Fall Prevention in the Hospital Setting by Including Patients in the Cause

Patient safety is fundamental to delivering quality healthcare services to the people. Today, healthcare organizations are striving to provide safe, effective, and patient-centered care. Patient falls are among the safety issues experienced in healthcare organizations that require intervention to minimize injury. In the United States, each year about 700 000 people fall leading to adverse outcomes such as fractures, lacerations, internal bleeding, or even death (Hopewell et al., 2020). There is evidence that falls can be prevented through the identification of risk factors and using a multidisciplinary clinical team approach. The focus of this discussion is to identify the causes of patient falls in my institution and a course of action to deal with the safety issue.

Clinical/Organizational Problem

Falls among patients is the most frequently reported safety incidents in my healthcare organization. The inpatient units report a significant number of patient falls each year and despite the use of different strategies the problem still persists. The elderly population is observed to be most affected by this issue with falls reported during admission and subsequent care in the wards. The main problem is adherence to the set guidelines on fall prevention in the facility.

The majority of falls in hospitals are no true accidents, but a combination of intrinsic and extrinsic factors related to the patient’s behavior. For example, the healthcare organization encourages mobility among patients, especially during prolonged hospitalization. However, the exercise can cause patient falls which can harm the patient further. The main cause of falls in this facility is the lack of a stepwise multidisciplinary approach to falls prevention. The nursing team is observed to assume more responsibility to monitor patients when all members of the healthcare team should be involved.

Most healthcare organizations focus on age as the risk factor for falls leaving other gaps unresolved. In my institution, the majority of falls observed are related to early mobility and lack of proper guidance for the population at risk. For example, the elderly population with chronic conditions find it difficult to move around the hospital and most experience falls even besides their hospital beds. Other risk factors that cause the adverse outcome include cognitive impairment, patients recovering from anesthesia, and the female gender. Despite the use of standardized assessment and intervention tools, falls are still occurring in the hospital setting

Description of the Problem

It is a known fact among healthcare professionals that falls in the hospital are a serious concern and preventing patient falls is of the utmost priorities. While not every fall can be prevented, we can eliminate the majority of them with specific patient-centered interventions and assessment tools that alert us to the risk. However, by including patients in the prevention hospitals can decrease them even more. Using a multidisciplinary approach to falls prevention is among the strategies used to ensure the adverse outcome is prevented. The practice is not well-established among the healthcare providers especially nurses in the facility. The nursing team is observed to be reluctant to properly implementing the set guidelines on fall prevention. Other healthcare team members also assume that it is the nurses’ and patient’s family’s role to ensure patients do not fall.

The effects of patient falls can range from minor complications to major health concerns like fractures or even death. There is a need to address the issue of patient falls because it affects the quality of patient care in many ways. Firstly, patient falls cause prolonged hospitalization which can be costly to patients. Prolonged hospitalization also means patients lose trust in the organization on matters of safety and recovery from disease. The end result is poor patient satisfaction and reduced revenue due to low patient turnover. The healthcare organization needs to address the issue of patient falls because it is their responsibility to ensure safety. Sometimes the organization can be sued due to negligence in ensuring the safety of patients while receiving healthcare. For example, lack of a wet floor sign in the wards can cause a fall that can seriously harm the patient. On this grounds, any adverse outcome means the hospital will have to take responsibility including treating the individual.

Explanation of Causes

The causes of patient fall in the facility can be classified into intrinsic and extrinsic factors. Most patients experiencing patient falls in the institution are those from theatre who have not yet recovered from anesthesia. Most of them wake up while they are confused making it difficult to move around. Last year, almost 50% of the patients who experienced falls in the facility were those in the surgical and medical units. Another cause of falls in the institution is poor monitoring of patients, especially at night. The nursing team report for the probable causes of falls indicated that lack of adequate staffing at night contributed to more falls. Additionally, the fall rate has increased since the COVID19 outbreak due to the limited availability of relatives to take care of the patients as per the hospital rules.

