FALL PREVENTION RESEARCH PAPER

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November/December 2018 • Vol. 27/No. 6 379

Preventing Falls: Is No Toileting Alone the Answer?

I n 2014, adults age 65 years and older who lived independently in their homes reported 29 mil- lion falls; more than 37% of those required medical treatment (Bergen, Stevens, & Burns, 2016). Approxi - mately 33,000 fall-related deaths occurred in 2015 (Centers for Disease Control and Prevention [CDC], 2018). Average estimates of the incidence of falls in the United States during acute care hospital admission range from 3.3 to 11.5 per 1,000 patients days (Bouldin et al., 2013). Falls with serious injury are consistently among the Top 10 sentinel events reported to The Joint Commission and compose the largest single category of reportable incidents in hospitals. The Joint Commission (2015) identified pre- vention of inpatient falls as a National Patient Safety Goal.

Substantial cost is associated with falls, including the cost of patient care associated with in - creased length of stay and liability. Beginning October 2008, the Centers for Medicare & Medicaid Services (CMS, 2015) eliminated payment to hospitals for costs incurred in the treatment of injuries resulting from falls during hospital- izations, citing these incidents as preventable and further compound- ing the fall-related costs to hospi- tals. Adjusted for inflation, direct medical costs for fall injuries are $34 billion annually; hospital costs account for two-thirds of that total. Direct treatment costs from falls by older adults are projected to escalate to $4.2 billion annually by 2020

Continuous Quality ImprovementContinuous Quality Improvement

Martha Cangany Lisa Peters

Karen Gregg Tracy Welsh

Barbara Jimison

Falls with serious injuries are the largest category of reportable inci- dents in hospitals. Of the interventions introduced as part of a com- prehensive fall prevention program, implementation of a no toilet- ing alone protocol led to the most dramatic decrease in the number of falls at one institution.

Literature Summary • One in three Americans age 65 and older fall each year, and 20% of those

falls cause a serious injury (Centers for Disease Control and Prevention, 2016).

• The Centers for Medicare & Medicaid Services (2015) eliminated payment to hospitals for costs incurred in the treatment of injuries resulting from falls dur- ing hospitalizations, citing these incidents as preventable.

• A protocol consisting of a nine-item fall risk assessment and six nursing inter- ventions resulted in substantially greater improvements (Barker et al., 2011).

• A study in a community hospital system reported 39% of falls were associated with toileting-related activities (Anderson, Dolansky, Damato, & Jones, 2015).

CQI Model Plan-Do-Study-Act (Deming Institute, 2018)

Quality Indicator with Operational Definitions & Data Collection Methods • Number of patient falls over 3 years • Audits of hospital incident reports of patients who fell to capture demograph-

ic data and fall location • Timeline of fall precaution interventions implementation • Staff turnover during project period

Clinical Setting 43-bed post-surgical unit in a not-for-profit healthcare setting in the midwestern United States

Average Daily Census 27

Program Objectives • Achieve median National Database for Nursing Quality Indicators benchmark

for falls in Magnet® facilities. • Reduce hospital or unit costs related to falls and falls with injury. • Identify the most effective intervention implemented within the 3-year period

to decrease falls.

November/December 2018 • Vol. 27/No. 6380

(CDC, 2016). Costs primarily are paid by the CMS through Medicare.

Identification of patients at risk for falling should be done on admission to the acute care setting. Various evidence-based fall risk scales have been developed to assist nurses in the assessment of identi- fied patient risk factors, including the Morse Fall Scale (MFS; Morse, 2009). Interventions must be tai- lored to individual risk factors to prevent falls from occurring.

Project Site and Reasons for Change

The rate for all falls at the begin- ning of this project was 4.45 falls per 1,000 patient days, and falls with serious injury occurred at 0.2 per 1,000 patient days. Target popu- lation for the project was all patients age 18 or older who fell between January 2010 and December 2013. The organization’s incident tracking system was used to capture incident-specific data for each fall.

The MFS (Morse, 2009) was cho- sen as the evidence-based instru- ment to assess patients’ risk for falling (low <25, medium 25-50, high ≥51). Variables assessed within the MFS include history of falling, secondary diagnosis, use of ambula- tory aids, presence of intravenous therapy or saline lock, gait, and men- tal status. Maximum score is 115.

Program In 2010, falls became a top prior-

ity among nurse-sensitive indica- tors on the project unit. Due to the increase in patient falls and the

need to identify possible interven- tions to decrease falls, a literature search was initiated by the quality improvement team. Team members included a registered nurse, clinical nurse specialist, unit manager, and unit-based clinical educator. Inter - ventions identified from the search were considered for implementa- tion on the unit. New interventions would be implemented strategically over time so the impact of each on outcomes could be understood.

