Responding four years ago to nationwide concerns about patient safety, NorthEast Medical Center, a 457-bed hospital in Concord, N.C., created a committee to address the issue.
But instead of diving straight into such hot topics as medication errors and wrong-site surgery, the patient safety committee started with a more commonplace safety problem--patient falls.
Patients were taking a tumble more frequently at NorthEast and the hospital's rate had reached an alarming level of 6.1 falls per 1,000 patient days, well above the national median of 3.5.
"We found that the trend of falls was on the rise in our organization," says Marie Gowdy, a clinical nurse specialist who chairs the patient safety committee.
Falling statistics
Three years later, using a combination of new equipment and changes in staff operations, NorthEast slashed its rate of falls by more than half, to 2.6 falls per 1,000 patients, significantly below the national median.
NorthEast is not alone. Hospitals across the country are setting up fall committees that choose equipment, make architectural changes and rethink the way patients are monitored in the unit. And they are seeing their fall rates drop.
"These programs were nonexistent a few years ago, and now they are popping out of the woodwork," says Jennifer Gleason, R.N., clinical manager of critical care at 106-bed St. Clare Hospital in Lakewood, Wash., which has reduced its fall rate through such measures as making sure staff regularly assist patients to the bathroom.
Safety matters
One of the reasons for this new attention is the inclusion of fall prevention in the 2005 National Patient Safety Goals of the JCAHO, Oakbrook, Ill.
The JCAHO's new goal instructs hospitals to "assess and periodically reassess each patient's risk for falling, including the potential risk associated with a patient's medication regimen, and take action to address any identified risks."
Some states also track hospital fall rates. For example, the New York State Patient Occurrence Reporting and Tracking System includes information on patient falls that result in fractures.
Like NorthEast, many organizations are getting reacquainted with patient falls as part of their patient safety campaigns. Falls represent the largest single category of reported incidents in a typical hospital.
The National Center for Injury Prevention and Control, Atlanta, reports that falls are the leading cause of deaths from injury for the elderly, accounting for more than 10,000 deaths each year.
Overall, 20 percent to 30 percent of falls result in injury, but the rate may be higher in hospitals. Barnes-Jewish Hospital in St. Louis, for example, reports that 42 percent of its patients involved in falls were injured to some extent.
Falls can add up to big expenses for a hospital. They cost $20.2 million a year in diagnostic tests, injury repair and rehabilitation, legal expenses, and patient and family dissatisfaction, according to a study in the Journal of Forensic Sciences.
The study says the average unlitigated fall with an injury costs $10,000, while the cost of litigated falls can go into millions of dollars.
Finding risk
The first step in any fall prevention program is to understand why patients are falling.
Research studies have cited a long list of reasons for falls, and the reasons can vary from hospital to hospital.
Causes involving a patient's physical problems include weak muscles, unstable balance, vision problems, side effects from medications, Parkinson's Disease, a history of stroke, lower body weakness, and confusion after having undergone a battery of tests.
Also, there are problems with a patient's surroundings, such as slippery floors, anything lying on the floor, poor lighting, objects out of a patient's reach, lack of a walker or cane, unfamiliarity with the surroundings and lack of assistance. Hospital fall teams bring together people from various parts of the organization to consider ways to lower the fall rate. Representatives from materials management rarely sit on these committees, but they are often consulted because antifall devices are an integral part of lowering the fall rate.
At NorthEast, Gowdy and her fall team did a kind of root cause analysis to determine the reasons patients were falling. They reviewed the units nurses' notes and other information for every reported fall and divided all the falls into categories of reasons why it happened. Within three years of work, the team developed a highly consistent picture of why patients fell.
About 80 percent of them were confused, had gait disturbance and were attempting to go to the toilet alone.
The next step was to use the findings to create a prevention program. The NorthEast team developed a risk assessment tool for new patients that uses 11 patient indices of fall risk, such as gait disturbance, confusion, falls in the past 12 months, generalized weakness and incontinence. Each fall risk was given a numeric value based on its severity.
The tool is administered to patients at admission and updated during a patient's stay. They are divided into groups with low, medium and high risk for falls. Staff are instructed to pay special attention to those at high risk.
No restraint
Hospital fall committees can spend a great deal of time assessing devices to reduce falls.
"The glory of this committee is that it gave us a chance to test equipment before we ran out and bought it," says Shawn Godfrey, R.N., director of psychiatric services at NorthEast Medical Center who sits on the hospital's patient safety committee. He says the committee conferred with the materials management department and tested some products before deciding what to order.
Antifall devices reviewed are different from what many hospitals used a decade ago. The old devices were restraints, which have virtually disappeared at most facilities because of concerns about patients' rights.
Old restraint devices included a vest that was similar to a straitjacket and the geri-chair, with a built-in table that locked a patient in place.
In a new policy introduced a few years ago, JCAHO declared that restraints should be used only if "the primary reason directly supports medical healing."