Falls in healthcare institutions can result from the use of medications and patient conditions especially for the elderly. Medications such as narcotics and sedatives can cause dizziness which can result in patient falls (Guirguis-Blake et al., 2018). Lack of enough education to the patients can make it difficult to understand the effects of these drugs leading to falls. Statistics in the hospital also indicate that medical conditions such as dementia result in patient falls due to frequent movement and lack of precaution when using washrooms. In another hospital medical unit, it was observed that lack of wet floor signs frequently resulted in slips and falls.

Healthcare organizations are moving towards the use of multidisciplinary approaches to promote patient safety and security. Lack of teamwork and good relationships between nurses and other healthcare professionals can be a contributing factor to patient falls in the facility. The nurses are the only team in the institution giving priority to the issue of patient falls. An educational program will greatly serve to inform other healthcare professionals of the importance of fall prevention. The issues with falls prevention in the institution exist because clear guidelines on the role of each healthcare team do not exist. There is also a lack of attention to falls prevention due to a lack of enough information about the importance of preventing falls in the facility.

Identification of Stakeholders

Falls prevention in healthcare institutions requires a multidisciplinary approach including the involvement of patients in their care. The key stakeholders that will be involved in fall prevention include the registered nurses, nursing educators, hospital administration, doctors, and the patients.

Nurses have a huge role to play in the improvement of quality in healthcare. Falls prevention is equally the responsibility of nurses because they spend more time with patients. The nursing team will be responsible for implementing new changes that will help reduce patient falls in the facility. They will be active members during education and training to increase their understanding of the healthcare concern. The second team involves the clinical nurse educator responsible for designing educational programs for quality improvement. The nurse educator will organize education and training for staff during falls prevention.

The hospital administration holds a key role in process improvement in any healthcare facility. The administrators ensure that new changes are made according to the hospital policy and that they are of benefit to the organization and to patients. The administration department will be involved in approving the proposed change to prevent falls across all hospital units. The administration will also deal with financial support for the process. The doctor’s team will also be another key stakeholder in the new change. Being active members of the healthcare team, they will participate in education and training on falls prevention. The doctors will collaborate with nurses to ensure medications are appropriately checked before administration to patients. Lastly, the patients will be involved in education on how they can reduce incidences of falls. Strategies such as using walking aids and observing precautions for the wet floor will be taught.

Discussion of Stakeholders

The registered nurses will participate in the prevention of falls exercise through engagement in education and training. The new change will primarily focus on the role of nurses in fall prevention because they spend most of the time with patients. The nursing team has the power to accept or decline the new change depending on its relevance to quality improvement. The nurses can play a key role in changing the monitoring of patients in the facility and collaborating with other professionals to prevent patient falls. The interest of the nursing team is on improving patient safety and improving the quality of care delivered to patients. Acceptance of the new change by patients can influence how the doctors and other healthcare professionals respond to the new strategies for fall prevention.

The second key stakeholder in the prevention of patient falls is the nurse educator. The clinical nurse educator will be involved in educating staff and other stakeholders on the importance of the new change. The interest of the nurse educator is on increasing awareness among healthcare professionals about falls prevention to improve quality patient outcomes. The nurse educator is also interested in the new change because it will provide an opportunity to utilize evidence-based practice in the facility. The support of the project by the nurse educator is likely to influence the engagement of other key players such as the nurses and the hospital administration.

The third key stakeholder is the administration department charged with ensuring the new change represents the interests of the patients. The administration has an interest in the new change because it is a quality improvement program aiming to improve safety in the facility. The new change will also have a huge financial impact that will benefit the organization if patient falls are reduced. Because of the administration’s role in the organization, it has the power to accept or decline the new change. The proposed change must demonstrate how improvement will be achieved regarding patient falls including long term and short term impacts of the change. The acceptance of the new change by the administration will influence the reception of fall prevention strategies in the facility.

The last team players of the new change involve patients and their families. These individuals will be directly affected by the new change and giving them a chance during implementation will serve to represent their interests. The patients will have no power or influence on the implementation of the new change. However, the patients have an interest in the project because properly laid strategies will lead to a reduction in falls. The patients will be interested to see how healthcare costs associated with falls will be reduced and how healthcare professionals will collaboratively work to make their hospital stay safe.

