Caps project

and

Leadership & Management

NUR4827

Professor Charlyn V. Myatt

Running head: FALL RATES IN PSYCHIATRIC PATIENT POPULATION 1

Capstone Part I: Integrated Literature Review

Introduction to Problem

Some nursing staff on psychiatric in-patient units believe that it is impossible to eliminate patient falls. Some administrators expect falls on in-patient psychiatric units, and may even budget for them. Unless we change this mindset we will continue to see patient falls increase on in-patient psychiatric units. It is our responsibility to educate both patients and staff on the high risk of falls on our in-patient psychiatric units, especially considering the multiple medications that this patient population are on that can cause hypotension. This patient population is the most discriminated against because they are labeled psychotic and do not always receive proper medical treatment and clearance before admission to the psych (mental health) unit. Prevention of Falls by Deglau et al., report that falls risk increases from 25% with one medication to 60% with six or more concurrent medications and that psychotropic medications have about a twofold increased risk of falls and fractures (Deglau et al.).

PICOT Question:

In Psychiatric patients on multiple medications (P), how does consistently measuring their orthostatic blood pressures and educating staff and patient of their fall risk (I) compared to the standard procedure of taking normal morning blood pressures(C) affect the overall fall rates (O) within three months (T).

Literature Review and Levels of Evidence

A literature search was conducted using CINAHL, Ovid and Medline for nursing research articles with key search terms prevention of falls and mental health patients. Articles in the past five years were critiqued for relevance of subject matter and application to the PICOT question identified. It was determined that an additional search would be obtained using The National Guideline Clearinghouse website (www.guideline.gov) for additional articles relevant to the subject matter since additional material was needed for this research. It was found that there was plenty of research done on patient falls but few particular to mental health in-patients.

Levels of Evidence

The level of evidence scale that was used to critique research studies in this paper was the Rating System for the Hierarchy of Evidence by Melnyk & Fineout-Overholt (2011) with the strongest or best research evidence at the top (Level I) and the weakest research evidence at the bottom (Level VII).

Level 1: Evidence from a systematic review or meta-analysis of all relevant randomized clinical trials (RCT).

Level II: Evidence obtained from well-designed RCTs

Level III: Evidence obtained from well-designed controlled trials without randomization

Level IV: Evidence from well-designed case-control and cohort studies

Level V: Evidence from systematic reviews of descriptive and qualitative studies

Level VI: Evidence from single descriptive or qualitative studies

Level VII: Evidence from the opinion of authorities and/or reports of expert committees (Melnyk & Fineout-Overholt, 2011, p. 25)

Guidelines Critique and Recommendations

Validity

A systematic review of fall prevention interventions for older people with mental health issues was done via electronic database and lateral searches to identify studies reporting falls data and fall related injuries in February 2011, November 2012 and October of 2013 (Bunn et al., 2014). There were 4614 studies identified of which 27 papers reporting 21 separate studies met the inclusion, seventeen were Randomized Control Trials and four uncontrolled studies used for this research article. The inclusion criteria is not included in the article but is available upon request from the authors. The Rating System for the Hierarchy of Evidence by Melnyk & Fineout-Overholt (2011), was used and the level of evidence for this article is Level I. According to the article the systematic review was carried out using the methodology from previous reviews and in accordance with that recommended by the Cochrane Collaboration. Two reviewers independently assessed the quality of the studies and if they did not reach an agreement on the quality a third reviewer assessed it and the three reviewers agreed upon the conclusion.

Results

The authors reported that of the 17 randomized control studies, sequence generation or allocation concealment were considered adequate in 13 of them but only 10 studies were judged to have both considered adequate. Four studies met all criteria and six met five or more of the criteria, one met none. Of the four uncontrolled studies three met three out of six and one met two out of six of the criteria but all were considered to be at high risk of bias because they had no control group. The research done that compares fall risk with medication regiment along with education of patient/family and staff in recognizing fall risks and the communication of such risks should prove relevant to the PICOT question at hand. However; the authors seem to be in agreement that there is not enough evidence presented in these studies to reinforce any interventions suggested, only that more research is needed regarding falls with this patient population.

