Quality Improvement on fall during the hospital stay

408 | wileyonlinelibrary.com/journal/ajr Aust. J. Rural Health. 2020;28:408–413.© 2020 National Rural Health Alliance Ltd.

1 | BAC KG R O U N D It is known that falls are a leading cause of mortality and morbidity, especially in the elderly.1 In 2017-2018, there were 64 385 falls that resulted in the need for hospitalisation in NSW, associated with an upward trend over the past dec- ade.2 Australian hospital statistics reported more than 40 000

inpatient falls during 2017-2018 in Australian hospitals that resulted in harm.3 Morello et al4 examined the incidence of inpatient falls across multiple sites in Australia from 2011 to 2013 and identified that 3.6% of hospital admissions involved at least one fall and 1.2% of admissions had at least one fall resulting in injury. One study involving two general rehabilita- tion inpatient wards in the Sydney area had a falls rate of 14%,

Received: 30 November 2019 | Revised: 25 April 2020 | Accepted: 18 May 2020 DOI: 10.1111/ajr.12646

Q U A L I T Y I M P R O V E M E N T R E P O R T

Reducing falls through the implementation of a multicomponent intervention on a rural mixed rehabilitation ward

Colleen Lok Kum Ma MBBS | Rebecca Ann Morrissey FAFRM

Department of Rehabilitation & Aged Care, Tamworth Rural Referral Hospital, Tamworth, NSW, Australia

Correspondence Colleen Lok Kum Ma, Rehabilitation Unit, Tamworth Rural Referral Hospital, 31 Dean Street, Tamworth, NSW 2340, Australia. Email: [email protected]

Abstract Problem: There is an absence of literature to guide staff in how falls can be reduced in a diverse patient population on a mixed acute/subacute rehabilitation unit, espe- cially one with daily fluctuations in acuity that occurs due to frequent changes in its acute/rehabilitation patient ratio. Design: Pre-intervention and post-intervention audits. Setting: The Rehabilitation Unit at Tamworth Rural Referral Hospital in Tamworth, NSW. Key measures for improvement: Improvement in the number of falls and repeat fallers. Strategies for change: A multicomponent intervention involving: (a) in-service education sessions for nursing staff about falls risk-increasing drugs, (b) patient and family education regarding falls risks and prevention strategies, (c) improving documentation of incident reports by using a set template, (d) ensuring that the cor- rect patient mobility status information is handed over between nursing shifts and physiotherapists providing timely and regular updates, (e) the introduction of the ‘traffic light mobility system’ and (f) enhancing the use of existing falls prevention strategies. Effects of change: The total falls reduced in number from 36 falls to 19 with a de- crease in the number of repeat fallers from 8 to 4. There was also increased compli- ance with existing falls risk tools and improved documentation of each falls incident which provided insight into activities and times with higher falls risk. Lessons learnt: A multicomponent approach remained effective even when applied to a mixed acute/subacute rehabilitation ward setting.

K E Y W O R D S

falls reduction, heterogeneous patient population, multicomponent intervention, rural

| 409MA And MORRISSEY with 4% having two or more falls.5 In the rehabilitation setting, the rate of falls varies with respect to the inpatient population characteristics particularly in the areas of continence and toi- leting, cognition, communication, balance and mobility.5,6

In 2017, statistics provided by the Peel Sector Falls Injury and Prevention Committee found that the Tamworth Rural Referral Hospital (TRRH) Rehabilitation Unit had the highest rate of falls when compared to the other in- patient wards. This was based on the number of falls per patient bed days across the entire hospital. The rehabilita- tion unit is a 22-bed onsite ward with acute medical and surgical patients and subacute rehabilitation patients being cared for in the same ward. This ratio of acute vs rehabil- itation patients can vary on a daily basis; thus, the range of functional abilities and conditions on the rehabilitation ward varies considerably.

There is an absence of literature to guide the staff in the care of acute patients alongside rehabilitation patients in re- ducing falls in this unique situation. Previous research has generally focused on either intervention implemented in a purely acute setting4 or in a rehabilitation setting,5,6 but not to- gether, presumably in part due to the large variation in patient characteristics.

