Abstract
Background:
Most fall prevention programs are only modestly effective, and their sustainability is unknown. An academic medical center implemented a series of fall prevention interventions implemented from 2001 to 2014.
Methods:
The medical center’s series of fall prevention interventions were as follows: reorganized the Falls Committee (2001), started flagging high-risk patients (2001), improved fall reporting (2002), increased scrutiny of falls (2005), instituted hourly nursing rounds (2006), reorganized leadership systems (2007), standardized fall prevention equipment (2008), adapted to a move to a new hospital building (2008), routinely investigated root causes (2009), mitigated fall risk during hourly nursing rounds (2009), educated patients about falls (2011), and taught nurses to think critically about risk (2012). To evaluate temporal trends in falls and injury falls, negative binomial piecewise regression with study unit-level random effects was used to analyze structured validated data sets available since 2003.
Results:
From July 2003 through December 2014, the crude fall rate declined from 3.07 to 2.22 per 1,000 patient days, and injury falls declined from 0.77 to 0.65 per 1,000 patient days. Nonsignificant increases in falls occurred after nurses started rounding hourly and after the move to the new hospital. On the basis of regression models, significant declines occurred after nurses began to mitigate fall risk during hourly rounds (p = 0.009).
Conclusion:
Instituting incremental changes for more than a decade was associated with a meaningful (about 28%) and sustained decline in falls, although the rate of decline varied over time. Hospitals interested in reducing falls but concerned about competing clinical and financial priorities may find an incremental approach to be effective.
Falling during hospitalization remains regrettably common. Across 1,200 hospitals in the United States, adults in medical and surgical units fall 3.56 times per 1,000 patient days, with 26.1% of falls resulting in patient injuries, such as lacerations, fractures, intracranial bleeding, and death.1 Compared to patients without falls, patients with serious fall-induced injuries stay 6.9 days longer and have hospitalization costs that are $13,806 higher (2009 dollars).2 Hospitals often absorb the costs of falls, particularly for patients insured under Medicare.3 Catastrophic injuries, such as death, can trigger investigations by regulators or result in legal claims.4
Given these consequences, diverse fall prevention interventions have been developed for the inpatient setting. Commonly studied examples include educating patients or staff, putting signs at the bedside or wristbands on high-risk patients, providing socks with treads, reviewing events that precede falls, scheduling toileting, reviewing medications, installing bed alarms, and checking bedrails, among others.5–7 Yet few programs have proven successful, and whether even successful programs can achieve lasting success is unknown because most studies end within 6 to 24 months.6–9 Achieving meaningful and sustained declines may require persistent and multidimensional efforts.
Since 2001, UCLA Medical Center has sought effective ways of reducing falls and fall-related injuries. In response to state and national policies, a few severe fall events, and a desire to provide high-quality nursing care, the hospital implemented a series of fall prevention interventions. Standardized, validated data on falls have been collected using the same methods since 2003. The objective of the current analysis was to describe the interventions and evaluate whether they were associated with a sustained decline in falls and fall-related injuries from 2003 to 2014. We have followed the SQUIRE 2.0 reporting standards.10
Methods
Setting
Ronald Reagan UCLA Medical Center is a 466-bed academic tertiary referral center with 23,000 admissions annually. Inpatients are referred from a network of clinics or transferred from hospitals throughout California, Arizona, and Nevada. To meet California seismic standards, inpatient services moved from an older building to the current hospital in July 2008. Patient acuity has increased since then because a nearby UCLA-affiliated hospital now cares for some lower-acuity patients.
The fall prevention interventions were implemented in 5 ICUs, 6 step-down units, 7 floor units, and 1 inpatient rehabilitation unit. The step-down units were restructured during the move such that 2 were combined, 1 very small unit was eliminated, and 1 was subsumed into a floor unit. The rehabilitation unit did not move. Because of differences in risk factors for falls, the pediatric and obstetric units developed their own programs, which we did not evaluate.
Ethics
The UCLA Office of the Human Research Protection Program approved this evaluation, which did not involve individually identifiable data.
Interventions
The changes instituted before the start of data collection in 2003 included (1) reorganizing the Falls Committee (2001); (2) assessing risk and flagging high-risk patients (2001); and (3) improving event reporting (2002). After 2003, intervention components included (4) increasing scrutiny of falls (2005); (5) instituting hourly nursing rounds (2006); (6) reorganizing leadership structure and systems (2007); (7) standardizing fall prevention equipment (2008); (8) routinely investigating the root causes of falls (2009); (9) instituting hourly assessment and mitigation of fall risk (2009); (10) educating patients about fall risk (2011); and (11) teaching nurses to think critically about risk factors for falls through problem-based-learning modules (2012). We now describe each of these interventions.
