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Fall Prevention in an Acute Care Setting

Falls prevention program presentation

Evidence-based practice proposal

Alyssa N. Jolicoeur rn, BSN, cen

Grand canyon university

September 12th 2018

Objectives:

Discuss how to determine the organizational culture and readiness

Discuss the problem of falls in an acute care setting (problem description)

Discuss the foreground question

Discuss the supporting literature and how it applies to the problem

Discuss the solution to the problem as found in research

Learn about the change model for successful implementation of evidence-based practice (EBP)

Discuss the plan of implementation of this proposal

Discuss the plan of continuing evaluation for quality improvement

Organizational Culture and Readiness

Determining an organization’s willingness and readiness for change is vital for success.

Seven elements to an organizations culture (Glaser & Associates, 2018)

Teamwork

Morale

Information Flow

Employee involvement

Supervision

Meetings

Customer Service

This Photo by Unknown Author is licensed under CC BY

Without enough readiness, a new practice change will ultimately fail if not instituted into an organization properly. When instituting something new into an organization determining whether they are ready will only help success. The person that is initiating the change or proposal should analyze these seven different elements. The educators should give a clear picture to the organization and it’s employees a their strengths and weaknesses (Glaser & Associates, 2018).

Organizational Readiness

Strengths

Teamwork

Supervision

Customer Service

Meetings

Weaknesses

Morale

Informational Flow

Employee engagement

Communication

The employees perceive the institution to be trustworthy, fair, consistent and for the most part management and employees create a team approach to their relationship (Glaser & Associates, 2018).

The hospital does work on transparency, however not all the information travels to all. Most departments do not cross and know how the others work although it is noticed to be a problem and leadership is actively working on the issue. Morale seems to be a problem at our facility as it is in most. Employees do feel respected however there is an element where motivation is lacking and have a small amount of being unproductive.

With improved employee engagement, productivity will improve, therefore improving the patient experience and employees more actively engaged will be more apt to implement changes successfully.

Problem Description

According to the Agency for Healthcare Research and Quality (2018), about 700,000 to 1,000,000 patients admitted to hospitals fall each year.

Most falls can be prevented, and clinicians have an obligation to not only treat the patient’s cause for admission but also keep that same patient safe (Dykes, et al., 2010).

Healthcare institutions increase the risk for patients to fall due to their treatments, illness, and being in an unfamiliar environment (Dykes, et al., 2010).

The Centers for Medicare and Medicaid Services (CMS) limit reimbursement for injuries that happen to a patient while admitted (Agency for Healthcare Research and Quality, 2018).

Patients that are admitted to the hospital or an acute care setting are at great risk to fall causing injuries or even death.

“Older adults are more likely to be injured from a fall. Injurious falls increase hospital costs and lengths of stay” (Dykes, et al., 2010, p. 2).

After a fall, patients could develop a fear of falling again creating a decrease in their mobility through a loss of function and increase their morbidity (Dykes, et al., 2010).

Fall prevention is a major concern for the healthcare system and because nurses are at the forefront of patient care and spend a great amount of time with patients, they are principally responsible for executing patient safety and fall prevention procedures within acute care settings (Avanecean, Calliste, Contreras, Lim, & Fitzpatrick, 2017, p. 3008).

Problem Description (cont.)

“Multifaceted causes for inpatient falls require a multipronged approach to reduce risk of falls, especially in patients with longer hospital stays” (Rheaume & Fruh, 2015, p. 320).

There is research that suggests effectiveness of fall risk tools and fall prevention programs will help prevent a patient from falling in the future and preventing injury or death.

Research suggests that prevention is key, and most falls can be preventable (Agency for Healthcare Research and Quality, 2018).

Establishing a multidisciplinary team for falls prevention will only prove beneficial to refine interventions and prevent systems to decrease the causes of inpatient falls (Morris & O'Riordan, 2017).

The expected outcome of this proposal would be that implementation of a fall risk assessment tool in conjunction with a multifunctional fall prevention team will reduce this risk of falling.

Foreground Question

In adults admitted to an acute care facility, how does solely utilizing a fall risk assessment tool compared to instituting a fall risk prevention program affect fall rates and injuries or death during admission?

1. The clinical question is what the best way is to assess a patient for their risk for falling and how to prevent those falls with a goal being decreased length of hospital stay, improved patient outcomes, improved mobility for patients, and ultimately improving the quality of care being provided by these institutions.

Literature Support

Several studies were found that were valid, applicable, and reliable.

The studies were all evaluated for inclusion and exclusion criteria.

28 studies were used to support the problem and foreground question and through screening five articles were found appropriate for the inclusion criteria.

A literature search was conducted electronically using databases such as Cochrane Database of Systemic Reviews, CINAHL, Ovid, Medline, and the Grand Canyon University Library.

The search keywords that were used for the study search were falls, fall prevention, fall risk assessment, fall prevention interventions, acute care hospitals, fall prevention program.

Inclusion criteria is “essential characteristics specified by investigator that potential participants must possess to be considered for the study” (Melnyk & Fineout-Overholt, 2015, p. 606).

Literature Support (cont.)

