Poster Presentation

Sunday, November 4, 2007
10:30 AM - 11:45 AM

Sunday, November 4, 2007
1:30 PM - 2:45 PM
This presentation is part of : Clinical Posters
Implementation of a Multidiciplinary Fall Prevention Task Force at Wellspan Health-York Hospital
Brenda A. Artz, RN, MS, CCRN, Surgical Service Line, Wellspan Health - York Hospital, York, PA, USA, Gregory M. Gurican, RN, MBA, MSNE, BSEE, ASDN, Nursing Affairs, Wellspan Health - York Hospital, York, PA, USA, and Nancy K. Mann, MS, APRN, PMH, BC, Behavioral Health Service Line, Wellspan Health - York Hospital, York, PA, USA.
Learning Objective #1: The learner will be able to describe use of a multidiciplinary team to address fall prevention methodologies in an acute care hospital setting.
Learning Objective #2: The learner will be able to identify contributing factors impacting upon fall occurrences and the rates of falls with and without injury.

 Background/Problem Statement
            During 2004, the Patient Safety Committee (PSC) and the Nursing PI & Research Council identified the need to reduce the rate of patient falls at York Hospital, which continued to increase following implementation of an evidence based assessment tool.
Method
            A multidisciplinary Fall Prevention Task Force (RNs, PT/OT, MDs, and RPh/PharmD) was initiated by the PSC.  Task force members reviewed every fall that occurred starting on February 1, 2006, and daily fall rounds were implemented.  The data collected from those rounds were reviewed and recommendations for improvements made.
Results
            Qualitative and quantitative data was gathered on all in-patient falls over a period of six months.  The Falls Task Force (FTF) identified multiple contributors to falls including issues of: staffing, specific patient populations, environmental contributors, clinical practice, and knowledge deficits related to the fall prevention program.  As a result of  FTF recommendations the number of falls and fall rates decreased from a pre-operational level of 56.5 falls/month and 4.8 falls/1000 Patient-days to 42.6 falls/month and 3.6 falls/1000 pt-days (p value < 0.05) which represented a 17.5% decrease.
Discussion
            The FTF observations revealed that:
1.       Certain patient populations, who would be at risk for falls, were not identified even when the risk assessment tool was correctly used;
2.       Over 40% of falls occurred on the day following an incomplete or incorrect use of the risk assessment tool; 
3.       Hand-off communication between shifts and/or units on fall events was inconsistent; 
4.       Greater than 90% of all patients who fell were on medications that contribute to increased fall risk; 
5.       The use of “Sitters” for patients served as an aide to prevent potential falls from occurring.
Conclusion:
The use of a multidisciplinary team to review all falls is a valuable intervention in an acute care hospital to prevent falls and reduce injury.