1. Reorganizing the Falls Committee (2001).
Historically, the Falls Committee was an informal group with unstructured meetings. After reorganization, it met on a regular basis, had meeting agendas, included specific leaders and nurses, and documented decisions.
2. Assessing Risk and Flagging High-Risk Patients (2001).
The Falls Committee improved the assessment of fall risk, enabling nurses to act to prevent falls. The hospital switched from a locally developed tool to the Morse Fall Risk Assessment tool because of its demonstrated validity and applicability in hospital settings.11–13 Patients at higher risk (score ≥ 45) were given color-coded arm bands. Starting in 2002, a reporting tool identified patients at risk on a daily basis and sent reports to nursing unit leaders; fall risk was displayed using symbols (falling stars) on doors to patient rooms. Changes to footwear were also made in 2001 (slipper socks with treads).
3. Improving Fall Reporting (2002).
As with any quality improvement intervention, efforts to prevent falls require standardized data so that trends can be assessed and iterative changes made. Voluntary reporting by nurses is the standard means of detecting falls and has been validated for this purpose, as discussed below. UCLA computerized its incident reporting system in 2002. The computer interface for reporting falls, implemented in 2003, included several standard follow-up questions for nurses to answer after falls (location, whether fall was witnessed, and severity of any injuries sustained). The Falls Committee also improved feedback from fall-related incident reports to nursing unit directors and clinical nurse specialists/educators.
4. Increasing Scrutiny of Falls (2005).
The Joint Commission added reducing the risk of patient harm from falls to the list of National Patient Safety Goals (Goal 9) in 2005 (fall prevention has been instead addressed as a standard—Provision of Care, Treatment, and Services (PC) PC.01.02.08—since 201014). In response, UCLA increased scrutiny of fall events, with more detailed investigations of selected events. Unit directors investigated falls and instituted remedies at their discretion. Rates of reported falls declined, but some nurses were concerned about being blamed for falls; changes to audit and feedback practices in 2007 were designed to address their concern, as we describe.
5. Instituting Hourly Nursing Rounds (2006).
Because both fall prevention and patient satisfaction were priorities at UCLA, the Falls Committee implemented hourly nursing rounds, which are associated with fewer falls, improved patient satisfaction, and decreased call light use.15,16 Hourly rounding represents proactive, patient-centered care in which nursing staff assess each patient on an hourly basis. At UCLA, this assessment focused on the “4Ps —include pain, personal needs (that is, issues pertaining to activities to daily living, including toileting), position (for example, the need to be repositioned in bed or assisted to a chair), and placement (whether items the patient may want are within reach).15 The same year, nurses started checking whether patients at high risk of falling had signage and arm bands as per policy, and the hospital replaced faulty bedside commodes.
6. Reorganizing Leadership Structure and Systems (2007).
Following a few severe fall events, hospital administrators selected fall rates as a performance benchmark. Accordingly, the Falls Committee underwent reorganization again, including establishing a standardized meeting format, tracking fall rates, and selecting a Falls Champion [C.M.W]. Nursing leadership reinforced fall prevention through regular meetings with nursing unit directors, and Clinical Nurse Specialists/Educators. Hospital leaders ensured that the Falls Champion had assistance or resources when obstacles arose, and the hospital covered the time that staff members devoted to fall prevention (15% of the Champion’s time, as well as meetings of relevant committees and training for bedside nurses). Clinical Nurse Specialists, who are expert clinicians, oversaw all fall-related activities on their units, including working with bedside staff who had patients fall during their shifts. Unit Directors became involved when falls were serious or when nurses had multiple patients fall.
The Falls Committee and nursing unit representatives established audit and feedback systems to track falls, such as wall dashboards and discussions during nursing unit huddles or staff meetings. The Falls Champion regularly reviewed fall rates, event reports, and the results of follow-up investigations. Any unusually high fall rates or key lessons were communicated to the nursing leadership and front-line staff via email or in-service training. In response to nurses’ concerns about blame, as cited earlier, , the Falls Committee publicly recognized nursing units that demonstrated substantial improvement, and the Falls Champion promoted a culture of trust and cooperation by focusing on system problems, incorporating front-line nurses’ concerns, and coaching individual nurses.
7. Standardizing Fall Prevention Equipment (2008).
Historically, the use of fall prevention equipment varied across nursing units and many nurses were unaware of the equipment available or its potential applications. The Falls Committee, therefore, standardized fall prevention equipment and trained nurses in its use. The Falls Champion examined benefits and costs for each piece of equipment. Low beds were obtained for selected patients. To improve accessibility, floor units were stocked with, for example, bedside commodes, fidget aprons, chair and bed binders, etc. Bed alarms were employed to facilitate timely rescue.
