It is estimated that by the year 2030, 21.2% of the population in the United States will be 65 years or older (Liptzin, 1987; Miller, 1990). Aging, and many of the disorders common in late life, can increase the risk for falling. In fact, falls among the elderly are the second leading cause of accidental death (National Safety Council, 1987).
In hospitalized patients, falls account for up to 90% of all reported incidences, which are occurrences outside the norm (Raz, 1987). Furthermore, the risk for falling is noted to be significantly greater in the hospitalized elderly than in other hospitalized age groups (Rhymes, 1988). This hazard provides a significant risk for nurses, health care personnel, and institutions caring for the geriatric population.
The purpose of this article is to describe quality assurance efforts to decrease the incidence of geriatric falls at MetroHealth Center for Rehabilitation. The Center for Rehabilitation is a 172-bed program within the 742-bed MetroHealth Medical Center in Cleveland. In conjunction with this quality improvement effort, a Falls Prevention Program and Awareness Campaign, which was instituted at the entire Medical Center, is presented.
There is an abundance of literature regarding patient falls. Most studies focus on risk factors and populations that have a higher incidence of falls. Consistently reported intrinsic variables that increase risk for falls include a history of previous falls, increased age, and gait problems (Gross, 1990; Maciorowski, 1988).
One fourth to one half of hospitalized patients who fall have experienced a previous fall, either prior to or during their admission (Johnson, 1986; Tack, 1987). A number of authors have noted that the risk of falls increases as a person ages (Tack, 1987). Johnson (1986) states that multiple falls and injuries are more prevalent among the elderly over the age of 75. Tinetti and associates (1987) report a significant relationship between gait problems and falling.
Other personal characteristics that have been found to increase the risk for falls are: sensory impairment, urinary and bladder dysfunction, and medical diagnostic categories, including cancer and cardiovascular, neurologic, and cerebrovascular diseases. Polypharmacy, substance abuse, certain drug classifications, and psychosocial issues also contribute to increasing the risk for falls (Grant, 1987; Hill, 1988; Lamb, 1987; Mion, 1989).
In addition, the literature cites extrinsic characteristics that place patients at risk for falls. Environmental factors such as unstable furniture, elevated bed positions, shiny floors, poorly soled or unsafe footwear, and dim lighting in rooms and hallways are identified as contributors to patient falls (Whedon, 1989).
In general, studies of time-related factors reveal few significant relationship between falls and time of day, or day of week, month, or season (DeVincenzo, 1987). However, falls most often occur during the first week of hospitalization, and again after the third week (Tack, 1987). Despite the multiple risk factors identified for falls in the elderly, no high-risk profiles have been developed with adequate sensitivity and specificity to be useful as a predictive tool (Whedon, 1989).
Elderly patients admitted to MetroHealth Medical Center for Rehabilitation exhibited many of the characteristics associated with falls. Statistics showed an increased rate of geriatric falls. In addition to claims for injuries related to falls, there were additional expenses incurred from increased lengths of stay, diagnostic /treatment procedures, and emotional suffering of both the patients and the nursing staff.
Retrospective Chart Review
In order to establish a baseline regarding patient falls, a retrospective chart review (N =71 cases) was conducted in a quality improvement effort on a 28-bed geriatric rehabilitation unit. Falls were examined during a 10-month period. A fall was defined as an uncontrolled and undirected occurrence in which the patient comes to rest on the floor (Mion, 1989).
The greatest incidence of falling occurred during the first (23%) and the fifth (26%) week of hospitalization.The highest percentage of falls occurred during the day shift, with 6% at 8:00 am and 15% occurring between 2:00 pm and 3:00 PM. Eight percent of evening shift falls happened at 10:00 pm. During the night shift, 8% of the falls occurred between 5:00 am and 6:00 am. The remaining percentage of falls revealed no trend.
Regardless of time of day, most falls occurred in the patient's room or bathroom. When analysis focused on the faller, the total number of cases was reduced from 71 (falls) to 36 (people). The largest percentage of fallers were in the 70 to 79 age range; males were predominant. The largest percentage of females were also in this group. Activities patients were trying to accomplish at the time of falls included attempting to get the bathroom, leaning forward in their chairs, and transferring in and out of bed.
Quality Improvement Activity
A review of the retrospective chart audit results - coupled with the perception that patients whose needs are anticipated and met fall less -provided direction for the next step in the quality improvement effort. The results revealed that the need to toilet, seek rest, or obtain nutrition and hydration were activities prevalent at peak fall times or at the time of an actual patient fall. A quality improvement monitor was designed to provide proactive nursing interventions to reduce potential falls during four peak fall times based upon patient care needs identified in the audit.
The four peak fall times were chosen. Thirty minutes prior to the start of these times, a nursing staff member asked each patient on the unit if there was a need for toileting, assistance in/out of bed or wheelchair, or fluids /nourishment. The nursing staff intervened to meet identified needs and reinforced calling for assistance for future needs. Examples of questions and interventions were included on the data collection form to ensure conformity of approach to each patient (Figure 1).
Quality Assurante Data Collection Form
Twenty-five patients were included in this quality improvement monitor, which was conducted over a 2-week time frame. Staff compliance with the interventions during this same time was 86%. The outcome criteria, to decrease patient falls without injury by 50% for a 2-week period, was met. A comparison between falls occurring during the monitor period and the same time frame for the years 1989 and 1990 showed an 80% and 88% decrease in falls, respectively. The success in reducing the number of falls through proactive nursing interventions supported the belief that patients whose needs are anticipated and met fall less.
