Good article on Fall Prevention:
When the Joint Commission for the Accreditation of Health Care Organizations (JCAHO) released its 2005 National Patient Safety Goals in the summer of 2004, many hospitals took note of the emphasis being placed on fall prevention. Once JCAHO made fall prevention initiatives a requirement for accreditation, facilities took action toward reducing the risk of falls on their premises.
“Each year, we revisit the safety goals to see what are currently the most important—what we’re hearing about through reporting of adverse events, what is available in terms of solutions for these events and what would be achievable in the organizations we accredit,” said Richard Croteau, M.D., JCAHO’s executive director for strategic initiatives. “The issue of falls resulting in serious harm came up in 2005—not for the first time, but it ranked higher on the priority list for certain types of organizations.”
Croteau explained that while long-term facilities were most concerned with fall risk among patients, the risk also exists at acute care hospitals, home care and all other types of health care settings. It is important, he said, that they all address the issue.
The goal, as listed in the 2005 National Patient Safety Goals, is to “assess and periodically reassess each patient’s risk for falling, including the potential risk associated with the patient’s medication regiment, and take action to address any identified risks.”
To identify these risks, Croteau said facilities must have a risk-assessment tool in place.
“The expectation is that organizations develop a screening process for looking at patients with certain characteristics that place them at high risk: certain physical disabilities, age, medications—certain types will affect a patient’s stability—as well as considering the physical environment that patients are in,” Croteau explained. “This is typically done with a brief screening assessment that’s part of a more general assessment done as the patient enters the organization.”
Croteau said that this assessment would typically be done by nursing staff when checking in a patient. Once risk is determined, a facility can then take whatever necessary steps it has determined will help either lessen the risk or lessen the harm from a fall if and when it should occur.
“Certainly, the major step is to identify the patients who are at risk. Until you do that, there’s not much you can do. Once a patient is identified as being high risk, then precautions can be taken, including providing extra assistance, placing patients in rooms designed for patients with physical limitations—anything more than the usual care that can be done in an efficient way,” Croteau added. “We’re not looking to create more of a burden for already busy nurses, but this is something that can be done efficiently and protect the patient.”
One hospital that has efficiently created a program to reduce fall risk and harm to patients is Northwestern Memorial Hospital, in Chicago, Illinois. In the first 11 months after rolling out its fall prevention initiative, called “Take a Glance,” the hospital reduced its number of falls by 20 percent. Since regrouping after the safety goals were put into place, the facility’s “Take a Second Glance” program has kept it well below the mean for both falls and injuries resulting from falls, according to Carol Payson, RN, MSN, interim director of inpatient surgical services at Northwestern Memorial Hospital.
“We worked under the assumption that all in-patients are at a risk—not just the older patients—and that all employees have a role in fall prevention—not just nurses,” Payson said. “We brought in anyone who had direct contact with patients, including physical therapists, occupational therapists, food service, housekeeping and, of course, physicians, and rolled out our program to everyone. This is a key part of our success.”
Payson explained that a multi-disciplinary task force got involved in creating the facility’s fall prevention program, which includes a computerized fall-risk assessment, based on a patient’s history of falling, prior admittance to a rehabilitation center or skilled care facility, mental status and mobility, as well as secondary risk factors, such as symptoms and diagnoses, medications and environment. Patients’ risk is reassessed every 24 hours.
The hospital also rolled out a video for nursing staff, physicians and ancillary staff, as well as senior management. In order to educate family members on fall risk, an orange sign: “Please prevent falls” is placed on the doors of high-risk patients.
“This is not done as a stigma, but as a way to generate discussion from people visiting the room about what this means for their loved one—helping them understand what we’re doing for them and educating them on what they can do,” Payson said, adding that the signs also remind staff to keep the patients’ beds in low position with wheels locked, the lighting up and the call button close to the patient. Patients determined to be high risk are also checked on more frequently.
At the 11 hospitals in the Iowa Health System, high-risk patients are monitored by frequent staff visits as well as by wristbands that designate them as high-risk. According to Gail Nielsen, Patient Safety Administrator at Iowa Health System, this is one way to improve communication across hospital units so all staff that come into contact with high-risk patients know how to accommodate them.
Nielsen explained that once a patient is determined to be at risk for falling, there are a number of precautions put into place to prevent a fall or reduce the harm that could result from one.
“There are universal precautions, such as keeping a clear pathway, keeping the call light within reach or providing assistive devices and footwear that doesn't allow them to slip and slide,” she said. “Depending on the patient, special interventions are added. We try to design them on a patient-by-patient basis.”
Since adding its fall prevention program, the Iowa Health System has seen a 19 percent reduction in falls across its 11 hospitals.
Another facility that has taken fall prevention to task is the University of Pittsburgh Medical Center, in Pittsburgh, Pennsylvania, where a Falls Committee has been established to address patients’ fall risks and strategize ways to reduce the impact of falls that do occur.
“We tried to come up with a simple admission assessment that would allow the nurses to assign a patient a rating as to whether or not they’re at fall risk,” said Cynthia Valenta, RN, MSN, clinical director of neuro and trauma services at the University of Pittsburgh Medical Center-Presbyterian Shadyside.
Valenta explained that the most important lesson is not assessing the risk, but deciding what to do with the patients after that risk is determined.
“By and large, you know the patient is at risk of falling, but how do you develop a strategy to deal with it? We found no one easy answer because you have to match the strategy to the patient,” she said.
The hospital system trialed a variety of equipment, including floor pads and soft helmets for patients at risk of falling after brain surgery and found that there’s not one method of care to treat all patients. Valenta explained that a disoriented patient at risk of falling out of bed might benefit from floor pads; for a dizzy patient, however, these same pads might be a trip hazard.
“The effort has to be toward tailoring fall prevention for the individual,” she said. “And in the future, it will be about designing hospitals and patient rooms more and more with safety in mind.”
According to the Wall Street Journal, which recently reported on the trend of patient fall prevention programs, other hospitals already have safety in mind with new innovations they’ve added to their roster of equipment, including bed alarms, non-skid footwear, hip-protecting pads and PottyCheck alarms that monitor patients at risk of falling in the restroom.
Payson said that in the near future, Northwestern plans to look into some of the new equipment available for injury prevention and possibly add it to their program. However, she also believes that the facility is already on the right track toward risk reduction.
“We’re going to look at new things and see if there are things we want to add, but we’ll continue with the oversight we have to pay attention to patients,” Payson said. “It’s nice to have equipment, but you need to have oversight at the unit level if you want patient safety to work.”
For more information on the 2005 National Patient Safety Goals, visit the JCAHO Web site