Development of fall prevention program.

MILITARY MEDICINE, 185, S2:28, 2020

Implementation of a Multicomponent Fall Prevention Program: Contracting With Patients for Fall Safety

CPT Arrah L. Bargmann, BSN, RN* ; Maj Stacey M. Brundrett, MSN, RN, AGCNS-BC*

ABSTRACT INTRODUCTION Falls during hospitalizations can increase the length and cost of a hospital stay. Review of patient safety reports on a 26-bed medical-surgical telemetry unit revealed that the number of falls went from 6 in 2015 to 12 in 2016. The reports identified a knowledge gap in the patient population and nursing staff related to high fall risk interventions. A literature review suggests that patient-staff safety agreements, in combination with proper implementation of Clinical Practice Guidelines, can successfully increase education and adherence to fall prevention measures and reduce the number of inpatient falls.

MATERIALS AND METHODS The objective of this evidence-based practice project was to determine if the implementation of a patient fall safety agreement in combination with an existing evidence-based fall prevention bundle reduces the number of falls. Based on the literature review, the unit developed a multicomponent fall prevention program that emphasizes staff and patient education. The program consists of (1) assessment of the patient’s fall risk using the Johns Hopkins Fall Assessment Tool, (2) daily patient education on factors contributing to the patient’s fall risk during the shift assessment, (3) an educational handout on fall risk factors maintained at the bedside, (4) ensuring compliance with implementation of previously existing fall prevention measures, and (5) a patient fall safety agreement.

RESULTS During the first 4 months, the fall rate decreased by 55% and staff compliance with interventions for high fall risk patients increased to 89%. To achieve added compliance, the unit implemented an incentive program, which resulted in the increased adherence to the fall risk interventions. The unit experienced 87 and 88 consecutive fall-free days, which was the longest consecutive days since May 2015. This project has reached sustainment and the unit continues to see a low fall rate, well below the national average for medical-surgical units.

CONCLUSION One of the largest obstacles to this project was staff and leadership turnover. However, the project found that patient fall safety agreements facilitate a dialogue among staff and patients as well as encourage patients to take ownership of their own care. They improve the safety of patients and create a collaborative environment for nurses to conduct safe, quality patient care.

INTRODUCTION Falls during hospitalizations are a safety concern, resulting in added healthcare costs, increased length of stay, and increased disability rates to name a few. According to the Agency

*Brooke Army Medical Center, 3551 Roger Brooke Dr, JBSA-Fort Sam Houston, TX 78234

Poster presentations at Tri-Service Nursing Research Program Evidence Based Practice and Research Dissemination Course in 2017, the San Antonio Military Health System and University Research Forum in 2017, and a podium presentation at National Association of Clinical Nurse Specialists Annual Meeting in 2018.

The views expressed herein are those of the authors and do not reflect the official policy or position of Brooke Army Medical Center, the US Army Medical Department, the US Army Office of the Surgeon General, the Department of the Air Force, the Department of the Army or the Department of Defense or the US Government.

doi:10.1093/milmed/usz411 Published by Oxford University Press on behalf of the Association of

Military Surgeons of the United States 2020. This work is written by (a) US Government employee(s) and is in the public domain in the US.

for Healthcare Research and Quality, falls are one of the most often reported incidences during hospitalizations.1 Since 2008, hospitals no longer receive reimbursement for traumatic injuries following falls that occur during a hospital stay.1

Furthermore, Oliver et al. found in their literature review that falls “are also associated with increased length of stay, higher rates of discharge to institutional care, and greater amounts of health resource use.”2 Therefore, falls sustained in the acute hospital setting remain a priority for any facility.

This project was conducted on a 26-bed medical-surgical telemetry unit at a 352-bed Level 1 military trauma center that cares for both civilian traumas and military beneficiaries. At the facility, policy defines a fall as “a sudden, unintended uncontrolled downward displacement of a patient’s body to the ground or other object. This includes situations where a patient falls while being assisted by another person.”3 Despite the Clinical Practice Guidelines already in place, retrospective reviews of the patient safety reporting (PSR) system and fall response team data within the facility indicated that the

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number of falls on the unit doubled in a year. According to the facility definition, the number of falls increased from 6 in 2015 (a fall rate of 0.83 per 1,000 patient days) to 12 in 2016 (a fall rate of 1.59 per 1,000 patient days). Although this rate is less than the national average of 3.92 falls per 1,000 patient days for medical-surgical units,4 the increase in falls was concerning to both leadership and staff nurses. Of these falls, approximately 42% (5 of 12) of them resulted in mild harm. The American Society for Healthcare Risk Man- agement defines mild harm as “minimal symptoms or loss of function, or injury limited to additional treatment, monitoring, and/or increased length of stay.”5 Thus, the fall was associated with additional cost to the facility and/or caused decline in the patient’s status.

