Prevention of Patient Falls - A Case Study

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Fall-related injuries can be some of the most common, disabling, and expensive health conditions encountered by adults, especially older adults. According to researcher Janice Morse, approximately 14% of all falls in hospitals are accidental, another 8% are unanticipated and 78% are anticipated falls. Guideline to prevent falls in the hospital has helped to bring down the numbers and improve patient safety.

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Prevention of Patient Falls - A Case Study

  1. 1. Prevention of Patient Falls - A Case Study
  2. 2. a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 1 7 5 e1 8 0 Available online at www.sciencedirect.com journal homepage: www.elsevier.com/locate/apme Quality in Health Prevention of patient falls e A case study Gaurav Loria a,b,*, Ankita Bhargava c a Coordinator Quality, Apollo Group, Jubilee Hills, Hyderabad, India National Head Quality, Jubilee Hills, Hyderabad, India c Executive Quality, Apollo Hospitals, Hyderabad, India b article info abstract Article history: Fall-related injuries can be some of the most common, disabling, and expensive health Received 23 January 2013 conditions encountered by adults, especially older adults. According to researcher Janice Accepted 18 February 2013 Morse, approximately 14% of all falls in hospitals are accidental, another 8% are unantic- Available online 28 February 2013 ipated and 78% are anticipated falls. Guideline to prevent falls in the hospital has helped to bring down the numbers and improve patient safety. Keywords Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved. Patient safety Precautions Morse fall risk scale Root cause analysis 1. Patient falls: introduction Patient falls have been identified by the Joint Commission as one of the top five sentinel events for home care organizations in its December 2003 sentinel event report.1 According to the researcher Janice Morse, approximately 14% of all falls in hospitals are accidental, another 8% are unanticipated and 78% are anticipated falls.2 Fall-related injuries can be some of the most common, disabling, and expensive health conditions encountered by adults, especially older adults. The number of persons above the age of 60 years is fast growing, especially in India. India as the second most populous country in the world has 76.6 million people at or over the age of 60, constituting above 7.7% of total population. The problems faced by this segment of the population are numerous owing to the social and cultural changes that are taking place within the Indian society.3 Every year thousands of cases of patient falls are reported which majorly comprise of the elderly. Main reasons for falls: Lack of staff communication, orientation and training No proper patient’s assessment Physical environment Care planning Organization culture Vulnerable patients are mainly those who are more susceptible to a fall when admitted in a hospital like patients above 65 years old (geriatrics), children less than 16 years of age (pediatrics), patients who are physically/ mentally challenged or patients who cannot perform acts of daily living. For effective management of such patients, five balancing steps are required. These are: * Corresponding author. Coordinator Quality, Apollo Group, Jubilee Hills, Hyderabad, India. 0976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved. http://dx.doi.org/10.1016/j.apme.2013.02.006
  3. 3. 176 a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 1 7 5 e1 8 0 1. Determine the vulnerability of the patient and identify them 2. Patient First program or a special program to be implemented 3. Frequent assessments and reassessments 4. Specific therapy 5. Supportive care Team composition: Quality Systems and Nursing in charges. 2. Objectives of study To study the trend of patient falls in the hospital To trace the causes of falls To make necessary interventions to reduce the fall rate To improve patient safety by introducing practices to prevent falls
  4. 4. a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 1 7 5 e1 8 0 177 3. The process flow/guideline for fall prevention Fall and fall-related injury outcome measures 4. Assessment parameters 1. Number of patient falls per month 2. Patient fall rate 3. Percentage of patients who were classified under ‘low risk’ but had a fall Key tasks: Modified Morse fall Risk Assessment was made a part of the admission record. A separate sheet was also designed and circulated in all Outpatient and Day Care Areas to ensure the assessments of the patients. Training of the nursing team was done by the Quality Team.
  5. 5. Interventions Patient education Nursing Medication Reassessments High Moderate Low - Orient patient to surroundings and hospital routines - Orient patient about the call bells and make sure patient is able to use it - Instruct patient to call for help before getting out of bed. - Instruct the patient and family about the significance of fall prevention program - Teach patient to use grab bars - Discuss toileting needs of the patient and implement bowel and bladder program if necessary - Instruct the patient on side effects of drugs Place Patient First Card bed side Side Rails Always Up Lock all moveable Equipment before transferring Provide adequate lighting Place Bed Pan/urinal within easy reach Position the bed at low level with brakes locked/position the foot stool in place Communication Board Placement Place assist devices within reach Develop a schedule for turning and positioning Increase frequency of patient rounds Instruct housekeeping supervisor to keep pathway clear from obstacles and keep toilet floor dry Consider obtaining doctors order for physiotherapy consult Vital signs recording as per orders Assess patient’s condition in his ability to do acts of daily living (ADL) Physical restraints ordered Physical therapy as ordered Document the falls in incident report form and inform Medical Head Minimize the use of medications that alter mental status. Use alternatives to sleeping medications Dispense diuretics before afternoon/evening Treat pain Screen and treat for hypoxia Assess the clinical status of delirious patients to rule out reversible etiologies Promote mobility and fitness Every hour - Orient patient to surroundings and hospital routines - Orient patient