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Recommended Citation
Holder K, Cole H, Rape C. Improving response times by enhancing the No Pass Zone initiative to decrease patient falls. Quality Improvement poster presented at Transforming Practice: The Intersection of Technology and Nursing Excellence; Advocate Health Nursing Research and Professional Development Conference 2025; November 12, 2025; Virtual.
Presentation Notes
Quality Improvement poster presented at Transforming Practice: The Intersection of Technology and Nursing Excellence; Advocate Health Nursing Research and Professional Development Conference 2025; November 12, 2025; Virtual.
Abstract
Background: Falls during hospitalization increase the risk of physical harm, psychological stress, reduced mobility, and fear of falling, which in turn impact recovery. Falls also lead to longer hospital stays and readmissions, affecting performance metrics and reimbursement. Challenges include delayed response times and patients getting up without assistance.
Local Problem: On the Medical Surgical Floor at Atrium Health Union, there were 54 falls in 2024, with 20 in the first quarter. Contributing factors were delayed call bell responses, patient population, and noncompliance with fall prevention strategies. When assessing 2024 call bell response times, the average time to respond to a patient was 7 minutes.
Methods: A multidisciplinary team implemented a quality improvement project aimed at reducing response times to patient calls in order to decrease falls. The goal was to reduce response times by 30% with a stretch goal of 50%. Key interventions included reinforcing hourly rounding, optimizing fall prevention education, increasing staff accountability for fall prevention bundles, and leveraging the Call Bell response system for real-time fall risk identification. Analyzing call bell response data helped identify trends and implement strategies to improve responsiveness, enhancing patient safety and satisfaction.
Results/Conclusions: A 50% reduction in falls was observed from Q1 2024 to Q1 2025, resulting in 10 falls in Q1. Average call bell response times decreased by 33% from 7 minutes to 4 minutes and 33 seconds. The No Pass Zone initiative increased staff awareness and prompt responses.
Implications for Practice: Standardized review of call bell response times and implementation of strategies to improve responsiveness can contribute to the reduction of falls. Sustainment of these strategies, including the No Pass Zone for all teammates, will require continued monitoring and reinforcement.
Document Type
Poster
Publication Date
11-12-2025
Improving response times by enhancing the No Pass Zone initiative to decrease patient falls
Background: Falls during hospitalization increase the risk of physical harm, psychological stress, reduced mobility, and fear of falling, which in turn impact recovery. Falls also lead to longer hospital stays and readmissions, affecting performance metrics and reimbursement. Challenges include delayed response times and patients getting up without assistance.
Local Problem: On the Medical Surgical Floor at Atrium Health Union, there were 54 falls in 2024, with 20 in the first quarter. Contributing factors were delayed call bell responses, patient population, and noncompliance with fall prevention strategies. When assessing 2024 call bell response times, the average time to respond to a patient was 7 minutes.
Methods: A multidisciplinary team implemented a quality improvement project aimed at reducing response times to patient calls in order to decrease falls. The goal was to reduce response times by 30% with a stretch goal of 50%. Key interventions included reinforcing hourly rounding, optimizing fall prevention education, increasing staff accountability for fall prevention bundles, and leveraging the Call Bell response system for real-time fall risk identification. Analyzing call bell response data helped identify trends and implement strategies to improve responsiveness, enhancing patient safety and satisfaction.
Results/Conclusions: A 50% reduction in falls was observed from Q1 2024 to Q1 2025, resulting in 10 falls in Q1. Average call bell response times decreased by 33% from 7 minutes to 4 minutes and 33 seconds. The No Pass Zone initiative increased staff awareness and prompt responses.
Implications for Practice: Standardized review of call bell response times and implementation of strategies to improve responsiveness can contribute to the reduction of falls. Sustainment of these strategies, including the No Pass Zone for all teammates, will require continued monitoring and reinforcement.
Affiliations
Atrium Health Union and Union West