The ABCs of Reducing Harm from Falls

Trinity Medical Center
Rock Island, Illinois, USA

Team

Trinity Medical Center, part of the Iowa Health System, was a participant in the RWJF/IHI Transforming Care at the Bedside Reducing Patient Injuries from Falls project.
 
The current team members working to reduce harm from falls include:
Carol Dwyer, MSN, MM, RN, Vice President Operations, CNE, President Trinity College (Senior Leader, Team Sponsor)
Jane Wiggins, BSN, RNC, Director of Women’s Services (Team Advisor)
Cindy Wage, BSN, RN, Emergency Department Staff Nurse
Prapa Black, BSN, RN, CMSRN, Medical Unit Staff Nurse
Jewels Stark, MSHCA, BSN, RN, Manager, Acute Inpatient Rehab Unit
Rachel Duffy, BSN, RN, Manager, Medical Unit
Jodi Dykema, MBA, Director, Rehab Services


Aim

In one year, reduce harm from falls beginning with a pilot unit and spread across all units:
  • Decrease the incidence of falls to a rate of no more than 2.5 per 1,000 patient days
  • Reduce the incidence of falls associated with moderate or severe injury to a rate of no more than 1 per 10,000 patient days

Measures
  • Fall rate for the hospital and pilot unit
  • Rate of moderate-to-severe harm from falls for the hospital and pilot unit
 
NOTE: Falls associated with moderate-to-severe harm includes sutures, fractures, higher level of care, and death. Falls associated with minor harm include bumps and bruises needing only band aids and ice packs. The combination of moderate-to-severe is also called “serious.”


Changes

The following changes were tested and implemented on pilot units and spread to all Trinity care units:

  • Built the belief among staff that injuries from falls can be eliminated
  • Used small tests of change to understand what changes make a difference to reducing harm from falls and how to improve implementation before spreading to additional units
  • Posted falls data monthly on care units
  • Increased the involvement of internal data analysis experts to look for opportunities
  • Consistently used a valid falls risk assessment tool
  • Identified patients at risk of injury from a fall by using the mnemonic (“ABCs”):
      • Age over 85
      • Bone disorders (e.g., metastasis, osteoporosis)
      • Coagulation disorders (e.g., bleeding, anticoagulant use)
      • Surgery (specifically thoracic or abdominal surgery or lower limb amputation)
  • Consistently communicated individualized information about patients at risk for injury from falls to all caregivers and hospital staff by:
      • Placing a red leaf-shaped icon on the at-risk patients’ doors
      • Convening staff huddles after each fall event to discuss and document the cause of the fall and ways to prevent similar falls
      • Discussing fall events and ways to mitigate risk to patients at monthly Fall Prevention Team meetings
      • All unit nurse managers attending monthly falls prevention meetings, including Trinity’s patient safety officer, the senior nursing executive, and a patient representative to develop a culture of safety
      • Using the SBAR communication technique and signaling communication handoff between caregivers with a yellow baton when they transport patients 
  • Conducted hourly comfort and safety rounds
  • Prevented falls and injuries with tools such as low beds with side rails, bed and chair alarms, one-to-one observation when necessary, non-skid slippers with treads on top and bottom, floor mats, and nurses walking patients with gait belts
  • Stocked all patient rooms with a falls prevention kit containing relevant signage, bed alarms, and other tools
  • Engaged the whole hospital using data displays on units, discussion at organizational meetings, awareness education, and safety fairs
  • Engaged ancillary staff in the process of fall and injury prevention, including handoffs between departments and assisting with identifying at-risk patients and keeping them safe
  • Incorporated more celebration into the process by recognizing units for days between falls and reducing falls and related injuries
 
The Trinity falls reduction team implemented the following to increase reliability:
  • Consistent education, auditing, and gap analysis (e.g., project leaders ensured that staff learned how to standardize comfort rounds)
  • Managers audited comfort rounds through staff observation and patient interviews during admission and after discharge
  • Project leaders integrated changes into routine work rather than creating additional tasks
 
Even before the team started the project in January 2006, Iowa Health System administrators provided nursing and physician executives with reports about fall prevention. They requested that hospital leaders ask unit staff three questions to learn how well units implemented fall prevention interventions and to reinforce their importance:
  • When was the last fall on your unit?
  • What did you learn from the event?
  • What did you change in response to the fall?


Results
Graph_Trinity_FallRate.jpg

Graph_Trinity_FallsMinorInjury.jpg

Graph_Trinity_HousewideFallRate.jpg

Graph_Trinity_FallsModerateInjury.jpg

Graph_Trinity_FallsSeriousInjuries.jpg

Summary of Results / Lessons Learned / Next Steps

Summary of Results:
  • Pilot Unit at Trinity Medical Center: Rate of Falls per 1,000 Patient Days
Although the serious injuries (moderate, major, and death) on the pilot unit are very rare, the rate of total falls and minor injuries decreased and has continued to decline. 
  • Housewide: Changes spread from the pilot unit to the local three-hospital system
During this project, the falls reduction team far exceeded the aim for reducing injuries from falls of 1 per 10,000 patient days (0.1 per 1,000 days) and although the falls have decreased, we have not reached our desired aim of 2.5 falls per 1,000 patient days. The average rate of falls across all units decreased from 2.76 before the project start to 2.59 (January 2008 to October 2008). Falls with serious injuries (moderate, major, or death) across all units decreased from 0.06 per 1,000 patient days to 0.03 in 2008.
 
  • Medical-Surgical Units: Falls with serious Injuries (including severe fractures and death) on medical and surgical units at Trinity Medical Center

Medical and surgical units overall demonstrated a decrease in serious injuries from 0.08 serious injuries per 1,000 days before the project began mid-year 2006 to 0.05 in 2008 (January to October). During the same period, the fall rate for medical-surgical units was 3.08 per 1,000 patient days.

 
Lessons Learned and Next Steps:
Sustainable change requires that standard work becomes part of the care system. Once the system is redesigned to include improvements, it was difficult to work on new fall prevention initiatives when a managerial position and several staff positions became vacant. Efforts did continue, though, because the work did not rely on any specific individual. Iowa Health System supported project momentum. Once Trinity filled its staff vacancies, changes were spread to other units.
 
We need to learn how to sustain the gains and set a more aggressive target for reducing harm from falls. It is possible to achieve a rate far less than 1 per 10,000 patient days.


Contact Information
Linda Guebert, RN, MS
Patient Safety Officer
Trinity Medical Center
guebertl@ihs.org

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