8. Moving to a New Hospital Building (2008):
The physical layout of a hospital also has the potential to affect fall rates, as does adapting to a new facility. The Falls Committee had to consider these issues during the move to the hospital building, which was accomplished in a few days. The hospital’s administrative structure, provider staffing, and patient populations remained the same, except for the reorganization of step-down units, as noted above.
At the original hospital, straight hallways met in a “T” at the main desk and work area, and many patients were in semi-private rooms, which increased nursing presence in the rooms. At the new hospital, the physical layout of nursing units makes it harder for nurses to monitor patient activity and see door signs reflecting high fall risk. Some hallways are curved; patients have private rooms; nurses have multiple work areas; and the medication rooms, charge nurses’ offices, and other nursing-related facilities are on closed central corridors.
To address these concerns, the Falls Committee redesigned signs reflecting fall risk, nursing units increased the use of aides to monitor high-risk patients, charge nurses were asked to circulate around the units instead of staying in their offices. The hospital purchased more bed alarms, placed fall prevention equipment in unit-based supply rooms, and configured the call-light reception board to flag high risk patients.
9. Routinely Investigating Root Causes of Falls (2009).
The Falls Committee sought to create accountability at the unit level, rather than just by individual nurses, to encourage creative strategies for preventing falls, and to share best practices across units. To this end, unit-based practice councils (groups of bedside registered nurses from each nursing unit) were asked to investigate selected falls to determine the circumstances, as they unfolded, and to identify opportunities for improvement. These investigations, referred to internally as “mini-root cause analyses,” were adapted from practices at another hospital.17 In a nonpunitive manner, the investigations engaged the nurses involved in the incident, peers, and, when possible, the patient and family.
10. Instituting Hourly Assessment and Mitigation of Fall Risk (2009).
Following two fall-related deaths, hospital leadership investigated common causes of falls and determined that most involved toileting. The Falls Committee then recommended that nurses on all general medical and surgical units incorporate fall prevention into their hourly bedside rounds, enabling risks, such as toileting issues, to be identified and mitigated on at least an hourly basis. This transformed the “4P Method” into the “5P Method” (preventing falls). Rollout involved slide presentations, handouts, posters, emails, visits to nursing units, discussions during unit huddles and meetings, and a train-the-trainer approach in which unit-level champions educated front-line nursing staff.
In addition, nurses were asked to complete fall prevention checklists documenting their rounding activities. However, mini-root-cause-analyses revealed that fall risk factors remained unmitigated despite use of the checklist, suggesting that nurses could sign off without thinking critically about each patient’s risk factors. Checklists were later discontinued.
11. Educating Patients about Fall Risk (2011).
In response to the Joint Commission requirement for a proactive risk assessment at least every 18 months (Leadership Standard LD.04.04.0514), in 2011, UCLA focused a Failure Mode and Effects Analysis on falls. The findings revealed that many patients did not realize they were at risk for falling. Consequently, the Falls Committee initiated efforts to educate patients who were at risk by providing written materials and a video on the hospital’s patient-education channel. These materials emphasized topics such as not getting out of bed alone and using the call light. During the same period, ICUs implemented an early mobilization program, which involved having critically ill patients get out of bed and walk to reduce long-term complications associated with immobility.
12. Teaching Critical Thinking to Nurses via Problem-based-learning Modules (2012).
Over time, the mini-root cause analyses and unsuccessful fall prevention checklists revealed that, in many instances, bedside nurses had not identified or adequately addressed individual patients’ risk factors for falls, even when those risk factors were common and well-established. The Falls Committee concluded that better critical thinking skills might help nurses to effectively assess and mitigate fall risk, consistent with the American Nursing Association’s encouragement of critical thinking by nurses.18 Accordingly, the Falls Committee and Champion developed a problem-based learning format in which nurses watched videos with vignettes of actual fall events and then discussed what went wrong and what could be done differently.19
Implementation
For each intervention, implementation involved interfacing with other clinical services (for example, physical therapy, pharmacy, physicians) to obtain input and buy-in; pilot testing changes in a few nursing units before dissemination; training Unit Directors and Clinical Nurse Specialists/Educators, who then educated unit nurses; recruiting nurses and nursing assistants to serve as champions for the change on each floor; having leadership round on nursing units; monitoring fall rates; and providing feedback to individual nurses and nursing units that needed additional support in making changes.
Challenges and Facilitating Factors
On the basis of the qualitative first-hand observations of the Falls Champion, certain challenges and facilitating factors affected the success of this program. One major challenge involved engaging float pool, night, and weekend nursing staff. For example, float pool staff were initially left out of the training process. Later, they were included and a member of the float pool joined the Falls Committee.
