From Gap Analysis to Outcome: Decreasing Falls Rates/Harm Severity in an Acute Inpatient Care Setting

A problem existed in our institution regarding the high rates of falls occurrences and falls with injuries. A change package based on best practices for multiple facilities across the country was published. This change package “Preventing Harm from Injuries from Falls and Immobility” highlighted themes from successful practices of high performing health organizations across the country and was developed through clinical practice sharing, organization site visits and subject matter expert contributions. The package includes a menu of strategies, change concepts and specific actionable items that can be implemented and is complimentary to literature reviews and other evidence-based tools and resources.

The change package uses primary and secondary drivers (system components or factors that cause a patient to fall) to develop change ideas. The primary drivers used to specify change ideas include:1) An Interdisciplinary House-Wide Approach; 2) A Learning Loop; 3) Identifying high-Risk Vulnerable Populations; 4) Assess and Implement a Multifactorial Plan; 5) Prevent Delirium and Functional Decline; 5) Provide Optimal Post-Fall Care; 6) Provide Appropriate Level of Surveillance/Observation; and 7) Engage Patients and Families. Using the proposed change ideas (127) that were submitted, a gap analysis was completed between our current state and the ideal.

The gap analysis was conducted with a newly formed committee of dedicated Geriatric Resource Safety Champions to identify approaches for falls improvement. This committee is composed of Registered Nurses and Licensed Nursing Assistants. Each change idea was rated as “Done”, “In Process” or “Need”. Best practices further identified as “low-hanging fruit” were chosen first for their presumed ease of acceptance and implementation. These included developing an orientation script to educate patients and families to our falls prevention policies upon admission and a neurological assessment protocol for a post-fall head injury. Reinforcement and education of current procedures that correlated with the change package was done. Unit performance dashboards were updated and standardized throughout the institution as were patient room whiteboards. Peer practice evaluations for falls were completed as well as falls bundle implementation compliance tracers.

Our falls rates decreased and the severity of harm went down as well, exhibiting more than a 50% decrease. Engaging clinical nurses and licensed nursing assistants as safety champions through increased education led to better compliance with other evidence-based practices throughout the organization. Champions felt empowered to conduct peer evaluations as well as to provide at-the-elbow-support and education to all caregivers, patients and families.

Next steps will be to partner with outpatient resources, Visiting Nurse Associations, Centers for Aging the presentation of our results in multiple venues and a Falls Awareness Day on the first day of Fall.