preventing patient falls

Preventing patient falls is one of those burning concerns that sits on the mind of the nurse at all times.  Falls cause physical and emotional damage to the patient and can even lead to death. With fall rates on the increase and patient risk factors following, how can we as nurses reduce falls? With the millions of variables the nurse faces on a daily basis, what systems can help the nurse and what systems can hurt the patient?

Fall prevention is a constant struggle that brings millions of variables to the table. For one, there is never a single time where a nurse faces all the same variables another nurse faces at a single time. Let me clarify that statement"

All the ingredients a nurse deals with during a particular shift are never the same. A nurse may have the same 4 or 5 patients, however some variable will always be different such as a new medication ordered, an admission, a different family member visits, different co-workers, different physicians or providers, or a change in status. With all the variability, how does the nurse prevent patients from falling?

Preventing patient falls: The strategy?

I was at a nursing recruiting exercise and I was approached by a nurse who was just made director of quality and safety. Our discussion led into patient falls and she asked me "So how does your hospital prevent patient falling?' As usual, my passion go the best of me as I started rambling of prevention strategies when I was quickly stopped. The next statement blew my mind!

"We don't have bed alarms and all that stuff you mentioned, my CNO just tells me to not let falls happen"

Ummm....excuse me! The best nurses with the greatest intentions simply can't be in all the right places at all the right times to prevent falls. There is a great strategy - "Just don't let them fall!"

I am sure all my experienced nursing colleagues are agreeing when I say that that is a pipe dream! Just don't let your patients falls...

Sounds great, but we might need a little help in terms of the correct systems in place to help the nursing staff.

First a quick story:

I was walking down the hall of a busy nursing home unit when I saw the puddle of blood ooze under the closed door of a patient room. I still recall the feeling that came over me just before I opened the door. The feeling of what was I about to find and what was going to happen to everybody involved on this wing. You see we had roughly 30 residents on this particular unit who, if you think about it were all fall risks due to one thing or another. The organization followed a policy where they promoted independence and saved the alarms for those extremely high fall risk patients such as severe dementia with weakness. In addition the unit was staffed with a LPN and 1 or 2 Nursing aides depending on availability.

I opened the door and my heart simply sank to the bottom of my stomach. This particular resident was in her early 80's and was always so full of joy and life. As I look at the blood seeping from her head, I felt a sudden panic arise that made the hair on the back of my neck stand. I called for help. I held her hand while we waited for EMS to arrive to mobilize her for transport. While waiting the LPN caring for her told me how the resident was confused today and that she requested an alarm for her bed. The LPN stated that the unit manager told her there were none available and just don't let her fall. I felt a gush of anger and range come thru my body. Despite the LPN's best efforts, the resident was out of bed and fell. Of course days later the investigation was completed for the staff who were working. I couldn't help t think why wasn't an investigation done on the staff who were not working? Primarily the nurse manager and the policy writers. You see that LPN was put in a bad position with the lack of resources and systems to help her take care of the residents under her care.

I have researched many patient fall programs and worked in many different healthcare environments. Having the right ingredients in place can help reduce falls and at least help the nurse feel they did as much possible if a fall does happen. 

Accurately assess the patient for risk of falling - This is always my favorite. The wrong assessment can give the false pretense that every patient is a fall risk. This waters down the whole reasoning of having an assessment score. With so many tools out there, it is important to pick the right one for the right environment. For example a tool for in-patient medical patients may not work for rehab patients or behavioral health patients. A  multi-disciplinary team, consisting of clinical nurses from the bedside, need to research and trial the best tools to accurately identify patients at risk for falling.

The universal fall risk color is yellow. Make sure everyone in your organization is educated to the color used to recognize fall risk. We need all hands on deck to prevent falls!

