Reducing Inpatient Falls

Accidental falls in inpatients is an important source of preventable morbidity and mortality in hospitals. This is especially so with patients who are more vulnerable and at risk such as those who are above the age of 65 years and frail (Guirguis-Blake et al., 2018). Inpatient falls are preventable and for this reason they are a quality improvement (QI) issue that must be addressed whenever they occur. An increase in the rate of inpatient falls indicates that the quality of nursing care in that facility or hospital is going down. It is precisely for this reason that the Centers for Medicare and Medicaid Services or CMS adopted a policy of non-reimbursement for services rendered to falls victims within hospitals beginning October of 2008 (Fehlberg et al., 2017). Across the United States, the rate of falls reported in hospitals ranges between 3.3 and 11.5 falls per 1,000 patient days. However, the national benchmark is at 3.44 falls per 1,000 patient days (Venema et al., 2019). A lot of research by quality bodies such as the Agency for Healthcare Research and Quality (AHRQ) as well as recommendations by other regulatory bodies like the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) have provided evidence-based strategies that can be employed to prevent inpatient falls (AHRQ, 2018). The purpose of this paper is to outline these approaches as applicable to hospitals with inpatients ho are at risk of falls.  Reducing Inpatient Falls Essay Paper

Readiness of an Organization for Change

In order to successfully implement change in terms of applying falls prevention practices within the hospital, the organizational culture must be favorable to change. It is for this reason that it is important to carry out a survey of the employees to gauge preparedness for change before attempting any of it. One of the useful tools in doing this is the Organizational Culture and Readiness for System-Wide Implementation of EBP (OCRSIEP) questionnaire. It is a Likert-type questionnaire that allows employees to answer questions with “completely agree” all the way to “completely disagree”. This way, the organizational culture of readiness for change can be accurately assessed.

Employees are by default resistive of change as they would prefer the status quo. However, if the organization has systems in place that induct the employee right from the time of recruitment to the ways of the organization chances of success with change are high. With the OCRSIEP assessment it will be clear whether majority of the employees are ready for the change or not. If most are pro-change then the change initiative of implementing evidence-based interventions for fall prevention can proceed. However, if most are anti-change then there will be a need for a slightly longer period of education and sensitization before the change can be attempted successfully.

Problem Statement and Literature Review

As has been stated in the introduction, the disease burden of inpatient falls in US hospitals is huge. Despite the fact that the CMS no longer reimburses providers for the care they give to those patients who have suffered falls within their premises, the problem of falls still persists. The cost to these institutions is therefore phenomenal as they bare it themselves. Furthermore, any legal action involving a suit for professional malpractice and negligence if successful is settled by the same providers in terms of damages (Buppert, 2021). The patients who suffer falls in hospitals (especially the frail elderly patients with mobility problems and multiple comorbidities) get injuries such as abrasions, fractures, and even concussions (Heng et al., 2020; Hill et al., 2016; McCarthy, 2016). If they were to have a short stay in the healthcare facility, the fact of these additional falls injuries will make them stay longer there. This means that the cost of hospitalization will go up as well as the risk of getting hospital-acquired infections or HAIs. Worse still, a serious fall may lead to traumatic brain injury or intracranial hemorrhage that may lead to death. This is mortality that is preventable with evidence-based fall prevention measures.

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The PICOT Question and Database Search

In searching for evidence that supports particular interventions that can effectively prevent inpatient falls, a PICOT question is formulated that will then guide the search in reputable research databases (Melnyk & Fineout-Overholt, 2019). The PICOT question in this case is: In hospitalized inpatients (P), does the application of the bundle of patient and staff education, hourly rounding, and use of bed alarms (I) compared to the usual care (C) result in a better reduction of inpatient falls (O) within a span of six months (T)?  Reducing Inpatient Falls Essay Paper

The databases that have been searched for this project are PubMed, CINAHL, Embase, ProQuest, and Cochrane. The key search terms that were used were “inpatient,” “falls,” “prevention,” and “evidence-based.” These terms were connected by the Boolean operator “AND” to give the search statement that was entered into the search engine of each research database. The first attempt brought up a total of 1,056 articles. Filtering was then performed to find out which articles very specifically addressed the PICOT question. After the filtering was done, only 18 articles remained. Of these, five were very particular in recommending three measures that can be used in a bundle together to effectively and efficiently prevent inpatient falls. The five articles were by Gavaller et al. (2019), Heng et al. (2020), Hill et al. (2016), Mileski et al. (2019), and Morgan et al. (2016). Together, these scholarly sources of evidence recommended three measures that have the most evidence for efficacy in preventing inpatient falls. These are:

