What You Need to Know
BWH’s next site survey from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is slated for January 2004. To help prepare nurses for the impending survey, BWH Nurse will continue to publish regular articles on appropriate processes and standards that apply to Nursing.
All nurses, who have not yet been through a JCAHO Survey, should work with their nurse managers and clinical educators to ensure understanding and expectations of the process.
Part V. Falls Prevention
Patient falls constitute the largest number of reportable adverse events in acute care settings, and serious injuries related to these events can contribute to an increased length of stay and resource utilization. It is therefore not surprising that the economic impact of injury resulting from a fall is a major concern to health care organizations. There is increasing evidence that falls are associated with rising health care costs and are the costliest injury among the elderly. The cost to acute care facilities for serious fall-related injuries (i.e. fractures) is estimated to be $8 billion annually.
BWH Experience:
The Department of Nursing’s Falls Prevention committee tracks all falls that occur both on in-patient and ambulatory care units. The completion of incident reports at the time a patient falls, enables the committee and nursing management to assess what factors may have contributed to the fall; what safety measures were in place; and what actions should be implemented to prevent a recurrent fall.
1. Analysis of Falls – Data shows that most falls occur when patients independently attempt to go to/from the bathroom. Falls occur in all age groups and are not limited to patients over 65 years of age.
2. The total number of falls occurring in FY’00 was 524. This number decreased to 471 in FY ’02. The average number of falls per month in 2001 was 47. This number decreased by 5 percent in 2002, with an average of 44 falls per month. The data for April ’03 shows that there were32 falls during the month.
3. The average age of a patient experiencing a fall in FY ’02 was 60 years old. The majority of these occurred with patients who were between 45 and 74 years old.
4. There are two time periods in which there is an increased incidence of falls: 4-6 a.m. and 4-6 p.m.
5. Services which have patients who are more susceptible to falls include Hematology- Oncology, General Medicine and Neurosurgery. Given the diagnoses and physical limitations of these patients, it is understandable that they are at a high or very risk for falls.
6. Most patients who fall do not sustain an injury. The majority of injuries that result from a fall are abrasions. However, there have been a small group of patients who have sustained serious injuries such as fractures.
Falls Prevention Protocol
The process for assessing patients at risk for falls was reviewed and revised by the Falls Prevention committee earlier this year. The Hendrich model for assessing patients at risk for falls was adopted to determine if a patient has a normal, high or very high risk for falls.
•Assessment/ Reassessment –
Every inpatient is assessed for falls risk as part of the admission process. The risk assessment includes determining if there is recent history of falls; confusion/disorientation; depression; altered elimination patterns; non-adaptive mobility/generalized weakness; dizziness/vertigo; primary cancer diagnosis; and multiple medications (noting if any can cause weakness). Based on the level of risk and the patient’s risk score, an intervention plan is developed. Patients should be reassessed, at a minimum of once a shift and if there is a change in condition.
• Nursing Intervention/Plan of Care –
Measures that should be in place for all levels of risk include assuring that a patient’s call light is within reach and that a patient is able to use it; bed in low position with brakes locked; side rail position (i.e. when 4 side rails are deemed necessary, and an MD order is required as this measure is considered a restraint); clutter-free environment; non-slip footwear; assistance with elimination, if indicated; mobility aids as appropriate; and falls prevention education to patient and family.
• High Risk Patients –
A sign indicating falls precautions should be posted on the door to a patient’s room and the medical record should be flagged; night light should be on during the evening and night shifts; and elimination needs should be assessed every two hours while patient is awake.
• Very High Risk Patients –
Measures listed for high-risk patients should be implemented. Additional measures include assuring that the bed exit alarm is in the “ON” position; commode at bedside, if indicated; bedpan/urinal within easy reach, if desired; and reorientation of patient to environment (time, person and place) as needed.
Nursing Actions for Patient Falls
In the event that a patient sustains a fall, he or she should be assessed for presence of injury and type (describe signs and symptoms); note circumstances leading to fall (i.e. ambulated unassisted to bathroom); record vital signs; determine if patient hit head in fall; mental status (indicate if there are any changes from previous assessment); notify MD and nurse manager/nursing administrator. The need for contacting patient’s family about the incident should also be determined. If appropriate, this should be done in a timely manner. Patient should be observed for signs and symptoms of possible injury – frequency and time frame per physician order. An incident report must also be completed.
Patient-Family Education
Patients and families should be educated about factors that can contribute to falls and what measures they should implement to prevent them. Where appropriate, they may need instruction on the proper use of assistive devices. Safety measures that should be maintained post-discharge from the hospital should also be reviewed with them.