Page header will display here

 

Falls in Hospitals Happen

Recognizing the issue, the Joint Commission has stepped in to require hospitals to implement falls-reduction programs as a requirement of accreditation, and the Centers for Medicaid and Medicare Services will no longer reimburse hospitals for the cost of care that results from inpatient falls. Hospitals have addressed the problem with initiatives that involve all staff, from trustees to caregivers to facility managers and housekeepers, among others. Yet, falls continue to occur. 

The Agency for Healthcare Research and Quality estimates that somewhere between 700,000 and 1,000,000 people in the U.S. fall in a hospital each year. Because all patients, but especially elderly patients, are often taking several medications, have many medical risk factors, are stressed, and vulnerable it's easy for them to lose their balance as they attempt to rise from a bed or a chair.
While a common method for preventing falls is to "alarm" chairs and beds so that a patient shifting position or is beginning to stand on their own sets off a warning to nurses that a patient is on the move, a fall can often happen before an intervention takes place. And unlike other hospital initiatives to fight patient harm - such as relatively simple checklists that are proven to stem the tide of infections - fall mitigation strategies are less definitive.  That is, there are many interventions for stemming falls - from exercises to in-depth patient education, to bedrails, non-slip footwear, safety "huddles", and more - but it's up to nursing administrators and their teams to sort through the strategies to find the right combination for each individual patient.

Heywood Hospital in Gardner, MA - a 134-bed community hospital - has assembled a team to deal with the falls issue, which at Heywood is made even more difficult by the presence of an in-facility geriatric psychiatric unit. Elderly patients, often with dementia, cycle from that unit into general hospital units when a medical issue arises.  Because geriatric psych patients often cannot remember cautions ("Call us if you need to use the restroom") and because they often wander or become frustrated, their fall risk soars. "The challenge is around the population you serve, the environment you are in, and the screening tools you use," says Tina Santos, R.N., M.S.N., M.B.A., Heywood's Chief Nursing Officer and V.P., Operations. "There's a lot of human factor in there to address the issue."

Christine Basil, R.N., Director of Acute Care Case Management, said the hospital's multidisciplinary team re-approached all aspects of the falls issue beginning with the assessment tool that is used for all patients admitted to the hospital. "We're moving from the Hendrich model to the Morse Fall scale," Basil said noting two of the main tools that caregivers use to rate patients on a scale of their likelihood to fall. Patients are "ranked" based on the medications they are taking, if they have hypotension, or if they are frail, are likely to wander and, most importantly, if they have a history of falls - among many other factors.
"Everyone is at risk of falls in the hospital," Basil says. "But you stratify patient risk based on the assessment." Then you work with your team to undertake patient-specific interventions. For instance, at Heywood, a very high-risk patient may be placed in a room nearest the nursing station. The dietary staff will be informed about a particular patient's special needs.  Even the cleaning staff is aware that patients with red socks are fall risks, so if the staffer is in the room and sees a red-socked patient attempting to get out of bed, that person can alert the nursing staff or advise the patient to wait for help from a staff member.
There is extensive falls-prevention literature that focuses on the optimum height for a patient's bed. Obviously, a bed that is too high could result in a patient falling as he or she attempts to get out. But research has shown that a too-low bed may result in weak patients losing their balance as they attempt to raise themselves up to stand. Heywood uses adjustable beds to ensure the height is optimum for the safety of each patient.

"Another tool we have is the 'scoot chair'," says Nora Salovardos, R.N., Director of Psychiatric Services. The chairs allow patients to propel themselves forward with their feet  (which allows mobility and freedom to get around) but they are slightly reclined (which makes it difficult for the patient to stand up - and fall). "With the scoot chair, we can promote independence with the patient, which is what they want and which is also important to their recovery," Salovardos says.
But no matter what tools are used, falls are likely to occur. And when that happens, Heywood, like many other hospitals, immediately forms a "huddle". Says Basil, "As immediate to the fall as possible, nursing leadership and all staff involved gather around to ask pertinent questions: 'What were the contributing factors? How did it happen? What are all the factors that contributed to the fall?' Then we do immediate coaching with staff while supporting and mentoring them, as well as ensuring that the care plan is changed if necessary and additional interventions are included."  Families are also notified about any fall that may occur and educated about the new plan of care.

"We're very transparent and look at ourselves closely," says Anne E. Hamm, RN, CRM, Director of Patient Care Assessment, Risk Management, and Patient Safety Officer. "We report everything. Our goal is not only to reduce falls but to eliminate injuries from falls." It's a hard task but one that Santos says her team is dedicated to by "embedding best practices into our workflow" every day.
"There isn't a one-size-fits-all way to address falls," Santos says. "Our success at Heywood so far is in really approaching the problem in a varied fashion and keeping our focus away from just tunnel vision. Rather we focus on the needs and interventions appropriate for each individual patient."