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FALL SAFETY IN HOME HOSPICE

Improving Staff Education to Reduce Patient Falls in Home Hospice Using Simulation

Taylor Bunyak

School of Nursing, University of Michigan

NURS 960, DNP Residency

Mary Franklin

October 2nd, 2023

Staff Education Regarding Fall Safety in the Home Hospice Setting Using an Escape Room Simulation Method

Introduction

Whether inpatient or outpatient, falls can significantly impact a patient's quality of life. Despite the awareness of the consequences, falls in the home setting remain an ongoing problem. Nearly one million inpatient falls transpire in the United States (US) each year, resulting in injury in approximately 30% of cases (Francis-Coad et al., 2020). According to Opsahl et al. (2017), the death rate among older adults related to falls has risen sharply from 30,208 in 2013 to 36,000 in 2022. On average, falls resulting in severe injury add $13,300 in expenses and extend an inpatient stay by six days (Opsahl et al., 2017). These avoidable costs pose a substantial burden to the US healthcare system. Annually, the cost of falls amounts to $50 billion, with Medicare and Medicaid covering 75% of these expenses (Centers for Disease Control and Prevention [CDC], 2023). Unfortunately, numerous factors can influence the frequency of falls, including staffing ratios, lack of resources, and patient confusion or unawareness of decreased physical limitations.

Background

Fall prevention has been studied in various settings including hospitals, rehabilitation units, and skilled nursing facilities. In all nursing settings, there are trained professionals who utilize their skills to assess patients’ risks of falling and adhere to facility policies regarding fall management. The hospice setting is unique due to hospice patients having more debility and comorbidity making them highly vulnerable creating a greater challenge of identifying risks of falling and how to prevent further falls as these patients have accepted an end-of-life form of care. According to Hospice of Michigan (HOM), they believe that hospice is a philosophy of care, not a place, as care can be provided in any location. HOM approaches care that seeks comfort rather than a cure, as they offer comprehensive, compassionate care for people at the end of their life, including providing support to their family members. The majority of patients admitted to home hospice have terminal chronic illnesses that require long-term pain management, increasing their risks for falls due to the nature of their side effects (Hospice Care, 2023). Research is limited in hospice due to patient or family distress, lack of experienced providers, and ethical concerns. Evidence-based practice in the hospice setting would be beneficial by increasing safety.

Problem Statement

Despite quality improvement efforts and guideline implementation, fall prevention remains a complex challenge that necessitates a comprehensive understanding of target interventions at the patient, clinician, and organizational levels (Francis-Coad et al., 2020). As of June 10th, 2023, a total of 654 falls have occurred at Hospice of Michigan for quarter two starting January 2023 to the present. Fifty-two percent of those falls occurred in the home setting, with 3% leading to severe injury and death. The Missouri Alliance for Home Care 10 (MAHC-10) tool has been utilized in the home healthcare setting to gather a baseline understanding of patients’ fall risk, allowing clinicians to implement individualized interventions to promote their safety. The MAHC-10 fall screening tool has been adopted and utilized by the Hospice of Michigan organization but has yet to show benefit with the organization’s fall rate due to underutilization by the staff, which leaves room for improvement. After a root cause analysis at Hospice of Michigan, it is determined that there is a need for further education regarding the proper use of the MAHC-10 tool. The MAHC-10 tool should be used for any changes upon admission, after every fall that the patient experiences, and every fifteen days. For the year 2023, 94% of fall risk assessments were completed on admission. During direct observation, the initial employee training discusses briefly fall policies and how to properly assess falls. There was no further education after orientation on how to directly apply the MAHC-10 fall screening tool when caring for the patients in their homes.

Falls persist as a significant problem in healthcare, and the need for education and evidence-based fall prevention strategies remains essential. Despite ongoing efforts, falls continue to cause injury and adversely affect patient outcomes. These incidents result in physical harm, increased healthcare costs, and diminished quality of life for patients. Therefore, it is imperative that advanced practice nurses utilize their skills and expertise to implement evidence-based strategies to prevent falls in healthcare settings.

Review of the Literature

There are many ways to implement education among staff based on their education level, understanding, and learning style. Options for staff education include brochures, digital versatile discs (DVDs), apps, and checklists (Opsahl et al., 2017). Recently, simulation has also become an integral component of nursing education. Simulation allows for the safe practice of critical nursing skills and can be used to reinforce best-practice guidelines, policies, and procedures. Incorporating a simulation for fall prevention may increase competence in preventing falls, provide a better understanding of fall-related care, and improve knowledge of the proper use of the MAHC-10 screening tool with appropriate reassessment intervals. Numerous methods have been studied to improve fall prevention. These methods include policies, staffing, increased staff training, telerehabilitation, use of the MAHC-10 fall assessment, environmental modification, medical condition management, and medication review.

