Transcript Opportunity Statement

Inpatient Falls Prevention
By
Nursing Performance Improvement
Restraint/Fall Liaison Committee
&
Judy Mc Hugh,
Nursing Performance Improvement Coordinator
Opportunity Statement
Patient falls hold a potential for increased morbidity, mortality
and economic loss to the institution on a problem that is
largely preventable.
By reducing patient falls we reduce the risk of patient injury.
While the LUHS fall rate range of 2.20 - 2.52 remains below
the University HealthSystem Consortium rate of 2.79, there is
an ongoing need to reexamine the LUHS fall rate.
Our goal is to continue to look at more fall prevention and
interventions.
Most Likely Cause
Inpatient falls are multi-factorial
Patient Decreased Sensorium
•Mobility such as muscle weakness, gait and balance
disorders, impaired physical mobility, and poor transfer/lift
technique.
•Confusion, disorientation or alcohol or drug withdrawal.
•Medication usage, which included sedatives, sleepers,
diuretics or cardiac medication.
Most Likely Cause
Inpatient falls are multi-factorial
Environment
•Elimination needs, which meant getting to the bathroom for:
urgency, diarrhea and incontinence.
•Room Clutter
•Wet Floors
Most Likely Cause
Inpatient falls are multi-factorial
People
•Lack of Fall Prevention Knowledge
Materials
•Restraint use
•Commodes
•Bed alarms not available
•Broken bed brakes
Solutions Implemented
•Implemented a Hospital-wide Level II Fall
Prevention Program
•Developed an annual fall prevention and restraint
application competency designed for direct
caregivers
– Employee Newsletter “Heartbeat”
– CPR/Restraint Application Marathon
– Fall Prevention Inservice.
Solutions Implemented
•Targeted high fall nursing units
– Piloted equipment
– Educated staff on the fall prevention program
•Produced and distributed monthly Fall Assessment and
Intervention QI Newsletter
•Utilized Patient Observer- High risk fallers were in visual
contact and within 5 feet of patient
Solutions Implemented
•Developed Fall/Restraint Reduction RN Liaison Role.
These nurses became an expert for their unit.
•Implemented a New Bed Alarm System for high-fall nursing
units
•Initiated Fall Nurse Documentation Quarterly Audit
Recommendations for Further
Study or Action
•Evaluate potential environmental fall risk factors
•Continue Quarterly Fall assessment audits
•Evaluate new equipment for fall reduction and injury
reduction
Recommendations for Further
Study or Action
•Nurse Call Integration for New HillRom Bed with alarm
•Hospital-wide Education for New HillRom Bed Alarm
Program
•Incorporate fall risk factors and history of fall into the
Electronic Medical Record EPIC
Falls
Environment
Wet floors
Urine
People
Bed
Bedroom
Water
Broken brakes
Clutter
IV Poles
Unavailable sitters
Elimination
Chairs
Commodes
High Acuity
Relatives
Ambulating Commode
Bathroom
Unassisted
Fall Risk Factors
& Restraint Application
Patient
Staff
Materials
Broken Bed
Lack of knowledge
Ancillary
MD
Nursing
Decreased Sensorium
Restraint Use
Bed Alarms Not Available
Medical DX
Age > 65
Medications
Vision
Gait/ Imbalance/Impaired Mobility
Old prescriptions
Sedation Narcotics Cardiac Drugs Sleepers
Seizure Meds