I N T RODU C T ION

Falls of hospitalized older adults can be serious and have potentially life threatening consequences for patients. Each year, somewhere between 700,000 and 1,000,000 people in the United States falls in the hospital (6). Of those who fall, 20% to 30% suffer moderate to severe injuries that impair mobility and increase risk of early death(2). U.S. hospitals demonstrated that 38%-47% of falls were associated with toilet-related activities that occurred in the bathrooms (5). According to the U.S. Centers for Disease Control and Prevention one-third of Americans aged 65+ falls each year (2).

I DE N T I F IC AT ION OF N E E D

The journey to reduce falls and injuries began with creation of a Fall Prevention Committee in 2012. Data analysis identified that more than 40% of all falls occurred while patients were trying to get to the toilet, return from the toilet or while trying to exit the bed to get to the toilet. It became evident that the existing program did not ensure a “nurse driven” team approach to fall prevention. Furthermore, “Hourly Rounding” evaluation at the unit level revealed gaps in staff knowledge. These factors suggested a need to redesign the existing fall prevention program through adopting best practices with specific nursing interventions to minimize the risk of falling.

Upon evaluating the fall prevention program, the following goals were identified:

1. Decrease incidence of falls2. Decrease severity of injuries from falls3. Decrease incidence of falls related to toileting

The following changes to practice were proposed:

1. Use the Hendrich II Fall Risk Assessment Tool a. Apply interventions based on assessment 2. Implement Purposeful Rounding3. Develop Stay With Me Program

M ET HOD S

The purpose of this observational study is to describe the effectiveness of a nursing quality improvement (QI) activity for a fall prevention program, with particular focus on specific evidence-based nursing interventions to minimize the risk of patient falling. In August of 2014, Maimonides Medical Center started a “change champion team” inclusive of a group of individuals with an interest in fall prevention. The team consists of frontline nursing and leadership team representatives. The goal of this team was to explore and adopt innovative practices that could result in a decrease in falls. A clear vision of fall prevention awareness including capacity, capability, and sustainability was established.

I M PL E M E N TAT ION

A stepwise approach to decreasing inpatient falls and falls due to toileting was proposed. With the patient experience paramount, the goal is reduction in fall-related patient harm while anchoring purposeful rounding behaviors, embedding a targeted toileting schedule and implementing “Stay With Me” guideline. The roll out of the restructured fall prevention initiative began as a pilot program on one medical unit where the process was readily embraced by GRN champions. Through education, frontline nurse involvement, and redesigning fall prevention approach, hourly rounding was promoted as a proactive falls prevention strategy with the goal of decreasing falls and, patient safety, health, and comfort promotion.

C ONC LU SION S

Early results of this performance improvement initiative have shown that direct care nursing staff making purposeful point-of-care rounds will experience positive outcomes in preventing patient falls. Results suggest that fall prevention is complex, and careful planning, implementation, and evaluation are required for successful nursing practice change. These findings suggest that all frontline nursing staff should be properly educated and trained on proactive fall prevention initiatives to anticipate hospitalized older adult needs. Team engagement and staff buy-in are critical to successful implementation and compliance with the policy!

References:1. Berg, K., Sailors, C., Reimer, R., O’Brien, Y., and Ward-Smith, P. (2011). Hourly rounding with

a purpose. Iowa Reporter, 24(3), 12-14.2. CDC - Older Adult Falls - Falls Among Older Adults: An Overview - Home and Recreational

Safety - Injury Center. (n.d.). Retrieved from http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html

3. Degelau, J., Belz, M., Bungum, L., Flavin, P. L., Harper, C., Leys, K., Lundquist, L. (2012). Prevention of Falls (Acute Care). Institute for Clinical Systems Improvement. Retrieved from https://www.icsi.org/_asset/dcn15z/Falls-Interactive0412.pdf

4. Deitrick, L, Baker, K., Paxton, H, Flores, H., and Swavely, D. (2012). Hourly rounding: challenges with implementation of an evidence-based process. Journal of Nursing Care Quality, 27(1), 13-19

5. Krauss, M.J., Evanoff, B., & Hitcho, E. (2005). A case-control study of patients, medication, and care-related risk factors for inpatient falls. Journal of General Internal Medicine, 20(1), 116-122

6. Overview | Agency for Healthcare Research & Quality (AHRQ). (n.d.). Retrieved from http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtkover.html#Problem

7. Tzeng, H. (2010). Understanding the prevalence of inpatient falls associated with toileting in adult acute care settings. Journal of Nursing Care Quality, 25(1), 22-30. Retrieved from http://dx.doi.org/10.1097/NCQ.0b013e3181afa321

Redesigning Fall Prevention ProgramB u i l d i n g o n t h e E v i d e n c e

Behavior Validation Pre-Implementation Post-Implementation Explain the purpose of hourly rounding at initial visit 13.3% 100% Describe purposeful rounding schedule 26.7% 100% PAIN 53.3% 100% POSITION 73.3% 100% POTTY 13.3% 100% POSSESSIONS 73.3% 100% Communicate when you will return 33.3% 100% Is there anything else that I can do for you? 46.7% 100%  

PDSA cycles were used to implement and anchor changes to the fall prevention program. One cycle used the simulation laboratory to observe previous practice with hourly rounding. After going through the initial simulation, the participant and facilitator debriefed to review the difference between hourly rounding and purposeful rounding as well as the expected behaviors.

The table below reveals that the previous practice of hourly rounding did not ensure that the core patient needs associated with rounding were adequately addressed. After debriefing, all participants (nurses and patient care technicians) were able to develop the language and dialogue to address care behaviors with Purposeful Rounding.

R E SU LT S

The fall prevention program evaluation was based on the following measurements

• Falls per 1,000 patient days• Injury falls per 1,000 patient days• Incidence of falls related to toileting

A process change on one pilot medical unit was effectively implemented. At the start of educational and simulation sessions for purposeful rounding, a decrease in patient falls, injuries related to falls, and incidence of falls related to toileting became evident. This decline was likely not entirely related to the revised rounding practice and testing out “Stay With Me” on the pilot unit. Key program elements such as integrating Hendrich II fall risk model, assessment-related interventions, and early ambulation initiatives had previously been implemented. However, falls related to toileting was sustained at zero (0) per 1000 patient days for three months after initiation of changes to the program.

Viktoriya Fridman – RN, MSN, ANP-BC • Dorothy Jean Graham-Hannah, MPA, MSN, BSN, RN, BC • Dexter Asido, RN, BSN • Michelle Cruickshank, RN, BSN • Barbara Donovan, RN, BSN • Luis Medina, RN, MSN, FNP

Success of the program requires a paradigm shift from “falls happen” to “falls are preventable.” This program provided the opportunity to develop fall prevention champions inclusive of Geriatric Resource Nurses to lead the way towards Zero Falls. However slow, the progress has begun.

Dexter Asido, RN

Michelle Cruickshank, RN

Yolanda Ambrosio, RN

Tzvya Lederman, RN