Factors facilitating success included strong support from hospital leadership, collaborations with other clinical services, active involvement and oversight by nursing Unit Directors, and ensuring that midlevel managers shared a common goal so that nurses reporting to them received consistent messages. These factors contributed to the diverse interventions being sustained over time. The commitment of the nursing Unit Directors was particularly important.
Evaluating the Intervention
Data Sources.
The primary outcome measure was falls per 1,000 patient days and the secondary outcome was injury falls, as defined by the National Database of Nursing Quality Indicators (NDNQI). The American Nursing Association established the NDNQI to monitor the quality of nursing care; currently, 2,000 hospitals report data to the NDNQI (including UCLA, since 2003). According to NDNQI, “a patient fall is an unplanned descent to the floor with or without injury to the patient, and occurs on an eligible reporting nursing unit (includes falls when a patient lands on a surface where you wouldn’t expect to find a patient, and both unassisted and assisted falls).”21 Injuries are classified as unknown, none, minor, moderate, major, death (we grouped moderate, major, and death due to small sample sizes, and unknown with none because most traumatic injuries are readily detectable).
For hospitals reporting data to the NDNQI, the standard method of fall detection is voluntary, computerized incident reporting by nursing staff. Nurses routinely receive training in what and how to report. This detection method has demonstrated validity and reliability.20,22 The rate of falls or injury falls per 1,000 patient-days is calculated as the number of events, divided by the corresponding patient days, times 1,000.23
Data on falls at Ronald Reagan Medical Center have been collected using the same methods since 2003. To validate reported data, the Falls Committee reviews administrative databases to detect Medicare Healthcare-associated Conditions and the Falls Champion visits the clinical nursing units in the hospital weekly. Underreporting appears to be minimal. For example, from July 2012 to July 2014, no additional events were detected using administrative data and three were detected during weekly visits, out of 467 falls reported (0.6%).
UCLA incident reports include patient age, gender, nursing unit, whether fall was observed or unobserved, and whether fall was assisted or unassisted. The Falls Champion reviews reports of fall-related events to determine whether they meet the NDNQI definition. Neither nurses reporting falls nor investigators could be blinded to the fall prevention interventions.
Data Analysis.
Rates of falls and injury falls were available from July 2003 through December 2014 (a total of 138 months, over 11.5 years), reflecting trends in falls over time as interventions were implemented and sustained. To assess patterns of changes in monthly falls per 1,000 patient days over the 138 months, we used a negative binomial piecewise regression model with nursing unit-level random effects that included implementation of the interventions as transition points. Since these patterns were unlikely to be constant over time, this approach allowed us to model how the changes in falls varied after implementation of each intervention. The regression analysis did not include (5 falls, 3052 patient days) from the stepdown unit that was eliminated after the move.
Next, we calculated rates of injury falls (minor, moderate, major, and fatal injuries) per 1,000 patient days in each year, and described overall trends in this rate over time.
All statistical analyses were carried out with SAS 9.3, and all the graphs were generated using R (R Development Core Team, 2014).24
Results
Characteristics of Falls
During the analytical period, there were 3,440 falls on study nursing units (Table 1). Fifty eight percent of the patients who fell were female, and the largest number of falls involved patients 60–79 years of age, compared to the other age categories. Most falls occurred on either surgical units (39%) or step-down units (33%). Seventeen percent were observed and 15% were assisted.
Table 1.
Characteristics of 3,440 Falls on Inpatient Adult Intensive Care, Step-down, Medical and Surgical Ward, and Rehabilitation Units during the Analytical Period (2003–2014)
| Characteristic | N (%) | |
|---|---|---|
| Gender of Patient, Female, N (%) | 1,986 (57.7) | |
| Age Group of Patient, N (%) | ||
| 18–39 | 416 (12.1) | |
| 40–59 | 1,176 (34.2) | |
| 60–79 | 1,420 (41.3) | |
| 80+ | 428 (12.4) | |
| Type of Clinical Unit, N (%) | ||
| ICU | 305 (8.9) | |
| Step-down | 1,117 (32.5) | |
| Surgical/ Medical-surgical | 1,330 (38.8) | |
| Medical | 455 (13.2) | |
| Rehabilitation | 230 (6.7) | |
| Observed vs. Unobserved, N (%) | ||
| Not Observed | 2,774 (83.0) | |
| Observed | 570 (17.0) | |
| Unknown/Missing | 96 | |
| Assisted vs. Unassisted, N (%) | ||
| Not Assisted | 2,828 (84.8) | |
| Assisted | 507 (15.2) | |
| Unknown/Missing | 105 | |
Fall Rates
From July 2003 through December 2014, the crude fall rate declined from 3.07 to 2.22 per 1,000 patient days, or 27.7% (Table 2). The predicted fall rate declined non-significantly from 2003 to 2006, increased non-significantly from 2006 to 2007 after nurses began to round hourly, declined from 2007 to 2008, rose non-significantly 2008 to June 2009 after the move to the new hospital, declined significantly from 2009 to 2011 after nurses began to assess and mitigate fall risk on an hourly basis (p=0.009), and remained relatively flat after 2011. Figure 1 displays the boxplots of observed monthly fall rates across study nursing units, as well as the estimated time segments (connected red lines) following the implementation of each intervention.
