Hourly rounding, huddles help prevent patient falls

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To reduce patient falls, hospitals should build a care plan that addresses every patient’s specific needs and frailties.

And should someone tumble despite those precautions, clinicians should form a postfall huddle to ask what happened, why it happened, and what can be done to prevent it from occurring again.

“Those ideas, in my mind, are powerful,” says Gail Nielsen, BSHCA, a fellow for the Institute for Healthcare Improvement (IHI) and clinical performance improvement education administrator for Iowa Health System. “However, this hourly rounding, the evidence is clear that we need to get this done. What we’re finding is that the work that goes away from getting into the patient’s room every hour is worth it. The call light usage diminishes, the falls diminish, and the pressure ulcers diminish. It really does relieve work.”

Nielsen should know. She’s not only on the faculty of IHI, she’s the point person for her organization’s participation in Transforming Care at the Bedside, an initiative of IHI and the Robert Wood Johnson Foundation (RWJF).

Perhaps most importantly, her health system has seen an enviable reduction in the number of patient falls through its work with IHI and RWJF.

From June 2005 to July 2006, before the organization took part in the initiative, three hospitals in the health system had 1.1 patient injuries per 10,000 patient days; IHI’s target is one per 10,000 patient days. The three hospitals in Iowa Health System participating in the project were able to reduce that figure to 0.8, a 27% decrease, from July 2006 to June 2007.

“Collectively, I think we’ve had pretty stunning results,” Nielsen says. Since 2001, the health system has set goals every year for reducing patient falls. “We exceeded our stretch target by a surprising amount during the study period,” she says. Consequently, she attributes part of her system’s success to participation in the Transforming Care at the Bedside project.

Iowa Health System has 10 hospitals, three of which volunteered for the project: St. Luke’s Hospital, a 560-bed facility in Cedar Rapids, IA; Iowa Health-Des Moines, which has 1,139 beds; and Trinity Regional Health System-Quad Cities, which has campuses in Iowa and Illinois and has 534 beds.

Nine key changes

Nielsen says changes the three hospitals implemented include:

1. Changing culture. Iowa Health System learned back in 2000 and 2001 when it worked with IHI on preventing medication errors that simply making technical changes won’t bring about solid and long-standing improvement. Rather, the hospitals needed to work on breaking the perception that falls are a fact of life in hospitals.

“One of the things we did was to build beliefs that injuries from falls can be eliminated,” Nielsen says.

2. Using small tests of changes. This allows the hospital to see whether a tiny change truly works before making it permanent or expanding it to other units.

“The small test of change means one nurse, one doctor; one nurse, one patient; one nurse, one set of patients for just a few hours, or perhaps at most a day,” Nielsen says. “You just do something once or twice to see if you can improve on it.” If it works, you ramp it up and test it for a month. If it’s still reaping success, it’s time to consider whether to make it permanent and how.

3. Engaging senior leaders. “Someone from the executive team does executive walk-arounds,” Nielsen says. “They ask people questions such as ‘How long has it been since your last fall, and what did you learn?’ ”

The idea, she says, is that everyone in the hospital, not just falls specialists, needs to understand what happened with the most recent fall and how to prevent it in the future, as well as techniques the facility has developed to protect patients from harm.

4. Investing in alarms and adjustable beds. The three hospitals bought more adjustable beds that kneel to the floor. They also installed personal alarms. Not only do the alarms alert nurses that a patient is trying to get up, but they have prerecorded messages for patients who might be confused. For example, if a frail father tries to stand up from his chair, it would prompt a recording of his daughter’s voice to go off in his room that says, “Dad, please sit down. The nurse will come; please sit down.”

5. Putting down bedside floor mats. “They go down at night and get picked up during the day and stored away, so if the patient should tumble from bed, there’s something softer than our hard floors,” Nielsen says. The mats are beveled so no one can trip over them.

6. Posting falls data in the care units daily. “Staff members didn’t really know what their fall rates were,” Nielsen says. “They didn’t know how many days since the last fall. So it’s a heightened awareness and engages everyone who sees the data. It seems to be a motivational device as well.”

7. Having integral data analysis experts look for opportunities. The data, Nielsen says, can be cut many ways, and an analyst was able to break down what times and locations patients were most at risk for falls.

“What does it mean if patients are falling more during meal times, and what does it mean if patients are falling more during the evening, like 9, 10, 11 at night,” she says. “We know that a high percentage of falls seem to be associated with toileting, so we began to change that dynamic.”

8. Holding safety fairs. This lets everyone, not just the nurses, know his or her role in protecting patients, Nielsen says. For example, if someone in housekeeping sees a patient unsteady on his feet, she can ask him to sit down while she gets a nurse.

9. Celebrating successes. “We built more celebration into the process, which helps raise the awareness,” Nielsen says. “When we met some benchmarks, we found lots of different ways to celebrate with the staff.”

Seven ways to prevent injuries

In addition to the three hospitals taking part in the project to prevent falls, the entire Iowa Health System is working toward preventing injuries when someone stumbles.

Actions the organization took include:

1. Screening to identifying patients at high risk of injury. “Those include patients who are 85 and older, because, in the literature, we find patients who are 75 and older are more likely to fall, but, at 85, they start getting greater injuries—for instance, a hip fracture,” Nielsen says. Hospitals look at chronological as well as physiological age. For example, a 35-year-old patient weakened and debilitated by disease might be the same physiological age as an 85-year-old.

2. Looking for thinning bone conditions such as osteoporosis.

3. Determining whether a patient is on an anticoagulant.

4. Bringing together the nurse and pharmacist to find out whether any of the medications a patient is on puts him or her at greater risk to fall.

5. Scoring, on a shift-to-shift basis, the risk of fall and harm. “Sometimes in hospitals, they’ll just assess the patient on admission, but now we’ve upped that,” Nielsen says. Nurses check from shift to shift whether something has happened to a patient that represents a change in condition.

For example, if a patient comes back from physical therapy and is exhausted, he or she is now at risk for falling, whereas the patient wasn’t at risk yesterday, she explains.

Medication can also change a patient’s condition, she adds, because some drugs initially can make patients light-headed. In that case, hospitals can put up temporary fall markers that protrude into the hallway, alerting staff members of the risk. The marker can be removed once the patient adjusts to the medications.

6. Increasing nurses’ use of gait belts. Units using gait belts the most see the fewest injuries, Nielsen says.

7. Labeling the charts to remind nurses to include in the handoff report not only the risk of the patient, but why the patient is at risk. “We actually have a CEO who says he wants zero falls,” Nielsen says. “I have a double mind on that. One is we don’t know what’s possible ultimately. The accidental falls we can’t prevent. What we can prevent are those anticipated falls.”

Editor’s note: For more information, see the November 2007 Quality Improvement Report.