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Essay: Improve Inpatient Falls with Quality Improvement: Strategies and Patient Safety

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Quality Improvement Regarding Inpatient Falls

Haifa Baalbaki

College of Staten Island

Abstract

When it comes to public health, quality improvement is essential in terms of progression and ensuring safety. Quality improvement teams from various facilities come together and exchange ideas, to learn the best ways to approach common problems and implement care using the plan, do, study and act formulation. Falls are common in hospital facilities even though it poses many risks and negative outcomes, especially in older patients. In this paper, analysis of the problem in hospital care regarding falls will be established as well as the definition of the scope of the issue and possible solutions that can decrease the occurrence of falls. The Richmond University Medical Center (RUMC) does have Quality Improvement measures regarding falls that is visible on all the units. A patient known as Mr. M, will be used as an example since he is a fall risk patient. In this paper, data regarding the occurrence of falls will be gathered based on nationwide statistics and the provided information on the Telemetry Unit at RUMC. Falls are considered a major safety concern in terms of leading to further injuries and causing irreversible or troublesome consequences. Thorough nursing care and interdisciplinary care is vital in avoiding falls especially in the elderly patient. The nurse and health care team should contribute in numerous ways to ensure patient safety. Injuries resulting from falls are a key factor for lawsuits against facilities and staff which can lead to loss of hospital funds and higher insurance premiums. Falls, besides injury and lawsuits, can lead to increased paperwork filing for staff and increased levels of care that is needed for the patient, thus leading to poor survey results. Overall, nationwide statistics and unit statistics suggest that patient falls still occur and that preventative measures must be taken to ensure quality improvement and patient safety.

Quality improvement measurements are taken in any healthcare field and unit to collect data, analyze the problem, seek and implement the solution and then measure the outcomes for improvement and control of the issue. In terms of what the definition of a patient fall is, “A patient fall is defined as an unplanned descent to the floor with or without injury to the patient” (Ganz, Huang, Saliba, & Shier, 2013).Falls in the health care setting are common, unfortunately, and do come with serious consequences in regards to the patient’s health and impacts the status of hospital care. Injuries are not necessarily associated with falls, however, the can occur and can lead to a multitude of consequences including longer hospital stays, lawsuits, paperwork, further surgeries, patient care and more. Falls can occur if the patient decides to get out of bed on their own, if the bed rails are not up, if the patient is walking and gets light headed or dizzy due to medication or illness, post surgery and numerous other reasons. On the Telemetry Unit at Richmond University Medical Center (RUMC), there is a QI data track sheet from 2017 that has records of falls and falls with injury on the floor. The purpose of this is to set a goal, implement care and safety precautions and document any incidents regarding the problem. If the number of falls decrease, that means the actions are working and this is beneficial to patients, the healthcare team and the facility itself. If not, patients are seemingly getting worse in the one place that's supposed to treat them and make them better. Hospital ratings will decrease and impact funding. Falls and falls with injury are undoubtedly common in healthcare facilities but are preventable with the help of quality improvement which consists of systematic and continuous actions that lead to measurable improvement in health care services.

    Falls can but do not always cause injury which is why it is vital to prevent it from occurring in the first place. According to the Agency for Healthcare Research and Quality, “Each year, somewhere between 700,000 and 1,000,000 people in the United States fall in the hospital. Research shows that close to one-third of falls can be prevented” (Ganz et al., 2013). The healthcare provider as well as other healthcare members carry a large load of responsibility for numerous patients so watching the patient becomes difficult when you have many to care for especially when the facility is understaffed. Which is why it is essential to communicate with other members of the healthcare team and interdisciplinary care comes into play. Patient who are neglected can push the patient to want to do things on their own even if they are not fully capable of doing so.

Patient falls result in many consequences especially if injury is associated. In continuation, “patients who have serious injury related to a fall during hospital stay average of 12 days of additional hospital time and incur higher costs than comparison patients ($13,316 more, on average) compared to their peers” (Bouldin, Andresen, Dunton, Simon, Waters, Liu, & Shorr, 2013). Aside from the fact that patients will be hurt due to these preventable falls, hospitals are impacted as well. In other words, depending on the insurance and injury, many insurances do not reimburse hospitals if the injury took place in the hospital during care. The cause of falls can be related to the patient’s health status which an example would be orthostatic hypotension, fainting or it can be that the floor was wet and the patient slipped. Falls can occur without intention and if a nurse or other member of the healthcare team tries to stop the fall by attempting to hold them up or catch them, it is known as an assisted fall which is still reported as a fall. The patient will be continuously monitored for twenty four hours or more if injury occurs and based on that injury, is interpreted on a scale of 1-4, with 1 being minor and 4 being that the injury caused the patient’s death. 1 being minor where a dressing, ice or topical agent was use used or the affected limb had to be raised or if the wound had to cleaned at all. 2 would be considered moderate as stitches, steri-strips, skin glue or a splint was used. 3 is known as major because the patient will need surgery, a cast, traction or a neurological consult. The most fatal being 4, in that the patient died due to the injuries that were caused by the fall (Bouldin et al., 2013). This scale shows how mild or fatal certain falls can be. One must consider the psychosocial aspect of the patient since they are already admitted with the hopes of getting better and going home. Therefore an extension of hospital stay can make them more anxious, upset and/ or fearful and can ultimately impact care.

