Download Reducing Falls: Hotspots Analysis, Mandatory Technology, and the

MPSC 2010 Annual Conference Solution Submission
Reducing Falls: Hotspots Analysis, Mandatory Technology,
and the Socratic Method
Organization Name: Sinai Hospital of Baltimore
Contact Person:
E-Mail:
Cory Silkman, MAR, BSN, RN-BC
[email protected]
Type:
Title:
Phone:
Acute Care Hospital
Manager, Patient Care Services
410.601.6012
IDENTIFICATION:
Patients on a 23-bed neuro-rehabilitation unit experienced falls per 1000 patient days at nearly
three times the nursing literature benchmark. The organization previously implemented a variety
of fall reduction interventions gleaned from the literature and those contained within a reputable,
published fall risk assessment and prevention tool, however, the falls rate for the unit remained
elevated.
Baseline falls data showed a quarterly falls rate per 1000 patient days as high as 24.23.
PROCESS:
Leadership conducted an in-depth analysis of falls data for the prior 12 months. The analysis
examined the relationship between actual falls and fall risk categories, repeat falls, time of day,
location, activity, and injuries.
Leadership conducted a literature review to determine standards of practice and best practices
related to fall prevention.
The unit’s Multi-disciplinary Committee -- consisting of medicine, nursing, and therapy service - reviewed the fall data analysis and approved the proposed fall reduction interventions.
The unit’s nursing Outcomes and Practice Committee -- consisting of frontline nursing staff -provided feedback on fall mechanisms and proposed fall reduction interventions.
The Advanced Practice Nurse reviewed the falls analysis data and proposed fall reduction
interventions.
Leadership examined the utilization of fall-reduction technologies available on the unit.
SOLUTION:
Mandatory Use of Safety Technologies
MPSC 2010 Annual Conference Solution Submission
•
Staff utilized midsection-triggered bed alarms on all patients except those with a “room
independent” activity order. Torso-activated alarms were used on high fall-risk patients
with impulsivity
• Toilet alarms used for all patients identified as a high fall risk
• Wheelchair alarms used for all patients identified as a moderate or high fall risk
Hotspots analysis
• Management created a color-coded guide to the unit’s physical layout to identify
locations in which falls were more likely to occur relative to other locations on the unit.
This intervention helped to determine the probability that a patient in a given location
would experience a fall, thereby indicating focus areas for rounds review
• The hotspots indicated the relationship between proximity to the nursing station and fall
occurrences
Socratic Method Rounds
• Management conducted a daily review of fall risk assessments, nurse-selected fall
prevention interventions, and the actual patient care environment for all high fall risk
patients and those in hotspots
• Nurses provided rationales on the spot for any discrepancies between prior and current
fall risk assessments, risk-reduction interventions left undocumented, and lack of
technology utilization in the patient care environment
• Afforded time to educate nurse on “erring on the side of safety versus that of patient
convenience”
OUTCOMES:
See attached graph of the fall rate per 1000/days.
MPSC 2010 Annual Conference Solution Submission
MPSC 2010 Annual Conference Solution Submission