Help I Have Fallen! What Could Have Prevented This?

Editor's Notes

• #3: Patient falls are one of the leading causes of injuries in hospitals, cost billions of dollars per year and are classified as nurse sensitive indicator High acuity patients for this presentation are patients at high risk for a fall. In a clinical setting, particularly on a medical surgical floor. Maybe due to history, surgery, trauma to name a few. I compared the effectiveness of two interventions - bed alarms and patient sitters. Both of these interventions are commonly used in the hospital, bed alarms are the most frequently used. The goal was to determine which of these interventions when applied correctly provided the most decrease in risk of patient falls
• #4: According to one report, forty-eight percent of patients studied in an acute care hospital were considered at a high risk for falls. This percentage is so significant because the list of risk of factors for a fall is extensive. Some of the most frequent risk factors include: sensory alterations, muscle weakness, gait and balance disturbances, use of four or more prescription medications alteration of daily living, depression, and a previous history of falls Patient falls are the number one reported adverse event in hospitals. In patients above 65, it is the leading cause of death. Complications such as bone fractures, soft tissue injury, patient fear of falling again and even death can result from a pt. fall. Hip fractures, are considered a frequent outcome of falls in the elderly and often result in decreased mobility, fear of falling and increased likelihood of nursing home placement. Every time a patient fall occurs in a hospital and results in an injury it costs, on average, $13,316 ). In the US, the total number of falls resulting in injury is predicted to be as high 17,293,000 by the year 2020 at the cost of $85.37 billion per year That price tag has the attention of more than just patient families. The government has realized the epidemic of falls and has put pressure on the hospitals themselves to make a change. The Centers for Medicare and Medicaid have began identifying falls that result in death or serious injury to be a hospital-acquired condition and subject to non-payment (Costantino et al., 2013, p. 86). Additionally, beginning in 2015, as part of the Affordable Care Act, the top 25% of hospitals with the highest percentage of hospital-acquired conditions will receive a reduction in Medicare payments for all discharges
• #5: This problem relates to two of the QSEN core competencies. The most obvious is safety. As I stated in the previous slide, falls put patients at a significant safety risk. The second QSEN core competency that this problem relates to is quality improvement. Falls are one of the nursing quality indicators monitored by the National Database of Nursing Quality Indicators, The National Quality Forum and The Collaborative Alliance for Nursing Outcomes. The Joint Commission requires all healthcare facilities to have a fall-prevention program in place and to conduct ongoing evaluations of that program. Due to the fact that all health care facilities are required to evaluate their fall prevention programs, fall prevention and intervention is a good way to monitor quality improvement.
• #6: Bed alarms emit a distinct sound to alert nurses once it detects that a patient is attempting to, or has already left their bed. In a 12 month study involving 362 patients, the effectiveness of pressure sensor alarm systems was evaluated. The study reported that there was a significant reduction in the risk of falls and the mean number of falls per patient. Another study testing bed alarm systems found that most nurses thought the bed sensor alarm was useful for monitoring patients getting out of bed and were satisfied with the system. They found it provided a means of helping to prevent falls and in the event of a fall it enabled a rapid response. Some articles consisted of interviews with nurses who are either part of a study involving bed alarms or who already use them daily. Nurses interviewed said that bed alarms may help prevent falls, but even with bed alarms in use nurses still need to monitor their patients hourly. One nurse was quoted saying, “Why use the alarms? You have to make routine rounds anyway” Many of the nurses claimed they were already too busy to use the alarms, stating that the alarms were a nuisance and that they would have to monitor the patient after applying the alarm anyway”. Regardless of the type, an alarm system price ranges from approximately 150 to 300 dollars per patient and is a major financial investment. The biggest issue with bed-alarms as a fall prevention method is alarm fatigue among nurses. There is so much medical equipment that can be sounding off an alarm at any time, for example: feeding pumps, sequential compression devices, IV pumps, and bathroom call lights. For this reason it does not always indicate that the patient is attempting to get out of bed, it could simply convey that they are changing positions in bed. Another study proved that up to 99% of alarms sounding off on a medical unit can be false alarms. This causes nurses to silence or ignore alarms that they always hear in order to turn their attention to the other aspects of their job that they have to attend to. When the nurses attempt to answer all of the alarms, their other work falls behind.