Falls Prevention Protocol
Falls Prevention Protocol
The focus of this falls prevention program is different from that of most documented falls programs. Rather than attempting to identify the multiple characteristics that are risk factors in potentiating falls in the elderly, the nurses intervened to prevent patient falls. Development of the MetroHealth Falls Prevention Program incorporated these proactive measures in conjunction with identified risk factors.
THE FALLS PREVENTION PROGRAM
A nursing task force was convened to address patient falls at the Medical Center. Membership consisted of staff nurses, unit managers, and clinical nurse specialists from rehabilitation and acute geriatric units, as well as representatives from education and quality assurance. The Falls Task Force agreed that the approach to decrease patient falls would be simple (to avoid a major increase in the nurse workload), and would focus on nursing interventions and risk factors for falls. The following Falls Prevention Protocol was written (and minor revisions made) after a 2week pilot study was conducted at two nursing units.
The Falls Prevention Protocol was developed to outline the nursing responsibilities and management for a patient at risk for falls (Figure 2). Protocols may be classified as dependent, independent, or interdependent (Smith-Marker, 1988). Historically, quality improvement falls study results found that staff nurse actions included all independent functions and orders. This Falls Prevention Protocol is classified as independent to reflect autonomous nursing actions and functions that require only a nursing order to implement.
Assessment, intervention, reportable conditions, patient /significant other instruction, and documentation were the areas addressed in the nursing intervention section of the protocol. According to the protocol, the nurse is responsible for assessing the cognitive, sensory, and mobility status of patients each shift. The criteria for degree of risk for falls is based on a level system focusing on these assessment areas. Level 1 patients would demonstrate no deficits, while Level 2 patients would demonstrate a deficit in one or more areas.
The intervention section focuses on strategies the nurse would implement for each patient level. The interventions content in Level 1 include basic nursing interventions, such as placing the call bell within the patient's reach and lowering the bed. Examples of Level 2 interventions include addressing the potential for injury through the standard (Potential for Injury) nursing care plan or through another related nursing care plan; reinforcing patient calls for assistance; and offering assistance for toileting.
Additionally, Level 2 interventions to alert the staff were developed by the Falls Task Force and had not previously been used at MetroHealth Medical Center. Included in these interventions are placement of a yellow wrist band on the patient, and posting of yellow signs that indicate implementation of the falls program above the bed and outside the patient's room. Note that Level 2 patient interventions include all Level 1 patient interventions.
Reportable conditions are any patient fall or change in cognitive, sensory, or mobility conditions. Instruction to the patient and or significant other is simply orientation and reinforcement of the falls program. To help accomplish this task, a simple, easy-to-read handout was developed that explains the program and contains guidelines for preventing falls. In the documentation section, the nurse is directed to document assessments in the medical record and/or applicable flow sheets. Initiation or discontinuation of Level 2 interventions is based on ongoing patient assessment.
Although the literature strongly supports increased nursing awareness to reduce patient falls, few articles suggest involvement of other professional and nonprofessional staff members (Grant, 1987; Hendrich, 1988; Hill, 1988; Mion, 1989). The Task Force agreed that, to be successful, the program must include the support and assistance of all individuals who have contact with a patient during hospitalization.
Two types of education programs were designed: one for nursing staff members and one for other professional and nonprofessional staff members. The nursing staff education component consisted of orientation to and implementation of the protocol.
The nonnursing staff was introduced to the Falls Prevention Program by focusing on what must be done to assist patients at risk for falls. Notifying the area staff when a patient identified at risk for falls is brought to or returned to the area is an example of such assistance.
The awareness campaign was designed to heighten consciousness of the staff, regardless of the type of patient contact. Included was a weeklong falls prevention poster presentation given at key times in the employee cafeteria. A one-page brochure describing the Falls Prevention Program was distributed to employees at this time.
An awareness of age-related changes and risk factors specific to the geriatric rehabilitation population enabled nursing to design proactive interventions that reduced falls. According to Miller (1990),
The role of gerontological nurses is to identify the factors that cause negative functional consequences and to initiate interventions that will result in positive functional consequences. The ultimate goal of the interventions is to enable older persons to function at their highest level, despite the presence of agerelated changes and risk factors.
Several implications for the practice of gerontological nursing are apparent. First, minimizing unsafe patient activity provides an environment conducive to less restraint use. Autonomy and self-esteem are supported if the geriatric patient - who is already dealing with multiple losses - is spared further loss of freedom. Furthermore, the nurse maintains a sense of control over patient safety without the ethical concern of restraining.
Second, planned interventions throughout the shift have implications for time management. Allowing for nursing interventions at prearranged times alleviates responding to multiple patient calls for assistance in the midst of other work activities or the more time consuming response to a fall.
Third, any measures that reduce falls directly control health care expenditures, much of which are borne by society and the health care system. The awareness campaign served the purpose of making employees more aware of measures that decrease falls.
Lastly, there are implications for further nursing research. Exploring systems that focus on nursing interventions in populations susceptible to falls - in combination with the identified risks of fallers - may be the key to further eradication of preventable falls.
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Quality Assurante Data Collection Form
Falls Prevention Protocol
Falls Prevention Protocol