FALLS ARE the leading cause of both fatal and non-fatal injuries among Americans 65 and older.1 These incidents are also costly for hospitals and other healthcare institutions, which are financially responsible for inpatient falls. To address a recent spike in falls, nursing leadership within a moderately sized, 194-bed acute care military treatment facility (MTF) in the Pacific engaged the Center for Nursing Science and Clinical Inquiry (CNSCI) in the summer of 2016 to help find any trends or common themes related to patient falls and introduce new practices that could help curb the problem.
The CNSCI's findings were surprising: Instead of creating new practices, the treatment facility needed to reinforce compliance with those already in place. This article discusses what shortcomings the investigation uncovered and how the findings were applied to improve nursing practice.
Launching an investigation
The CNSCI, which aims to enable nurses to discover, generate, and evaluate research and use evidence-based methodologies to inform best practice in every care environment,2 sent two PhD-prepared nurse scientists and two master's-prepared clinical nurse specialists to help with the investigation. This team first completed a thorough assessment of both the existing policies and practices of nursing staff related to reducing falls and better understanding the conditions possibly leading to the recent increase in falls.
The initial step was to validate institutional policies by reviewing the nursing literature related to inpatient falls. This search confirmed that the organization's fall policies and procedures reflected current national recommendations, guidelines, and U.S. Army Medical Command (medcom) policy.
National recommendations direct organizations to use a valid and reliable fall risk assessment tool, initially assess fall risk, regularly reassess fall risk, establish environmental interventions to create a safe environment, customize interventions for patients, and individualize interventions for patients at a moderate to high risk of injury (see The Joint Commission's recommendations on falls prevention).3-5 As mandated by medcom regulations, this facility utilizes the Johns Hopkins Fall Risk Assessment Tool to assess a patient's risk for falling. Per hospital policy, nurses must assess fall risk within 4 hours of admission, during each shift assessment, whenever the patient's condition changes, upon transfer to another unit, and any other time a staff member feels reassessment is necessary.6 For patients who score within the medium-to-high risk categories, nursing staff are required to apply a yellow "Fall Risk" armband, place a standardized falling star visual cue card on the patient's door to communicate fall risk to all care providers, place nonslip yellow socks on the patient's feet, and initiate appropriate nursing interventions based on the fall risk score. Beyond these standards, the organization had responded to the increase in fall incidence by mandating the use of a bed alarm for patients at high risk for falls.
The question then asked was this: If the institutional policy is based on best practice and if that policy is being followed, why are patients still falling?
Conducting a one-day prevalence assessment
Before considering new interventions to prevent falls, the team decided to verify nursing compliance with the current policy and procedure related to fall risk. To do this, the team conducted an unannounced one-day prevalence assessment of all patients within the facility. All adult inpatient medical records were reviewed to verify assessments, per protocol, and nurse-initiated orders were activated. This was followed by a direct observation audit verifying that fall interventions for patients with moderate or high fall risk correlated with interventions prescribed by the fall policy. To evaluate patient education, patients were interviewed to determine their knowledge of their fall risk, interventions implemented, and use of the nurse call light.
The audit, which focused on compliance with the four aspects of the facility's existing policy, included 123 patients. Of these patients, 81 (65%) were assessed as being a moderate or high fall risk. The following findings were revealed:
* Appropriate nursing interventions had been initiated for 72% (58 patients).
* Of all patients considered at a moderate-to-high fall risk, 79% wore armbands, 76% wore yellow socks, and 70% had the falling star applied to their doors.
* Of patients at high fall risk, only 44% (11 patients) had activated bed alarms in place as mandated by facility policy.
These results indicated that overall compliance with all four items was 74.4%.
Interviews with patients revealed fall risk education provided varied considerably. Information given to patients regarding their fall risk status, interventions implemented on their behalf, and measures they could take to reduce their risk of a fall was inconsistent or not provided.
Conclusions and remedies
This one-day compliance audit highlighted several deficiencies in nursing practice. Conversations with nurses and patient safety staff led the team to suggest that nonadherence with existing policy standards may have contributed to the increase in falls. Additionally, a lack of relevant patient education delivered consistently and in a way the patient could comprehend, act on, and reinforce was identified.
Identifying the lack of consistency in both policy and procedure compliance and education provided may reflect on staff turnover and leadership engagement. To address these issues, executive and midlevel leaders were first educated about the results of the audit, and staff were reeducated on requirements of existing policy and procedure. This also served as the launch for a standardization of all patient education using the "teach-back" method.
The organization experiences a high rate of turnover due to the composition of staff and organizational mission. This high rate of turnover is also seen at the middle management level. In many facilities, not just in MTFs, leaders lack experience. Unit-based managers can be sidelined by the trappings of daily operations and staff issues. Highlighting the deficiencies of staff in following established processes provided an opportunity to educate novice leaders about the importance of directly evaluating the clinical practice of their staff.
The journey toward becoming a high-reliability organization (HRO) and creating a culture of safety begins with consistency and reliability across an organization.7 Healthcare organizations that embrace HRO principles strive for consistency across processes such as compliance with established policy and procedure. Eliminating variance and improving compliance with current fall prevention policies will likely decrease the number of falls.
Problematic outcomes such as an increase in fall incidence could indicate flawed policies or shortcomings in staff adherence. In this case, a thorough baseline assessment revealed variability in complying with existing policies and procedures related to knowledge deficits, nursing practice inconsistencies, and lack of leadership engagement.
This audit helped the hospital avoid expending resources to implement something new in response to the spike in falls. Instead, efforts were refocused on compliance with existing policies. Further, ongoing audits to ensure compliance have been the largest contributor to 18 months of decreasing fall rates.
The Joint Commission's recommendations on falls prevention
* Lead an effort to raise awareness of the need to prevent falls resulting in injury.
* Establish an interdisciplinary falls injury prevention team or evaluate the membership of the team in place.
* Use a standardized, validated tool to identify risk factors for falls.
* Develop an individualized plan of care based on identified fall and injury risk, and implement interventions specific to a patient, population, or setting.
* Standardize and apply practices and interventions demonstrated to be effective, including a standardized handoff communication process and one-to-one education of each patient at the bedside.
* Conduct postfall management, which includes a postfall huddle; a system of honest, transparent reporting; trend research and analysis of falls, which can inform improvement efforts; and reassessing the patient.
Source: The Joint Commission. Preventing falls and fall-related injuries in health care facilities. 2015. http://www.jointcommission.org/assets/1/18/SEA_55.pdf.
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