Patient Fall Contract - It is important for the nurse to contract with both patient and family to ensure patient and family behaviors do not lead to falls. This serves as a means to educate the patient and family on the fall prevention strategies used as well as a way to visually remind those in the room. Help the family member understand why they shouldn't turn off the bed alarm or the importance of keeping things within reach after they leave. Preventing falls is a group effort and NOT just the responsibility of the nurse. 

This a fall contract I implemented on my 46 patient medical flor. It is now hospital wide. We post 1 copy in the chart and the top copy in the room. It is visual and coordinates with the fall prevention socks, blanket, and wrist band we use. The nurse explains the reasons why the patient can fall as well as the staff's role in preventing that fall. The patient and family are educated on their role to ensure safety. We implemented this following a quarter of 18 falls. Since implementation we average 4-6 falls a quarter and meet the NDNQI 50% or better in falls with injury. 

Easily accessible Equipment - Have a plan for mobilizing patients who are at risk for falling. Again, based on the type of unit this must be tailored. For example gait belts on a medical floor are great, yet not so great for an in-patient behavioral unit as they can be used as a suicide device or weapon. Ensure all staff are competent in equipment use. 

The gait belts are yellow to match the high fall risk color and the fall contract. They are easily accessible in every patient room. 

Bed and Chair Alarms - Facilities must invest in alarms to notify the nursing staff if a patient who has been identified as a high fall risk is getting out of bed. Nurses simply can't be everywhere at once. Alarms notify the nurse when a patient is getting out of bed. Alarms must be responded to as soon as possible by ANYONE on the unit in order for them to be effective. 

My talented Assistant NM  matched the fall score number with what bed alarm zone and created a guide to help the nursing staff. These guides are on the intranet and at the bedside for staff. We have committed ourselves to staying with the patient whenever they are out of bed. This is where true teamwork must exist. If you are with a high fall risk patient, you must stay with them and rely on your team to ensure other areas of the unit are attended to. 

Bedside Report - During report the patient fall score and last fall assessment are briefly discussed. Now the nurse leaving and nurse arriving can visually make sure the bed alarm is on, call bell close, visualize the fall contract hanging next to the white board, and have a conversation with the patient and family if needed to ensure they continue to understand our concerns for safety. 

Hourly Rounds: Many times patient falls are contributed to getting up to go the bathroom, changing position, or reaching for an item on the bedside table. Hourly rounds can help reduce this by offering and toileting patients, making sure things are in reach, the floor is free of trip hazards, and the patient is in a comfortable position. 

Organizational Buy-In - We simply can't say we don't want falls in our organization and expect just the nurses to do this. Everyone must be trained on fall prevention and their role. Walking by a bed alarm and saying the nurse will get it does not protect the patient if that nurse is with another fall risk patient. Take a minute to watch this video by UMC Health System and see my point!!

Sitter and other means of safety - Sometimes a patient just needs someone to be there at all times or to watch them. This is a huge resource, however implementing a sitter is a last dig measure to preventing a fall. Make a care plan and strategy for each patient. When resources like man power are low, optional sitters can include remote cameras such as the AVASYS system. See video below.

preventing patient falls: business side

Everything I mentioned is great if your organization buys into the important of fall prevention. The CNO in the above story that did not purchase bed alarms and simply stated don't let patient fall needs to be educated on the business side of fall prevention. Investing in the right equipment can pay for itself by the prevention of a single hip fracture. Nurse staffing must also be equated into the formula when preventing falls. If 50% of your unit is a high fall risk and 3-4 bed alarms are going off at once, you need the right number of staff present. 

Many variables go into fall prevention. Whether it is accurate assessment, communication among team members and patient, use of a gait belt, or implementing a sitter, fall prevention must be an organizational commitment. Review your organizations data and create a fall council to look at trends and patterns. This way you can tailor your approach to what you are experiencing. Not every recipe is correct for every organization. I hope my tips and tools are helpful. Please share this article if you found it beneficial. 

For more strategies other organizations use please view this PDF on a systematic approach to Preventing Patient Falls