The initial intervention was the use of a fall bundle (yellow blanket, yellow socks, yellow armband, yel- low magnet to be placed outside the door) for all patients scoring 51 or greater on the MFS. This fall bundle included visual cues to identify a patient as high risk for falling, and to increase awareness and commu- nication among caregivers who interact with patients.

A comprehensive approach was taken to educate nursing staff, implement a falls program, and support nurses in the management of patients identified as at high risk for falling.

This unit transitioned from a 43- bed unit to a new 34-bed unit in March 2012, with new equipment aimed at improving patient and staff communication. Specifically, bed alarms were linked to the hospi- tal-issued telephone carried by each care team member. Alarms were programmed to go to the entire team, not just the nurse assigned to the patient. This allowed quicker response. The unit experienced a slight drop in falls with this specific intervention.

In 2013, two additional interven- tions to reduce patient falls were

implemented: placement of chair alarms in every patient room, and the expectation that no patient toi- lets alone for the first 24 hours after surgery. With the reduction of falls after the implementation of these interventions, the expectation that no patient toilets alone was expanded to all patients at high risk for falls.

Evaluation and Action Plan Throughout this multi-year proj-

ect as interventions were added gradually to nurses’ toolkit for fall prevention and safety, a steady decline in the number of falls occurred. Within 3 years, the unit consistently met and exceeded the National Database for Nursing Quality Indicators (NDNQI) bench- mark for similar units (see Figure 1). Falls declined from 4.45 to 1.53 falls per 1,000 patient days (approxi- mately 70% decrease). Falls with serious injury declined as well; for the year ending this inquiry, they remained at zero. The most drastic reduction in falls occurred after implementation of a no toileting alone program in 2013 for patients in the first 24 hours after a surgical procedure. This intervention was followed by implementation of the same program for all patients who were at high risk for falling (see Figure 2).

The gradual introduction of interventions to complete a com- prehensive fall prevention program allowed staff members to incorpo- rate the interventions into their daily practice in maintaining patient safety and preventing falls. It also allowed accurate analysis of data to identify which intervention had the greatest impact in decreas- ing falls and falls with serious injury. No statistical analysis was completed of data collected during this inquiry. However, demographic information indicated the majority of patients who fell were female (n=62) with an average age of 55.5. Forty-five percent of all falls (n=111) were related specifically to toileting. The mean MFS score for involved patients was 61.756, indicating those patients who fell were at high fall risk.

Continuous Quality Improvement

Martha Cangany, DNP, RN, ACNS-BC, is Clinical Nurse Specialist, Medical-Surgical Nursing, Franciscan Health, Indianapolis, IN.

Lisa Peters, MSN, RN, NE-BC, is Clinical Nurse Manager, Post-Surgical Care, Franciscan Health, Indianapolis, IN.

Karen Gregg, BSN, RN, CMSRN®, CPHQ, is Quality Coordinator, Franciscan Health, Indianapolis, IN.

Tracy Welsh, BSN, RN, CMSRN®, is Patient Care Coordinator, Medical-Surgical Nursing, Franciscan Health, Indianapolis, IN.

Barbara Jimison, MSN, RN, ONC, is Clinical Educator, Post-Surgical Unit, Orthopaedic/Neuroscience Unit, and Liaison, Carmel Inpatient Unit, Franciscan Health, Indianapolis, IN.

November/December 2018 • Vol. 27/No. 6 381

Preventing Falls: Is No Toileting Alone the Answer?

FIGURE 1. Total Falls and Fall Rates

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0.5

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2013 YTD

1.53

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2.79

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2.57

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2011

3.18

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2.75

Fall rate

Fall rate with serious injury

Benchmark

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FIGURE 2. Total Falls

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1Q & 2Q 2012

3Q & 4Q 2011

1Q & 2Q 2011

3Q & 4Q 2010

1Q & 2Q 2010

Number of falls Implementation of fall bundle

Moved to new unit location Training and introduction of chair alarms

Implement no toileting alone first 24 hours post-op

Implement no toileting alone if at high risk for falls

23 24 15 17 15

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November/December 2018 • Vol. 27/No. 6382

Results and Limitations While implementation of the fall

bundle, linking the call system to bed alarms, and use of chair alarms in every room led to a gradual decrease in the total number of falls, the implementation of a no toi- leting alone protocol led to the most dramatic decrease in the number of falls. These results supported previ- ous findings that toileting was a high-risk activity requiring specific interventions in acute care settings and a major factor related to inpa- tient falls (Kalisch, Tschannen, & Lee, 2012).

