Collazo S, et al. Reducing serious injury from falls in two veterans' hospital medical-surgical units. J Nurs Care Qual. 2009;24(1):33-41. [PubMed]

Improving quality by reducing harm from falls: success stories from the field. Robert Wood Johnson Foundation. June 20, 2007. Available at: http://www.rwjf.org/pr/product.jsp?id=21143

Quigley, P. Guest editorial. Prevention of fall-related injuries: a clinical research agenda. 2009-2014. Guest Editorial 2009, JRRD, Under Review. July, 2009.

Sorock GS, Quigley PA, Rutledge MK, et al. Psychotropic medication changes and the short-term risk of falls in nursing home residents: a case-crossover study. Geriatric Nursing. 2009;3(5):334-40.

Applegarth SP, Bulat T, Wilkinson S, et al. Durability and residual moisture effects on the mechanical properties of external hip protectors. Gerontechnology. 2009;8(1):26-34.

Footnotes

1 Kohn LT, Corrigan J, Donaldson MS. To err is human: building a safer health system. Washington, DC: Nat Acad Press; 2000.
2 Inpatient falls: lessons from the field. May/June 2006. Available at: http://www.psqh.com/mayjun06/falls.html
3 The Joint Commission 2009 National Patient Safety Goals. 2009. Available at: www.jcrinc.com/common/PDFs/fpdfs/pubs/pdfs/JCReqs/JCP-07-08-S1.pdf
4 Veterans Affairs National Center for Patient Safety Falls Toolkit. 2004. Available at:
http://www.innovations.ahrq.gov/content.aspx?id=2648
5 Fonda D, Cook J, Sandler V, et al. Sustained reduction in serious fall-related injuries in older people in hospital. Med J Aust. 2006;184:379-82. [PubMed]
6 Oliver D, Hopper A, Seed P. Do hospital fall prevention programs work? A systematic review. J Am Geriatr Soc. 2000;48(12):1679-89. [PubMed]
7 Quigley P, Hahm B, Collazo S, et al. Reducing serious injury from falls in two veterans' hospital medical-surgical units. J Nurs Care Qual. 2009;24(1):33-41. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: May 12, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 23, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 28, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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