Staff-Related Fall Prevention

Staff-related fall prevention is impacted by many variables, including education, training, experience, pay, and skill level, (Teresi et al., 2019; Luo et al., 2022; Staggs et al., 2016). Multiple investigators studied the impact of staff training programs, pay differences in staff, and telelecture for staff members on fall rates (Teresi et al., 2019; Luo et al., 2022; Staggs et al., 2016). Severance et al. (2022) created a collaborative implementation approach to examine the outcomes of fall prevention training programs among healthcare workers in different areas. The study indicated collaboration could effectively reach at-risk older adults and significantly improve fall efficacy (p<0.001). Acosta et al. (2022) discuss simulation among staff in the nursing home setting and the utilization of fall prevention simulation. The focus of the study was to evaluate employees’ perspectives on simulation-based education for fall prevention. The results of the study concluded that 80% of the participants expressed they would apply these newly learned skills in the future when caring for a patient who falls. As a result, there was a reduction of patient falls by 54% after educating staff as the simulation promoted clinical care skills, interdisciplinary teamwork, and communication. Diemer et al. (2019) designed and studied the results of a safety-directed escape room among medical staff, discovering after completing the escape room confidence increased from 63.5% to 80% when identifying fall risks and how to properly apply interventions for different situations. Of the 102 participants sixty participants strongly agreed that this was relevant to their everyday practice. All participants were able to complete the escape room in the allotted amount of time of twenty minutes and were able to identify all 32 safety-related events during the activity.

Risk Factors and Fall Prevention Strategies

Risk factor identification is often used in conjunction with fall prevention. Ward et al. (2018) discussed the neuromuscular impairment burden as a significant risk factor for falling. Vincenzo et al. (2022) discussed barriers from a patient's perspective as to why they do not practice fall prevention strategies. Both studies showed a lack of knowledge amongst both patients and staff about preventable or modifiable falls and the risk factors associated with falling. Guo et al. (2022) discusses how to incorporate fall prevention through a patient engagement framework, and Francis-Coad et al. (2020) discuss implementation early during the patient's initial admission process to prevent harmful outcomes. Lastly, Kowalski (2017) studied hospice patients and their fall rates during admission. Approximately 44% of falls occurred within five days of admission and 35% were repeat falls (Kowalski, 2017). Attention to fall prevention among hospice patients is relatively new and limited. Kowalski (2017) found that patients who experience functional decline but are focused on keeping independence, are at a greater risk of falling.

Framework Model and Implementation

The Plan-Do-Study-Act (PDSA) framework is composed of four stages to create change or improve a process including: planning, doing, studying, and acting upon (see Appendix A), (Hua et al., 2019). According to these constructs, this model carries the ability to guide the thinking process into breaking down the task into steps, then evaluates the outcome, how to improve on the outcome and how to test again, (Hua et al., 2019). Due to time constraints of the overall process this model allows for a shorter duration, making the PDSA cycle as short as possible to gain the results of the study, (Hua et al., 2019). The intent of PDSA is to first plan the project by strategizing the goals and objectives that are to be accomplished. The next step includes presenting the proposed project to the appropriate personnel, implementing the actual program and collect data based on the implementation, (Hua et al., 2019). The last step of the model after the data collection has been completed will be to present the results and recommendations to the administration, (Hua et al., 2019). The PDSA has been used frequently in fall prevention strategies to promote safety, as evidence shows the constructs of the model have intent to create quality improvement, (Hua et al., 2019).

Purpose and Objectives

The purpose of this Doctor of Nursing Practice (DNP) project is to improve fall prevention with staff education using simulation. The following objectives guided this project:

· 1. Assess staff fall prevention knowledge and attitudes toward fall prevention

· 2. Develop and implement an escape room simulation and case study for staff

· 3. Assess staff satisfaction and knowledge after escape room participation

The expected outcomes of the project are measured by engagement, behaviors, and experiences during the simulation escape room activity. Such information can be used to further evaluate the impact of the proposed workplace intervention by assessing changes over time, before versus after implementation, (Santomauro et al., 2020). The context for experience means that the experience had by the individuals was useful and they are likely to implement the knowledge they have obtained into their practice, (Santomauro et al., 2020).

