Help I Have Fallen! What Could Have Have Prevented This?

Christina Bolster

P – high acuity patientsI – bed alarms C – in comparison to patient sitter monitoring O – decreased risk for patient falls

Clinical Problem

48% at high risk for falls

The number one reported adverse event in hospital

The cause of multiple complex complications The leading cause of death in patients 65 and

older

$13,316 per fall 85 billion per year

Significance of Problem

Safety Quality Improvement

Relationship to QSEN to Problem

Study of 362 PatientsNurse InterviewsFinancial CostAlarm FatigueFalse Alarm

Bed Alarms

Pennsylvania Study 54, 289 falls 323 with sitter present

Other research journalsDifficult to implement as an intervention

Expensive

Patient Sitters

Patient fall during commode - bed transfer

Risk factorsOutcome

Broken Back Extended Hospital Stay

Patient sitter

Case Example

Bed Alarms or Patient Sitters? Neither… and Both

Multifactorial Programs 58.3% reduction in falls, and $776,064 reduction in costs

More Research Larger randomized trials Discover a singular intervention

Education Basic Training Continuing Education

It is up to us!

Conclusion/Implications for Practice

Brush, B., Capezuti, E., Lane, S., Rabinowitz, H., & Secic, M. (2009). Bed-exit alarm effectiveness. Arch Gerontol Geriatr, 49(1), 27-31. doi: 10.1016/j.archger. 2008.04.007Costantinou, E., Gabbart, P., Limbaugh, C., Rensing, K., & Wolf, L. (2013). Fall prevention for inpatient oncology using lean and rapid improvement event techniques. Health Environments Research & Design Journal, 7.1, 85-101.Daniels, K. (2014). Fighting bed alarm fatigue in orthopedic units. Nursing, 44(9), 66-68. doi: 10.1097/01.NURSE.0000453007.17772.ecDavis, S., Hubbartt, B., & Kautz, D. (2011). Nurses’ experiences with bed exit alarms may lead to ambivalence about their effectiveness. Rehabilitation Nursing, 36.6, 196-199.Dodd, K., Hill, K., Phillips, B., & Wong Shee, A. (2014). Feasibility, acceptability, and effectiveness of an electronic sensor bed/chair alarm in reducing falls in patients with cognitive impairment in a subacute ward. Journal of Nursing Care Quality, 29(3), 253-262. doi:10.1097/NCQ.0000000000000054Duong, T., George, A., & Johnson, M. (2011). Analysis of falls incidents: Nurse and patient preventative behaviors. International Journal of Nursing Practice, 17(1), 60-66. doi: 10.1111/j.1440-172X. 2010.01907.xFeil, M., & Wallace, S. (2014). The use of patient sitters to reduce falls: Best practices. Pennsylvania Patient Safety Authority, 11(1), 1-14.Harding, A. (2010). Observation assistants: Sitter effectiveness and industry measures. Nursing Economics, 28(5), 330-336. Hilsenbeck, J., & Trepanier, S. (2014). A hospital system approach at decreasing falls with injuries and cost. Nursing Economics, 32.3, 135-141.Kueny, A., Mackin, M., Shever, L., & Titler, M. (2011). Fall prevention practices in adult medical surgical nursing units described by nurse managers. Western Journal of Nursing Research, 33(3), 385-397. doi:10.1177/0193945910379217

Bibliography