Strengths/Limitations

The strengths of this article are that there were seventeen randomized control studies found related to this subject that were used that included patient populations in four major countries with several interventions evaluated. The limitations of this study are that there was no real evidence discovered that could be used to reduce the fall risk in this patient population with any real validity. More research is needed to reinforce staff and patient confidence in a relevant falls prevention program for this patient population. Staff caring for this patient population will continue to struggle with controlling falls while more research is needed that will prove effective interventions to reduce falls among the mental health patient population, especially Dementia/Alzheimer and psychotic patients.

Validity

· Implement a unit peer leader program,

· Customize use of hip protectors to reduce risk of hip fractures

· Customize use of floor mats to reduce trauma from bed-related falls

· Expand patient assessment to include injury risk on admission

The program evaluation included both quantitative and qualitative methods and reported post implementation p-Levels as low as P<.0001 in some cases. The Rating System for the Hierarchy of Evidence by Melnyk & Fineout-Overholt (2011), was used and the level of evidence for this article is Level VI and is a single qualitative study.

Results

The authors implemented three separate projects:

· Fall prevention program customized for inpatient psychiatry

· Unit peer leader program for falls

· Customization of hip protectors and floor mats in psychiatry settings

Strengths/Limitations

Summary

In summary, even though the studies researched do not provide specific information regarding falls on psychiatric units that are related to positive orthostatic blood pressures, they do report valuable information that can be used. The studies report information regarding patient and staff education and how important it is to get total buy in from all parties involved in order to effectively reduce fall rates among this patient population. Education and change in staff attitudes regarding falls prevention seem to be common themes that can be utilized to effectively reduce falls among the psychiatric patient population. There is no doubt that more studies would provide greater detail into fall rates among this population and provide insight into how nursing staff can best use the information to make a greater change. It is all too often assumed that falls among psychiatric patient populations are intentional and un-preventable but there is more research that's beginning to show data that disputes this mindset. It will take a great deal of research to prove fall rates among the psychiatric patient population can and should be reduced to zero tolerance.

Part II Education and Evaluation Plan

Teaching Plan

This training session is intended to bring light to the fact that psychiatric patients have a higher risk of falling in inpatient settings because of the multiple medications they are on and not because of their attention seeking behavior ("throwing themselves on the floor").

The purpose of this education regarding the correlation between orthostatic blood pressures, psychiatric medications and fall rates on psychiatric units is to enlightened nursing personnel why there is an increased risk for falls on these units. This research will show that many of the medications they are on can and do cause orthostatic hypotension. Administrators, nursing staff and personnel on psychiatric units have expected higher fall rates on psychiatric units because of the behavioral issues present among this group of patients. It is the intent of this research project to explore and educate staff, patients and patient families that there are precautions that prudent staff can take to reduce/eliminate falls on psychiatric units. The target audience for this teaching session will be all the staff on an inpatient psychiatric unit. The method of delivery will be PowerPoint slides, lecture and handouts. Statistics show that about half of the falls that occur in in-patient settings can be directly related to a decrease in the patients’ blood pressure.

Objectives:

· At the end of this training session staff will be able to identify at least three psychiatric medications that can cause orthostatic hypotension.

· Staff attending this training session will be able to identify at least two symptoms of orthostatic hypotension.

· By the end of this training session staff will be able to define what orthostatic hypotension is.

· By the end of this training session staff will be able to show return demonstration of how to accurately take orthostatic blood pressures.

· By the end of this training session staff will be able to teach patients/families about high-risk medications, how to prevent falls, and signs and symptoms of orthostatic hypotension.

At the end of the training session there will be a return demonstration given and personnel will be checked off on their new skill set. Throughout the presentation there will be opportunity for question/answer sessions. This material will be presented in an open forum type of setting.

