By Jason Bramwell
Photo courtesy of Harborview Medical Center, Seattle.
As part of a yearlong fellowship, Harborview Medical Center patient safety officer Ross Ehrmantraut, RN, had to design a project that would advance patient safety and quality improvement in his organization.
At that time, the Seattle-based hospital's medicine/geriatric unit had a worrisome patient fall rate: more than six falls per 1,000 patient days, versus a hospitalwide average of just under five falls per 1,000 patient days. Even more alarming: During 2008, 21.5 percent of the unit's patients who fell suffered serious harm, such as a fracture, head injury, or even death.
Ehrmantraut had his fellowship project: to build a multidisciplinary team approach to preventing falls in the medicine/geriatric unit. The project's goal was to reduce patient falls on the unit by 20 percent in six months. Recognizing that not all falls can be prevented, the project team also focused on decreasing harm in patients who fell.
When the pilot project concluded in December 2010, the multidisciplinary team had exceeded its goal, reducing falls on the unit by 35 percent-and none of the falls resulted in serious harm. Six months later, patient falls on the unit decreased by another 21 percent.
"In 2011, our rate of patients who fell with serious harm dropped to 16.5 percent," says Ehrmantraut. "We were guarded about our results early on, thinking it could be a fluke. But it's not a fluke-it's a sustained improvement."
The majority of patient falls are preventable-and expensive. According to the Centers for Disease Control and Prevention, the average hospitalization cost for a fall injury is $17,500. Hospitals are no longer reimbursed by Medicare for certain hospital-acquired conditions-such as patient falls-that could have been reasonably prevented.
To determine how to prevent falls among medicine/geriatric unit patients, Ehrmantraut and four other team members-a nurse manager from the medicine/geriatric unit, a clinical nurse specialist, a physician, and a pharmacist-began reviewing the causes of falls, such as going to the bathroom without assistance.
"Our medicine/geriatric floor has patients who suffer from drug and alcohol addiction, and some falls were related to delirium or confusion associated with withdrawal," says Ehrmantraut. "Also, during physical therapy, for example, if a patient starts to fall and the physical therapist helps them to the floor, we count that."
The team also realized that physicians and pharmacists had little to no involvement in fall prevention. "It's always been the nurses' and patient care assistants' job to deal with fall prevention and risk assessment," says Ehrmantraut. "The physicians seldom put any energy into it. Pharmacists were involved in fall prevention on a limited basis-or not at all. In fact, pharmacists and physicians were unaware that the nurses conducted a daily fall risk assessment at 8 a.m. every morning."
The physician on the project team-a geriatrician who had previously been involved in fall prevention-was instrumental in changing this dynamic and getting physicians and pharmacists more involved in assessing and addressing fall risks, says Ehrmantraut.
Ehrmantraut credits the following strategies for reducing patient falls on the medicine/geriatric unit.
Presenting intensive reviews to staff. Ehrmantraut says the biggest factor to reducing patient falls on the medicine/geriatric unit was involving staff in solutions through monthly intensive reviews. Staff had previously received a monthly report that summarized how many falls occurred during the previous month and how many had resulted in harm. Now, Ehrmantraut gives a more detailed PowerPoint presentation to the unit's day and night shifts. The presentation breaks down falls by patient, location, fall risk score, and other details. During the monthly meeting, Ehrmantraut encourages staff to discuss ways to prevent those patients from falling again.
"I was surprised by how much staff love this," he says. "During a meeting, I'd say, 'Here are the five patients who fell in your unit last month. Here's Mr. Smith's fall risk assessment score, his fall history, and where he fell. What can we do to prevent this from happening again?' I put a name to the number, and that's been powerful."
Access Sample Intensive Review
Developing a new fall prevention tool. Harborview nurses assess a patient's likelihood of falling by using the Morse Fall Scale. Nurses assign a score to six variables-the higher the risk, the higher the score.
However, the tool is sometimes inaccurate in predicting a patient's fall risk, says Ehrmantraut. "I review patients' risk assessment scores across their hospital stays, and oftentimes, I'd see a patient was given a 'no risk' score the same day she fell," he says.
This prompted the team to develop its own fall prevention discussion tool, which encourages nurses and physicians to assess a number of fall factors that are not included on the Morse Fall Scale, including the following:
Access Sample Fall Prevention Discussion Tool
"For example, a nurse and physician may agree that a patient has a high fall risk due to his medication and would check with the team's pharmacist to determine if the medication needs to be re-evaluated," says Ehrmantraut. "During morning rounds, the pharmacist might say that the patient was started on a new antihypertensive drug two days ago, and that he would be a high fall risk. When possible, medications are adjusted to decrease the fall risk."
Using yellow to identify fall-risk patients. The hospital adopted the industry standard of using yellow to identify patients who are fall risks. Those patients are recognized by yellow armbands, yellow blankets on their beds, and yellow slippers. "Our staff knows to call a nurse immediately to assist patients who are walking by themselves in a hallway wearing yellow slippers," says Ehrmantraut.
Implementing hourly rounding. A nurse or a patient care assistant is required to stop in a patient's room each hour to check on the patient and identify any needs the patient may have, such as assistance to the bathroom.
Pleased with the results on the medicine/geriatric unit, Harborview leaders asked the multidisciplinary team to help spread the fall prevention strategies to other units, which has resulted in widespread success. For example, the psychiatric unit-which had the second-highest fall rate-realized a 33 percent drop in patient falls in the past six months after implementing intensive reviews and the fall prevention tools. Also, the number of repeat fallers at Harborview has dropped 50 percent in the past six months.
This past May, the National Patient Safety Foundation, in conjunction with the National Association of Public Hospitals and Health Systems, awarded Harborview the 2011 Patient Safety Initiative at America's Public Hospitals Leadership Award for its work in preventing and reducing patient falls.
"It was big news around here. Our CEO, our medical director, and our CNO were very excited. Our front-line staff, including physicians and pharmacists, were ecstatic-they were the ones who did the work," says Ehrmantraut. "It turned into a mission for the medicine/geriatric unit to prevent falls, and it's now turned into a mission for most of the hospital's units. We used to have the attitude, 'Well, falls happen.' That has changed."
Jason Bramwell is associate editor of newsletters and Forums, HFMA (email@example.com).
Interviewed for this article:
Ross Ehrmantraut, RN, is patient safety officer, Harborview Medical Center, Seattle (firstname.lastname@example.org).
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