After further review, the unit practice council (UPC) along with the unit’s clinical nurse specialist (CNS) discovered location and circumstances of the falls varied. Four of the falls occurred in the bathroom and the others occurred during ambulation or patient changing positions, i.e., reaching for items or trying to transfer self from bed to chair. Despite the differences in location and cause of the fall, similarities among the falls became evident: (1) not all the fall preven- tion measures were implemented and (2) the patient lacked understanding of their fall risk and corresponding prevention measures. It was also noted that at the time, the only edu- cational guidance provided to patients was in the form of a brief trifold handout for patients to reference. Therefore, there were areas for improvement within the fall prevention program on the unit. This article describes the development, implementation, outcomes, and challenges of implementing an enhanced evidence-based fall prevention safety program on a medical-surgical unit. This project falls under the category of an evidence-based practice (EBP) project because it inte- grates clinical expertise with a systematic analysis of current evidence to guide practice change on the unit to positively impact patient care.6

METHODS The Iowa Model7 served as the framework of the EBP project. Following the Iowa Model’s outline, a review of PSRs, injury reports, and feedback from nursing staff, floor management, and the unit’s CNS identified falls as the trigger issue for the unit. Due to the significant increase in the number of falls, reducing falls was determined to be a priority for unit leadership. Then, a team was formed that included the CNS and members of the UPC. A literature review was conducted guided by the clinical question: On a medical-surgical unit, does the implementation of a patient fall safety agreement in combination with current Clinical Practice Guidelines for fall prevention reduce the number of falls? The terms “falls,” “patient education,” “patient safety,” “prevention,” and “agreement” drove a search in Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Ovid MEDLINE databases. The goal was to discover if there

were any additional interventions the unit was not currently implementing that could affect the unit’s fall rate.

Most of the literature discussed the use of bundled fall prevention programs suggesting that there is no one inter- vention that significantly reduces falls in the acute inpatient setting. For instance, one systematic review, consisting of four meta-analyses and 19 studies, suggested that multifactorial fall programs can reduce fall rates in the inpatient population by up to 30%; however, the optimal bundle of interventions could not be identified from the systematic review.8 Typical interventions for fall prevention include fall risk assessment, yellow wrist bands, nonskid socks, and bed alarms.

In addition to fall prevention interventions, education and a culture of safety are important for reducing falls. Leone and Adams9 describe a quality improvement project to pre- vent falls. Part of their intervention was changing their unit’s culture of safety, which allowed staff to feel comfortable reporting falls and unsafe conditions. Staff education is also important when changing the culture on a unit as well as implementing anything new; everyone must accomplish the new process the same way as well as understanding the purpose for the new process or intervention.

A safety agreement may improve patient education about falls and adherence with fall interventions. According to one research study, patient fall safety agreements provided struc- tured fall education, which may lead to reduction in the degree of injury following a fall.10 Additionally, Nicolas et al.11 saw a reduction in their fall rate after implementing a patient fall safety agreement with their patients and families. Finally, the Joint Commission Center for Transforming Healthcare: Pre- venting Falls Targeted Solutions Tool12 (TST) highlights the importance of a customizable multifactorial approach to fall prevention that includes the use of safety agreements. The TST is an evidence-based tool that guides an organization through a step-by-step process to address patient falls with the goal of generating customizable solutions to address previously identified barriers. It utilizes the rapid process improvement methodology to measure fall rates and identify contributing factors and implement targeted solutions. This methodology is a “fact-based, systemic, and data-driven problem-solving methodology” that includes elements from Lean Six Sigma and change management methodologies.13 The TST from the Joint Commission Center for Transforming Healthcare supports the use of safety agreements to improve call light use, patient awareness, and patient acknowledgement about their fall risk during hospitalization. All five of the organizations that initially participated in the pilot study experienced a 62% decrease in falls with injury and 35% decrease in their fall rate.14

Altogether the literature review revealed two common themes. Regardless of intervention, increased education of patients and nursing staff and a culture of safety were two key factors in the reduction of fall rates in hospital settings. Based on the findings from the literature review and PSR data, the UPC enhanced the existing fall prevention program

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to emphasize patient education, improved communication, and a culture of safety.

