Promotion of Patient Safety Through The Implementation of Bed and Chair Alarms

Fall prevention: Applying the evidence By Kathleen Fowier, MSN, RN, CMSRN Quality Improvement Manager

UPMC St. Margaret, Pittsburgh, Pennsylvania As told to Janet Boivin, BSN, RN

S u c c e s s f u l fall pre­ vention program s use m u lti­

m odal interventions, such as detailed fall risk assessments, fre q u e n t m o n ito rin g by

staff, and a p p ro p ria te use o f equipm en t. Healthcare facilities typically im p le m e n t best practices in b un­ dles, m aking it often d iffic u lt to determ ine which in­ terventions are the m ost effective.

UPMC St. M argaret Hospital in Pittsburgh, Penn­ sylvania jo in e d the Pennsylvania Hospital Engage­ m ent N etw ork (PA HEN) in A pril 2012 to reduce falls w ith injury. This set us on a path th a t resulted in a 75% reduction in falls w ith serious injuries. (See graph.) Here is how we accom plished this reduction.

Analysis: Role of data and best practices A fte r jo in in g PA HEN, we fo rm e d a m ultidisciplinary team tasked w ith review ing and investigating all fall events, extracting and analyzing data, and evaluat­ ing best practices im p le m e n te d as a result o f root cause analysis.

Case study This case study illustrates our fall team in action

An 80-year-old fem ale p a tie n t w ith im paired cognitive function and m u ltip le risk factors— including an unsteady gait, im paired vision, and m u ltiple m edications— was assessed as a high fall risk when a d m itte d to our facility.

The nursing staff im plem ented a bed alarm to alert them when the p a tie n t was g e ttin g up w ith o u t using the call light. They also m oved her closer to the nurse's station and used purposeful rounding to anticipate and attend to her needs. The average response tim e fo r alerts w ith this p a tie n t was a rapid 10 seconds. D espite these steps, the patient's bed alarm sounded several tim es to alert staff, who fou n d her standing beside the bed.

The nurses reached o u t to the fall team fo r support. The team reviewed th e bed-alarm settings (three sensitivity settings— low, m edium , and high) and sim ulated alarm tim e studies w ith the nursing staff. Their efforts revealed m isperceptions in em ployee understanding o f bed-alarm settings. For example, the staff th o u g h t the bed alarm w ould alert them th a t the p a tie n t was o ff the p e rim e te r o f the mattress no m atter what the sensitivity setting.

The fall team used sim ulated bed-alarm scenarios to educate the staff and help to change practice. The nursing staff learned it's not enough to sim ply engage

the alarm; the alarm also needs to be at the a p p ropriate setting. The staff began using more sensitive settings fo r patients w ith im pulsive behaviors.

We learned an im p o rta n t lesson: How well em ployees understand facility equipm ent, its variations, and how to use it are im p o rta n t considerations when analyzing p a tie n t fall events.

AmericanNurseToday.com July 2016 American Nurse Today 21

The multidisciplinary fall team implemented prevalence

rounding and post fall debriefing. Despite best practice implementation, we discovered

variations and inconsistencies in our practice envi­ ronment. We found that making sense of the data collected through a revised post-fall debriefing and delivering the information to staff in an easily under­ stood format was the "magic bullet" in our success story.

Strategy: Debriefing Debriefing engages staff, patients, and families while providing educational opportunities. Our debriefing process was critical for abstracting usable data. The facilitator who is responsible for debriefing the fall event needs to have expertise in the debriefing process to ensure data integrity. He or she must be objective and promote a nonjudgmental atmosphere of inquiry. The goal is to engage all participants, in­ cluding the patient and family. A t the end of the de­ briefing, the facilitator determines root causes and shares them with team members. Identifying root causes is invaluable to the debriefing process.

Root causes are then converted into frequency charts, which are useful for analysis and clearly illus­ trate the variables with the greatest impact on partic­ ular outcomes. Our team focused on tangible root causes, such as safety equipment, which proved suc­ cessful in reducing falls in our facility. (See Case study.)

Multiple bed manufacturers and sensitivity variations of bed alarms; lack of standardization

If staff is not familiar with a particular type of bed, they're less likely to use the equipment properly, if at all. We educated staff so they would develop an awareness of variations and use bed alarms correctly.

Insufficient ratio of bed alarms to chair alarms

A patient who needs an alarm when in bed also needs one when sitting in a chair. So we added a chair alarm* in each room to ensure our fall prevention efforts were consistent.

Lack of available or accessible equipment

If equipment is not available or accessible, staff won't use it. We streamlined the process for obtaining equipment. For example, disposable pads used with the chair alarms were stocked in each department.

Variations with the nurse call system bed/chair alarm alerts

The multidisciplinary team collaborated to standardize visual and auditory alerts that resulted in improved alarm response times.

‘ M anufa ctu re d by Posey

Outcomes: Falls reduction In the first year of our initiative, we had a 50% reduc­ tion in falls with injuries and won the 2013 Hospital

Strategy: Enhancing equipment use Commonly used fall prevention equipment includes bed alarms, chair alarms, low beds, floor mats, and nurse call system/alarm integration. Based on its analysis of various types of falls and process-improve­ ment initiatives, the team put interventions in place that essentially resolved identified equipment issues.

Association of Pennsylvania Achievement Award for Patient Safety.

We've achieved the following reductions over the past 4 years: • 75% reduction in falls that resulted in serious injuries • 60% reduction in falls that resulted in injuries • 25% reduction in all falls.

Our ability to sustain these improvements keeps patients safer during hospitalization.

This is the first in a series o f three case studies illustrating success stories in preventing falls and injuries from falls. The series is brought to you by Posey (http://www.posey.com). Watch fo r the next case study in the September issue of American Nurse Today.

22 American Nurse T o d a y Volume 11, Number 7 AmericanNurseToday.com

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