Patients who experience falls have a longer hospital stay and higher costs. The financial impact of these extended lengths of stay, as well as the risk for litigation which can result from a fall with an injury, adds to increased cost for organiza- tions (Morello et al., 2015). The decrease in total falls at the project site reduced associated cost. At the inception of the project in 2010, total cost of all falls was $611,000; at the conclusion of the project in 2013, the total cost of falls for the year was $169,000. This is a $442,000 (72%) reduction in costs related to patient falls.

A small sample was a limitation of the project, which should be replicated with a larger sample of varied patient populations. At the onset of this project, the MFS score was not available; the patient med- ical record only indicated the MFS was completed and specific inter- ventions initiated. Once the MFS became available in the patient record, those data were captured to help understand the range of risk scores for patients who were falling.

Lessons Learned/ Nursing Implications

Results of this project affirmed the need to assure patient safety during toileting. Nursing staff should acknowledge the impor- tance of patient safety related to toi- leting when patients are of high risk for falling and remain with these patients while toileting. They also should discuss the rationale for this strategy with patients. Nurses need to reinforce frequently with pa - tients and their families the impor- tance of not getting out of bed with- out assistance when needing to toi- let. By remaining with patients while they are toileting, staff can minimize risk for falling and thus decrease the number of falls and falls with serious injury. Strategies must be identified to allow nursing staff to remain with patients assessed at high fall risk while accommodating the needs of other patients. Until there is greater understanding of factors preventing staff from staying with patients while toileting, the full benefits of a no toileting alone protocol will not be realized.

Conclusion Multiple interventions were im -

plemented over a 3-year period. During that time, the most dramat- ic decrease in falls and falls with serious injury occurred when a no toileting alone protocol was imple- mented for patients at high risk for falls. Project outcomes revealed decreased falls and falls with serious injury as well as decreased cost related to falls. Within 1 year of this project, all units within the facility implemented the no toileting alone

protocol. Since the conclusion of this project, this nursing unit has sustained fall rates well below the NDNQI benchmark.

REFERENCES Anderson, C., Dolansky, M., Damato, E.G., &

Jones, K.R. (2015). Predictors of serious fall injury in hospitalized patients. Clinical Nursing Research, 24(3), 269-283.

Barker, A., Brand, C., Haines, T., Hill, K., Brauer, S., Jolley, D., ... Kamar, J. (2011). The 6-PACK programme to decrease fall-related injuries in acute hospitals: Protocol for a cluster randomised con- trolled trial. Injury Prevention, 17(4), e5- e5. doi:10.1136/injuryprev-2011-040074

Bergen, G., Stevens, M.R., & Burns, E.R. (2016).  Falls and fall injuries among adults aged ≥65 years – United States. MMWR Morbidity and Mortality Weekly Report, 65(37), 993-998.

Bouldin, E.L.D., Andresen, E.M., Dunton, N.E., Simon, M., Waters, T.M., Liu, M., ... Shorr, R.I. (2013). Falls among adult patients hospitalized in the United States: Prevalence and trends. Journal of Patient Safety, 9(1), 13-17.

Centers for Disease Control and Prevention (CDC). (2016). Important facts about falls. Retrieved https://www.cdc.gov/ homeandrecreationalsafety/falls/adult falls.html

Centers for Disease Control and Prevention (CDC). (2018). Welcome to WISQARS™. Retrieved from https://www.cdc.gov/ injury/wisqars

Centers for Medicare & Medicaid Services (CMS). (2015). Hospital-acquired condi- tions. Retrieved from https://www.cms. gov/ Medicare/Medicare-Fee-for-Service- Payment/HospitalAcqCond/ Hospital- Acquired_Conditions.html

Deming Institute. (2018). PDSA cycle. Retrieved from https://deming.org/ explore/p-d-s-a

Kalisch, B.J., Tschannen, D., & Lee, K.H. (2012). Missed nursing care, staffing, and patient falls. Journal of Nursing Care Quality, 27(1), 6-12.

Morello, R.T., Barker, A.L., Watts, J.J., Haines, T., Zavarsek, S.S., Hill, K.D., ... Stoel - winder, J.U. (2015). The extra resource burdern of in-hospital falls: A cost of falls study. Medical Journal of Australia, 201(9), 367.

Morse, J.M. (2009). Preventing patient falls: Establishing a fall prevention program (2nd ed.). New York, NY: Springer Publishing Company, LLC.

The Joint Commission. (2015). Preventing falls and fall-related injuries in health care facilities. Sentinel Event Alert #55. Retrieved from https://www.jointcommis sion.org/sea_issue_55/

Continuous Quality Improvement

Since the conclusion of this project, this nursing unit has sustained fall rates well below the

NDNQI benchmark.

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