At all military facilities, policy outlines guidance related to fall prevention, and it focuses on three components: assessment using the Johns Hopkins Fall Assessment Tool (JHFAT),15 nurse-initiated orders, and education of the patient and family. The UPC reviewed the existing fall prevention bundle, and updated it based on the above literature review. The pre-project fall prevention bundle included five main components: (1) assessment utilizing the JHFAT; (2) nurse- initiated order sets; (3) patient and family education; (4) visual cues such as falling star, falls wheel, and yellow socks; and (5) other safety measures such as nonskid socks, gait belts, and bed alarms. Nurse-initiated orders are a group of orders in the electronic health record that serve as reminders and a way to document interventions taken such as bed alarm on, offering toileting, and remaining with the patient at all times when they are out of bed for high fall risk patients.

The new fall bundle included the previously existing fall prevention measures plus (1) daily patient education on factors contributing to the patient’s fall risk during the shift assess- ment; (2) a patient educational handout on fall risk factors at the bedside, which included a modified JHFAT and key fall safety education points; and (3) a patient fall safety agreement. Modifications to the JHFAT included removing age and com- bining all the mobility and cognitive items into one box to simplify the form, thus easing communication of risk factors for patients. The modification to the tool was agreed upon by the UPC members under the guidance of the CNS; it was simplified for patient understanding. The goal of the abridged tool was to involve patients in the fall risk assessment. In each shift, the patient was reassessed and received reinforcement education of all the fall prevention measures associated with the patient’s specified fall risk.

The adherence of this EBP bundle was measured by determining the level of the patient’s fall risk understanding and associated fall prevention interventions pre- and post- patient fall safety agreement implementation. Additionally, staff adherence with pre-existing fall prevention interventions outlined in accordance with hospital policy pre- and post- implementation was monitored via audits. In preparation for the implementation of the bundle, the UPC collected baseline fall data from the PSR system and created an in-service for staff members, the patient fall safety agreement, an education handout, an abbreviated JHFAT sheet, and ambulation status for the white boards. The fall safety agreement included items such as the patient has been educated on fall risk prevention strategies and that they acknowledge falling can cause serious injuries. Therefore, they agree to ask for help in order to prevent falling.

Implementation of the bundle began in early February 2017 once 90% of the staff received face-to-face in-services, which outlined the new bundle. The in-service addressed baseline fall data collected from the PSR system and post-fall response team reports, the purpose of the project, as well as

explanations and examples of the new forms. The forms included the patient fall safety agreement, modified JHFAT, fall prevention information handout, and new signs for the patient rooms. Copies of the patient education handout, the modified JHFAT, and fall prevention signs were laminated on yellow paper and placed on the bedside table or on the white board at the foot of every patient’s bed, within their line of sight. Upon completion of the in-service, staff members were encouraged to sign a pledge to promote a culture of safety and utilize the tools of the fall prevention bundle.

During the in-services, which occurred during shift change safety huddles, the staff were instructed to ensure all patients received the fall prevention education and had a documented JHFAT and a signed patient fall safety agreement upon admis- sion or transfer to the unit. Staff members were allowed up to 24 hours to have the bundle implemented if patients arrived to the unit sleepy postoperatively or with altered mental sta- tus. Nursing staff were also encouraged to educate family members especially if the patient was not able to receive the education upon arrival. Once patients received the fall risk and prevention education, they were encouraged to sign the agreement with the nursing staff. Then, the signed safety agreement was placed in a separate binder that contained all the patient fall safety agreements for the unit. Then, the nursing team placed a star by the patient’s name on the charge nurse census board to serve as a visual cue to the auditors, nursing staff, and unit leaders that the patient received the education and signed the agreement. The modified JHFAT was to be updated by the nurse in the presence of the patient each shift, hung in the room, and utilized as a communication tool for nursing staff to see which risk factors contributed to the patient’s fall risk.

