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Recommended Citation
Duncan J, Sparks K, Proctor C. Can you escape? A quality improvement 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 are an unwanted occurrence in all healthcare facilities; They are complex and do not have a “one solution fixes all “answer. Each fall we can reduce is a patient who is safer while in our care.
Local Problem: Atrium Health Cleveland (highest fall units 4M and ED) have had consistently high fall rates compared to like size facilities; 2.97 against goal of 2.6 (2023). Data review showed correct scoring and interventions as our greatest opportunity.
Methods: We utilized a multi-faceted approach to falls prevention aligning with our Obeya work that began in Q3 2023. A multi-disciplinary team partnered to create Winter Wonderland patient safety workshop in Q1 2024. All bedside teammates completed a falls escape room; the activity bringing scoring, interventions, and types of falls to life. This interactive, educational approach has helped to set the stage for falls reduction and increased patient safety. Throughout these targeted interventions, real time huddle observations, monthly audits, and quick-wins occurred at the unit level.
Results: We did see a one-month initial decrease in falls, we also saw an improvement in post fall huddle completion. Units 4M and ED had a 5-point decrease in their unassisted/unwitnessed falls from Q4 23 to Q1 24. We have not yet seen a sustained reduction, but project to see a decrease in NDNQI total falls by years end. The huddles have significantly improved allowing teammates to identify process gaps, not people failures.
Implementations for Nursing Practice: A regular educational session for bedside teammates is recommended to ensure quality measures stay top of mind. The implementations and interventions are now hard-wired in these unit's practice. Organizational support is essential for prolonged and sustained improvement. By reducing total falls, injuries decrease, safety increases, and practice is improved.
References
Hester, A. (2022). Fall prevention. HD Nursing. https://www.hdnursing.com/hd-nursing-falls-prevention-program
Michalcova, J., Vasut, K., Airaksinen, M., & Bielakova, K. (2020) Inclusion of medication-related fall risk in fall risk assessment tool in geriatric care units. BMC Geriatrics. 20(454). https://doi.org/10.1186/s12877-020-01845-9
Montejano-Lozoya, R., Miguel-Montoya, I., Gea-Caballero, V., Mármol-López, M.I., Ruíz-Hontangas, A. & Ortí-Lucas, R. (2022). Impact of nurses’ intervention in the prevention of falls in hospitalized patients. International Journal of Environmental Research and Public Health,17(17), https://doi.org/10.3390/ijerph17176048
Morris, M.E., Webster, K., Jones, C., Hill, A.M., Haines, T., McPhail, S., Kiegaldie, D., Slade, S., Jazayeri, D., Heng, H., Shorr, R., Carey, L., Barker, A., & Cameron, I. (2022) Interventions to reduce falls in hospitals: a systematic review and meta-analysis. Age and Ageing, 51(51) https://doi.org/10.1093/ageing/afac077
Document Type
Poster
Publication Date
11-13-2024
Can you escape? A quality improvement falls reduction initiative
Background: Falls are an unwanted occurrence in all healthcare facilities; They are complex and do not have a “one solution fixes all “answer. Each fall we can reduce is a patient who is safer while in our care.
Local Problem: Atrium Health Cleveland (highest fall units 4M and ED) have had consistently high fall rates compared to like size facilities; 2.97 against goal of 2.6 (2023). Data review showed correct scoring and interventions as our greatest opportunity.
Methods: We utilized a multi-faceted approach to falls prevention aligning with our Obeya work that began in Q3 2023. A multi-disciplinary team partnered to create Winter Wonderland patient safety workshop in Q1 2024. All bedside teammates completed a falls escape room; the activity bringing scoring, interventions, and types of falls to life. This interactive, educational approach has helped to set the stage for falls reduction and increased patient safety. Throughout these targeted interventions, real time huddle observations, monthly audits, and quick-wins occurred at the unit level.
Results: We did see a one-month initial decrease in falls, we also saw an improvement in post fall huddle completion. Units 4M and ED had a 5-point decrease in their unassisted/unwitnessed falls from Q4 23 to Q1 24. We have not yet seen a sustained reduction, but project to see a decrease in NDNQI total falls by years end. The huddles have significantly improved allowing teammates to identify process gaps, not people failures.
Implementations for Nursing Practice: A regular educational session for bedside teammates is recommended to ensure quality measures stay top of mind. The implementations and interventions are now hard-wired in these unit's practice. Organizational support is essential for prolonged and sustained improvement. By reducing total falls, injuries decrease, safety increases, and practice is improved.
References
Hester, A. (2022). Fall prevention. HD Nursing. https://www.hdnursing.com/hd-nursing-falls-prevention-program
Michalcova, J., Vasut, K., Airaksinen, M., & Bielakova, K. (2020) Inclusion of medication-related fall risk in fall risk assessment tool in geriatric care units. BMC Geriatrics. 20(454). https://doi.org/10.1186/s12877-020-01845-9
Montejano-Lozoya, R., Miguel-Montoya, I., Gea-Caballero, V., Mármol-López, M.I., Ruíz-Hontangas, A. & Ortí-Lucas, R. (2022). Impact of nurses’ intervention in the prevention of falls in hospitalized patients. International Journal of Environmental Research and Public Health,17(17), https://doi.org/10.3390/ijerph17176048
Morris, M.E., Webster, K., Jones, C., Hill, A.M., Haines, T., McPhail, S., Kiegaldie, D., Slade, S., Jazayeri, D., Heng, H., Shorr, R., Carey, L., Barker, A., & Cameron, I. (2022) Interventions to reduce falls in hospitals: a systematic review and meta-analysis. Age and Ageing, 51(51) https://doi.org/10.1093/ageing/afac077
Affiliations
Atrium Health Cleveland and Kings Mountain