This blog is part of an ongoing series focused on introducing the current quality initiatives. This month, we are featuring the work being done to reduce injuries resulting from falls. Thank you to the Quality Improvement Program team for sharing their important work with us and thank you for taking the time to learn more about the vital work that goes on to improve the care we provide to our patients.
Patient falls are a challenging problem to solve since there is no one-size-fits-all approach to reducing falls and preventing injuries. All health care team members (e.g., provider, nursing, therapy, transport teams, etc.) have the ability—and responsibility—to make a difference in the safety of our patients. A fall event typically occurs unexpectedly, but many of these falls can also be anticipated through the completion of a thorough fall risk assessment.
What risk factors are patients assessed for?
The fall risk assessment is completed to assess for multiple risk factors including:
- Elimination: Most common activity contributing to falls
- Mobility/Ambulation: Gait, unsteadiness, weakness, assistive devices, etc.
- Mental Status: Delirium is a major risk factor for falling and is preventable.
- Sensory/Communication Deficit: Neuropathy, vision, hearing, etc.
- Medications: Cardiac and central nervous system medications
- Last fall: Including admission due to a fall or a fall during hospitalization
- Age-related risk
- Nursing judgment: Alcohol withdrawal, encephalopathy, impulsivity, impaired judgment, etc.
Fall prevention interventions are multifactorial and individualized. Recognizing what makes your specific patient population unique and using the information obtained from the fall risk assessment to understand your patient’s fall risk factors will aid in initiating appropriate fall prevention strategies.
What is a fall with injury?
We have standard definitions that are provided to us by the National Database of Nursing Quality Indicators (NDNQI) to ensure a standard process in defining a patient fall and the level of injury. A patient fall event is defined as a “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., a trash can).” The NDNQI further defines the injury levels by providing a framework of examples including but not limited to:
- No injury: Resulted in no signs or symptoms of injury as determined by post-fall
- Minor injury: Resulted in application of ice or dressing, cleaning of a wound, limb elevation, topical medication, pain, bruise or abrasion
- Moderate injury: Resulted in suturing, application of steri-strips or skin glue, splinting, or muscle/joint strain
- Major injury: Resulted in surgery, casting, traction, required consultation for neurological (e.g., basilar skull fracture, small subdural hematoma) or internal injury (e.g., rib fracture, small liver laceration), or patients with any type of fracture regardless of treatment, or patients who have coagulopathy who receive blood products as a result of a fall
- Death: The patient died as a result of injuries sustained from the fall (not from the physiological events causing the fall) evaluation”
There is a monthly multidisciplinary Fall Prevention Committee that consists of nursing leaders, staff nurses, nursing assistants, physical therapists, occupational therapists, a pharmacist, and a provider. We are also developing a task force consisting of a smaller core team that will review the data on current themes with opportunities for patient falls and quick decision-making for opportunities in fall prevention, as well as the correlation of other patient factors to their fall risk.
Metrics being tracked:
In addition to the total number of patient falls each month, we also monitor the number of assisted falls and falls that result in an injury within Tableau. Each quarter, we also submit our data on total patient falls and falls with injury to the NDNQI. We use this data from the NDNQI to benchmark against other academic medical centers and other comparative units (down to the unit level), allowing for fair comparison for each unit/clinic that submits data to the NDNQI. Inpatient and ambulatory/non-inpatient falls and falls with injury are monitored and shared each month (data is through the month of May 2022).
What is the team doing to improve metrics?
Generally, patient falls are multifactorial, which is why a thorough fall risk assessment and understanding of how each risk factor impacts the patient’s risk of falling is important. In some instances, the fall risk assessment may have been completed just to “check the box,” ultimately missing the correlation between risk factors and the appropriate fall prevention interventions.
Reinstituting post-fall huddles is one way UI Health Care is working to improve metrics. Additionally, the post-fall huddle form was redone, including the development of an electronic version. The updated form is broken down by risk factor to assist staff with making the connections and linking appropriate interventions with the patients identified risk factors. The team is continuing to work with various departments to assist staff with making the connections between risk factors, interventions, and hardwiring practices that will promote routine use of patient-specific strategies for fall prevention.
Patient fall events have been an ongoing national concern that has resulted in The Joint Commission’s sentinel event definition in January 2021. Any patient fall that results in a major injury or death (as defined above) is now reported to the Joint Commission as a sentinel event.
So, as we continue our work reducing falls and preventing injuries for our patients, it’s important to remember that change doesn’t happen overnight. We encourage you to make short-term attainable goals that are specific for your area that include realistic components that will help you hit those milestones. Understand what the top three risk factors/causes are for patient falls in your area, build a plan with your team with realistic interventions, and implement those interventions to minimize those identified risks. A good rule of thumb is to start with the primary risk factor and continue to build as you make progress.
Focus areas for improvements
- Education for thorough and accurate fall risk assessment
- Education on connecting risk factors with appropriate interventions
- Complete a multidisciplinary post fall huddle (paper or electronic version) after every fall to learn from fall event