Methods

Ethical Considerations

University Of Michigan Internal Review Board (IRB) approval will be obtained prior to initiating the DNP project. No identifying information will be collected from participants. All data collected will be stored electronically and on paper copy surveys provided by the hospice facility. All data will be reported in an aggregate form. The project is conducted on a voluntary participation basis with informed consent. Per the hospice facility training has been completed regarding code of conduct, HIPPA training, confidentiality agreement and rights and responsibility act to further protect rights of the facility, staff and patients.

Setting

Hospice of Michigan (HOM) has 13 offices located throughout Michigan, making the Ann Arbor/Ypsilanti office the main location. Due to Hospice of Michigan’s large service area, much of the collaboration among staff is located in person at the Ann Arbor/Ypsilanti office. The DNP student worked in conjunction with the HOM education director, HOM quality improvement director and U of M faculty. The DNP project will take place in the Ann Arbor/Ypsilanti center campus where the simulation room is located for the company. The DNP project's focus is to educate the staff members who have direct contact with patients in the home hospice setting regarding fall risks and MAHC-10 tool interventions.

Participants

The current participants for the DNP project are staff members who have direct contact with individuals in the home hospice setting. The participants include but are not limited to registered nurses, case managers, social workers, and home health aides. At this time there is no direct interaction with community members or patients associated to HOM for this project.

Intervention

Pre-intervention

Before the project was implemented, the DNP student used survey questions obtained from HOM for the participating parties. With the support of the PDSA model, the following questions were used:

· Prebriefing increased my confidence and was beneficial to my learning

· During the simulation are the staff better prepared to respond to changes, have a better understanding, more confident in assessment skills, empowered to make clinical decisions, have a better understanding of medications, had the opportunity to practice clinical decision making, increase confidence in prioritizing care and communication, teach patients about the interventions, and use evidence-based practice to provide care

· Debriefing contributed to learning, allowed open communication on the scenario, was valuable in improving clinical judgment, allowed for self-reflection, and was constructive evaluation.

The questions asked were used to assess how the participants felt during each phase of the simulation; prebriefing, during the scenario and the debriefing stage. The survey contains a number system for grading including strongly agree as 3, somewhat agree as 2 and do not agree scored as 1. There is an additional box at the end of the survey for an open-ended response regarding the simulation, if there are any further concerns or ideas of improvement from the staff’s experience for the education team to better the overall experience.

Secondly, the DNP student had support from the HOM faculty in recruitment for participants. Quarterly, there is education provided by the educational team at HOM regarding areas of improvement. Currently, the staff present are from different areas around the state, have different lengths of experience and different roles. Once the participants have been identified the DNP student worked in conjunction with the director of education and director of quality improvement to format an escape room simulation and case study to correspond with the simulation.

Intervention

During the intervention phase, participants were able to experience the simulation escape room and participate in a post-simulation survey for data analysis. The purpose of the simulation is to provide additional education regarding fall risks and an understanding of the MAHC-10 screening tool.

Measures

In order to measure the outcomes of the DNP project, HOM has an online survey tool where data is collected and extracted for use. Most participants are able to utilize both paper copies and the online survey to complete the survey to ensure all data is collected for analysis.

Analysis

· 1. Assess staff fall prevention knowledge and attitudes toward fall prevention

· 2. Develop and implement an escape room simulation for staff

· 3. Assess staff satisfaction and knowledge after escape room participation

The DNP student is to evaluate the responses from the post simulation survey to analyze if the staff found the simulation escape to be beneficial to their future practice by analyzing score changes and use of frequent high score rating of 3. Over the eight-week implementation period, the simulation escape room reached 30 staff participants and 30 surveys were recorded successfully. The graph will represent scores of pre simulation, during and post simulation. The data will be collected over multiple simulation periods for comparison. A graph of the survey results is to be presented in Appendix B.

Sustainability Plan

The projected data collection for the DNP project is to be ended in January 2024. The overall data, simulation and case study will be owned by Hospice of Michigan and will continue to be used by HOM at their digression. With hopeful positive project outcomes, the project can be used by future DNP students and HOM staff to continue to educate new and current staff regarding fall safety and MAHC-10 tool use to better patient outcomes.

Results

Discussion

Conclusion

References

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Appendix A

Pennington, Deidra, "Reducing inpatient falls on a cardiovascular progressive care unit: A quality improvement study to implement interprofessional intentional rounding" (2019). Doctor of Nursing Practice (DNP) Final Clinical Projects. 25. https://commons.lib.jmu.edu/dnp201019/25