Table 2.
Interventions, Falls Rates, and Summary of Piecewise Negative Binomial Mixed-Effects Regression Model
|
Year |
Interventions |
Descriptive Statistics for Calendar Year |
Piecewise Negative Binomial Regression Model with Time Segments at Implementation Dates |
|||||
|---|---|---|---|---|---|---|---|---|
| Patient Days a |
Total Falls a |
Crude Fall Rate b |
Time Segment (Dates) |
Change per Month (%) |
95% Confidence Interval |
P Value |
||
| 2001 | Reorganize Falls Committee; Flag High Risk Patients | |||||||
| 2002 | Improve Fall Reporting | |||||||
| 2003 | -- | 65,048 | 200 c | 3.07 | 7/03–6/05 | −0.70 | (−1.87, 0.48) | 0.246 |
| 2004 | -- | 132,906 | 402 | 3.02 | ||||
| 2005 | Increase Scrutiny of Falls | 128,140 | 358 | 2.79 | 7/05–6/06 | −1.24 | (−3.38, 0.94) | 0.263 |
| 2006 | Institute Hourly Nursing Rounds | 131,216 | 327 | 2.49 | 7/06–6/07 | 1.75 | (−0.93, 4.50) | 0.203 |
| 2007 | Reorganize Leaders hip Structure and Systems | 129,336 | 361 | 2.79 | 7/07–6/08 | −1.78 | (−4.38, 0.89) | 0.190 |
| 2008 | Standardize Equipment; Move to New Hospital Building | 121,570 | 281 | 2.31 | 7/08–6/09 | 1.84 | (−1.87, 5.69) | 0.335 |
| 2009 | Routinely Investigate Root Causes; Institute Hourly Assessment and Mitigation of Fall Risk | 116,644 | 318 | 2.73 | 7/09–6/11 | −1.58 | (−2.75, −0.40) | 0.009 |
| 2010 | -- | 114,141 | 238 | 2.09 | ||||
| 2011 | Educate Patients about Fall Risk | 116,192 | 235 | 2.02 | 7/11–6/12 | 0.15 | (−2.40, 2.76) | 0.911 |
| 2012 | Teach Critical Thinking to Nurses via Problem-based-learning Modules | 119,020 | 230 | 1.93 | 7/12–12/12 d | 0.47 | (−3.10, 4.17) | 0.799 |
| 2013 | -- | 111,501 | 242 | 2.17 | 1/13–12/14 | 0.29 | (−0.79, 1.37) | 0.602 |
| 2014 | -- | 111,907 | 248 | 2.22 | ||||
Per calendar yeark
Falls per 1,000 patient days
Starting July 1, 2003
Figure 1.
The figure displays boxplots (median, 25th and 75th percentile [interquartile range], upper and lower whiskers) of observed fall rates across study nursing units at each time point. Red line represents predicted fall rates over time, based on negative binomial regression model with study nursing unit-level random effects.
Observed and Predicted Fall Rates from July 2003 Through December 2014 (Event Indicator)
Injury Falls
About 26% of the falls involved injuries, including 25% with minor injuries and 1.4% with moderate, major, or fatal injuries. From 2003 to 2014, the rate of injury falls declined from 0.77 to 0.65 per 1,000 patient days, or 15.6% (Table 3).