RESULTS UPC members and unit management conducted audits on dayshift and nightshift at least three to five times per week to observe adherence with the unit fall prevention bundle before, during, and after the project. Pre-implementation auditors checked to ensure all interventions were in place that corre- sponded to the patient’s documented fall risk. After project implementation, auditors were instructed to check the desig- nated binder for a signed fall agreement as well as review the patient’s charted fall risk as determined by the bedside nurse using the JHFAT prior to beginning each audit. The auditors would then ask the patient if they knew what their fall risk was: low, moderate, or high. If the patient’s response did not match the assessment, reeducation was immediately given using the patient education handout on the patient’s bedside table or whiteboard. Finally, the auditors would then visually check rooms to ensure all interventions were in place based on the patient’s identified fall risk. Inter-rater relia- bility was not measured. However, for each intervention the observation was either adherence or not. For instance, the bed alarm was either on or off for a high-risk patient. Auditors

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received education on each item to examine prior to starting the audit process. Unit Practice Council members collected post-implementation surveys that patients received prior to discharge and compared them to the visual and verbal audits during the hospital stay. All data from the audits were recorded on a spreadsheet and then compared to baseline data retro- spectively from the PSR system and post-fall response team reports.

The initial audit revealed only 5 (approximately 30%) of 17 patients identified as high fall risk patients had bed alarms on and there were 2 recent falls on the unit. Within the first 2 weeks of implementing the fall bundle, the bed alarm adherence increased to 71%. Hoping to achieve a bench- mark of 90%, the UPC instituted an incentivized performance improvement project known as “Catch ‘em Doing Good.” The incentive was “Sunshine Fund” dollars, which staff could use to purchase snacks from the unit’s snack bar. In each shift the staff were audited on their adherence with all the fall bundle interventions. Staff earned a star when 100% of the nursing interventions were in place for all the patients on their team, the fall safety agreement was signed, and all their patients demonstrated understanding of their fall risk. With the addition of the incentive program, adherence with bed alarms and fall safety agreement rose to 89% after 3 months.

The incorporation of the fall bundle with the patient fall safety agreement notably increased the percentage of patients that correctly stated their fall risk and verbalized understand- ing of what prevention measures correlated with their fall risk. Implementation of the staff incentive program improved the culture of safety on the unit and resulted in a profound increase to 95% of patients correctly stating their fall risk suggesting a positive correlation with understanding interventions and the bundle, while seeing a negative correlation with falls. Since the implementation of the project, the unit’s fall rate decreased from 1.59 per 1,000 patient bed days for 2016 to 1.38 per 1,000 patient days for 2018 (see Fig. 1). The lowest fall rate was seen during the second quarter of 2017, which was right after implementation of the bundle; the fall rate was 0.54 per 1,000 bed days. Additionally, the unit has experienced two of the longest stretches of fall-free days since May 2015, 87 and 88 days.

As a result of this project, the fall rate and the number of falls with mild harm have remained low. The unit only experienced no harm or mild harm events; none of the fall events were classified as moderate or severe harm or death. If the patient experiences a slight change in status or requires limited additional treatment, then the event classifies as mild harm. If the event resulted in an injury that impacts daily functioning or quality of life to some degree, then it would receive a classification of moderate or severe harm.5 Since the implementation of the project, only three (approximately 37.5%) of the eight falls in 2017 resulted in mild harm (see Fig. 2). In 2018, 5 (50%) of the 10 falls resulted in mild harm. However, all five of these were due to a medical event, two resulted in a code blue and two in a rapid response team

activation; the staff followed all the applicable fall interven- tions for each of these events. While there was an upward trend in the number of fall events in 2018, all except one in the third and fourth quarters of 2018 had the appropriate fall prevention interventions in place prior to the event. And, overall the unit has consistently gone longer between fall events. From mid-February through December 2018, the average number of days between falls was 35.96 days. Prior to the intervention (January 2016 to early February 2017), the average number of days between falls was 27.8.

Age did not seem to play a factor in the falls. In 2016 prior to the project implementation, patients age 18–49 accounted for eight (approx. 67%) of the falls. The following year the ages were more evenly distributed, with each decade account- ing for one or two falls. In 2018 six (60%) of the falls were patients between the ages of 50 and 64. However, the medical- surgical unit that conducted the project admits mostly civilian traumas and surgical patients.