What is already known on this subject: • Falls remain common in patient populations with

cognitive impairment requiring assistance with mobility and personal care and in those with a di- agnosis of stroke

• Currently, the majority of literature is targeted to- wards falls reduction in a relatively homogenous patient population with existing falls risk strate- gies. There is limited research into preventing falls on a mixed acute/subacute rehabilitation unit

What this study adds: • A tailored multicomponent approach to falls re-

duction remains effective in a mixed of acute/sub- acute rehabilitation unit with daily fluctuations in patient acuity

• Existing falls reduction tools are only effective if used correctly

• The traffic light mobility system can help prevent falls and contribute to patient goal setting, an im- portant component of the rehabilitation process

T A B L E 1 Summary of gaps and interventions

Gaps in existing falls reduction plan Proposed interventions

Education

Insufficient patient and staff education regarding identification of risk factors

Example: Education regarding management of cognitively impaired patients: equipment such as bed alarms and pressure sensors should be used for patients with cognitive impairment as they might not realise they have to buzz for assistance when mobilising

(i) Nursing staff required to redo online falls modules and review policy regarding falls prevention

(ii) Medical team provided in-service presentations on common falls risk-inducing drugs and their associated side effects

(iii) Promote active patient and family involvement during the Falls Risk Screen (FRS)/Falls Risk Assessment Management Plan (FRAMP) assessment to identify personalised strategies for falls reduction

Documentation

Inconsistent completion and utilisation of the FRS/FRAMP assessment tools (missing or incomplete)

(i) Improve completion rates of the existing FRS/FRAMP tools

Highly variable accuracy and quantity of information provided in IIMS reports regarding the circumstances of each fall

Example: Some reports did not provide any detail of the circumstances leading up to the fall, only that the patient was found on the ground.

(i) Use a set template developed by the hospital inpatient falls committee with the essential data to be included in each report

Mobility status identification

Whiteboards at the bedside not updated with current mobility status (outdated or missing)

Mismatch in patient mobility status handed over by the physiotherapist and nursing handover (both verbal and written)

(i) Daily updates of the white bedside care boards by a nominated nursing staff

(ii) Improving consistency through regular checks each day for any disparity in mobility status by an assigned nursing staff member

Difficulty with identifying patient's mobility status in an efficient manner when patient away from bedside

(i) Introduction of the traffic light mobility system: patients requiring assistance had a red tag attached to their mobility aid with an elastic band. Patients requiring standby assistance or supervision had a yellow tag and patients that were cleared to mobilise independently had a green tag

410 | MA And MORRISSEY

2 | M E T H O D S An audit tool was developed following a review of the existing literature.5,6 This tool was used in both the pre- intervention and postintervention audits to investigate the circumstances and characteristics surrounding each fall and to assess the unit's compliance with risk assessment tools and documentation. The information was gathered using the existing Incident Information Management System (IIMS) tool (which captured information regarding pa- tient characteristics, risk factors and the fall incident itself) along with a file review to ensure accuracy and completion

of the IIMS data and to collect the remaining data of inter- est such as medications and mobility status. The total num- ber of inpatient admissions during the study period was collected using the search function in the hospital patient management system.

This quality improvement initiative consisted of three parts: the pre-intervention audit (November 2017-April 2018), assessment and intervention phase (with interventions implemented from July 2018 onwards) and the postinterven- tion audit (October 2018-March 2019).

The pre-intervention audit was conducted to eval- uate patient characteristics and the circumstances

Patient characteristics Preliminary audit (n = 27) Reaudit (n = 14)

P value

Gender

Male 17 (63.0%) 10 (71.4%) .734

Female 10 (37.0%) 4 (28.6%)

Age

65 and below 5 (18.5%) 6 (42.9%) .140

Over 65 22 (81.5%) 8 (57.1%)

Care status

Acute 9 (33.3%) 2 (14.3%) .275

Rehabilitation 18 (66.7%) 12 (85.7%)

Condition type

Amputee 1 (3.7%) 3 (21.4%) .326

Deconditioning 7 (25.3%) 3 (21.4%)

Orthopaedics 2 (7.4%) 0 (0.0%)

Other 4 (14.8%) 3 (21.4%)

Stroke 13 (48.1%) 5 (35.7%)

Cognitive impairment

Yes 21 (77.8%) 11 (78.6%) 1.000

No 6 (22.2%) 3 (21.4%)

Mobility status

Assistance 11 (40.7%) 8 (57.1%) .818

Supervision 10 (37.0%) 1 (7.1%)

Independent 6 (22.2%) 5 (35.7%)

Mobility aid

Wheelchair 5 (18.5%) 5 (35.7%) .449

Frame 2 (7.4%) 2 (14.3%)

4WW 10 (37.0%) 5 (35.7%)

Walking Stick 7 (25.9%) 2 (14.3%)

Nil aid 3 (8.1%) 0 (0.0%)