Correlated Content

A. Identifying at risk patients

1. Defining orthostatic hypotension

2. Identifying high risk medications

B. Technique for taking accurate orthostatic blood pressures

1. Introduce yourself to the patient and explain what you are about to do.

2. Identify proper fitting cuff.

3. Position patient properly

4. Measure blood pressure and heart rate.

5. Record results in the EMR (electronic medical record) properly.

6. Notify the nurse/Physician of the results.

7. Return Demonstration.

C. Patient Education

1. Identify at least 2 symptoms related to orthostatic hypotension.

2. Explain what to do if you experience any of the symptoms.

D. Question and answer session

Teaching Strategies

The strategies used in this training session will be:

· PowerPoint presentation

· Discussion

· Handouts

· Return Demonstration

· Question and Answer session

By using these strategies it is the intent to show statistics the will lead to a better understanding of why inpatient psychiatric patients are at a higher risk for falls, what we can do to reduce that risk and how to best educate our patient population.

Evaluation Methods

To evaluate the effectiveness of this training session there will be a question/answer session at the end of the presentation. To reinforce the proper technique for accurately checking orthostatic blood pressures a return demonstration will be used. There are also handouts that will be given to those in attendance and patients will receive a simplified version of the handouts in their admission packets that will explain their higher risk of falls, medications that can cause them to fall, symptoms associated with the medications, and what they can do to reduce their risk of falling.

Educational Material

The material that will be used to teach the patients is a simple handout that identifies symptoms of orthostatic hypotension and what they should do if they experience any of the symptoms. There will also be a handout for staff that identifies medications that can cause orthostatic hypotension, symptoms of orthostatic hypotension and some facts regarding falls on psychiatric units. A PowerPoint slide presentation will be used in the educational presentation to staff members in an attempt to reinforce the importance of monitoring patients more consistently and accurately for postural hypotension. The intent is to keep this educational program as simple as possible for the patients and to teach/train staff to consistently monitor patients at high risk of developing orthostatic hypotension. The hope is to establish a consistent monitoring system to identify those patients at risk of falling early in their hospitalization so that a plan can be developed to reduce that risk and ensure the patients safety.

The survey for evaluating the effectiveness of this training presentation was developed by the Falls Committee studying Fall Rates on the Behavioral Health unit. A search was done using CINAL and key words: falls, psychiatric, evaluation, forms, and questionnaires and no suitable evaluation form was found that fit the needs of this project. A questionnaire and return demonstration documentation form was developed to test the effectiveness of staff training. The key to preventing falls is early identification of higher risk patients and a strong staff/patient education program. Success will be measured by a reduction in fall rates and injuries, along with early identification of at risk patients who are at risk.

Preceptor Interview Summary

The preceptor chosen for this project is JG who is a Registered Nurse who has her master’s Degree in Psychology and is the Nurse Manager of at in-patient Behavioral Health unit at a major hospital in Jacksonville Florida. The standard practice at the facility as far as EBP goes is to present a research topic at the Performance Improvement (PI) Committee meeting after gaining approval from the directors level for the project. JG was contacted regarding this particular project because of the fact that she had accumulated fall statistics for the Behavioral health unit for several years and was in the process of developing a performance improvement plan to reduce the number of falls that occurred on the unit. A DMAIC and Performance Improvement Plan was created by cohort and a plan was set to action. JG contributed many suggestions toward the DMAIC and assisted with proper verbiage for the final product. She played a major role in assisting with the development of the Performance Improvement Plan, approval of educational objectives, educational tools, and mandatory departmental education plan.

JG's assistance with this project is much appreciated, without her assistance this project would have been very difficult if not impossible to complete. The knowledge and guidance that she has provided serves as a guide to EBP preceptors in the future. There has been a joint concerted effort on this project by RN's, Techs, Pharmacists, and other staff that have been instrumental in implementing this project.

Evaluation

Change is beginning to take place on the Behavioral Health unit at a local not-for profit hospital. Mindsets are slowly changing, education has been provided to staff and is being utilized in admission packets presented to patients at the time of admission. A Magnet Fair at that local not-for profit hospital was recently utilized to share the falls reduction plan with hospital staff and upper management. Staff on the Behavioral Health unit, are currently in the process of completing return demonstration check-off's and the falls reduction plan will soon be set into place. Patients are currently being educated upon admission to the unit of their increased risk of falls due to their medication regiment. Posters are being utilized as a constant reminder to patients of their responsibility should they experience any symptoms of orthostatic hypotension, the acronym DASH (Dizzy? Always Sit down and call for Help) is being utilized to remind patients of the action they should take to prevent falls. Verbal reports at shift change are being utilized now instead of taped to ensure that information regarding the patients fall risk is being communicated amongst all staff. There are no current statistics to compare as of yet on the effectiveness of this training and the use of consistent monitoring of orthostatic blood pressures has not yet been implemented.