(Lim & Yam, 2016)

Quantitative, descriptive, cross-sectional research design

From Private Hospital over 2 months

Convenience Sampling techniques

(Morello, et al., 2017)

Large multi-site randomized control trial (RCT)

Daily bedside observation, medical records, resource utilization diaries, and nurse surveys (Morello, et al., 2017).

12 acute wards (medical and surgical) from six public hospitals (Morello, et al., 2017)

(Barker, et al., 2017)

Multi-centre mixed method study in accordance with COREQ guidelines

From 24 acute wards (16 medical and 8 surgical) utilizing program evaluations with focus groups and interviews

Nurses who worked on the wards for greater or equal to 7.5 hours a week (Barker, et al., 2017)

(Lim & Yam, 2016) Nurses needed further education regarding the purpose and competency in the use of the Morse Fall Scale and a more structured training and education program is needed for the prevention of patient falls.

(Morello, et al., 2017) Implementation fidelity was enough in the utilization of the 6-PACK and it is unlikely that falls were due to lack of fidelity.

(Barker, et al., 2017) Staff believed suitable and beneficial way to assist them to reduce falls.

Literature Support (cont.)

(Tzeng & Yin, 2017)

Exploratory, cross-sectional study

Five non-profit health systems, 68 critical care, step down, and noncritical acute care units of adult inpatients (Tzeng & Yin, 2017).

Nurses working with direct patient care for at least 12 months prior to the survey and at least 20 hours per week

(Breimaier, Halfens, & Lohrmann, 2015)

Before and after mixed-method design used within a participatory action approach (Breimaier, Halfens, & Lohrmann, 2015).

Surgery Center in a teaching hospital using questionnaire, guided group discussions, and semi-structured interviews at the beginning, middle, and end of the project (Breimaier, Halfens, & Lohrmann, 2015).

(Tzeng & Yin, 2017) Need to address priorities of resource allocation making interventions feasible and available to staff.

(Breimaier, Halfens, & Lohrmann, 2015) “multifaceted strategies tailored to the specific setting within a participatory action research (PAR) approach and guided by the CFIR enabled the effective implementation of a clinical practice guideline (CPG) into acute care nursing practice” (Breimaier, Halfens, & Lohrmann, 2015, p. 10).

These studies are more than enough to answer the clinical question.

Solution Description

The 6-PACK falls prevention program includes completing a fall-risk tool to be done by the nurse daily while the patients is admitted (Morello, et al., 2017).

The research provides a conclusion that implementation of the 6-PACK falls prevention program is successful when adherence by nursing staff is done.

This study also implies that staff would need leadership support, education, and continued audits for quality improvement regarding adherence to the program (Morello, et al., 2017).

This program is inclusive of a fall risk assessment to determine the severity of the risk for a patient to fall while being admitted. After the assessment, interventions should be done based on the patient’s severity.

The expected outcome of this clinical questions is to have a reduction in patient falls in the population of admitted patients. This will improve the reimbursement to the hospital from the Centers for Medicare & Medicaid Services (CMS).

Methods to achieve this outcome is to provide education and training to the nursing staff and to provide instructional guidelines as to the importance of the program.

Change Model

Rogers’s Diffusion of Innovations is a change model that is used by healthcare organizations to use for implementation of evidence-based practice (EBP) (Melnyk & Fineout-Overholt, 2015).

Innovators

Early Adopters (Instrumental in facilitating change)

Early Majority

Late Majority

Laggards

The premise of this change model is how individuals adopt innovation and they are labeled as innovators, early adopters, early majority, late majority, and laggards (Melnyk & Fineout-Overholt, 2015).

Innovators are people in your organization that are ready for change and recognize the opportunities (Melnyk & Fineout-Overholt, 2015).

Early Adopters, “These are individuals who are highly influential in organizations and encourage others to adopt innovations” (Melnyk & Fineout-Overholt, 2015, p. 322).

The early majority group of Rogers’s Diffusion of Innovation are followers (Melnyk & Fineout-Overholt, 2015).

Laggards, These people are traditional and have difficulty with change although they eventually will adopt the change it may be prolonged (Melnyk & Fineout-Overholt, 2015).

Implementation Plan (1st phase)

This program will be implemented for patient safety and to improve quality of care provided.

Senior leadership will be essential in this program to provide support both fiscally and managerially (Melnyk & Fineout-Overholt, 2015).

The time needed to complete this project will be at least a minimum of 6 months and may take up to 9 months for proper implementation.

“Multilevel support for integration of EBP into curricula is imperative. Administrators, educators, librarians, and learners are key stakeholders in this initiative” (Melnyk & Fineout-Overholt, 2015, p. 339).

Technology will be utilized for education to implement this program. “In the IOM report, Educating Health Professionals to Use Informatics (2002), informatics is described as an enabler that may enhance patient-centered care and safety, making possible EBP, continuous improvement in quality of care, and support for interdisciplinary teams” (Melnyk & Fineout-Overholt, 2015, p. 340).

Implementation Plan (2nd Phase)

The second phase of this timeline will be to educate the staff both nursing and ancillary staff on the completion of the fall risk assessment and the intervention needed for the falls prevention program.

