Reducing patient falls: Two healthcare systems, two different approaches
As patient falls continue to plague healthcare facilities of all shapes and sizes, health systems in Georgia and Nebraska share their success stories
Patient safety experts contend with a multitude of intricate health complications, from healthcare-associated infections to medication management. However, amid these complex problems, one outwardly simple adverse event continues to pervade the industry: patient falls.
The Agency for Healthcare Research and Quality (AHRQ) estimates that as many as 1 million patients fall in the hospital each year. Falls may result in a few minor bumps and bruises, but in many cases, they can also lead to further health complications, including fractures, lacerations, or internal bleeding. AHRQ estimates that one-third of patient falls are preventable; however, what may seem like a straightforward problem is in fact very complicated. Falls can occur for any number of reasons, ranging from medication side effects to lower body weakness.
Healthcare facilities have found success in stopping patient falls by establishing an organized fall prevention program that identifies unique fall risk factors associated with each patient. Recently, two separate healthcare systems have been recognized for their efforts in this area.
In January, Grady Health Memorial Hospital in Atlanta was awarded the Quality and Patient Safety Award by the Partnership for Health and Accountability for a program that significantly reduced patient falls. Meanwhile, the University of Nebraska Medical Center (UNMC) in Omaha has received national attention for its "CAPTURE Falls" program (Collaboration And Proactive Teamwork Used to Reduce Falls), which developed a multidisciplinary team approach to fall prevention in 19 Nebraska hospitals, many of which were critical access hospitals (CAH).
Although each provider took a different approach to fall prevention, both found that when they had leadership support and organizational awareness directed toward determining the risk factors associated with patient falls, their fall rates declined, sometimes significantly. In the first quarter of 2014, following the rollout of a revamped fall prevention program, Grady Memorial reported a 75% decline compared to baseline measurements from 2011. Compared to the average fall rates in the three years before the program, the CAPTURE Falls program saw a 31% reduction in total falls during the first two years of the program, coupled with a 33% reduction in injurious falls.
These decreases occurred in the context of increased reporting, says Katherine J. Jones, PT, PhD, associate professor in the division of physical therapy education at the School of Allied Health Professions at UNMC and one of the leaders of the CAPTURE Falls program. Many hospitals did not report assisted falls that did not result in harm, nor did they include skin tears or bruises as injuries, both of which were emphasized during the rollout of the program.
Although some of the initial phases of the program were difficult to implement, hospitals ultimately saw the patient safety benefits to a team approach to fall prevention.
"We're not talking about cardiac catheterization here, we're talking about basic patient care," Jones says. "If we can't keep our patients safe from falls, then we really are not able to provide high-quality care."
Identifying a problems
Both fall prevention initiatives started with a few simple questions: How frequently were patients falling, and why? For Grady Memorial, that question arose in 2011. During that year, the hospital reported 20 falls with injuries, which translated to a 15% fall rate. But in 2012, falls with injuries more than doubled to 46, jumping to a 28% fall rate.
"In that one year, we had more than twice as many falls than we had the previous year," says Rosiland Harris, DNP, APRN, RNC, ACNS, BC, director of professional nursing education, practice, and research at Grady Memorial. "We did not want to see that rate continue to go upwards."
Grady Memorial set out to identify the reasons behind patient falls, but it couldn't pinpoint one particular risk factor. Instead, the hospital determined that its entire falls program was insufficient.
"We were not adhering to the best practices for fall prevention and didn't have the best processes in place at that time to really accurately monitor falls or look at some of the debriefings that occurred after a patient fall to see if there was any opportunity for us to prevent those falls," Harris says.
In Nebraska, the CAPTURE Falls program was born out of the desire to obtain a better understanding of fall rates specifically within CAHs. Sixteen of the hospitals that participated in the program are CAHs with 25 or fewer beds. Jones says there was very little research that looked specifically at small, rural hospitals, but researchers at UNMC believed that the risks would be higher for the following reasons:
- CAHs care for an older adult patient population that is more at risk for falls.
- CAHs often provide swing bed care that focuses on physical therapy and improving independence.
- CAHs have limited quality improvement resources and frequently have one person performing multiple duties.
- There are no valid benchmark rates for patient falls in CAHs. Fall prevention is difficult to prioritize if hospital leaders don't have the data to indicate it is problematic.
- CMS still pays CAHs for some healthcare-acquired conditions, including injuries from a fall. Larger hospitals are no longer reimbursed for those complications.
In 2011, Jones and others from UNMC conducted a baseline assessment of hospitals in Nebraska and found that fall rates were approximately 50% greater in CAHs compared to traditional hospitals (5.9 vs. 4.0 per 1,000 patient days), while injurious fall rates were 88% more likely (1.7 vs. 0.9 per 1,000 patient days). Their assessment was published in the Journal of Rural Health in 2014. Based on that assessment, researchers at UNMC determined that CAHs lacked organizational structures that addressed fall prevention.
"What we found was there wasn't a lot of variability between CAHs and larger hospitals in terms of interventions at the bedside," Jones says. "Where the variability occurred was in what was done organizationally. So what types of training programs did you have? Were you using a validated tool? Did you dedicate staff to your fall risk reduction program? Did you report assisted falls, and did you do a medication review prior to a fall?"
Risk reduction focus areas
Once each organization had evaluated baseline data, both Grady Memorial and UNMC took a broad approach to addressing patient falls. Recognizing that fall prevention varied at an organizational level, UNMC researchers sought to develop a comprehensive program that would involve physical therapy and pharmacy, as well as nursing. With a grant from AHRQ, UNMC developed the CAPTURE Falls program, emphasizing a team-based approach to care.
Through the AHRQ funding, UNMC developed a toolkit that would "plug a gap we saw in other toolkits," Jones says. Key focus areas included how to choose an appropriate fall risk assessment, determining what patients may be at risk for falls, tracking assisted falls, and assessing a fall prevention program through the use of a scorecard. "Those hospitals that were the most successful understood the need for the change, and they recognized that what they were learning was a process they could apply to all safety and quality challenges," she says.
In Atlanta, Grady Memorial used its baseline assessment to refocus fall prevention efforts. The hospital's chief nursing officer took the lead on redesigning the program, assigning a nurse educator as the fall team leader and identifying fall champions for each unit.
After formalizing the goals and objectives of the program, Grady Memorial made tweaks by redefining what qualified as a fall, adding color-coded signs for at-risk patients, providing patient education, and conducting hourly rounding. She adds that Grady Memorial achieved a 75% decrease because the program evolved into a competition between units. Fall injury rates were included in unit director goal reports that were reported to senior leadership, which offered accountability for every unit. "When other units had done everything they were supposed to do and they were getting good compliance, it just got legs and started taking on a process," Harris says. "Everybody really got engaged and began to really focus."