Published in the October 2011 issue of Today’s Hospitalist
DESPITE EVERYTHING that is known about falls “including how they threaten a patient’s health and a hospital’s bottom line “successful, sustainable prevention programs are hard to find. Many hospitals have seen their fall rates stall or even climb, all while the Centers for Medicare and Medicaid Services has stopped reimbursing the costs of treating inpatient falls. Estimates of those costs run as high as $20 billion a year.
Physicians at Staten Island University Hospital, a 714-bed tertiary hospital in New York, know how frustrating it is to not see those rates go down. In 2005, the hospital analyzed its data on falls and found a record high: 3.9 falls per 1,000 inpatient days. Even worse, the number of inpatient falls was increasing 6% every quarter.
But by 2010, the hospital could tell a much different story. As a result of many interventions, it slashed its number of falls by two-thirds (63.9%). (A description of those efforts appeared in the July 2011 Joint Commission Journal on Quality and Patient Safety.)
Getting to that point took a lot of staff commitment, says physiatrist Jeffrey Weinberg, MD, MBA, chair of rehabilitation medicine, who co-chairs the hospital’s fall prevention initiative. It also required the hospital to set a new bar for accountability.
The problem with most fall prevention programs, Dr. Weinberg explains, is that hospitals rely on crafting new protocols. But the real culprit is low compliance with protocols that are already in place.
"We made sure that we had systems to determine compliance," says Dr. Weinberg. "It’s not as important to me how many falls there were, but how many falls there were when protocols weren’t being followed."
The need for critical thinking
Many of the interventions were designed to encourage staff to become much more aware of fall risk and prevention efforts. But first, initiative leaders identified gaps to be filled. For one, the hospital realized that it wasn’t thoroughly investigating the falls that took place. Investigations were even less thorough on nights and weekends when unit managers were off duty.
The initiative committee solved that off-hours problem by holding a series of meetings with the onsite assistant directors of nursing who worked nights and weekends, and charged them with investigating those falls.
"The investigations," Dr. Weinberg and his colleagues wrote in their study, "became consistently complete and accurate."
Another problem was that staff, particularly floor nurses, did not think critically about how changes in patient care affected patients’ fall risk. While admitting nurses screened patients for that risk, nurses caring for the patient often did not revise that initial assessment.
As part of the falls initiative, nurses were charged with overriding assessments if they could document a reason for doing so.
"Say someone was assessed and then received a PRN Benadryl order," Dr. Weinberg says. "That changes everything." Although nurses can’t conduct new assessments every hour, he points out, they are expected to watch for major changes.
A new accountability
An even bigger change was raising the visibility of fall prevention efforts and making everyone responsible for them.
Before the initiative began, individual nurses were considered accountable for falls that happened on their watch, but that accountability didn’t extend to nurse managers. Now, however, nurse managers and floor nurses hold daily fall rounds to discuss each patient’s fall risk.
Nurse managers were also charged with identifying breaches of protocol when falls took place, and they began receiving monthly falls reports with unit-specific data. Units also hold competitions to see which unit goes the longest free of falls.
Both nurse managers and floor nurses also meet monthly with initiative leaders “including the chief nursing executive “to discuss the falls that take place, get feedback on prevention efforts and suggest remedies to head off subsequent falls.
Bed alarms and bathroom help
While many interventions were designed to increase accountability, two changes proved critical to the initiative’s success. The first was offering and documenting assisted toileting.
While many hospitals offer patients assisted toileting, Staten Island asked nurses to both offer and document that service every two hours during the day and at night when a patient is awake. That’s now one of the first compliance issues reviewed after a fall.
"We go back to the chart and see if people were really offered assisted toileting," says Dr. Weinberg. "In many cases where patients fell going to the bathroom, they weren’t."
The second change was introducing bed and chair alarms for patients at risk for falls. Sensors in the alarm pads alert a nurse when patients try to get out of bed or up from a chair themselves.
While most changes targeted nurses, doctors were asked to review the medications of each patient who fell. And since September 2006, the hospital has restricted the use of two sleeping aids “diphenhydramine and hydroxyzine “for patients 65 and older. When the initiative also discovered that some patients were falling at night after receiving the diuretic furosemide, the hospital changed the time the drug is administered from 9 p.m. to 6 p.m. That simple change helped eliminate night-time trips to the bathroom.
Dr. Weinberg admits that insisting on broader accountability and compliance caused some initial friction.
"When they first asked me as a physician to be involved, I looked at everyone’s role," he says. "If I said a nurse wasn’t toileting the person, nurses might say things like, ‘You’re a doctor “don’t look at the nurses.’"
Fortunately, he adds, that tension evaporated as fall rates began to tumble. "It became much more collaborative," says Dr. Weinberg. "People were proud of their success."
Although fall prevention is now engrained in the hospital culture, the results vary each year and vigilance is still required. The annual fall rate is now averaging 55% lower than during the pre-intervention days. This August, the hospital posted its best improvement yet (a 78% reduction).
At the same time, the quality improvement techniques that the initiative ushered in are now being applied throughout the hospital. Using daily reviews to assign private aides to patients, for instance, has produced a 30% reduction in the number of hours those aides spend with patients.
And daily discharge planning and utilization rounds now bring together an interdisciplinary team to discuss the lapses and problems causing discharge delays. (That team includes the chair of medicine, doctors, case managers, nurses, physical therapists, emergency department and bed management staff, and others as needed.) As with the daily fall rounds, participants come up with preventive or corrective actions, and specific providers are given problems to solve.
"Nothing discussed at those meetings is different from what’s been said over the years," says Dr. Weinberg. "The difference is that people are now made accountable for getting things done."
Marcia Frellick is a freelance health care writer based in Chicago.