Table 3:
Injury Falls: Crude Fall Rate per 1,000 Patient-days, by Severity
| Any Injury | |||||
|---|---|---|---|---|---|
| Year | Falls | Non-Injury a | Minor Injury | Moderate, Major, or Death |
Total |
| 2003 b | 200 | 2.31 | 0.71 | 0.06 | 0.77 |
| 2004 | 402 | 2.34 | 0.64 | 0.05 | 0.69 |
| 2005 | 358 | 2.10 | 0.66 | 0.04 | 0.70 |
| 2006 | 327 | 1.78 | 0.70 | 0.02 | 0.72 |
| 2007 | 361 | 2.09 | 0.67 | 0.03 | 0.70 |
| 2008 | 281 | 1.78 | 0.49 | 0.05 | 0.54 |
| 2009 | 318 | 2.01 | 0.69 | 0.03 | 0.72 |
| 2010 | 238 | 1.51 | 0.55 | 0.03 | 0.58 |
| 2011 | 235 | 1.45 | 0.55 | 0.02 | 0.57 |
| 2012 | 230 | 1.41 | 0.49 | 0.03 | 0.52 |
| 2013 | 242 | 1.54 | 0.58 | 0.04 | 0.62 |
| 2014 | 248 | 1.57 | 0.62 | 0.03 | 0.65 |
| Total | 3,440 | 1.82 | 0.61 | 0.03 | 0.64 |
None or unknown
Starting July 2003.
Discussion
After an academic medical center implemented a series of interventions in its adult nursing units from 2003 through 2014, there was a meaningful and sustained reduction in fall rates—from 3.07 to 2.22 per 1,000 patient days, about a 28% unadjusted reduction, in an 11.5-year period. By comparison, the fall rate in hospitals in the United States declined by 8.4% (from 3.59 to 3.29 per 1,000 patient days) from 2004 to 2009, and by 15% from 2010 to 2015.21,25 Several interventions in the current program are well-established, being described in prior systematic reviews and meta-analyses of hospital fall-related interventions.5–9,26,27 In a systematic review of 54 studies at acute care hospitals, typical components of multifaceted interventions included fall risk assessment at admission, signs indicating patients are at risk, patient education, bed alarms, and reviews after falls. The study duration was not reported. Among 8 studies that were considered amenable to meta-analysis, declines in falls did not reach significance (rate ratio 0.77; 95% CI 0.52–1.12).7 In another meta-analysis of 6 studies, interventions included risk assessment at admission, evaluation and care for any mobility limitations, review of medications, education about risk factors for falls, flagging patients at high risk using signs or similar means, employing bed alarms, and scheduling toileting. The pooled odds ratio was 0.903 (95% CI 0.826–0.986), but only one study lasted longer than a year.6 In a narrative review, six of 17 multifaceted fall prevention interventions were associated with significant reductions in falls or fall-related injuries but most studies lasted under two years and one lasted five years. Successful interventions were more likely to include performing post-fall reviews, educating patients, educating staff, providing advice on footwear, reviewing medications, and scheduling toileting.26
Certain interventions in the current program have not been as widely reported, such as instituting hourly rounding by nurses, standardizing fall prevention equipment, incorporating fall risk-assessment into hourly nursing rounds, and training nurses to think critically about risk factors for individual patients.5,6,7 However, our data suggest that both instituting hourly nursing rounds and moving to new facilities may cause transient disruptions in practice, temporarily increasing fall rates, albeit not significantly, until nurses became accustomed to the changes. In a previous narrative review on hourly rounding, fall rates declined in 7 of 9 studies (significance was not reported).15 Two studies have included selective rounding on patients at high risk of falls (rate ratios 0.69 [95% CI 0.56–0.84] and 0.74 [95% CI 0.53–1.05], respectively), 7,28,29 and one study observed that a lack of critical thinking contributed to falls.31 In contrast, we found that adding fall prevention to hourly rounds was followed by a significant decline in falls, although this change could also represent a return to prior rates after a transient increase from the move to a new hospital.
Our analysis also differs from previous ones in that we documented both substantial and sustained effects for almost 12 years. The effectiveness of fall prevention programs, a context-sensitive patient-safety practice, depends on nursing behavior as well as organizational leadership, teamwork, and culture31—none of which can be changed quickly or easily. Perhaps relatively few fall prevention programs have proven successful because they did not persist long enough. Further, the sustainability of successful fall prevention programs remains unknown because most studies have lasted under two years. 6–9 We have shown that making a series of relatively modest incremental changes every few years can have, cumulatively, a lasting effect. This approach is likely to appeal to both leaders and front-line nurses because it gives them time to incorporate each change, making it routine before the next expectation is created. Costs are spread over time as well, which may improve feasibility at institutions with competing financial priorities.
Limitations
This evaluation has several limitations. Data were only available after 2003, after some interventions had already been implemented; therefore, no baseline data were available. We did not formally compare trends at Ronald Reagan with the declines in fall rates among hospitals in the United States.21,25 We cannot exclude the possibility that results were attributable to secular trends, and hospitals faced similar incentives to reduce falls nationally. We do not have direct, objective measures of adherence to interventions, due to their diversity and the long period of time over which they were implemented. Data were based on falls reporting, which means that both trends in reporting and trends in falls can affect measurement; however, nursing leaders used multiple approaches to ensure detection of fall events. Our data set was de-identified so we were unable to account for patients who may have fallen more than once. Finally, the study took place at a single institution; generalizability to other institutions remains to be determined. However, none of the interventions requires specific skills or resources.