• #7: A patient sitter, or observation assistant, is a staff or volunteer that provides a means of direct observation of patients for the purpose of providing a safer environment for the patient. A study on the effectiveness of patient sitters to reduce falls was performed in Pennsylvania. The study identified that 54,289 fall events were reported by hospitals during the months of January 2012 to July 2013. Of those 54,289 falls only 323 of them were identified as occurring with a sitter present. Also, none of the assisted falls with a sitter present resulted in patient injury. According to a journal on sitter effectiveness, one study found that instituting sitters had no affect on fall rates, and another found that fall rates actually increased. In addition, sitters can sometimes be a difficult intervention for a nurse manager or supervisor to accommodate. There are times when sitter needs arise after the time of request has passed. The nurse then has to attempt to re-allocate staff to meet the needs of the patient. This causes the nurse to weigh the cost benefit of removing a staff member to become a patient sitter versus accepting the safety risks of having a sitter request go un-met. The cost of patient sitters is also a major concern when implementing them as a fall-prevention method. Patient sitters are incredibly expensive, especially because they are not reimbursable by third party payers. In 2007 it was discovered that a hospital with 220 beds had an unbudgeted expense of $515,480 directly related to the cost of patient sitter. A report completed by Harding (2010), compiled 18 months of data that concluded that patient sitters are ineffective and expensive and should not be used as a rapid human intervention for patient falls.
• #8: Recently I was involved in a patient fall while in the middle of a commode to bed transfer. The 86 y/o female was on unit for an infected central line, and had fallen previously that day. I turned to dispose of a soiled rag, and in that moment the patient attempted to step on her own power and fell. The patient was discovered to have a broken back and as a result had an extended hospital stay. Although the patient was fully aware of the precautions in place for her safety from the fall earlier that same day, she chose to ignore them. Which brings me to the theory of Costantino et al that patients commonly view themselves negatively after a fall, often viewing it as a disability or clumsiness. This creates new hurdles for health care providers because patients neglect to corporate with specific safety interventions or neglect to acceptance the fact that they are a fall risk at all. Another example of a fall on our unit involved a PCA sitter from white 7 who was present in the room at the time of the patient fall. The patient only had one arm and the other arm was secured to the bed rail. However, during the night the patient still fell out of bed. This may have been due to the sitter’s inattentiveness or possibly being asleep, but it proves that no intervention is guaranteed.
• #9: The research shows that a patient who is at risk for falls would not necessarily benefit from either bed alarms or patient sitter’s alone, but rather from an amalgam of the two and consideration of the individuals needs. A report detailing bed exit alarms concluded: that there is conflicting evidence regarding any one type of intervention when it comes to patient falls. Another study claimed that although modestly effective on their own, these interventions are best utilized when they are part of a broader fall prevention program that addresses each patient uniquely. In order for an intervention to be truly effective it must be proactive and be tailored to the patient’s specific risk factors. One study monitored the use of a program with multiple interventions and found it to be very successful. In fact it boasted that their multifactorial program reduced falls with injuries by 58.3% over two years and avoided $776,064 in cost in 2013. More research is required in the area of fall prevention. Specifically, larger randomized trials of interventions should be performed to determine the actual effectiveness of the different existing interventions, as well as discovering an intervention that may be effective on its own. Until then hospitals with low fall numbers will continue to use multiple prevention methods at a high cost. Fall prevention education is very important and is something that every health care facility should practice. Most health care professionals should have received basic training and information during their certification courses on the dangers that falls can present. Continuing education would allow them to be vigilant and expand on their knowledge once they begin to practice and to be up to date on new prevention methods Although patient falls continue to happen on a global scale in health care facilities, it is recognized and being monitored closely. New interventions and prevention methods are constantly being introduced and studied. With agencies like the World Health Organization and the Joint Commission taking notice, patient falls have started to decrease. However, it will always come down to the nurses, who are on the front lines, to do what is best for their patients and ensure their safety.