The evaluation of the educational portion of this Falls Prevention Plan's project at a local not-for-profit hospital was met through the use of a Likert scale with a five question survey presented to end users of this training program. The training session was made available to all staff on an in-patient Psychiatric unit and was presented on nine occasions prior to the recap at the monthly staff meeting. It is for this reason that it is believed to have skewed the Likert scale portion of this evaluation. All seventeen participants surveyed rated all five questions of the survey as strongly agree (see Addendum F ), which would seem to confirm their agreement that the training session was successful. Only time will tell if indeed this training program has been a success and that will be measured more unbiased by actually seeing a reduction in fall rates on the Behavioral Health unit at this local not-for-profit hospital.

Capstone Part III: Quality Improvement Proposal

A. Problem and Setting

The problem is that falls continue to increase on Mental Health/Psychiatric in-patient units and at times the falls are expected by hospital personnel. It is often thought that falls are an expected occurrence for psychiatric patients. Best practice is to monitor patients closer for orthostatic hypotension because many of the medications that this patient population take can cause severe drops in blood pressure causing dizziness, lightheadedness and nausea just to mention a few. In order to ensure the safety of the patients and reduce the number of falls the patient at higher risk of having orthostatic hypotension must be identified early in their admission to in-patient units so that fall precautions can be initiated.

PICOT Question:

In Psychiatric patients on multiple medications (P), how does consistently measuring their orthostatic blood pressures and educating staff and patient of their fall risk (I) compared to the standard procedure of taking normal morning blood pressures(C) affect the overall fall rates (O) within three months (T).

B. Recommended Changes

The key elements to reduce fall rates on in-patient Psychiatric units are:

· Changing mindsets about falls on in-patient Psychiatric units

· Education of staff

· Education of patients/families

· Early identification of at risk patients

· Consistent monitoring of at risk patients for orthostatic hypotension

· Consistent/accurate exchange of information among staff during shift report

In order for fall rates to decrease on in-patient Psychiatric units the whole mindset of staff must change from being an expected occurrence to one of being preventable. Statistics consistently show that this patient population is at great risk of falling because of the medications that they are on and not because the biggest percentage of them "throw themselves on the floor".

The plan to reduce falls on in-patient Psychiatric units should include a means of identifying at risk patients early in the admission process. We currently use a medication reconciliation process that can help to identify at risk patients early in the admission. These higher risk patients should be educated on their higher risk of falling and should be instructed on what to do if they experience any hypotensive symptoms. Staff should then be educated also on the proper falls precautions to implement to ensure the patients safety.

Education remains the key to reducing falls on in-patient Psychiatric units and is mandatory if changes are to be seen. The mindset of staff can only be changed if results are seen in the form of falls reduction. Upper management could validate that a change in mindset is necessary by providing accolades to exemplary staff that have been observed educating patients, assisting patients, preventing a fall, or just using the available tools to reduce the fall rate. It is imperative that all staff from upper management to ACP's experience a change in the mindset that falls are an expected occurrence on in-patient Psychiatric units.

Consistent monitoring of orthostatic blood pressures can be initiated along with consistent and accurate shift reports to ensure that all staff are aware of the increased fall risk. Statistics are already available that have measured the current fall rates on these units. New statistics can be gathered and compared with previous ones to measure whether initiating these key elements have made any difference in fall rates.

Consistent exchange of information by staff through the use of shift reporting and the Morse Fall scale also play vital roles in the reduction of fall rates. Staff must be aware of those patients at higher risk of falling and pass that information along in order to effectively reduce falls. The Morse Fall scale is a tool that can be utilize to help staff identify higher risk patients early in the admission but must be consistent in order to be effective.

C. Change Strategy

The evidence-based practice (EBP) model that a local not-for-profit hospital uses is the IOWA model and therefore is the one that would be most useful for this Falls Reduction Plan to be implemented in this instance and the one that was chosen. The plan for this EBP project is that it be implemented on the Behavioral Health/Psychiatric unit at BMC. In order for change to take place in this particular environment the tools that a local not-for-profit hospital already has in place must be utilized. The IOWA model is a tried and true model that has been used effectively for years and the one that a local not-for-profit hospital is currently using.