Explanation of Project

The use of evidence-based practices in healthcare today is a practice that has improved the quality of care given to patients. Patient falls are a healthcare problem that has existed for many years and still poses challenges despite the implementation of various strategies. The purpose of this project is to propose an evidence-based practice change focusing on the role of nurses in preventing patient falls. Upon completion of the project, the institution will be able to improve aspects of patient safety through the prevention of falls. Completion of the project will also see the synthesis of key professional competencies in areas of communication and building relationships, knowledge of the healthcare environment, leadership, collaboration, and organizational business administration.

Proposed Solution

Falls among hospital patients are the most frequently reported safety incidents that require appropriate prevention intervention programs. Preventing falls in the hospital setting is not an individual task, but a combination of efforts from multidisciplinary teams. Doctors of all grades and disciplines should come together to prevent harm resulting from patient falls. Evidence suggests that not all falls are preventable, but the assessment of risks and intervening promptly can reduce 20- 30% of falls (Morris & O’Riordan, 2017). Nurses can play a key role in the reduction f falls through timely assessment of patients at risk and involving other healthcare teams in managing at-risk patients.

The proposed solution for the prevention of falls in the organization is the use of purposeful hourly rounding. Nurses often perform ward rounding to observe the well being of the patients while identifying their needs. Increasing evidence suggests that most falls can be prevented if timely identification of risk factors is done and prompt action is taken (Schuchman & Graziano, 2020). Purposeful rounding for fall prevention will target those patients that are at risk for falls to ensure interventions are made promptly. The hourly rounding approach will contain a checklist that will guide the nurses to identify patients at risk of falls. This approach is identified to create a transparent culture that encourages the participation of the care team and their patients. Additionally, hourly rounding by nurses will encourage collaborative practice including effective decision making to minimize patient falls.

Evidence Summary

The Burden of Patient Falls

Patient safety is a healthcare discipline that has gained attention in the past due to the rise of patient harm in healthcare facilities. The World Health Organization (WHO) explains that the occurrence of adverse events is one of the top 10 leading causes of disability and death in the world (WHO, 2019). Although 80% of patient harm results from medication errors, patient falls account for a significant number of adverse events observed in acute care facilities. Morris and O’Riordan (2017) explain that about 20 to 30% of patient falls experienced in hospitals can be prevented through the use of proper screening measures. In a report produced by the Agency for Healthcare Quality and Research (AHRQ), it is estimated that each year around one million patients fall in the United States (AHRQ, 2018). These falls increase the cost of patient care and can cause irreversible damage to patients.

Risk Factors for Falls in Hospital

The problem of patient falls in the hospital can be caused by intrinsic and extrinsic patient factors. One study documents that patient falls are associated with factors like age, male sex, history of recent fall, gait instability, confusion, and neurocardiovascular instability (Najafpour et al., 2019). Other studies have focused on extrinsic patient factors contributing to falls. For instance, the issue of staffing can indirectly lead to an increased number of patient falls. Lack of enough staffing is associated with poor monitoring of patients leading to inattention. Eventually, most patients will try to wake up in their unstable state leading to falls. Other factors include wet floors, longer hospital stays, and manual transfer of patients.

Strategies for Fall Prevention

Evidence to guide falls prevention in healthcare is limited due to the lack of clear approaches to the healthcare issue. However, studies have tried to propose solutions to the prevention of falls. There is strong evidence suggesting that routine assessment of mobility, toileting, and continence needs can help reduce the risk of patient falls (Morris & O’Riordan, 2017). Another strategy that is well supported by evidence is the use of purposeful hourly rounding. A study conducted in Baltimore Maryland LTC suggests that hourly rounding is important in identifying the needs of the patients including the position of patients which reduces falls (Linehan & Linehan, 2018). Other studies have supported the use of multifactorial interventions like the use of walking aids, routine rounding, wet floor signs, and education of staff on patient safety (Lee & Hayter, 2019). Despite the existence of these approaches, there is no definitive measure observed to decrease patient falls.

Plan of Action

The initial plan involves meeting with the project managers to discuss the healthcare problem and course of action. The meeting will involve various nurse managers from different units to discuss the impact of patient falls and how a new plan can help improve patient outcomes. During this meeting, the health benefits of improvement will be discussed and the relevant key stakeholders wrote down. These stakeholders will be informed about the proposed change and how their power and influence will be key to the realization of positive results.

