Emergency Department Falls Project

Project overview Projects goals and objectives Creating a culture of quality and safety Process, progress, and completion of project Obstacles and challenges of project Ethical/professional issues encountered Lessons learned as a leader and project manager

Project overview To develop a system that identifies patients who are fall risk during triage and implement the interventions patients scored at to promote for best outcomes. A study conducted by a Trauma I hospital in Hartford looked at fall risk assessment tools used in inpatient settings and how they do not adequately capture the risk factors of patients presenting to the emergency department. The ability to accurately identify patients at risk for falling at the point of entry is the first step toward preventing patient harm. Once patients are identified as at risk for a fall, the next challenge is to be sure that they do not fall. With improved identification of fall risk patients and consistent application of innovative prevention strategies, we were able to show a trend toward reduction of falls and fall-related injuries in our emergency department (Alexander, Kinsley,Waszinski,2013). Research had shown that a high percentage of patients who had fallen did so within the first 3 hours of being in the hospital. That is why it was important to identify these fall risk patients early.

Project goals WHY NOW? 2013 we had 23 patients falls 2014 had 24 falls 2015 so far have had 8 falls 8 of the 24 falls in 2014 resulted in injury 1 inpatient fall resulted in death Staff confusion and consistency on fall interventions used: when and why?

Objectives The project goal is to demonstrate by implementing an emergency department fall scoring system along with staff education and fall interventions will show a decrease in falls. A CMS study shows some 3 to 20% of inpatients fall at least once during their hospital stay; these falls result in injuries, increased lengths of stay, malpractice lawsuits, and more than $4,000 in excess charges per hospitalization. Thus, hospital falls represent a major patient-safety problem and may complicate a patient's care and treatment (Inouye, Brown, Tinetti,2009). Create a interdisciplinary team Increase awareness to staff on fall prevention. Introduce new “ED Fall” scale to help identify our at risk patients. Educate staff on interventions to promote a safer ED environment. Education of current process if patient falls. By implementing a scoring system during triage, staff education, and the use of interventions the objective was to show a decrease in patient falls. Not only are falls a major patient safety problem it is also a major cost to hospitals who now have to cover the cost associated with a fall. To create a interdisciplinary team so the process was used in all aspects within the ED Increase the staff awareness on the topic of fall prevention Introduce the triage scoring system Educate the staff on the interventions Re educate staff on the falls process which consisted of VOICE, post fall documentation and a post fall huddle form

Creating a culture of teamwork and safety A survey given to staff for input on fall interventions they would most use: 1.Hourly rounding by all ED staff: Studies have shown that 45.2% of all falls were toileting related. 2.Bed alarms 3.Keep hospital bed in low position with brakes locked. 4.Bed rails up 5.Yellow fall bracelet/socks 6.Staff/Family education 7.Curtains/doors open 8.Sitters 9. Signs in rooms “call don’t fall” 10. High risk patient closer to nurse’s station 11. Familiarize the patient to the environment. 12. Have the patient "teach back" all light use. 13. Keep the call light within reach at all times. 14. Keep patient's personal possessions within reach. 15. Utilize night light or supplemental lighting. 16. Keep floor surfaces clean and dry. Clean up all spills promptly. 17. Keep patient care areas uncluttered. 18. Different colored gowns 19. Pelvic protectors 20. Floor mats 21. Helmets This was my first attempt creating a culture of teamwork and safety by handing out a survey that listed interventions the staff thought would be most useful in the department to decrease falls. There was approximately %50 of the surveys turned back in by staff. The survey was then tallied and emailed back to the staff.

Project process An educational posterboard put in the break room and a PPt presentation was used to educate the staff on the new fall program. Our ticket to ride was changed with the additional fall scoring and follows that patient throughout the time in the emergency department. It will become part of the patients permanent record so that the document will not be lost and we can retrieve the data from them when we reevaluate the process.

Project process cont Research of other hospitals showed an increasing commitment to continuous quality improvement through enhanced safety awareness and staff being accountable, contributed to their initiative's success and led to a change of normative behavior and a culture of safety. Many of them saw significant decreases in falls within their hospital.

Lesson learned That you want to have an adequate time frame of putting together a project. To make changes in practice you want to have a well developed system in place that staff will be willing to try. I found that using interdisciplinary teamwork it gave me a chance to see and hear what has worked and why. My manager helped me immensely by directing me to people that could help me on this project. What I most learned is being flexible with my times for accomplishing goals and meetings with team members. My manger had directed me toward the supply person for socks. She invited me to hospital meeting on falls that involved unit managers and hospital management regarding falls. After researching historical data from VOICE reports I found that a %100 decrease in falls would be an unattainable goal. You need to account for the intentional falls and hope that there is a decrease in the unintentional ones.

Obstacles and challenges of project One challenge was trying to keep appointments with everyone's busy schedule. There was a period of couple of weeks where CMS made there visit to the ED. There were also employee evaluations done during this period that tied up management. It prolonged the period to move forward on policy changes within the ED. To get around these obstacles we were able to keep communication going with more emails than face to face meetings.

Professional Matters Professionally I thought everyone came together nicely on the project. Members of the team were able to express their ideas and concerns then make compromises. It was understood that this was the beginning of a new process and we would get together in the future to reevaluate when enough data is gathered. Nothing in the beginning is 100%.

References Alexander, D., Kinsley, T. L., & Waszinski, C. (2013). Journey to a Safe Environment: Fall Prevention in an Emergency Department at a Level I Trauma Center. JEN: Journal Of Emergency Nursing, 39(4), 346-352. doi:10.1016/j.jen.2012.11.003 Inouye, S., Brown, C., & Tinetti, M. (2009). Medicare nonpayment, hospital falls, and unintended consequences. New England Journal Of Medicine, 360(23), 2390-2393. doi:10.1056/NEJMp0900963