1. Intentional or purposeful hourly rounding by nurses (Gavaller et al., 2019; Morgan et al., 2016)
2. Patient and staff education and training (Heng et al., 2020; Hill et al., 2016)

• The use of intelligent bed alarms (Mileski et al., 2019)

The Proposed Solution for Inpatient Falls

The proposed solution for preventing inpatient falls as has been outlined above will be implemented in a bundle. That means that for them to be effective in preventing falls, they have to be implemented together and not separately. Intentional or purposeful rounding refers to the act of nurses within a shift doing rounds every hour to see what problems the patients have that may make them want to get out of bed. For instance, a glass of water may be on a bedside table far away from the reach of the patient. By bringing it near the patient, a fall incident is prevented where the patient could have attempted to get out of bed to reach that same glass of water. Another example is that during the hourly rounds, the nurse may note that the bed rails may have been left low and therefore raise them to prevent the patient from falling off the bed. In essence, the purposeful hourly rounds are supposed to be a troubleshooting and problem-finding solution.

The second intervention in the bundle is patient education and staff training and education. This is a two-pronged intervention that involves educating the patients and their relatives on the risk of falls that they are in. If the patient is not old and with cognitive impairment due to dementia, they will understand when told that they are at risk of falls. This understanding will enable them to avoid actions that would precipitate the likelihood of an accidental fall occurring. Nurses and other healthcare professionals also require further training and education on how to perform risk assessment for falls in patients. After finding those patients that are at the highest risk of a fall, they can then use the knowledge that they have been trained on to help them prevent the occurrence of a fall. One of the falls risk assessment tools that they can be trained to use is the Morse Fall Scale (Falcão et al., 2019). Ghahramani (2016) also suggests other alternative fall risk assessment tools that the nurses can be trained to use. These are tools such as the Berg Balance Scale (BBS), Romberg Test (Tandem Stand Test), the Sit to Stand Test (STST), or the Dynamic Gait Index (DGI) amongst others. The nurse can use any of these to screen the identified patient for fall risk.  Reducing Inpatient Falls Essay Paper

The last intervention in the care bundle for preventing inpatient falls is the use of intelligent bedside alarms. Studies carried out on bedside alarms indicate that when used alone they are not as effective as when used in conjunction with the other two interventions in a bundle. Gavaller et al. (2019) made a surprise and contradicting conclusion on bedside alarms and purposeful rounding. Unlike their colleagues in the previous trials, these researchers discovered that removing bedside alarms resulted in a decrease in the rate of falls. Furthermore, implementing purposeful rounds after the alarms were removed had the unintended consequence of substantially increasing the number of falls. Other studies have however since confirmed that using the two together as well as adding nurse education and training and patient education provides desired results.

The Change Model to Use: Rogers’ Diffusion of Innovations (DOI) Model

In order to carry out any change initiative successfully, a change model has to be used to guide the implementation in a systematic and scientific manner. For this project, the change model selected is the Rogers’ Diffusion of Innovations model. The model is made up of five distinct but also related steps that flow logically one into the next. A satisfaction of the previous step is a clear indication that the next step will also in all probability be successful. These steps are knowledge, persuasion, decision, implementation, and confirmation (Dearing & Cox, 2018). The first step of knowledge is concerned with creating awareness about the need for the change in how to prevent inpatient falls. It will require innovators and educators within the rank and file of the organization to educate and sensitize the other employees on why they need to start doing things differently if they are to prevent the occurrence of inpatient falls.

Persuasion is the next step that involves concentrating on the naysayers and opposers who think that the project is not necessary. These are the skeptics and those employees who are comfortable with the status quo and do not want to work towards improving the situation. Naturally, they will need a little bit more convincing so that they can give their buy-in. Once the critical mass of employees who are ready for the implementation is reached, the next steps of decision and implementation are embarked upon. The decision is made to go ahead with the project and resources are made available for the same. These resources are fiscal, human, and material in nature. Implementation takes place within the timeframe stated in the PICOT question and this will then be followed by the step of evaluation. Evaluation means that the outcomes of the project will be measured against the objectives and goals and then it will be determined whether the project has been successful or not. In the event that the project is not successful, it can be redesigned and retried again at another point in time.  Reducing Inpatient Falls Essay Paper

Conclusion

The problem of patient falls is a significant healthcare issue that presents a quality problem within healthcare organizations like hospitals. Despite regulatory pressure by JCAHO and other organizations, the problem continues to persist. The cost of the problem to both the patient and the provider is immense. The patient gets to stay longer in the hospital and may suffer lasting disability. The provider on the other hand has to spend their own resources to care for the fall patient because the CMS no longer reimburses for care given to fall victims. Luckily, there are evidence-based interventions that can be employed as a bundle to prevent the occurrence of inpatient falls. They are intentional hourly rounds by nurses, the use of bed alarms, and the education of patients and training/ education of nurses and their assistants.