The second phase will involve seeking approval from the hospital administration and other relevant bodies to implement the project. The administrators have the power to accept, decline, or make changes to the proposal in alignment with the organizational goals. During seeking approval, the project team will provide evidence about the burden of patient falls in the institution, the population involved, the health risks associated with the condition, and how the new change will benefit the organization. The research department will be contacted to provide statistics and facts about the health concern and how the current interventions have failed to elicit desired responses.

The third phase of the project will involve studying the evidence-based recommendation change and communication of best practices to the stakeholders. An intensive literature review will be done to ensure the best practice change is chosen to prevent falls in the facility. Communication of the plan will be made to the administration and other stakeholders. Key stakeholders to receive the plan include the nurses, doctors, the administration department, and patients. The nursing educator will be part of the project implementation team responsible for educating healthcare providers about the new change and collecting their responses.

The last phase will involve the education and training of the nurses after acceptance of the proposal. The clinical nurse educator will play a key role in this process through the mobilization of resources and education of staff. Nurses will be educated on the importance of fall prevention and aspects to consider when performing the hourly rounds. Upon completion of this step, the actual implementation of the project will follow. Hourly rounding will be done in the various units during shifts and the results recorded daily. The fall incidences will be recorded and communicated weekly. Monthly reports will be combined by the implementation team to act as a guide during benchmarks.

Timeline

A five weeks timeline will be enough to implement the proposed change in the organization. Week 1 of the project will include meeting with the nurse managers and discussion of the healthcare problem. Statistics about the burden of patient falls will be collected at this phase. The key stakeholders will be identified and information relayed about their roles in the project implementation. The second week will involve the communication of the new change to the administration to seek permission. The research department will be utilized to present facts about the healthcare issue and the importance of the new change. Communication to the hospital departments through nurse managers will be made after approval of the project.

The third week of the project will involve a literature review and discussion of the new change. Steps for implementation and necessary resources will be allocated at this stage. The nurse educator will plan for the education and training of nurses about purposeful hourly rounding. The fourth week will involve mobilization of nurses, education, training, and testing of the new change. During week five, the actual implementation of the new change will commence. The implementation team through the nurse manager will collect daily incident reports on patient falls which will be used as a measure of success during bench-marking.

Required Resources

The proposed change will require material and human resources for the realization of goals. The new change will require a computer system to collect and store data about patient falls in the organization. The new project will involve the education and training of nurses to conduct hourly rounding. Resources for education will include a hall, seats for staff, accessories such as monitors and microphones, books for taking notes, and attendance sheets to ensure all staff participates. Financial resources will be required to organize the training sessions and weekly meetings of stakeholders to discuss the progress of the project. The clinical nurse educator and other relevant guests will be available to discuss the importance of the new change to the organization.

Proposed Change Theory

The rapidly evolving healthcare environment requires a change to keep pace. Those organizations that are able to manage change flourish while those that fail to adapt to new change are subject to closure or decline. Change management varies depending on the type of organization and different models are available to explain change management. Kurt Lewin’s change management model is among the theories explaining how organizations can adopt new changes using three simple stages. The model discusses change in relation to unfreezing, changing/moving, and refreezing stages.

The unfreezing stage demonstrates the beginning of change management in an organization. This stage encompasses ensuring readiness for organizational change through the preparation of staff to understand and accept the need for a new change. It involves breaking down the status quo and challenging the existing behavior to create urgency for new changes (Wojciechowski et al., 2016). Lewin described the need to gather support from the management and other key stakeholders because they have the power and influence to change the process in the organization. Communication is important during the unfreezing stage to support the persuasive actions leading to acceptance of the new change.

The changing or moving stage represents a state when people have accepted the need for change and are moving towards the new practices. There is a period of uncertainty in the organization during this stage which calls for monitoring and adjustment of the new ways. Implementation of change at this stage should include methodical communication and consistency. The leaders and management team can help strengthen change by providing support and conveying the need for change to the employees. Lewin explained that role modeling, making quick plans, and reminding employees will act as quick actions to support the new change.

