Sunday, November 13, 2005
This presentation is part of : Innovations in Clinical Excellence Evidence-Based Practice Contest Winners I
Nursing Leadership in the Development of an Evidence-Based Fall and Injury Prevention Program
Lourdes Mellino, MA, MEd, RN1, Leanne Currie, RN, DNSc2, Suzanne Bakken, RN, DNSc3, Gina Bufe, RN, PhD1, and Wilhelmina M. Manzano, MA, RN, CNAA, BC4. (1) Division of Nursing, NewYork-Presbyterian Hospital, New York, NY, USA, (2) Columbia University School of Nursing/NewYork-Presbyterian Hospital, New York, NY, USA, (3) Columbia University School of Nursing, New York, NY, USA, (4) Division of Nursing, NewYork-Presbyterian Hospital/Columbia University School of Nursing, New York, NY, USA
Learning Objective #1: Identify the role of nursing leadership in the establishment of an evidence-based fall and injury prevention program
Learning Objective #2: Understand the application of evidence-based methods towards addressing clinical issues in the acute care environment

Introduction Nursing leadership is integral to the development and implementation of hospital wide initiatives. In 2002, a project targeted to decrease fall rates and prevent fatal falls in the adult inpatient environment was spearheaded by nursing at NewYork-Presbyterian (NYP) Hospital, a multi-center academic hospital. Clinical nursing leadership collaborated with nurse researchers in an effort to base the fall and injury prevention program on the current best evidence. A three phase approach was used toward the development of the program. The first phase included the identification of the scope of the problem and the characterization of targeted actions. The second phase involved the development of a fall and injury risk assessment instrument and interdisciplinary policy with subsequent pilot testing of both the instrument and the policy. The third phase included revisions to the policy and the implementation of the policy and associated instrument across the institution.

Problem Falls in the inpatient environment continue to be a frequent occurrence. Fall rates in the adult inpatient setting range from 1.7-25 per 1000 patient days depending on the care area (Halfon, Eggli, Van Melle, & Vagnair, 2001; Leape et al., 1991; Mahoney, 1998; Morgan, Mathison, Rice, & Clemmer, 1985). Fall prevention has reached national attention owing to efforts of various patient safety organizations. These efforts have culminated in the establishment of the 2005 Joint Commission of Accreditation of Healthcare Organizations (JCAHO) National Patient Safety Goal to “Reduce the risk of patient harm resulting from falls.” This goal includes not only assessment but also reassessment of fall risk for hospitalized patients.

Since 2002, NYP has participated in the National Database of Nursing Quality Indicators (NDNQI). Participation in this national database provides a method of benchmarking, internally as well as externally, nursing sensitive quality indicators such as fall rates and fall related injury rates. Based on the external benchmarks, fall rates were deemed to be a problem in certain areas at NYP, and thus the fall and injury prevention project was initiated.

Methodology and Evaluation The methodology was distinct for each of the three phases. First, a nursing led interdisciplinary team was formed to analyze potential failure modes and existing processes in the care of patients at risk for falls using the Failure Mode, Effects and Criticality Analysis (FMECA) methodology. Next, a fall-injury risk assessment instrument was developed via a retrospective case-control study with closed chart audits for ninety fallers matched with ninety non-fallers. Chi-square and logistic regression analyses were conducted in the identification of factors to include in the instrument. A new interdisciplinary fall prevention policy was established and the instrument and policy were pilot tested in three adult inpatient units over three months in 2003. Finally, the policy was revised based on the data from the pilot testing and the revised policy was implemented throughout the organization in both paper and electronic formats. In addition, the electronic format of the instrument was usability tested via qualitative methodology including inspection evaluation and performance usability testing.

Improvement Strategy and Implementation The interdisciplinary team, which consisted of nurses, physicians, and occupational and physical therapists, identified three main inefficiencies associated with the existing Fall Prevention policy: 1) The need for standardization of fall risk assessment; 2) The need to improve interdisciplinary communication; and 3) The need for standardization of post-fall care. Following the FMECA analysis, an instrument was developed from a retrospective case-control study via closed chart audits. The team also identified the necessity to include ‘Injury Risk' so as to capture the full conceptual nature of fall-injury risk and to streamline post fall management. In order to improve interdisciplinary communication, the physician, nurse practitioner or physician's assistant were brought into the assessment process by asking these disciplines to perform a single assessment for each patient on admission to the hospital. Post-fall care was standardized by eliciting involvement from all care providers including nursing, medicine, and physical and occupational therapy. A rigorous schedule was established to disseminate the results of each phase of the process improvement plan to these disciplines. The relationship between adherence to the policy and fall rates is being monitored on an ongoing basis through Nursing Research and Quality Assurance teams.

Outcomes/Results The results of the pilot study indicated that the falls risk instrument is a promising new instrument that includes risk for injury as a factor. During pilot testing, there was a decrease in the fall rates on two of the three pilot units; the instrument showed an inverse correlation between fall rates and adherence to the policy/instrument. Ongoing research is examining the strength of this inverse relationship across care areas. Usability testing revealed that the electronic instrument was useful and easy to use.

Lessons Learned The use of an interdisciplinary team in the initiation of the project established the support required to implement the policy changes. The use of the FMECA methodology provided a strong basis of identifying potential indicators for risk of fall and injury that were later either supported or refuted via the statistical analysis and pilot testing. The importance of the collaborative effort between clinical nursing leadership and nurse researchers became evident in eliciting the support from physician colleagues to institute the practice changes based on the data. Furthermore, knowledge of the clinical arena and rapport with support staff from information services was vital in the establishment and implementation of the electronic version.

References Halfon, P., Eggli, Y., Van Melle, G., & Vagnair, A. (2001). Risk of falls for hospitalized patients: A predictive model based on routinely available data. Journal of Clinical Epidemiology, 54(12), 1258-1266. Leape, L. L., Brennan, T. A., Laird, N. M., Lawthers, A. G., Localio, A. R., Barnes, B. A., et al. (1991). The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. New England Journal of Medicine, 324(6), 377-384. Mahoney, J. E. (1998). Immobility and Falls. Clinics in Geriatric Medicine, 14(4), 699-726.

Morgan, V., Mathison, J., Rice, J., & Clemmer, D. (1985). Hospital falls: a persistent problem. Am J Public Health, 75(7), 775-777.