Seven steps of the IOWA model:

1. Selection of a Topic

2. Forming a Team

3. Evidence retrieval

4. Grading the Evidence

5. Developing an EBP Standard

6. Implement the EBP

7. Evaluation

A local not-for-profit hospital utilizes the IOWA model for all EBP projects initiated within the medical center through the use of an EXCEL program for nursing staff that rewards nurses monetarily for participating in the program and completing the requirements in a given time frame. One of the requirements is that each nurse in the program must complete a project of their choice with management approval. The choices are Evidence-Based Practice (EBP) project, Performance Improvement (PI) project or Literature Review (Lit Review). This program plays a vital role in a local not-for-profit hospitals ability to stay abreast of Best Practice and ensures that research is at the forefront of their practice.

The planned change to reduce falls is:

· Changing mindsets about falls on in-patient Psychiatric units

· Education of staff

· Education of patients/families

· Early identification of at risk patients

· Consistent monitoring of at risk patients for orthostatic hypotension

· Consistent/accurate exchange of information among staff during shift report

Mindsets are already beginning to change on the Behavioral Health unit and were reinforced at a recent Magnet Fair at a local not-for-profit hospital with leadership personnel. Staff have all been educated and are currently in the process of completing return demonstration check-offs. Patients are currently being educated at time of admission on their increased risk of falls. The Morse scale for fall risk is currently being utilized to identify higher fall risk patients early in their admission. The use of consistent orthostatic blood pressures will be implemented once all staff have completed their return demonstration check-off. Staff, are currently using verbal shift reports instead of taped ones in an attempt to enhance the transfer of knowledge from one shift to the other more accurately and consistently. This is all a work in progress and will require the entire staff to sharpen their communication skills in order to make sure that the whole team is on the same page and that vital Fall Risk information is passed from one shift to the other.

D. Legal, Ethical and Regulatory issues

The legal, ethical and regulatory issues to be considered are:

· Falls are a preventable occurrence

· Medicare/Medicaid will no longer pay for the rehab that is required post fall

· The hospital must be able to show that they are doing everything possible to prevent falls

· It is the right thing to do to protect our patients from injury

· Hospital acquired injuries and infections are monitored by government agencies

· The Joint Commission, AHCA, DOC and others play vital roles in ensuring patient safety measures are met

In order to ensure that everything possible is being done to prevent falls on in-patient Behavioral Health units and all medical units within the hospital accurate complete statistics must be kept, measured, evaluated and scrutinized for possible improvement measures that could be implemented to reduce the risk of a similar event (fall) taking place. Patient safety must be the number one priority and FALLS cannot be an expected event on any unit including Behavioral Health/Psych units.

Ethically, we must do the right thing for the patient to ensure their safety is met while they are in our care. It is not okay to expect any patient to have a fall, even Psych patients. There may be some cases where a Psych patient who is seeking attention throws themselves on the floor but that is not the norm. We must do everything possible to make sure that our patients are not harmed and all safety measures are met while these vulnerable patients are in our care. Medications must be monitored closely for side-effects, vital signs must be monitored consistently, education must be completed timely, all falls precautions must be adhered to at all times, and staff mindsets must change in order to ensure that everything possible is being done to reduce falls.

State and Federal agencies are monitoring in-patient hospital acquired injuries and incidents closely and we are all being held accountable for any and all occurrences. The Joint Commission, Department of Children and Families and American Health Care Association are just a few of the regulatory agencies that hospitals are required to report to. There are also many different rating systems out there that sole purpose is to rate the care provided by hospitals, staff, and doctors and compare it with other hospitals in the area, state and nation. Pay-for-Performance is now becoming a reality for Medicare/Medicaid reimbursement and we must be more conscious of the affects it will have on our bottom line profits/losses. The reality is that hospitals and in-patient settings cannot afford to ignore Falls Prevention Plans and continue to stay afloat financially in the future.