The refreezing stage involves institutionalizing the desired changes, ensuring they are widely accepted, utilized all the time, and incorporated into the organizational culture (Wojciechowski et al., 2016). There should be a clear plan to sustain the new change at this stage including providing support through education and training. The employees should be supported by any means to preventing going back to the old ways. Actions to support the new change include giving rewards, benchmarks and celebrating the success of the change, for instance, using policies can help sustain change in an organization after a process improvement.

Lewin’s change management theory will be used to plan for fall prevention in the organization. During the unfreezing stage, I will explain the existing gap in the organization leading to increased fall rates. Identification of key stakeholders such as the administration and the nursing educator will ensure availability of support for the new change. During the transition or moving stage, communication will be important to ensure the timely provision of feedback. Education and training of staff will ensure that employees get to understand the relevance of the new change. Intermittent evaluations will ensure the nurses are kept on track and that necessary changes are made to the initial plan. The refreezing stage will be represented by making the new change a norm in the organization. Successful implementation of the new strategies will lead to the formulation of policies on hourly rounding. The plan to sustain the new change will include education and training of new employees on falls prevention.

Barriers to Implementation

The new strategy on fall prevention is likely to face a few challenges. First, the issue of falls remains a challenge in many hospitals despite the implementation of evidence-based practices. There might be challenges with acceptance of the proposed change by the nurses and the hospital administration. Secondly, the issue with staffing is likely to make it difficult to fully implement hourly rounding. Each unit has a shortage of nurses and this will make it difficult to do purposeful rounding hourly. Another challenge is proper education of staff on falls prevention due to time problems and mixed shifts in nursing. For example, it will be difficult to create time for education for night duty staff. This means that staff might get little understanding of the healthcare problem which can hinder the achievement of the desired outcome.

References

Agency for Healthcare Quality and Research. (2018). Preventing patient falls: Overview. Retrieved from https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/overview.html#Problem

Guirguis-Blake, J. M., Michael, Y. L., Perdue, L. A., Coppola, E. L., & Beil, T. L. (2018). Interventions to prevent falls in older adults: Updated evidence report and systematic review for the US Preventive Services Task Force. JAMA, 319(16), 1705-1716. DOI: 10.1001/jama.2017.21962

Hopewell, S., Copsey, B., Nicolson, P., Adedire, B., Boniface, G., & Lamb, S. (2020). Multifactorial interventions for preventing falls in older people living in the community: A systematic review and meta-analysis of 41 trials and almost 20 000 participants. British Journal of Sports Medicine, 54(22), 1340-1350. http://dx.doi.org/10.1136/bjsports-2019-100732

Lee, A., & Hayter, M. (2019). Evaluating falls prevention strategies in community settings: Marginal reduction on rate of falls with individual risk-based multifactorial interventions compared to ‘usual care’. Evidence-Based Nursing, 22(1), 20-20. http://dx.doi.org/10.1136/ebnurs-2018-102995

Linehan, J., & Linehan, J. (2018). Fall prevention in long term care using purposeful hourly rounding. Journal of the American Medical Directors Association, 19(3), B17. https://doi.org/10.1016/j.jamda.2017.12.056

Morris, R., & O’Riordan, S. (2017). Prevention of falls in hospital. Clinical Medicine (London, England), 17(4), 360–362. https://doi.org/10.7861/clinmedicine.17-4-360

Najafpour, Z., Godarzi, Z., Arab, M., & Yaseri, M. (2019). Risk factors for falls in hospital in-patients: A prospective nested case control study. International Journal of Health Policy and Management, 8(5), 300–306. https://doi.org/10.15171/ijhpm.2019.11

Schuchman, M., & Graziano, J. (2020). Management of frequent fFalls. In Home-Based Medical Care for Older Adults (pp. 49-55). Springer, Cham. https://link.springer.com/chapter/10.1007/978-3-030-23483-6_8

Wojciechowski, E., Pearsall, T., Murphy, P., & French, E. (2016). A case review: Integrating Lewin’s theory with lean’s system approach for change. Online Journal of Issues in Nursing, 21(2). DOI: 10.3912/ojin.vol21no02man04

World Health Organization. (2019). Patent safety. Retrieved from https://www.who.int/news-room/fact-sheets/detail/patient-safety