Successful applicants to the ASGE Endoscopy Unit Recognition Program submit a summary of a recently conducted quality improvement (QI) project as part of the application process. The quality assurance and performance improvement (QAPI) project in the spotlight this month looked at improving preventative fall measures.
Patient Falls in Hospitals – Background and Define
Patient falls can be devastating and are a preventable complication of hospital care, particularly in the elderly population. It is estimated that 700,000 to 1 million patient falls occur in U.S. hospitals, resulting in around 250,000 injuries and up to 11,000 deaths. In the U.S., patient falls equate to approximately $50 billion spent on medical costs, annually.
Their causes can vary; however, the outcome can increase mortality and/or morbidity, which can prevented. An early leader in fall prevention, Janet Morse, classified causes of patient falls, from accidental falls related to extrinsic factors, such as environment, to anticipated physiologic falls related to confusion, sedative agents, etc., to unanticipated physiologic falls related to an acute event, such as a stroke. Typically, patients across the health care spectrum are assessed using various fall risk screening tools, deeming patients low to high risk for falls.
In our endoscopy unit, we began seeing an increase in patient falls over a year—most occurred in our recovery area. We experienced an alarming two-fold volume increase in patient falls in our unit at 13 total patient falls in 2023, up from 6 the prior year. Falls increased despite that, in endoscopy, we consider all patients to be a high fall risk post sedation.
The goal of our quality improvement project was to determine our patients' fall risk factors, both intrinsic and extrinsic, and improve preventative fall measures and our patient outcomes, supported by our analytics. We ensured all caregivers had awareness and education on the interventions we implemented through our initiatives, eliminating falls in our department.
Analyze/Measure
Prior to creating our interventions, we felt we needed to gather, measure and analyze more data around the falls we were experiencing. We did this through discussions with our team (facilitating buy-in, or desire in the ADKAR [Awareness, Desire, Knowledge, Ability, Reinforcement] change model, and targeting interventions developed by the Gemba) while also developing detailed data transparency for our entire department.
We began openly reviewing and discussing falls in our department, monthly, in all staff meetings. Historically, falls were only reviewed with specific staff involved in post-fall huddles, completed post-fall huddle forms, safety event reports only viewable to the assistant nurse manager (ANM) level or above, and takeaways discussed with the team during staff meetings and staff emails. We recognized and targeted commonalities in the ongoing falls that were reported, which helped us determine our specific interventions. Fall correlations included patients preferring to dress independently, specifically, leaning activities around donning pants, socks and shoes post anesthesia. We identified there were team members who were not educating patients and/or not removing rollable equipment that patients deemed stable to lean on while dressing, attributing to several falls. We were inconsistent at providing a stable chair to patients to utilize while dressing. We also worked with IT at our organization to help create a more detailed report that could be viewed by the entire department. Report details not only included fall volumes but trend information, such as patient age, weekday and time of fall, causation, and whether or not there was injury to the patient. This report is now posted monthly on our quality information board for all caregivers to review.
Improve
The five main interventions that were implemented were:
- Removed all rollable equipment in recovery when patients were redressing
- Completely removed rolling stools from the unit
- Added Morse Fall Risk Assessment to be repeated in recovery, historically in pre-op only
- Required all patients to be provided with a stable (non-rolling) chair to utilize when redressing
- Provided education
Education was broken down into two parts: team education and patient education. Our team was educated regarding all facets of patient recovery safety, including historical fall data and common causations, reviewing of added interventions and the need for specific patient education around fall risks prior to redressing. Endoscopy nurses began educating all patients—whether they denied redressing assistance or not—regarding fall risks and safety measures. All measures were implemented over three months starting in November of 2023, and we saw improvement, initially in the team buy-in and eventually resulting in standard processes of compliance that were sustained by all caregivers involved.
Control
By February 2024, all facets of our patient fall initiative had been rolled out, and we were seeing full compliance amongst the endoscopy team. We have had zero patient falls since February of 2024! The endoscopy fall report is posted monthly and congratulations on the endoscopy crew's great work are being communicated, with a celebration on the way. As we all know, health care requires continuous improvements and preoccupation with failure to truly make a difference in our patient outcomes. Further work is being performed in this area in our department to include an endoscopy-specific policy on falls, and adjustments to our hospital’s post-fall huddle forms to better fit procedural areas, like endoscopy.
References:
Currie L. Fall and injury prevention. In: Hughes RJ, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Agency for Healthcare Research and Quality. https://www.ncbi.nlm.nih.gov/books/NBK2653
LeLaurin JH, Shorr RI. Preventing falls in hospitalized patients: state of the science. Clin Geriatr Med. 2019;35:273-283. https://doi.org/10.1016/j.cger.2019.01.007
We hope sharing this project summary will be useful to you and your practice. Learn more about gaining honoree status in the ASGE Endoscopy Unit Recognition Program. EURP honoree units may use the ASGE Quality Star logo in promotion of their units, receive premium educational content via an exclusive e-newsletter The Huddle, and enjoy a range of additional benefits. Questions should be directed to eurp@asge.org.