Conclusion
This multidimensional fall prevention program involved instituting a series of incremental changes every few years over about a decade. This was associated with a sustained decline in falls from 2003 through 2014. Hospitals interested in achieving meaningful reductions in falls but concerned about overburdening frontline nurses or with competing financial priorities may, too, find that an incremental approach and persistence pay off.
Acknowledgements.
The authors are grateful to Tracy Hoos and Loretta So, who participated in the implementation of the falls program and assisted with the acquisition of data for this analysis; Bryant Duong, who participated in data acquisition; and to Lance Tan and Sara Barfield, who assisted with preparation of the manuscript; and to Margaret Kelley, who assisted with data management.
Funding and Disclaimer. This evaluation was funded by the University of California Center for Health Quality and Innovation (CHQI). During the period of this work, Dr. Nuckols was the recipient of a Mentored Clinical Scientist Career Development Award (K08) from the Agency for Healthcare Research and Quality (grant number HS17954). The funders played no role in study design, conduct, or reporting.
Footnotes
Conflicts of Interest. All authors report no conflicts of interest.
References
- 1.Bouldin EL, Andresen EM, Dunton NE, et al. Falls among adult patients hospitalized in the United States: prevalence and trends. Journal of patient safety 2013;9(1):13–7 doi: 10.1097/PTS.0b013e3182699b64|. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Wong CA, Recktenwald AJ, Jones ML, et al. The cost of serious fall-related injuries at three Midwestern hospitals. Joint Commission journal on quality and patient safety / Joint Commission Resources 2011;37(2):81–7 [DOI] [PubMed] [Google Scholar]
- 3.Inouye SK, Brown CJ, Tinetti ME. Medicare nonpayment, hospital falls, and unintended consequences. The New England journal of medicine 2009;360(23):2390–3 doi: 10.1056/NEJMp0900963|. [DOI] [PubMed] [Google Scholar]
- 4.Oliver D, Killick S, Even T, et al. Do falls and falls-injuries in hospital indicate negligent care -- and how big is the risk? A retrospective analysis of the NHS Litigation Authority Database of clinical negligence claims, resulting from falls in hospitals in England 1995 to 2006. Quality & safety in health care 2008;17(6):431–6 doi: 10.1136/qshc.2007.024703|. [DOI] [PubMed] [Google Scholar]
- 5.Miake-Lye IM, Hempel S, Ganz DA, et al. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Annals of internal medicine 2013;158(5 Pt 2):390–6 doi: 10.7326/0003-4819-158-5-201303051-00005|. [DOI] [PubMed] [Google Scholar]
- 6.DiBardino D, Cohen ER, Didwania A. Meta-analysis: multidisciplinary fall prevention strategies in the acute care inpatient population. Journal of hospital medicine : an official publication of the Society of Hospital Medicine 2012;7(6):497–503 doi: 10.1002/jhm.1917|. [DOI] [PubMed] [Google Scholar]
- 7.Hempel S, Newberry S, Wang Z, et al. Hospital fall prevention: a systematic review of implementation, components, adherence, and effectiveness. Journal of the American Geriatrics Society 2013;61(4):483–94 doi: 10.1111/jgs.12169|. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Cameron ID, Murray GR, Gillespie LD, et al. Interventions for preventing falls in older people in nursing care facilities and hospitals. The Cochrane database of systematic reviews 2010(1):Cd005465 doi: 10.1002/14651858.CD005465.pub2|. [DOI] [PubMed] [Google Scholar]
- 9.Oliver D, Connelly JB, Victor CR, et al. Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses. BMJ (Clinical research ed) 2007;334(7584):82 doi: 10.1136/bmj.39049.706493.55|. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Ogrinc G, Mooney SE, Estrada C, et al. The SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines for quality improvement reporting: explanation and elaboration. Quality & safety in health care 2008;17 Suppl 1:i13–32 doi: 10.1136/qshc.2008.029058|. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Kim KS, Kim JA, Choi Y-K, et al. A Comparative Study on the Validity of Fall Risk Assessment Scales in Korean Hospitals. Asian Nursing Research;5(1):28–37 doi: 10.1016/S1976-1317(11)60011-X|. [DOI] [PubMed] [Google Scholar]
