Falls remain the most commonly documented adverse event in the hospital setting.
Patient falls are another “never event” for which the Centers for Medicare & Medicaid Services (CMS) decided 2 years ago it would no longer reimburse hospitals. According to Janette S. Nazareno, RN, BSN, OCN, and Alison Gardner, AOCNS, PhD, of the University of Texas M.D. Anderson Cancer Center in Houston, despite CMS’ action in 2008, falls remain “the most commonly documented adverse event in the hospital setting” and result in injury one-third of the time. Many institutions in the United States have been examining ways to reduce not only the number of falls but also the harm they cause to patients. At the 35th Oncology Nursing Society (ONS) annual congress, nurses from two different institutions presented research designed to contribute to our understanding of falls in an effort to combat them.
Program Reduces Falls by 20%
Nazareno and Gardner were concerned about falls in their leukemia unit at M.D. Anderson, which had been averaging 2.4 per month in 2006. With input from staff on the unit, they developed and implemented a tool to assess the risk of falls and a new system for reporting falls. Then, they tracked its effectiveness and randomly audited the staff for compliance with the program.
Beginning in April 2008, whenever a patient fell, the attending nurse was required to interview the patient, family, and any witnesses to the fall and record the data on the new form. Nazareno and Gardner monitored the data and used it to identify the most common reasons for falls on the leukemia unit. From January to October 2009, the most frequent causes of falls were patient weakness and use of diuretics or medications with a sedating effect. They found that 68% of patients who fell had received sedating medication within 8 hours of the incident. Approximately three-quarters (74%) of patients who suffered a fall were aged >60 years. In addition, the vast majority of falls (89%) occurred in the 12 hours between 7 AM and 7 PM.
The data compiled is routinely shared with staff members, who collaborate to develop strategies for preventing falls. Some of the interventions they have devised include risk assessments and educational programs for patients and employees. The authors describe “full fall precaution” as comprising hourly safety checks and documentation, a red stop light sign on the patient’s door, use of a yellow wrist band, a “Call Don’t Fall” sign placed inside the room, and use of a bed alarm. When auditing staff for compliance with these measures, the most common failure was activating the bed alarm.
Nazareno and Gardner said from January through October 2009, the unit averaged 1.9 falls per month, “an approximately 20% decrease” from when data were first collected. They plan to continue using the post-falls data collection tool.
Specific Interventions Cut Falls with Injury from 36% to 0%
The second study, led by Michelle Kasprzak, RN, BSN, OCN, at Duke University Hospital in Durham, North Carolina, focused on fall prevention on an inpatient medical oncology unit. At every quarterly assessment for 1 year, Kasprzak and colleagues found that the number of falls on the unit exceeded their goals. Falls, the authors said, “impact length of stay, quality of life, discharge planning, and nurse-patient relationships.” In addition, the authors said the financial burden the institution incurs from treating falls places it ability to continue delivering quality care in jeopardy.
The hospital established a Falls Reduction Task Force, which analyzed 12 months of data on patient falls to identify causes. They also audited staff to identify any gaps in adherence to fall prevention measures. Staff failed to perform safety checks 32% of the time and 32% of patients’ rooms had obstructions on the path to the bathroom.
The Task Force instituted a mandatory interactive education program that instructed staff on CMS criteria and fall risks in cancer patients and showed them videos depicting correct and incorrect safety checks. At 1 month, 60% of patients reported that pain, restroom needs, and requests for personal belongings were being addressed. Only 12% said they were not asked if they needed to use the bathroom. Another 20% said personal belongings were not placed within reach.
In an audit of the staff members’ practices, 40% of patient interactions did not include the patient’s involvement in a safety check or ensure that a staff member would return within 2 hours. Two falls occurred when patients were left alone in the bathroom.
The Task Force decided they needed more focused interventions and examined the literature to compile fall prevention practices, which they ranked according to their feasibility. They developed an evidence-based campaign that included pins with slogans designed to increase awareness of fall prevention among the staff and patients. They also created an outline of shared team responsibilities, better systems for patient calls and alarms for leaving bed, and greater effort to involve patients in safety checks. In a subsequent step, monthly goals were set, including leaving no patient unattended in the bathroom, offering toileting every 2 hours, ensuring patients could reach personal items, and promising to return in 2 hours to mitigate the likelihood that the patient would try to help themselves and risk a fall.
Since these additional measures were implemented, the unit has not experienced any falls resulting in injury; previously, 36% of falls resulted in injury. The unit has also achieved its year-to-date target in incidence of falls and the rate of falls overall has declined, coming closer to the national average.
The authors concluded that simply rolling out an education program is not sufficient to produce long-term changes. “Sustainable practice change takes time and focused endeavors,” they said. The Task Force uses positive reinforcement, celebrating sustained improvements and communicating with the staff monthly on achievements. They have created an orientation program to educate new oncology nurses on the unit on falls prevention and continue to have a one-on-one debriefing after each fall.
These studies demonstrate that while it is difficult to prevent falls entirely on oncology units, the implementation of standard procedures, staff and patient education programs, and monitoring for compliance contribute to lower rates. Developing effective tools for preventing falls requires documenting and investigating the cause of every fall on the unit to identify factors or behaviors that place patients at greater risk.