Patient Safety Measures

Inpatient falls constitute a major clinical, supervisory, and legal issue, though not much information exists on the subject of successful fall reductions (Rosenthal, 2007). CMS (Centers for Medicare and Medicaid Services) has ceased to reimburse healthcare facilities for traumatic inpatient falls. With increased aging of the American population, preventing falls has become more important than ever before. Elderly, weak patients depict greater risk of falls, with more serious consequences. Fall prevention within the nation’s acute care facilities gives rise to distinctive challenges, considering the fact that it involves severely ailing patients with an average hospital stay of a mere 4.9 days. Such a compressed acuity increases healthcare practitioners’ burden to ensure patient safety; thus, fall prevention intervention results for long-term patient care organizations might not be applicable to facilities providing acute care. Likewise, international results might probably not be generalizable to the American context, as international hospitalization durations tend to be longer. Fall prevention initiatives are generally multifaceted and involve a number of aspects dependent on leader participation and multi-disciplinary frontline employee cooperation. Initiatives might call for sound monitoring plans for ensuring hospital employees abide by established patient care rules (Hampel et al, 2013).
For facilitating identification of patients’ fall risk factors and guiding fall prevention initiatives within the acute care context, falls are generally classified into the following categories: expected physiologic falls, accidental falls, or unexpected physiologic falls. Further, risk factors are also grouped as extrinsic or intrinsic, the latter including:
· Low endurance of physical exertion
· Orthostatic hypotension or decrease in blood pressure due to dehydration, standing, or lower extremity muscular weakness
· Reduced mobility, poor balance, or unsteady walk on account of neurologic conditions, pain, or musculoskeletal abnormalities
· Foot issues which lead to peripheral neuropathy (paresthesia) or pain
· Vision impairment on account of glaucoma, cataract or low depth perception
Extrinsic factors or factors with external origins include physical environmental conditions (e.g., inadequate lighting, slippery floor because of any kind of spill, irregular threshold, or clutter) (American Nurse Today, 2015).
Implementation of a Falls Prevention Program
A complex, multidisciplinary strategy was adopted for formulating and applying a falls prevention initiative in the year 2004. Firstly, baseline information was noted and studied for determining problem magnitude. The information gleaned was communicated to every team member; subsequently, team members relied on individual clinical networks for creating initiative awareness among the remaining employees. The initiative was of a policy-driven nature (i.e., in line with the 2003 WADOH (Western Australian Department of Health) Fall Prevention Policy). The policy’s publication prompted the creation of a healthcare organizational Falls Risk Management Policy. The subsequent step involved creating and putting into place an official post-fall evaluation procedure, deemed appropriate in a group consensus meeting. Normally, risk evaluation entails admission evaluation for established risks, focusing on patient mobility and psychological status in relation to age, post-surgical condition or medications administered (McCarter-Bayer et al., 2005; Zdobysz et al., 2005). But in spite of such risk awareness, a large number of risk evaluation instruments have proven imprecise or shown limited effectiveness owing to diverse factors’ / units’ variability (e.g., new recruits, occupancy rates, and patient acuity).
Here, it was essential to develop the risk evaluation instrument based on local patient flow awareness, physical layout of the healthcare facility, resources (like working relationships between fall prevention initiative team members) and environmental elements. This facilitated initiative contextualization to the distinct setting, besides enhancing inter- and intra- disciplinary communication (which isn’t invariably easily achievable within larger hospital settings) (Woloshynowych, Rogers, Taylor-Adams & Vincent, 2005).
The CFR (Clinical Fall Review) evaluation form was created using the contributions of every team member. It aids hospital employees in reevaluating the range of possible causes and, wherever relevant, prompts allied health or pharmacy referrals. Causative factor evaluation includes: patient’s mobility and need for manual handling; clinical elements like tests and urinalysis; risk of falls (which includes hazardous footwear); environmental elements (including hi-lo adjustable beds and bedrails wherever possible, and concentration of obstacles within patient bathrooms and bedrooms); and pharmacological elements (hypnotic or opioid medication commencement, multiple drug alterations since hospitalization, or poly-pharmacy). Nurse care plan reforms for reflecting falls evaluation information offered clinical staff members with fresh prompts to remain cognizant of care requirement modifications. As the initiative was introduced in the year 2004, the CFR evaluation form is completed after in-hospital fall events, and subsequently passed on to Risk/ Quality Management Coordinators for the purpose of processing, together with the fall incident/ accident form. This form is added to patient clinical record for future reference (McKinley et al., 2007).