about the call bells and make sure patient is able to use it - Instruct patient to call for help before getting out of bed - Instruct the patient and family about the significance of fall prevention program - Teach patient to use grab bars - Orient patient to surroundings and hospital routines - Orient patient about the call bells and make sure patient is able to use it Place Patient First Card bed side Lock all moveable equipment before transferring Provide adequate lighting Place Bed Pan/urinal within easy reach Position the bed at low level with brakes locked/position the foot stool in place Place Patient First Card bed side Side Rails Always UP Lock all moveable equipment before transferring Provide adequate lighting Vital signs recording as per orders Assess patient’s condition in his ability to do acts of daily living (ADL) Physical restraints ordered Physical therapy as ordered Document the falls in incident report form and inform Medical Head Minimize the use of medications that alter mental status. Use alternatives to sleeping medications Dispense diuretics before afternoon/evening Vital signs recording as per orders Assess patient’s condition in his ability to do acts of daily living (ADL) Physical restraints ordered Physical therapy as ordered Document the falls in incident report form and inform Medical Head Minimize the use of medications that alter mental status. Use alternatives to sleeping medications Dispense diuretics before afternoon/evening Frequent Every day a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 1 7 5 e1 8 0 Documentation 178 Interventions annexure4
  6. 6. a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 1 7 5 e1 8 0 5. 179 The falls project The project was implemented as a pilot for a week wherein few departments were covered. The success in the pilot project helped us to implement the same initiative all across the hospital. Data collection: The patient fall-related incidents were reported to the Quality Team by Incident Forms. These forms were the source of information of the falls which were further analyzed through Root Cause Analysis (RCA). Sustainability initiatives: The completion of the form was also checked through the Wake Up Call Rounds and reported to the Nursing Heads. Continuous surveys and surprise checks for documentation compliance and equipment safety were carried out to ensure safety. Patient and Family Education (PFE) was an integral part of the whole process. Handbooks were introduced which helped in explaining the patients and attendants better. Improvement: Before taking up the project, our patient falls were about 7 in the first six months (JaneJun 2011). With vigorous training of the staff the incidents reporting also improved and the number of falls reported was high in the next six months (JulyeDec 2011). The following six months (JaneJun 2012) the numbers came down drastically which was a result of PFE and vigorous staff training. Findings/Results: Findings Number of falls Reasons JanuaryeJune 2011 JulyeDecember 2011 JanuaryeJune 2012 7 Patient fell in bathroom (no assistance) Patient ambulating to bathroom Patient fell from bed Patient’s physiological condition Broken chair 14 Patient fell in bathroom (wet floor) Patient fell in the bathroom (no assistance) Patient slipped in the room Patient’s physiological condition 4 Patient’s physiological condition Patient fell from the bed
  7. 7. 180 a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 1 7 5 e1 8 0 The number of patient falls per 1000 discharges were found to be well within the benchmarked limits. It was also found that of all the patients who had a fall 21% were already categorized by the nursing staff as one vulnerable to fall while 42% at a moderate risk and 37% at a low risk. The major reasons for fall were also analyzed after completing a detailed review of every fall. The major reasons ranged from patient’s fall from the bed to his physiological condition to a fall in the bathroom at night. It was also observed that maximum patient falls happened at night (between 1 am and 4 am) when patients try to go unassisted to the toilet without informing anyone (even the attendant). 6. Conclusion The implementation of the guideline has brought some important outcomes. The number of falls have been varying from 0 falls to 5 falls per month. The staff has been trained on prevention and management of falls. The Patient and Family Education has been stressed upon with the bilingual patient education booklets and flip charts. Patient falls have happened due to various reasons of which patient falls in the bathroom and physiological condition of the patient have been the major causes. These have been taken seriously and brought to the notice of the patient caregivers. Adequate assessment of the fall risk has been stressed upon to reduce the risk and training is being given to ensure fall prevention. To reduce such patient falls, patients as well as attendants are being educated using flip charts. We have also conducted training programs and competency assessments for the entire staff of the hospital. Conflicts of interest All authors have none to declare. references 1. Reducing the Risk on Falls in Your Health Care Organization. Joint Commission Resources http://www.patientsafety.gov/ SafetyTopics/fallstoolkit/index.html. 2. Preventing Patient Falls e Establishing a Fall Intervention Program (2nd ed.) Janice M. Morse. 3. Falls in older people. National/regional review India. Dr. B. Krishnaswamy, Professor and Head; Dr. Gnanasambandam Usha, Assistant Professor, Department of Geriatric Medicine, Madras Medical College and Government General Hospital, Chennai City, Tamil Nadu State, India. 4. http://www.downstate.edu/patientsafety/falls.html.
  8. 8. A o oh s i l ht:w wa o o o p a . m/ p l o p a : t / w .p l h s i lc l ts p / l ts o T ie: t s / ie. m/o p a A o o wt rht :t t r o H s i l p l t p /w t c ts l Y uu e ht:w wy uu ec m/p l h s i ln i o tb : t / w . tb . a o o o p a i a p/ o o l ts d F c b o : t :w wfc b o . m/h A o o o p a a e o k ht / w . e o k o T e p l H s i l p/ a c l ts Si s ae ht:w wsd s aen t p l _ o p a l e h r: t / w .i h r.e/ o o H s i l d p/ le A l ts L k d : t :w wl k d . m/ mp n /p l -o p a i e i ht / w . e i c c a y o oh s i l n n p/ i n no o a l ts Bo : t :w wl s l e l . / l ht / w . t a h a hi g p/ e tk t n

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