Use a uniform instrument to estimate fall rate
Accurate tracks are a matter of cooperation
All units at Gratiot Community Hospital in Alma, MI, use a uniform instrument to record fall data. This proved especially important when Jill Goodell, MS, CPHQ, quality and risk manager, worked with the unit managers there to try to figure out why falls had increased. To arrive at the fall rate, Goodell calculates the number of falls per 1,000 patient days.For example, if there were 1,192 patient days for the quarter, dividing that number by 1,000 results in 1.192. If there were 10 falls during that quarter, 10 is divided by 1.192. That would result in a rate of 8.4 falls per thousand patient days.
"Our last measurement was 1.5 falls per thousand patient days for the overall facility," Goodell notes. "We’ve seen an increase in the number of patient days and the census since we started this program, but there’s been no increase in falls. We haven’t eliminated falls, but we’re keeping them down, and we now have a way to keep track and step in when necessary."
Seeking risk predictors
"We started looking at trends to see how we could identify those patients at risk for falling and create risk predictors for prevention purposes," says Pauline Desjarlais, a nurse manager at FirstHealth Moore Regional Hospital in Pinehurst, NC. The facility’s fall index rate is similarly based on the number of falls per month divided by the number of patient days in the month.FirstHealth staff started tracking data at the facility’s rehab center and compared them to another facility. The data were dissimilar. "More patients had reported falls during the daytime at the other institution; here there are more reported falls in the evening," notes Desjarlais. In both institutions, however, patients who had right hemispheric strokes with left hemiparesis fell the most. (See chart listing falls by diagnosis, p. 35.)
"We didn’t want to tell patients not to do risky things, because in rehab, they have to be willing to take some risks," Goodell explains. "But we found that some family and staff were not cognizant of the risks from falling. They might visit the patient or bring him back from X-ray, then just leave him alone in the room and not realize that’s a risk."
"You want patients to work toward being independent," says Desjarlais. "But it becomes a matter of Catch-22 when they think they’re more independent than they are. Those are the patients more at risk than the more cautious ones."
To counter those problems, Goodell and the unit managers at Gratiot Community Hospital implemented these solutions:
• All staff who transport patients throughout the hospital take inservice training. Included is information about the risk of falls, how they happen, and common preventive steps. For example, they are told it is risky to wheel patients to their rooms on the medical rehab unit and then leave them there. Unlike other units, staff are told, these patients are very likely to try to get up and walk on their own.
• Similar information is provided to family members when they are oriented to the unit. The risk of falls is explained, and they are urged to contact a staff member before leaving the patient alone.
• A special notice is posted on the inside of every patient door, cautioning both staff and visitors not to leave the patient unprotected in the room: "To visitors: Do not leave this patient unattended in a wheelchair — please notify the nursing staff when leaving."
The facility’s fall reports are analyzed on a quarterly basis, and Goodell watches for trends that suggest room for improvement. A recent analysis showed one unit had a higher number of patients who were falling as they tried to get up to go to the bathroom. The information was relayed to the unit manager, who then met with staff to help them understand how such falls could be anticipated and prevented. (See chart listing falls by location, p. 36.)
What exactly constitutes a fall?
Establish a facilitywide definition of what constitutes a fall. "Every organization has a different definition," says Ann Kobs, associate director of the Joint Commission on Accredi tation of Health care Organizations in Oakbrook Terrace, IL.Gratiot Community Hospital originally had no set definition, and that got in the way of gathering reliable statistics. "There were times in the past when staff didn’t consider it a fall if they lowered the patient to the floor, or if the patient said he didn’t fall," Goodell says. "We wanted to include anything that might be considered a fall, so we came up with a broad definition that includes everything."
Now the hospital’s definition of a fall is "any time a patient is found on the floor, and we don’t know how he got there; an unplanned lowering of the patient to the floor; or actually observing the patient falling."
Two years ago, FirstHealth Moore Regional Hospital defined a fall as "a sudden unexpected change in position that causes a part of the body to touch the floor." Last year, the hospital changed the definition to "an event that results in a patient or body part coming to rest inadvertently on the ground or other surface lower than the patient."
"It skews the statistics when some only report patients that fall to the floor, and others assist people down," Desjarlais says.
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