Activities of daily living status

Assistance 18 (66.7%) 11 (78.6%) .490

Supervision 1 (3.7%) 1 (7.1%)

Independent 8 (29.6%) 2 (14.3%)

T A B L E 2 Patient characteristics

| 411MA And MORRISSEY

surrounding each fall in order to identify gaps in falls prevention. Recommended strategies to address these (Table 1) were presented by the authors to the ward quality improvement team, which included issues involving edu- cation about common falls risk factors, documentation and identification of the patient's mobility status. A discussion surrounding the proposed interventions included input from each discipline in the rehabilitation team: such was essen- tial to ensure a unified approach for successful implementa- tion of the interventions.

We strived to optimise current resources and clinical prac- tices first, as these were not being used to their full potential. This included ensuring completion of the Falls Risk Screen (FRS) and Falls Risk Assessment and Management Plan (FRAMP) in a timely manner. The only new addition was the traffic light mobility system (TLMS).

The specific interventions, as outlined in Table  1, were implemented in July 2018 and subsequently became incor- porated into clinical practice thereafter, as per the Plan- Do-Study-Act cycle recommended by the NSW Clinical Excellence Commission.7

The post-intervention audit was completed following the implementation of the interventions.

2.1 | Statistical analysis The statistical significance of the pre- and post-intervention groups was analysed using the Chi-square test for categorical variables with Fisher's exact test used for expected values of <5. The Mann-Whitney U test was used for ordinal data such as mobility and activities of daily living (ADL) status. The accepted significance level was set at P < .05. The software used was Statistical Package for the Social Sciences version 19 (SPSS, 115 Chicago, IL, USA).

2.2 | Ethics approval An application was submitted to the Hunter New England Human Research Ethics committee for ethics approval— the decision from the committee was that this project in its current forms as a quality improvement project did not re- quire HREC approval to proceed (authorisation number: AU201809-12).

3 | R E S U LT S Patient and fall characteristics are listed below in Tables  2 and 3, respectively, with falls risk tools compliance rates listed in Table 4. Male patients contributed to the majority of falls in both audits.

Data collected from the pre-intervention audit identified 259 inpatient admissions to the rehabilitation ward with a total of 36 falls. There were 27/259 (10.4%) patients having at least one fall, and of these fallers, 8/27 had more than one fall.

The post-intervention audit included 257 inpatient admis- sions to the rehabilitation ward with a total of 19 falls. The number of fallers overall decreased in the post-intervention audit with 14/257 (5.4%) patients that had at least one fall, and of these fallers, 4/14 had more than one fall.

As shown in Table  2, many falls in the pre- and post-intervention audits involved patients recovering from a stroke and individuals with cognitive impairment, those requiring hands-on assistance and/or requiring a four-wheel walker for mobility and those requiring assistance with their ADLs. Most falls were sustained during transfers and when mobilising. All repeat fallers in both audits met the criteria for having at least two of these aforementioned characteristics.

T A B L E 3 Falls characteristics

Fall characteristics

Preliminary audit Reaudit

P value(n = 36) (n = 19)

Activity type

Mobilising 12 (33.3%) 5 (26.3%) .178

Transfers 17 (47.2%) 6 (31.6%)

Leaning 3 (8.3%) 4 (21.0%)

Rolled out of bed 2 (5.6%) 4 (21.0%)

Unwitnessed 2 (5.6%) 0 (0.0%)

Location

Bedside 22 (61.1%) 9 (47.4%) .232

Hallway 2 (5.6%) 0 (0.0%)

Lounge room 0 (0.0%) 3 (15.8%)

Physiotherapy Gym 2 (5.6%) 2 (10.5%)

Shower 3 (5.6%) 3 (15.8%)

Toilet 7 (19.4%) 2 (10.5%)

Fall risk assessment tools completion

Preliminary audit (n = 27) Reaudit (n = 14)

P value

FRS (on admission) 27/27 (100%) 13/14 (92.9%) .000

FRAMP (on admission) 24/27 (88.9%) 13/14 (92.9%)

FRAMP (postfall) 17/36 (47.2%) 18/19 (94.7%)

T A B L E 4 Falls risk assessment tools completion

412 | MA And MORRISSEY Falls risk assessment tools used at Tamworth Hospital

include the FRS and FRAMP. There was a significant im- provement in compliance with FRAMP updates in the post-intervention audit as seen in Table 4.