Additional data and Research 2017 and beyond:

A Fall Defined:

FALL - sudden, unintentional descent, with or without injury to the patient, that results in the patient coming to rest on the floor, on or against some other surface (e.g. a counter), on another person, or on an object (e.g. trash can) (NDNQI, January 21, 2016)

In 2017, additional research and statistics were compiled and an attempt to reduce falls even more is constant and on-going. The Behavioral Health (BH) in-patient unit has gained success in reducing the overall number of falls the past fiscal year and is on track to reduce falls even more this current fiscal year. There is a renewed emphasis on reducing falls system wide and additional mandatory training to reduce falls took place in June 2017. BH continues to strive to be the safest unit possible and discover new innovative ways to reduce falls within our patient population. The unit has and continues to see a shift in culture. Staff no longer expects to see falls among “Psych Patients” but rather they are shocked to hear that a fall occurred and determined to find ways of preventing them in the future.

According to research, “Purposeful Rounding” remains the primary means of reducing falls on any in-patient setting. The BH unit continues to research and implement fall reduction initiatives. To date, “Broda Chairs”, skid proof socks with rubber soles, education and exercise/strength training have all been utilized to help curve the incidence of falls. Although, no single effort can take credit for the overall decrease in falls, it is noted that when staff presence is increased through “Purposeful Rounding” (PR) patients are less anxious and more confident their needs will be met.

According to the article in the Canadian Journal by Bansal et.al: “A history of a recent fall (e.g., within the past six months to one year) has consistently been identified as a strong risk factor for subsequent falls among older adults” (2016). The admission process is the single most important factor in determining the risk factor for patient falls. The information gathered can determine whether a patient is at a higher risk for falls if complete historical information is gathered regarding the patients fall history. History of patient fall within the past six months continues to be the single largest factor in identifying high fall risk patients.

Exercise and strength training can add value in reducing falls on the in-patient unit and add “quality of life” value to patient population. According to NCBI: “Exercise can prevent falls in older people. Greater relative effects are seen in programs that include exercises that challenge balance, use a higher dose of exercise, and do not include a walking program. Service providers can use these findings to design and implement exercise programs for falls prevention.”(2017) Exercise that focuses on core strength can improve balance and help reduce falls.

BH units are different than any other medical unit because the patients are free to walk around the unit. Many falls have occurred when the patient was ambulating down the hallways. The BH unit is piloting non-skid rubber soled slippers (see Addendum I) for the geriatric psych patients. The soles are thin and flexible but give just enough support to resemble hard soled shoes. As of this writing, no patient falls have occurred while patient was ambulating in these slippers. The slippers are more costly than the regular ones but if they will help prevent a patient from falling they are well worth the additional expense(See Addendum I).

Purposeful rounding is by far the most important aspect of preventing falls. For many gero-psych patients regularly scheduled rounds can prevent a patient fall. Toileting, hydration and comfort needs can all be met on a regular basis and prevent the patient from attempting to get out of bed by themselves.

Research on hourly rounding in 14 hospitals revealed impressive improvements:

· 12% increase in Patient Satisfaction scores.

· 52% reduction in patient falls.

· 37% reduction in light use.

· 14% decline in skin breakdowns.

· In addition, one hospital measured a 20% reduction in the distance walked each day by the nursing staff.(Stanford 2017)

The fall rates on the BH unit have steadily declined over the past three fiscal years as adjustments to the protocol have changed. There is a continual effort to reduce the fall rates on the unit and a renewed emphasis on striving for zero falls. As fall rates trend downward, a shift in the culture has been noted. Staff now expect to not have a fall on the unit. They are actually diligent regarding the prevention of falls. The chart below depicts the progress made in reducing falls on the thirty four bed BH unit.

*Fiscal year 2017 does not end until September 30th 2017 (approximately 3 months remain)

One could argue that not one single intervention can be credited for this decline in falls but that

many factors have attributed to successfully reducing falls on the BH unit. It is true that the BH

unit has implemented several fall reduction measures in a relatively short period of time.

However, purposeful rounding is thought to have had the highest impact on reducing falls and

adding value to patient satisfaction scores.