DISCUSSION The implementation of a multifactorial fall prevention bundle, including a patient fall safety agreement and staff incentive program, served as a pivotal instrument for the fall rate on the unit and has several implications for nursing. The safety agreements and patient education handouts provided nurses with a standardized set of tools to ensure structured education is provided to each patient on a consistent basis. The signed patient safety agreements and staff safety pledges also pro- moted a culture of safety making both patients and nursing staff responsible for interventions related to fall prevention. To encourage adherence, the UPC implemented a staff incen- tive/recognition program known as “Catch ‘em Doing Good” to increase staff motivation and adherence with fall prevention policies despite the frequent changes on the unit. Initially, the incentive program revitalized the project, served as an effective means of reinforcing components of the bundle, and increased staff adherence with components of the fall prevention program. Unfortunately, the audits required to sustain the incentive program proved to be too much of a burden to continue in the long term. The benefit of these audits was to increase the number of personnel asking the patients about their fall risk status. Therefore, the patients received reinforcement of their education, which likely contributed to the early success of the project.

While only one medical-surgical unit in the facility implemented this bundle, other units and their leadership took note of its success. After presenting this project in numerous forums to the Facility Nurse Practice Council and local and national conferences, parts of this bundle were incorporated into the facility policy. Staff members educated other units about the lessons learned throughout this project as other units began to adopt parts of it prior to the facility officially updating the fall policy. Leadership agreed that the most effective component of the project was the fall safety agreement since it

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FIGURE 1. Quarterly Falls Rate.

FIGURE 2. Falls by Definition.

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encouraged a dialogue between the staff and the patient. Plus, it enabled the patient to be an active participant in their care.

Like most projects the implementation of the bundle was not without its challenges. For the first 4 months, the unit showed a positive trend in the fall rate. However, with staff turnovers and complacency, the rate began to increase at the beginning of 2018. Leadership did a push, re-engaging with the staff at shift change huddles to re-energize the program (annotated by an ∗ in Fig. 1). At that time, there was also a decrease in the adjusted fall rate, which does not include assisted falls. Assisted falls occur when the staff is in the room with the patient and all the appropriate interventions are in place. The staff are with the patient when they begin to fall and assist them to a seated position on the floor. The facility’s definition of a fall still includes these events as a fall. However, in these instances the staff probably prevented mild or even moderate harm since they were with the patient and eased them to the floor; they implemented all the appropriate fall interventions.

Military facilities are unique in that floor management and staff change frequently. For instance, during the first 11 months of the project, the head nurse changed twice, 9 staff members (approx. 32% of the military staff) received rou- tine military reassignments, and 15 (approx. 28%) additional nursing staff were oriented to the unit. This created a need for continuous reinforcement of the bundle components to ensure all staff members were aware of the unit’s fall prevention program and safety agreement. Additionally, medical-surgical units are staffed with nurses with less experience. Using Benner’s Model,16 the majority (approximately 65%) of the staff would be considered advanced beginners. Therefore, the experience level on the unit is low. On a shift there are a mix of between 7 and 10 registered nurses and licensed vocational nurses, including the charge nurse. Of those, at least four or five have less than 2 years of nursing experience. Military charge nurses typically have about 2 years of experience, while civilian charge nurses could have anywhere from 3 to over 10 years.

More studies and research are needed to further evaluate the sustainability and efficacy of multifactorial fall prevention programs with safety agreements in both military and civilian healthcare facilities. Additionally, the optimal bundle of fall prevention interventions has yet to be identified. It would be helpful for future studies to determine the interventions best suited to prevent falls in the medical-surgical setting, the essential elements of a patient education program, and specific factors appropriate to increase a culture of patient safety for fall prevention.

CONCLUSION Despite the limitations and challenges previously discussed, since implementation the unit has seen (1) decreased frequency of falls; (2) less total falls per given time; (3) maintained low fall rate per 1,000 patient days, and (4) a

maintained low number of falls with mild harm. While falls are concerning, the unit started with a rate well below the national average. Therefore, any improvement is difficult to achieve. The unit also experienced 87 and 88 consecutive fall-free days which were the longest consecutive number of days since May 2015. Effective education and adherence with fall prevention measures in both nursing staff and patient populations were a vital component of fall prevention and increased patient safety. Safety agreements and bundled prevention approaches facilitate a dialogue among staff and patients. It improves the safety of patients, and it creates a collaborative environment for nurses to conduct safe, quality patient care.

ACKNOWLEDGMENTS The authors acknowledge the effort of the staff and unit leadership who helped during the implementation of the project. Special thanks to Tri-Service Nursing Research Program for their assistance in the publication process. The authors also declare that the evidence-based project was not funded by any agency or organization.

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