References

Agency for Healthcare Research and Quality [AHRQ] (2018). Preventing falls in hospitals. https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html

Buppert, C. (2021). Nurse practitioner’s business practice and legal guide, 7^th ed. Jones & Bartlett Learning.

Dearing, J.W. & Cox, J.G. (2018). Diffusion of innovations theory, principles, and practice. Health Affairs, 37(2), 183-190. http://dx.doi.org/10.1377/hlthaff.2017.1104

Falcão, R.M.M., Costa, K.N.F.M., Fernandes, M.G.M., Pontes, M.L.F., Vasconcelos, J.M.B., & Oliveira, J.S. (2019). Risk of falls in hospitalized elderly people. Revista Gaúcha de Enfermagem, 40(e20180266), 1-8. http://dx.doi.org/10.1590/1983-1447.2019.20180266

Fehlberg, E.A., Lucero, R.J., Weaver, M.T., McDaniel, A.M., Chandler, M., Richey, P.A., Mion, L.C., & Shorr, R. I. (2017). Impact of the CMS no-pay policy on hospital-acquired fall prevention related practice patterns. Innovation in Aging, 1(3), 1-7. http://dx.doi.org/10.1093/geroni/igx036

Gavaller, M., Gavaller, M., & Oh, H. (2019). Impact of bed alarm removal and implementation of hourly rounding to reduce falls. Journal of the American Medical Directors Association, 20(3), B19. https://doi.org/10.1016/j.jamda.2019.01.080

Ghahramani, M. (2016). Fall risk assessment in older people. The International Journal of Engineering and Science, 5(11), 1-14. http://dx.doi.org/10.9790/1813-05110114

Guirguis-Blake, J., Michael, Y., Perdue, L., Coppola, E., & Beil, T. (2018). Interventions to prevent falls in older adults. JAMA, 319(16), 1705. https://doi.org/10.1001/jama.2017.21962

Heng, H., Jazayeri, D., Shaw, L., Kiegaldie, D., Hill, A-M., & Morris, M.E. (2020). Hospital falls prevention with patient education: A scoping review. BMC geriatrics, 20(140), 1-12. https://doi.org/10.1186/s12877-020-01515-w

Hill, A-M., Waldron, N., Francis-Coad, J., Haines, T., Etherton-Beer, C., Flicker, L., Ingram, K., & McPhail, S.M. (2016). ‘It promoted a positive culture around falls prevention’: staff response to a patient education programme—a qualitative evaluation. BMJ Open, 6(12), e013414. https://doi.org/10.1136/bmjopen-2016-013414

McCarthy, M. (2016). Falls are leading cause of injury deaths among older people, US study finds. BMJ, 354 (i5190). https://doi.org/10.1136/bmj.i5190

Melnyk, B.M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare: A guide to best practice, 4^th ed. Wolters Kluwer.

Mileski, M., Brooks, M., Topinka, J.B., Hamilton, G., Land, C., & Mitchell, T., Mosley, B., & McClay, R.  (2019). Alarming and/or alerting device effectiveness in reducing falls in long-term care (LTC) facilities? A systematic review. Healthcare, 7(1), 51. https://doi.org/10.3390/healthcare7010051

Morgan, L., Flynn, L., Robertson, E., New, S., Forde-Johnston, C., & McCulloch, P. (2016). Intentional rounding: A staff-led quality improvement intervention in the prevention of patient falls. Journal of Clinical Nursing, 26(1-2), 115-124. https://doi.org/10.1111/jocn.13401

Venema, D.M., Skinner, A.M., Nailon, R., Conley, D., High, R., & Jones, K.J. (2019). Patient and system factors associated with unassisted and injurious falls in hospitals: An observational study. BMC Geriatrics, 19(348), 1-10. https://doi.org/10.1186/s12877-019-1368-8

Reducing Inpatient Falls Essay Paper