A power-point presentation will be uploaded onto the learning drive with a test of understanding and staff will be given a time frame of one month for completion.

Once the project is successfully educated and initiated ongoing monitoring will take place for quality improvement.

The education will be completed using informatics through an education learning drive and this will be the most efficient manner to educate within a reasonable time.

“To know if the change to evidence-based curricula was effective, the transition requires focused evaluation. This could be part of ongoing quality improvement of the EBP integration” (Melnyk & Fineout-Overholt, 2015, p. 355).

Continuing Education and Quality Improvement

Implementation of this plan would need to be continually evaluated for effectiveness. The monthly meetings of the multidisciplinary team will be convened to maintain this effectiveness.

Quality improvement initiatives are vital to the success of any change proposal. The impact of studies is very important to measure the outcomes for the effectiveness of quality instead of quantity (Melnyk & Fineout-Overholt, 2015).

The results will be evaluated for validity including accurate, appropriate, and reliable information. The methods of evaluation are to be clearly described and if the measures appropriate. The statistical and clinical significance of the number of falls and the method of evaluation (Melnyk & Fineout-Overholt, 2015)

“Evaluation of outcomes be conducted in a manner that is valid and reliable. These outcomes must be accessible to healthcare leadership as well as to the point-of-care providers to increase the likelihood that all those in healthcare engage” (Melnyk & Fineout-Overholt, 2015, p. 233).

The method of collecting data for the falls prevention program will be auditing and measuring the number of falls as well of the reasons for the falls. “It is important that evaluation of outcomes be conducted in a manner that is valid and reliable” (Melnyk & Fineout-Overholt, 2015, p. 233).

Implications for Future Practice and Research

The future of practice should be considered, and changes need to be made to reflect health care changes.

Health care continues to change, and health care practice should change. If the falls prevention program does not work for this organization and population, then further research should be conducted for evidence-based practice. The clinical question may need to be re-evaluated.

1. If the outcomes do not provide positive results, then the falls prevention program will be re-evaluated for effectiveness. The individual falls will be evaluated to see if the fall was a direct result of the program implementation. If the fall was indeed a result of the falls prevention program, then perhaps then certain elements of the program should be evaluated by the multidisciplinary team.

References

Agency for Healthcare Research and Quality. (2018, July). Preventing Falls in Hospitals. Retrieved from Agency for Healthcare Research and Quality: https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html

Avanecean, D., Calliste, D., Contreras, T., Lim, Y., & Fitzpatrick, A. (2017). Effectiveness of patient-centered interventions on falls in the acute care setting compared to usual care: A. Joanna Briggs Institute, 15(12), 3006-3048. doi:10.11124/JBISRIR-2016-003331

Barker, A. L., Morello, R. T., Ayton, D. R., Hill, K. D., Brand, C. A., Livingston, P. M., & Botti, M. (2017). Acceptability of the 6-PACK falls prevention program: A pre-implementation study in hospitals participating in a cluster randomized controlled trial. PLOS One, 1-15. doi:10.1371/journal.pone.0172005

Breimaier, H. E., Halfens, R. J., & Lohrmann, C. (2015). Effectiveness of multifaceted and tailored strategies to implement a fall-prevention guideline into acute care nursing practice: a before-and-after, mixed-method study using a participatory action research approach. BMC Nursing, 14(18), 1-12. doi:10.1186/s12912-015-0064-z

References

Centers for Medicare & Medicaid Services. (2018). Hospital-Acquired Condition (HAC) Reduction Program. Retrieved from Centers for Medicare & Medicaid Services: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HAC/Hospital-Acquired-Conditions.html

Dykes, P. C., Carroll, D. L., Hurley, A., Lipsitz, S., Benoit, A., Chang, F., . . . Middleton, B. (2010). Fall Prevention in Acute Care Hospitals. Journal American Medical Associates (JAMA), 304(17), 1912-1918. doi:10.1001/jama.2010.1567

Glaser & Associates. (2018). Organizational Culture Survey. Retrieved from Glaser & Associates: https://www.theglasers.com/organizational-culture-survey.html

Lim, S. G., & Yam, S. W. (2016). The level of knowledge and competency in the use of the Morse Fall Scale as an assessment tool in the prevention of patient falls. International E-Journal of Science, Medicine & Education, 10(3), 14-23.

References

Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Morello, R. T., Barker, A. L., Ayton, D. R., Landgren, F., Karnar, J., Hill, K. D., . . . Stoelwinder, J. (2017). Implementation fidelity of a nurse-let falls prevention program in acute hospitals during the 6-PACK trial. BMC Health Services Research, 17(383), 1-10. doi:10.1186/s12913-017-2315-z

Morris, R., & O'Riordan, S. (2017). Prevention of falls in hospital. CME Geriatric Medicine, 17(4), 360-362.

Rheaume, J., & Fruh, S. (2015). Retrospective case reviews of adult inpatient falls in the acute care setting. Medsurg Nursing, 24(5), 318-324.

Tzeng, H.-M., & Yin, C.-Y. (2017). A multihospital survey on effective interventions to prevent hospital falls in adults. Nursing Economics, 35(6), 304-313.