4 | D I S C U S S I O N The number of falls on the rehabilitation unit was reduced following the implementation of a multicomponent interven- tional approach. This resulted in a change in the number of patients falling from 10.4% to 5.4% of all admissions and a statistically significant change in the compliance rate for up- dating the FRAMP following a fall. This might account for the reduced number of repeat fallers in the post-intervention audit. This study showed that falls reduction can be achieved with inexpensive and simple changes in clinical practice when dealing with diverse states of patient acuity.

Previous studies have shown that a multicomponent ap- proach is the most effective method of preventing falls in the hospital setting with a 30%–47% reduction in the over- all amount of falls postinterventions.8,9 As noted in the sys- tematic review by Chang et al,10 the difficulty remains in identifying which component of the multifactorial approach contributed the most towards falls reduction.

It is known that falls rates are significantly higher among stroke patients in rehabilitation, with figures ranging from 16.3% to 37% of inpatients having at least one fall,11,12 with a large majority of falls attributed to deficits in gait and bal- ance.13 Measured outcomes from the National Stroke Audit 201814 showed that 15% of stroke patients (included in the audited rehabilitation units) sustained a fall during their ad- mission. Multiple studies have also shown a link between declining cognition (in particular, deterioration in executive function) in the elderly with an increased risk of falling.15,16 A study by Fischer et al17 identified that fallers tend to carry out ADLs requiring mobility in an unsafe manner. Similar trends were reflected in both audits completed at TRRH with stroke patients and those with impaired cognition or requiring assistance with their ADLs making up a large pro- portion of fallers. Future quality improvement research on this ward could focus on providing tailored interventions to- wards this high-risk population with the adaptability to be modified when the patient demographics change.

There were fewer falls in patients requiring supervision. It is hypothesised that this could be attributed to the implemen- tation of the TLMS. Both staff and visitors have found the TLMS to be useful in providing an easily identifiable visual aid, especially for cognitively impaired patients requiring as- sistance with mobilisation, which is consistent with findings in a previous study.18 In general, there is a scarce amount of literature currently available on the use of the TLMS in the rehabilitation setting.

A surprising outcome of the TLMS was that it also re- sulted, subjectively, in increased levels of patient motivation due to its role in contributing to patient goal setting, which in itself is also an important part of the rehabilitation process.19 Since its implementation, numerous patients have celebrated ‘advancing a level’ in their mobility from red to yellow to green, with others making the goal to advance to the desired ‘green tag’ level within a certain amount of time.

One limitation was the small sample size secondary to the constrained time frame. To audit again after a period of 12 months would increase the sample size and highlight any changes that might arise with the inclusion of data from the winter months, which is consistently associated with a higher number of patient admissions to our hospital.

Another limitation is that the data in this study were based on existing IIMS reports, which varied in quality due to the staff member making the report and the circumstances of the fall, some of which were unwitnessed. Subjectively, the quality of information provided did show improvement in the post-intervention audit.

5 | C O N C L U S I O N Due to the association of falls with increased morbidity and mortality, falls prevention and reduction remain an important part of a patient's hospital admission. Patients with the fol- lowing characteristics had higher rates of falls in both audits: male, cognitively impaired, age over 65 years, a diagnosis of stroke and requiring assistance with mobilising and personal care.

Key interventions included the implementation of a TLMS to provide visual aids for mobility, increased com- pliance with existing falls risk tools and the improved docu- mentation of each falls incident which provided insight into activities and times with higher falls risk. These results are promising in that a multicomponent approach was shown to remain effective even when applied to a mixed acute/reha- bilitation ward setting. This study demonstrated inexpensive and simple ways of addressing falls risk when dealing with a heterogeneous patient population.

AC K N OW L E D G E M E N T S None.

C O N F L I C T S O F I N T E R E S T None to declare.

AU T H O R C O N T R I B U T I O N S Colleen Ma contributed to the design, acquisition, analysis and interpretation of the data and drafted the work. Rebecca Morrissey contributed to the design, analysis and interpreta- tion of the data and made critical revisions of the draft. Both

| 413MA And MORRISSEY contributors have given final approval of the version to be published and agree to be accountable for all aspects of the work.

O RC I D Colleen Lok Kum Ma  https://orcid. org/0000-0003-2125-1485 Rebecca Ann Morrissey  https://orcid. org/0000-0003-2060-1594

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How to cite this article: Ma CLK, Morrissey RA. Reducing falls through the implementation of a multicomponent intervention on a rural mixed rehabilitation ward. Aust J Rural Health. 2020;28:408–413. https://doi.org/10.1111/ajr.12646

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