That wording puts some devices in a gray area. For example, Susie McBeth, associate director of standards interpretation at the JCAHO, advised in October that a bedrail is a restraint if it is used to restrict movement but not if it is used to "facilitate mobility in and out of bed."
Hill-Rom Co. in Batesville, Ind., still sells the Vail bed, which encloses patients in a mesh screen. "The system allows freedom of movement and reduces the side effects caused by traditional mechanical restraints," the company states.
On the other hand, Posey Co. of Arcadia, Calif., which used to make patient restraints, now sells a wide variety of self-releasing belts for wheel chairs and beds. The company says the products conform to CMS' opinion that a device is not a restraint if it allows "freedom of movement or normal access to one's body."
Of their own device
Gleason says St. Clare Hospital uses some restraints but not for patients at risk for falls. She argues that a restraint actually prompts falls because "all it does is make a patient agitated."
To take the place of restraints, she says her fall committee opted for a bed-exit alarm, which is a pressure-sensitive device that is placed under the sheet. An alarm goes off in the nurses' station when a patient leaves the bed.
St. Clare uses the Sensormat, made by the Bed-Check Corporation of Tulsa, Okla. Bed-Check also makes the Chair Sensormat for chairs and Potty-Check System for the bathroom.
But some hospital fall committees have rejected antifall devices because the alert may come too late. "The drawback is that by the time someone gets to the room, the patient is already on the floor," says Melissa Krause, a research coordinator at 904-bed Barnes-Jewish Hospital, which tested the device. The hospital also found that bed exit alarms were not being used consistently.
At NorthEast, Godfrey says his committee determined the bed alarm was effective but it did not want a separate device like the Sensormat, because it would be one more item to keep track of and clean or replace. So NorthEast chose a bed by Hill-Rom that incorporates the sensor in it.
The company also offers a low bed, which prevents injury from falls by lowering it to 6.75 inches from the floor.
Hip pads are another way of protecting patients from a fall. HIProtector in Wellesley, Mass., makes Hips, a two-piece hip protector; HipGuard, a similar model that fits over clothing; and CuraMedica, a protector for incontinent patients. VA hospitals report that hip pads have reduced hip fractures by 50 percent to 75 percent.
Godfrey recalls that NorthEast's committee was initially excited about hip pads. "We really, really wanted them," he says, "but they turned out to be impractical. Our patients are older, confused and incontinent, and we found that these guards and incontinence did not mix."
But Godfrey says the hospital bought a new device for its fall-prone patients made by the Merry Walker Corporation in Richmond, Ill. Like a regular walker, it allows a patient to walk with support, but patients can also sit in it. Godfrey says it is light yet difficult to overturn.
And in one low-tech decision, NorthEast also bought canes and walkers to lend to patients when they arrive. The hospital discovered that falls often happened because patients forgot to bring these items from home.
On the surface
Perhaps the most universal solution to patient falls is the introduction of nonslip material all over the hospital.
Officials on the fall committee at Barnes-Jewish Hospital say they put to good use the nonslip material used under rugs. It is used in mats at the side of a patient's bed and is cut up and put behind patients when they sit in a chair so they don't slip out.
Barnes-Jewish also has nonskid surfaces on both the inside and the outside soles of all booties issued to patients because sometimes the booties get turned inside out.
Nonslip surfaces and other antifall features are also prominent in hospital redesigns. For example, a new addition at 744-bed Northwestern Memorial Hospital in Chicago has nonslip floors and grip bars in all the bathrooms.
Hospital architects also recommend double doors for bathrooms so that patients can enter on their wheelchairs or even in wheeled beds. Floor layouts can also lower the risks of falling. Methodist Hospital in Indianapolis reports that when it redesigned its 56-bed cardiac critical care unit, making such changes as moving nursing stations closer to patients' rooms, falls declined 75 percent.
Gowdy says NorthEast is employing the latest antifall concepts in construction of a children's hospital and a clinical services building. The plans include specially treated floor surfaces and removal of sharp edges from furniture.
Some hospitals, on the other hand, put more emphasis on making sure staff are aware of potential hazards, which is an essential ingredient in all fall programs.
In Northwestern Memorial's fall program, which began in January 2003, each unit is encouraged to increase the number of days between falls. The hospital reports that average days between falls with injury more than doubled in the first 11 months of the program.
Stephanie Kitt, R.N., director of quality and clinical decision support at Northwestern, says staff watch a video presenting several scenarios involving falls.
In one, a nurse assists a patient to the bathroom and tells him she will return soon. In another, she tells him to call when he is done and then waits outside the door. And in a third scenario, a patient cannot reach his call light and tries to reach the bathroom by himself.
Kitt says this teaches staff the importance of making sure items are within a patient's reach and the need for staff to make hourly rounds to see if patients prone to falling need to be escorted to the bathroom.
Leigh Page is a freelance writer based in Oakbrook, Ill.
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