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Recommended Citation
Yates J, DePrey V, Witkofski H. ASLSS Falls Reduction Initiative. Quality Improvement poster presentation at Elevating Nursing Excellence: Purpose, Profession, Passion; Advocate Health Midwest Region Nursing Research & Professional Development Conference 2024; November 13, 2024; virtual.
Presentation Notes
Quality Improvement poster presentation at Elevating Nursing Excellence: Purpose, Profession, Passion; Advocate Health Midwest Region Nursing Research & Professional Development Conference 2024; November 13, 2024; virtual.
Abstract
Background
Falls in older adults have grave consequences, resulting in prolonged length of stay, increased morbidity, and loss of independence.
Local Problem
Between July 2022 and June 2023, Aurora St. Luke’s South Shore (ASLSS) had 112 inpatient falls; 75% took place on two medical surgical departments.
Method
Nursing established a multidisciplinary Falls Reduction Steering Committee to drive process change. The committee first addressed data collection, developing a post-fall huddle form for staff utilization and trend log. Next, the committee utilized the Rapid Plan-Do-Study-Act (PDSA) performance improvement methodology and set a goal for 20% reduction in average monthly falls over six rolling months or less than 5.6 falls/month. Frontline staff completed root cause analysis using the five-why process, which guided committee leaders to select three cycles: frequent ambulation, CIWA score-triggered monitoring, and RN/CNA shift report.
Results/Conclusions
Cycles were tested on two units with the highest falls. In Cycle 1, the committee established a goal for nursing staff to ambulate 80% of eligible patients twice daily. Department leaders conducted daily ambulation huddles with staff to assess ambulation barriers. Both units met goal of 80% compliance by conclusion of Cycle 1. Drilldowns revealed that patients experiencing alcohol withdrawal fell frequently. Leaders designed a CIWA score-driven virtual patient monitoring algorithm and tested its impact on falls for Cycle 2. Neither unit experienced any falls among the test population throughout implementation. In Cycle 3, leaders tested how standardized report between RNs and CNAs impacted falls. In November 2023, the cycle was completed with 100% compliance in RN/CNA report. Between November 2023 and April 2024, the two test units averaged 4.8 falls per month, meeting goal of 20% reduction over six rolling months.
Implication for Practice
All tests of change remain in practice today. One unit experienced 119 consecutive days fall-free. Ongoing sustainment of CIWA algorithm implementation resulted in no falls among this population.
References:
Boot, M., Allison, J., Maguire, J., & O’Driscoll, G. (2023). Qi initiative to reduce the number of inpatient falls in an acute hospital trust. BMJ Open Quality, 12(1). https://doi.org/10.1136/bmjoq-2022-002102
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
Pitchai, P., Dedhia, H., Bhandari, N., Krishnan, D., D’Souza, N. J., & Bellara, J. (2019a). Prevalence, risk factors, circumstances for falls and level of functional independence among geriatric population - A descriptive study. Indian Journal of Public Health, 63(1), 21. https://doi.org/10.4103/ijph.ijph_332_17
Xu, Q., Ou, X., & Li, J. (2022). The risk of falls among the aging population: A systematic review and meta-analysis. Frontiers in Public Health, 10. https://doi.org/10.3389/fpubh.2022.902599
Document Type
Poster
Publication Date
11-13-2024
ASLSS Falls Reduction Initiative
Background
Falls in older adults have grave consequences, resulting in prolonged length of stay, increased morbidity, and loss of independence.
Local Problem
Between July 2022 and June 2023, Aurora St. Luke’s South Shore (ASLSS) had 112 inpatient falls; 75% took place on two medical surgical departments.
Method
Nursing established a multidisciplinary Falls Reduction Steering Committee to drive process change. The committee first addressed data collection, developing a post-fall huddle form for staff utilization and trend log. Next, the committee utilized the Rapid Plan-Do-Study-Act (PDSA) performance improvement methodology and set a goal for 20% reduction in average monthly falls over six rolling months or less than 5.6 falls/month. Frontline staff completed root cause analysis using the five-why process, which guided committee leaders to select three cycles: frequent ambulation, CIWA score-triggered monitoring, and RN/CNA shift report.
Results/Conclusions
Cycles were tested on two units with the highest falls. In Cycle 1, the committee established a goal for nursing staff to ambulate 80% of eligible patients twice daily. Department leaders conducted daily ambulation huddles with staff to assess ambulation barriers. Both units met goal of 80% compliance by conclusion of Cycle 1. Drilldowns revealed that patients experiencing alcohol withdrawal fell frequently. Leaders designed a CIWA score-driven virtual patient monitoring algorithm and tested its impact on falls for Cycle 2. Neither unit experienced any falls among the test population throughout implementation. In Cycle 3, leaders tested how standardized report between RNs and CNAs impacted falls. In November 2023, the cycle was completed with 100% compliance in RN/CNA report. Between November 2023 and April 2024, the two test units averaged 4.8 falls per month, meeting goal of 20% reduction over six rolling months.
Implication for Practice
All tests of change remain in practice today. One unit experienced 119 consecutive days fall-free. Ongoing sustainment of CIWA algorithm implementation resulted in no falls among this population.
References:
Boot, M., Allison, J., Maguire, J., & O’Driscoll, G. (2023). Qi initiative to reduce the number of inpatient falls in an acute hospital trust. BMJ Open Quality, 12(1). https://doi.org/10.1136/bmjoq-2022-002102
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
Pitchai, P., Dedhia, H., Bhandari, N., Krishnan, D., D’Souza, N. J., & Bellara, J. (2019a). Prevalence, risk factors, circumstances for falls and level of functional independence among geriatric population - A descriptive study. Indian Journal of Public Health, 63(1), 21. https://doi.org/10.4103/ijph.ijph_332_17
Xu, Q., Ou, X., & Li, J. (2022). The risk of falls among the aging population: A systematic review and meta-analysis. Frontiers in Public Health, 10. https://doi.org/10.3389/fpubh.2022.902599
Affiliations
Aurora St. Luke's South Shore