Education is a key component to reducing falls on any inpatient unit but especially true in

the BH unit. This patient population is generally ambulatory and most of them have some sense

of cognition. This patient population is not in bed all day recovering from a surgical procedure.

They are up and about going to group therapy, meeting with the psychiatrist, therapists, and

other interdisciplinary team members throughout the day. They may be in bed for most of their

first day of stay but afterwards they are expected to attend groups, eat meals in the dining area,

come to the nurses’ station for medications or any other needs they may have. The BH unit has

incorporated falls risk training in their admission packets to alert them on the reasons they may

be at a higher risk for falling. Educating this patient population early in the admission can be a

deterrent to falls. Statistics show that a patient’s highest risk of falling is within the first 24 hours

of admission.

Staff education is equally important and must take place before initiating a fall

prevention program. Staff initially expected to see a high rate of patient falls on the BH unit and

were shocked when the fall rate on the BH unit began to decrease. System wide Falls Prevention training was completed in June 2017 and included simplified universal signage (See Addendums G and H). All staff including housekeeping, dietary, nurses, CNA’s, and ancillary staff were required to attend a mandatory training session base on their level of patient evolvement. Patient education continues to be a focus primarily on admission when the patient is given their admission folder that includes a reminder of the risk for falling and educated on the reason why they are a higher risk for falling(See Addendum A). As we move toward zero a goal of zero falls on the BH unit we will surely meet additional obstacles and research additional solutions to those obstacles. For now we strive to have zero falls on the BH unit.

Conclusion:

Great strides have been made to reduce falls on the Behavioral Health unit and the culture has seen a change. We don’t discount a FALL because they are a “Psych Patient” and they are prone to throw themselves on the floor in an apparent rage because they didn’t get what they wanted. We are more aware that psychotropic medications play a large role in fall risk. There is a greater percentage of our patients who are prone to seizure activity. The BH unit house an increasing number of long-term geriatric patients with Dementia and Alzheimer’s. Many of our patients have several comorbidities (Diabetes, Hypertension, Heart disease, etc.). It has been quite the challenge to get our fall rates down to a manageable level, but we are not done yet.

Best Practice and Magnet endorse culture change and research that will improve patient outcomes. We must continue to find innovative ways to protect our patients and our health care organizations against the rising costs of preventable injuries on our inpatient units. Both Medicare and Medicaid, along with the Centers for Disease Control have deemed falls on inpatient units as preventable occurrences. We must continue to take them seriously and promote an atmosphere of resolve (not blame), in order to effectively reduce/eliminate falls. It is what is best for our patients, staff, and organizations.

Many interventions have affected our fall rates and we have faced many challenges along the way. It is the resolve of the entire BH team that has and will continue to change the culture and attitudes regarding falls on the “Psych unit” and improve the safety of our patient population. We can’t afford to sit still, we must continue to strive for excellence and become an exemplary Health Care system for patient safety. We must continue to endorse research and education and provide our staff with the tools they need to provide Best Practice. We must continue to educate our patients and their families on high risk issues. Our patients deserve the best, safest, most innovative, industry leading care possible and it is up to all of us to deliver it.

References:

Bansal, S., Hirdes, J. P., Maxwell, C. J., Papaioannou, A., & Giangregorio, L. M. (2016).

Identifying Fallers among Home Care Clients with Dementia and Parkinson’s Disease. Canadian Journal on Aging = La Revue Canadienne Du Vieillissement, 35(3), 319–331. http://doi.org/10.1017/S0714980816000325

(2014, February 10). Preventing falls among older people with mental health problems: a systematic review. BioMed Central, 13:4(13:4). http://dx.doi.org/10.1186/1472-6955-13-4

National Database of Nursing Quality Indicators: (NDNQI), accessed January 21, 2016.

www.nursingquality.org/ (NDNQI)

Quigley, P. A., Barnett, S. D., Bulat, T., & Friedman, Y. (2015). Reducing falls and Fall-Related Injuries in Mental Health: A 1-Year Multihospital Falls Collaborative. Journal of Nursing Care Quality, 29(1

Stanford Health Care “Nursing: Quality and Safety”, (accessed July 2017), https://stanfordhealthcare.org/health-care-professionals/nursing/quality-safety/purposeful-rounding.html