    Falls are documented through incident reports and as a total number each month. On the Telemetry Unit of RUMC, statistics show the rate of patient falls vary between 3.1 and 7.18 as of January – July of 2018. However, there was no report of fall with injury. The 2017 end of year value was 3.9 and there was a set goal of 3.4 for 2018. When analyzing this data, there are many more falls reported in seven months of 2018 than there was in total of the year 2017. So far, from January to July, the average is 4.09 which is already higher than the anticipated goal. Although it is impressive that there are no injuries reported with falls, it is still questionable as to why there are more falls in seven months of 2018 than there was in total in 2017.

    Certain patients carry a fall risk based on their diagnosis, medications or pre-existing health conditions. In terms of my patient, Mr. M is a sixty-six year old male who is on contact precautions due to MRSA of the wounds. His diagnosis was septic shock and has urosepsis. He also had a below the knee amputation on his right leg. Given that the patient is an amputee, is on isolation and has an infection which includes alteration in body temperature, heart rate and BP, puts this patient at a risk for falls. My patient was a prime example of the kind of fall risk patient that should be monitored frequently. My team and I made sure to lower the bed to the lowest position after we finished assessments, put up three of the four side rails and left the call bell within the patient’s reach. We also placed the table close to him as well. Although the room was small we also made sure to leave the room clutter-free.

    There are numerous methods to prevent patient falls in the hospital care settings. According to The Joint Commission, one of the actions suggested to be used to falls and fall-related injuries is to “use a standardized, validated tool to identify risk factors for falls” (The Joint Commission, 2015). These tools can include the Morse Fall Scale or the Hendrich II Fall Risk Model. In addition, each patient should individually assessed to see if they are at risk for falls. Medications can cause the patient to feel confused, light headed and even cause them to faint. Another method includes raising awareness of the Ned to. prevent falls. All staff members should be notified and educated as to what patient safety entails. Chair alarms, bed alarms are all useful in preventing falls by allowing the healthcare team to be notified when the patient who is a fall risk is attempting to get up without help. All members of the healthcare team should be aware that the patient’s safety is essential and that all are responsible in maintaining that safety. Each patient has different needs in terms of their diagnosis, physical and mental limitations, medications and so on. If the patient had suffered from a stroke or brain bleed, they might have impaired vision on one side of their eyes so the staff should know that objects and call bell should be placed on the side with better vision. A commode should be readily available for those who need assistance to the bathroom. Maintaining a clutter-free environment and ensuring that the patient wears non-slip socks is vital as well. Keeping the patient’s important objects close by is useful. The healthcare team should also attempt to answer the call bell when they see Oreo hear it so the patient does not feel ignored or have the need to get up on their own. Change of shifts reports should include any specific patient information that the next staff member will need to know. If a fall has already occurred, the patient and staff should all discuss the incident, how it occurred and what caused it. Further discussion should be made as to how to fix this and prevent it from happening. Depending of the injury, the patient’s plan of care may alter. The patient should be continuously re-assessed for at least twenty-four hours. It should also be noted that ensuring the patient’s room is adequate in terms of lighting as well could be of benefit. The patient’s floor should be dry and if it is wet, a sign should be displayed at all times.

In conclusion, many complications arise from falls that go behind just the potential for injury. Falls can be seen in any unit with patients of all ages and diagnoses. However, patients who experience delirium, dementia, are frail, suffer from neurological degenerative diseases, are on sedatives or pain medications, can all be considered at a higher risk for falls. Complications can include fractures, strains, shoulder/back and spinal cord injury, internal bleeding and possibly even death. Thus potentially leading to complaints, lawsuits, patient’s loss of trust towards healthcare team and prolonged hospital stay. This puts the hospital at risk for poor ratings, increased paperwork load, and immense amount of fund loss. Prevention is key and in order to prevent falls, nurses, healthcare providers, and all members should be aware of the issue and how to prevent it from happening like answering call bells promptly and using bed and chair alarms. Risk assessments should be made to indicate which patients are at a higher risk for falls. Even the patient should be educated on the important of preventing falls due to the injuries that could occur and what they can do in order to prevent it from happening. Rooms should be suitable and equipped for those on fall precautions. The patient’s room should remain uncluttered and have everything within reach like the call bell and telephone. Beds should be lowered as close to the ground as possible and rails should be up if necessary but not all four to avoid the patient from feeling like they are being restrained. The patient’s hearing aid and glasses should be close and functioning as well. Patient falls in the healthcare setting is problematic nationwide especially in relation to falls. Quality improvement measures are taken to the better skills and techniques to reduce the occurrence of this issue.

References

Bouldin, E. D., Andresen, E. M., Dunton, N. E., Simon, M., Waters, T. M., Liu, M., Shorr, R. I.

(2013). Falls among Adult Patients Hospitalized in the United States: Prevalence and

Trends. Journal of Patient Safety, 9(1), 13–17. Retrieved from the Web 4/30/18,

http://doi.org/10.1097/PTS.0b013e3182699b64.

Ganz, D. A., Huang, C., Saliba, D., & Shier, V. (2013, January). Preventing Falls in Hospitals.

Retrieved November 16, 2018, from

https://www.ahrq.gov/sites/default/files/publications/files/fallpxtoolkit_0.pdf

The Joint Commission., (2015). Sentinel Event Alert 55: Preventing falls and

fall-related injuries in health-care facilities. Retrieved from the Web, 4/29/18,

https://www.jointcommission.org/assets/1/18/SEA_55.pdf

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