Evidence-based practice: a falls prevention program that continues to work

MedSurg Nursing, August, 2008 by Lydia Dacenko-Grawe, Karyn Holm

Nursing staff and nursing administrators are acutely aware of the importance of preventing patient falls, a dreaded consequence of hospitalization for any patient. When a patient falls, particularly when fracture is the consequence, the net result is an increased length of stay, increased costs of hospitalization, and prolonged recovery (Perell et al., 2001). At Saint Francis Hospital (Evanston, IL), fall rates declined by 50% over a 3-year period without rebound after instituting a fall prevention protocol. This success resulted from educating all hospital staff members about who is most likely to fall. The development of the Saint Francis Hospital Fall Prevention Protocol is described.

Background

Saint Francis Hospital (SFH) is a 325-bed acute care teaching hospital located in Evanston, IL, a suburb of Chicago. The hospital service area is diverse, reflecting a variety of ethnic, religious, racial, and socioeconomic groups. Annual inpatient admissions averaged 12,500 in the period of 2003-2006; many admissions originated from the emergency department, which has approximately 34,200 visits annually. A professional translation service is well utilized by the multicultural and multilingual nursing staff to effect accurate patient care and instruction. The nursing staff show a dedication to professional development as evidenced by 34% certification in nursing specialty areas. The nursing staff also is dedicated to patient safety, and was integral to the decrease in the fall rate. Nursing staff practice on the inpatient units is shown in Table 1. Psychiatric admissions are referred to another member hospital of Resurrection Health Care. The emergency department supports a Level 1 Trauma Center. Cardiology, cardio-thoracic surgery, and oncology are prime specialties and reflect the majority of the inpatient diagnoses.

[FIGURE 1 OMITTED]

In 2002, SFH experienced higher inpatient fall rates for the first three quarters of the year, with rates of 4.1, 4.5, and 4.3 falls per 1,000 patient days respectively. This placed SFH above the national average of 3.9 inpatient falls that year. The SFH nursing educators were charged by the chief nursing officer to develop and immediately implement a fall prevention program, subsequently named the SFH Fall Prevention Protocol.

As evidenced in the literature (Perell et al., 2001), a common first step in fall prevention strategies is the development or adaptation of a fall-risk assessment tool. We thus realized that choosing the best tool for the patient population was an important decision (O'Connell & Myers, 2002). Using a tool that inadequately predicted fall risk at SFH could lead to falsely assuming fall rates were declining when in fact they were either stagnant or even increasing. In a survey of area hospitals, including those hospitals that are partners in the health care system, we found that the Morse Scale (Morse, 2002), the Schmid Scale (Schmid, 1990), or a tool unique to the institution was used most often. Common reasons cited for using particular tools included high inter-rater reliability, ease of calculating total score, and ease of patient assessment. We also found within the context of the survey that system partner hospitals did not use a specific fall-risk assessment tool, thus lending impetus to create a tool by modifying a safety assessment tool in use prior to 2002 to better capture fall risk at SFH.

Methods

The SFH Safety Assessment tool was modified to score patients, rather than merely to identify the presence of, each of 10 areas that appeared on the original tool: history of falls, age 65 and older, impaired cognition, active bowel preparation, activity intolerance, elimination, impaired mobility, sensory deficits, medications, sleep patterns. Scores could range from 0 to 95, with patients scoring 25 points or above categorized as high risk for falls and requiring implementation of the SFH Falls Prevention Protocol. Very importantly, the modified SFH Safety Assessment tool included a criterion related to age. Patients age 65 and older composed 12.5% of inpatient admissions in 2002 and 2003 yet accounted for 70% of patient falls in those same years, lending support for content validity. See Figure 1 for the modified SFH Safety Assessment Tool.

In developing a fall prevention protocol, we reviewed many published protocols. The SFH Fall-Prevention Protocol was developed using ideas from Schmid (1990) who described a fall prevention program at a Veterans Administration Hospital where fall rates declined from 5 to 4 per 1,000 patient days in 1 year. After patients at high risk for falls were identified, this information was shared with every employee working in that patient's environment--not just the nursing staff--so vigilance could be maintained.

At SFH, patients at high risk for falls are identified with an orange wrist bracelet and have an orange autumn (fall) leaf placed on their door. Staff who spend any part of the work day in patient care areas--nurses, physicians, laboratory and radiology technicians, dietary aides, housekeepers, maintenance personnel, and secretaries--were instructed in the meaning of the orange identification bracelets and fall leaves. They also were instructed to monitor identified patients more closely (Meade, Bursell, & Ketelsen, 2006) and accompany them as they walked to the bathroom (Hitcho et al., 2004) or to their beds. If non-nursing staff were not in a position to assist the patient, they were instructed to call for nursing help immediately. Confused patients and those who could not follow instructions had a portable bed monitor applied underneath the bed linens which would alarm loudly in 3 seconds if the patient left the bed. We realized that the use of these bed monitors precluded the use of physical restraints on the greater majority of these patients; the use of restraints enforces immobility with ensuing muscle weakness and thereby contributes to the potential for patient falls when the restraints are released. All patients, regardless of their fall-risk assessment score, were instructed to wear hospitalsupplied non-skid footwear at all times.