A second key step entails flagging system development, in which every fall-risk patient has a fall risk reminder added to his/ her EPMS (electronic patient management system) record. Colorful laminated reminder cards were added to patient medical records’ front covers for flagging risk status. Additionally, a notification system was developed for alerting pharmacists of patient falls, and the need to review medicines prescribed/ administered. Pharmacist recommendations were also added to patient health records for physician/ nurse review. The alerts continue to be active during patient de-hospitalization, and remain evident during re-hospitalization to ensure hospital employees become instantly aware of prior patient fall risk (McKinley et al., 2007).
Evaluation and Recommendations
Initiative assessment was customized bearing in mind extant policies and the local situation. The main assessment approach was monitoring clinical fall indications ever since the time of initiative commencement, by utilizing the AIMS (Australian Incident Monitoring System) targeted at classificatory reporting. The system supplies monitoring information based on overnight stays for affording an explicit image of quality improvement levels. This strategy is commonly employed in the assessment and monitoring of fall risk, as other research scholars employing fall rate (i.e., number of reported/ observed falls for every 1,000 patient days) or growth in average days between injury-causing falls as their comparison basis at diverse times report (Szumlas et al., 2004). AIMS system information covers patient and involved parties’ identification, verbal account of fall event, and informant views on causative factors and ways of avoiding a similar accident in the future (Woloshynowych et al., 2005).
Modern hospital management has a number of associated challenges, especially when a dearth in nursing staff has led to healthcare organizations vying for qualified personnel recruitment and retention. Management plans concentrating on the development of a sound, reasonable interdisciplinary group approach to caring for patients have proven more professionally apt (Aiken, 2005). Further, evidence-based hospital management practices (EBM/ EBPs) are reflective of modern day administrative EBPs when it comes to flattening hospital management hierarchies and restructuring institutional plans to incorporate participatory, team decision-making approaches. EBM accomplishes a sound fit with safety and quality agenda, besides driving and informing continuous holistic quality improvement. When hospital executives promote EBP within any clinical practice domain, it frequently leads to the creation of a template to sustain EBPs, with team members exhibiting increased likelihood of seeking out best evidences for other initiatives, and consequently developing novel skills. This promotes a learning environment within the healthcare organization, with procedures and systems continuously questioned, resulting in fresh opportunities to develop organizational chance capacity. In the end, EBM may function as a self-perpetuating employee development model, considering the strong influence of leadership ability role-modeling from across diverse fields and levels (McKinley et al., 2007).
References
Aiken, L. (2005). Improving quality through nursing. In D. Mechanic, D. L. Rogut, D. Colby, & J. Knickman (Eds.), Policy challenges in modern health care (pp. 177). New Brunswick: Rutgers University Press
American Nurse Today. (2015). Focus on falls prevention. Retrieved from https://www.americannursetoday.com/wp-content/uploads/2015/07/ant7-Falls-630_FULL.pdf
Hampel, S., Newberry, S., Wang, Z., Booth, M., Shanman, R., Johnsen, B., … Ganz, D. (2013). Hospital Fall Prevention: A Systematic Review of Implementation, Components, Adherence, and Effectiveness. J Am Geriatr Soc, 61(4), 483–494. doi: 10.1111/jgs.12169
McCarter-Bayer, A., Bayer, F., & Hall, K. (2005). Preventing falls in acute care. Journal of Gerontological Nursing, 31(3), 25-33.
McKinley, C., Fletcher, A., Biggins, A., McMurray, A., Birtwhistle, S., Gardiner, L., … Lockhart, J. (2007). Evidence-based Management Practice: Reducing Falls in Hospital. Collegian, 14(2). Retrieved from https://www.collegianjournal.com/article/S1322-7696(08)60551-X/pdf
Rosenthal, M. B. (2007). Nonpayment for performance? Medicare's new reimbursement rule. N Engl J Med, 357, 1573–1575
Western Australia Department of Health. (2003). Falls Prevention Policy. Perth: WADOH
Woloshynowych, M., Rogers, S., Taylor-Adams, S., & Vincent, C. (2005). The investigation and analysis of critical incidents and adverse events in healthcare. Health Technology Assessment, 9(19).
Zdobysz, J., Boradia, P., Ennis, J., & Miller, J. (2005). The relationship between functional independence scores on admission and patient falls after stroke. Stroke Rehabilitation 12(2), 65-71.