Patient Falls Initiative

The patient falls workgroup of the MPSC organized to reduce the number of patients who experience a fall during hospitalization at any of the Madison hospitals. The MPSC goals were to:

• share information to enhance fall prevention programs
• improve provider ability to monitor aspects of falls using standardized fall reporting tools
• prevent and reduce falls by implementing and evaluating targeted interventions

The MPSC patient falls workgroup began by analyzing initial falls data from all of the Madison hospitals and designing the action plan components and timeline for a targeted intervention. Based on literature, best practices from other settings and analysis of patient falls data from the hospitals, four priority areas were identified:

• assessment and identification of patients at risk for falls

• investigation into the impact of certain types of medications

• environmental modification of patient rooms and the use of assistive and protective equipment and

• provider and patient education 

Interventions

At each hospital, interventions were piloted on one unit before they were expanded house wide. The choice of pilot unit was guided by the units with the highest fall rates.

Intervention planning and refinement occurred in Quarters 1 and 2. Implementation occurred in Quarter 3. The quarter in which the intervention was implemented was considered the “run-in” quarter; whereas the quarter post-implementation was considered the timeframe for tracking changes in fall rate.

Lessons Learned

Throughout this large scale initiative, the Fall Reduction team experienced several valuable lessons:

Attrition of the hospital teams

• Three of the four hospital teams lost at least one team member.
• Attrition was due to maternity leave, sick leave and new jobs at other employers. 

This did however make progress difficult for the organizations—with one team losing all but one member. This particular team was not able to get the sleeper protocol started and sustained for the duration of the pilot. Other components of the project were implemented, however. Careful construction and maintenance of project teams is essential for progress.

HIPAA regulations

• Difficult to share a common database among hospitals

Aggregating data

• Each hospital had different incident reports and tracked different factors related to falls.

The project allowed the group to evaluate whether key components were included in each hospital’s incident report, such as patient medications, and incorporate those absent.  The most successful approach to sharing information was to have each hospital periodically share its aggregate analysis of incident reports with the other hospitals.

Results

The goal of this initiative was to achieve at least a 20% decrease in the falls rate for the target units post-intervention.

Secondary goals were to:

1. Decrease the use of sleepers on target units
2. Decrease the percentage of fallers who had received a sleeper within 12 hours prior to the fall
3. Create and maintain high staff adherence with safe room set-up
4. Increase the percentage of patients who are assessed for falls risk at admission
5. Demonstrate that an increased percentage of fallers have been assessed for falls risk before the fall

The group implemented numerous processes to prevent falls and harm at the hospitals and achieved significant progress in each of these priority areas. Important process steps implemented through this project include the formation of a defined fall prevention team at each hospital and ensuring that all hospitals include a fall risk assessment tool in the patient admission profile.

• Fall rates were down in the fourth quarter (Q4) for the 3 hospitals where Q4 was the first quarter post-intervention.
• Fall rates were down in both the third (Q3) and fourth quarters for Hospital B, where Q3 was the first quarter post-intervention.
• In the first quarter after interventions were in place at all 4 organizations falls were down an average of 51%.

Percentage change in fall rates from Q3 to Q4

Topics comprising education included: fall risk factors, assessment & identification, the prevalence & consequences of falls, impact of medications, environmental modification, use of assistive and protective equipment, and toileting, etc.

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