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One year ago the patient fall rate at New Hanover Regional Medical Center (NHRMC) in Wilmington, North Carolina was deemed “acceptable” compared to national standards. Statistically, the hospital wasn’t any worse off than hospitals of a similar size, but patient safety experts and administrators within the institution still felt there were missed opportunities to reduce their rates and improve patient care.
“We were doing a good job,” says Mary Ellen Bonczek, chief nurse executive at NHRMC. “It’s not like we had a problem compared to national organizations our size, but we clearly felt like we could do a better job and we began to change our mind-set towards prevention and elimination.”
The facility had already seen some positive gains in reducing infections simply by focusing on prevention and elimination strategies, and administrators within the facility felt they would see the same progress if they applied those principles toward reducing patient falls.
One year later, patient falls have decreased 22% to 2.5 falls per 1,000 patient stays, which translated to an estimated $500,000 in savings, according to an op-ed by NHRMC President and CEO Jack Barto published on WilmingtonBiz.com.
“This is but one example of how healthcare providers, by standardizing best processes and consistently following them, can change the delivery of care, one improvement at a time,” Barto wrote. “Over time, these improvements will add up to better patient experience, better quality of care and significant savings.”
The patient fall reductions that the facility saw were a result of a few simple, no-cost interventions developed by a patient services fall team, which implemented a patient risk assessment, standardized best practices, hourly rounding, and visual cues to focus on eliminating preventable falls.
“We challenged ourselves to look at things differently and begin to change our mind-set around patients at risk for falls,” Bonczek says.
Reevaluated patient falls
Although NHRMC already had a fall prevention team, last summer it applied Lean methodology to improve its process of discovering preventable patient falls. The multidisciplinary team?consisting of physicians, nurses, therapists, pharmacists, transportation employees, and environmental services employees?utilized value-stream mapping to uncover process improvement and design modifications.
“That value-stream mapping was great because [the patient fall team] came back with some focused opportunities and tactics that we could put in place to continue that journey of providing our patients with a safe experience,” says Johnsie Davis, director of patient safety services at NHRMC.
From there, NHRMC developed a fall prevention toolkit that could be implemented at the bedside throughout the organization. NHRMC tested the new toolkit in a pilot unit in the fall, and after seeing notable success, rolled the program out across the organization by the end of 2013.
Included in the toolkit was a patient fall risk assessment tool. Patients are assessed upon admission and periodically throughout their stay, depending on the changes in their condition. If the patient is a high risk for falls, visual cues?including yellow signs, armbands, and socks?are implemented so that everyone knows which patients need additional attention.
The assessment specifically identifies certain factors like medications the patient may be taking and mobility constraints, so that anyone entering the room knows what to expect.
“Every person that walks into the room knows that this patient might have an unsteady gait, so that in itself lets you know that this patient may need help getting up or may need an assistive device,” Davis says.
If a fall occurs, NHRMC protocol requires an immediate fall huddle with staff members that were present, the family, and the patient to discuss what happened and what could have been done differently. Each unit also tracks how many days have passed without a fall, and are rewarded when they meet certain benchmarks, Bonczek says.
“We put a visual sign on our board that says how many days since the last fall,” she says “When they have to erase that number because a patient fell and they have to take that number from 52 days to zero, it’s powerful and the staff own it.”
Using visual cues and promoting individualized care
Visual cues have been a huge factor in helping clinical staff to not only recognize the patients that are at risk for falling, but why they are at risk, Davis says.
During each shift, staff members huddle to discuss the risk factors for various patients on the floor. Those that are at a high risk are posted on a whiteboard near the nurse’s station, identifying patients by room number.
Daily huddles and visual cues help make everyone in the hospital aware of individual fall risks. Walkers are placed next to the bedside of any patient who is high risk, and every person on the floor recognizes the risk, including patients and their families.
“Even our environmental services folks are engaged,” Bonczek says. “Once that patient is identified, supplies are brought to the room and bed alarms are put into place and checked and validated every day. We do change of shift reports in the patient’s room as part of that discussion using the teach-back method.”
Another key component of the fall prevention program is that frontline staff members are empowered to individualize each fall prevention plan depending on the changes to the patient’s condition. Although the NHRMC’s fall prevention toolkit serves as the backbone for interventions, staff members are encouraged to make nuanced changes, which are discussed during the daily huddles.
“They are able to tell you what pieces of our fall program that they have individualized, which is a key element individualizing that plan for the patient,” Davis says. “They can pull different resources out of the toolkit to meet the needs of the patient, realizing that our patients may change over the course of their hospital stay, so they continue to reassess and reevaluate.”
NHRMC also uses hourly nurse rounding as part of its fall prevention plan. The medical center actually instituted hourly rounding seven years ago, but it wasn’t effective in reducing falls because staff education fell short.
“I’ll be honest with you, in the very beginning stages, [hourly rounding] wasn’t received well at all because we didn’t do a good job at communicating and educating our staff on the why,” Bonczek says. “Something like that can’t be a top-down approach where I tell you what to do, it needs to be, how does it improve my work environment, the patient’s environment, and patient safety?”
Once hospital leadership had a better grasp on how hourly rounding could be effectively utilized to impact patient care, staff members were much more open to complying with the mandate, she adds. Ultimately, hourly rounding has helped reduce patient falls?particularly those that result when a patient has to use the bathroom?reduced anxiety and pain, and patients are less likely to use the call light when they know a nurse is coming into the room every hour.
“It really helped establish a mutual trust between the patients and their caregivers,” Davis says. “They know who they are, they know they are coming back, and it’s about feeling safe.”
NHRMC also conducts leadership rounding, where hospital administrators and CEOs come onto the units and observe the fall prevention protocols, Bonczek says. Sometimes corrective action is necessary, but other times there are institutional barriers that make compliance with the fall bundle more difficult.
“If I round in a patient’s room and they are a high risk for falls, and I find one of the key elements of the bundle isn’t in place, I immediately recognize that and bring it to the care provider’s attention,” she says. “We have an opportunity to talk about it and either eliminate the barrier that has stopped them from putting that in place, or it’s an opportunity to educate and coach.”
Staff involvement and empowerment was crucial for the success of the fall prevention program, Bonczek adds. In transitioning toward a team-based approach, clinical staff began to think critically about fall prevention and utilize the toolkit to create individualized prevention plans.
For hospital leaders, the key was changing the perspectives on patient falls.
“We needed to remove the barriers in our own minds that this isn’t going to happen or that we can’t be defect-free,” Bonczek says. “We can have no infections and we can have no falls, but as leaders, until we can remove that barrier from our brain, we’ll never be able to remove that barrier for our staff.”