- 12.Morse JM, Morse RM, Tylko SJ. Development of a Scale to Identify the Fall-Prone Patient. Canadian Journal on Aging/La Revue canadienne du vieillissement 1989;8(04):366–77 doi: doi: 10.1017/S0714980800008576|. [DOI] [Google Scholar]
- 13.Morse JM, Black C, Oberle K, et al. A prospective study to identify the fall-prone patient. Social science & medicine (1982) 1989;28(1):81–6 [DOI] [PubMed] [Google Scholar]
- 14.The Joint Commission: Comprehensive Accreditation Manual for Hospitals (E-dition). Oak Brook, IL: Joint Commission Resources, 2016. [Google Scholar]
- 15.Halm MA. Hourly rounds: what does the evidence indicate? American journal of critical care : an official publication, American Association of Critical-Care Nurses 2009;18(6):581–4 doi: 10.4037/ajcc2009350|. [DOI] [PubMed] [Google Scholar]
- 16.Meade CM, Bursell AL, Ketelsen L. Effects of nursing rounds: on patients’ call light use, satisfaction, and safety. The American journal of nursing 2006;106(9):58–70; quiz 70–1 [DOI] [PubMed] [Google Scholar]
- 17.Quigley P Bundle of Interventions Targeting High-Risk Patients Reduces Falls and Fall-Related Injuries on Medical-Surgical Units. AHRQ 2010(Service Delivery Innovation Profile) [Google Scholar]
- 18.American Nurses AI. Nursing : scope and standards of practice. Silver Spring, Md.: American Nurses Association, 2010. [Google Scholar]
- 19.Worldwise Productions. All Can Prevent a Fall. Accessed Nov. 8, 2017 http://wwpvideo.com/ucla-fall-prevention.
- 20.Press-Ganey®. Nursing Quality (NDNQI). Nursing Quality (NDNQI). Accessed Nov. 8, 2017 http://www.pressganey.com/solutions/clinical-quality/nursing-quality.
- 21.He J, Dunton N, Staggs V. Unit-level time trends in inpatient fall rates of US hospitals. Medical care 2012;50(9):801–7 doi: 10.1097/MLR.0b013e31825a8b88|. [DOI] [PubMed] [Google Scholar]
- 22.American Nurses Association Inc. Guidelines for Data Collection on the American Nurses Association’s National Quality Forum Endorsed Measures In: (NDNQI) TNDoNQI, ed. Silver Spring, MD: 2012. [Google Scholar]
- 23.The National Quality Forum Safe Practices for Better Healthcare, 2006 Update: A Consensus Report. Washington, DC: National Quality Forum, 2007. [Google Scholar]
- 24.Bunn A, Korpela M. Time Series Analysis in dplR. R Foundation for Statistical Computing, 2014 [Google Scholar]
- 25.Agency for Healthcare Research and Quality R, MD. National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts To Make Health Care Safer, 2016. [Google Scholar]
- 26.Oliver D, Healey F, Haines TP. Preventing falls and fall-related injuries in hospitals. Clinics in geriatric medicine 2010;26(4):645–92 doi: 10.1016/j.cger.2010.06.005|. [DOI] [PubMed] [Google Scholar]
- 27.Coussement J, De Paepe L, Schwendimann R, et al. Interventions for preventing falls in acute- and chronic-care hospitals: a systematic review and meta-analysis. Journal of the American Geriatrics Society 2008;56(1):29–36 doi: 10.1111/j.1532-5415.2007.01508.x|. [DOI] [PubMed] [Google Scholar]
- 28.Dacenko-Grawe L, Holm K. Evidence-based practice: a falls prevention program that continues to work. Medsurg nursing : official journal of the Academy of Medical-Surgical Nurses 2008;17(4):223–7, 35; quiz 28 [PubMed] [Google Scholar]
- 29.Krauss MJ, Tutlam N, Costantinou E, et al. Intervention to prevent falls on the medical service in a teaching hospital. Infection control and hospital epidemiology : the official journal of the Society of Hospital Epidemiologists of America 2008;29(6):539–45 doi: 10.1086/588222|. [DOI] [PubMed] [Google Scholar]
- 30.Weinberg J, Proske D, Szerszen A, et al. An inpatient fall prevention initiative in a tertiary care hospital. Joint Commission journal on quality and patient safety / Joint Commission Resources 2011;37(7):317–25 [DOI] [PubMed] [Google Scholar]
- 31.Shekelle PG, Pronovost PJ, Wachter RM. Assessing the Evidence for Context-Sensitive Effectiveness and Safety of Patient Safety Practices: Developing Criteria,www.ahrq.gov Contract No. HHSA-290–2009-10001C. Rockville, MD: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, 540 Gaither Road, Rockville, MD 20850, 2010. [Google Scholar]