HCA 699 Section A: Problem Description

Background of the Problem

In clinical settings, falls amongst admitted patients has become a major concern for stakeholders such as the Center for Medicare and Medicaid Services (CMS), Joint Commission, patients, caregivers and healthcare facilities. The occurrence of falls among the inpatient population can lead to negative consequences such as premature hospital re-admission, increased mortalities and hospital stays, extended pain and potential disabilities. According to statistics, the average fall rates amongst inpatients in the clinical settings is 17.1 per 1000 bed days (King, Pecanac, Krupp, Liebzeit, & Mahoney, 2018). Further, it is approximated that of patients admitted to the inpatient units, five of them will experience falls at least once during their stay at the hospital. As such, the prevalence of falls at hospitals ranges from 1.9%-3% even after several interventions have been adopted. As a result of the falls, 9-33% of the patients may suffer from injuries ranging from mild to fatal (de Souza et al., 2019). The Institute of Healthcare Improvement in its published report concluded that falls account for the most mortalities in older patients, 65 years and above, with 10% of these deaths occurring within the clinical setting (Bhise et al., 2018). Moreover, the falls have also been shown to predispose patients to other issues such as anxiety, distress and depression, which can affect their mental functioning along with physical abilities.

Leon and Adams (2016) demonstrated that the occurrence of falls has the capacity to increase patient costs by approximately $13,000 dollars. Other parameters such as healthcare spending per fallen patient can increase up to 60% in comparison to other patients. As such, Pearson and Coburn (2012) estimated that the costs associated with injuries and treatment will rise to approximately $54.9 billion this year. Therefore, hospital falls amongst inpatients in clinical settings is a significant matter that should be addressed.

Stakeholders/ Change Agents

The Center for Medicare and Medicaid Services and Joint Commission always seek to examine issues that will improve the safety and quality of care offered to patients. As such, they will be important stakeholders in a project that seeks to address hospital patient falls. In addition, nurses, providers, nursing students and other healthcare workers will also play a crucial role as they will be the frontline change agents for the project (Anderson, Postler, & Dam, 2016). Other interested parties in the project will entail families and patients themselves as they are the ones who suffer the consequences of falls.

The PICOT Question

In order to address the issue of patient falls at the facility, the present project proposes the adoption of hourly rounds. Thus, the following PICOT question will form the basis of the project: For adult inpatients in medical surgical units (P) does the use of hourly nursing rounds (I) reduce the future risk of falls (O) when compared with call lights (C)?

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The Purpose and Project Objectives

The purpose of the project is to reduce the prevalence of falls amongst adult inpatients in the medical surgical unit. Specifically, the project will seek to compare the effectiveness of nursing rounds and call lights regarding the reduction of the prevalence of patient falls in the medical surgical units (Anderson, Postler, & Dam, 2016). Therefore, patient fall measurements will be taken before and after the introduction of nursing hourly rounds and comparing call lights to determine which intervention is more effective.

Importance of Resolving Falls to Nursing

As mentioned, nurses are the frontline workers that are directly impacted by patient falls. The prevention of patient falls will thus improve nursing work morale and help to prevent them from suffering burnout, as the workload and stress caused by patients suffering after a fall, will be reduced. Moreover, addressing patient falls will allow nurses to practice their care maximally as the patients will not suffer from the effects of the same (King et al., 2018). Further, resolving the issue of patients falls will support the role of nurses as it relates to keeping patients safe. Therefore, addressing patient falls is fundamental to the roles and responsibilities of nurses as well as their workplace wellbeing.

Literature Support

Research is an important component that promotes evidence-based practice in nursing. It provides clinical data about the various interventions that can be used to promote the health and wellbeing of the patients. As a result, it makes it evident that nurses should explore different sources of data to understand the manner in which clinical outcomes can be achieved. Therefore, this section of the project summarizes the different sources of data that will be utilized to support the PICOT statement of the project. It also examines the search strategy that was used in obtaining the relevant research materials along with the validity of the research.

Search Method

The articles for this proposed project were obtained from a number of databases. They included Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, National Guideline Clearinghourse, CINAHL, Ovid, Google Scholar, PubMed and Medline. The search keywords that were used included patient falls, preventing patient falls, safety issues, risk factors, hourly nursing rounds, and call lights in patient falls. An inclusion and exclusion strategy was utilized in selecting the articles for the review. Firstly, articles that were selected were published in English, they must have also focused on the issue of patient falls and the articles were required to have been published over the last five years. An exclusion strategy was developed and was comprised of excluding studies that were written in languages other than English, published more than five years ago, and did not focus on the issue of patient falls. The search resulted in eight articles that shed light on the effectiveness of the proposed intervention in reducing and preventing rates of patient falls.

Summaries of the Articles

The first article that was obtained from the search is the one by Goldsack, Bergey, Mascioli, and Cunningham (2015) that aimed at investigating the effectiveness of hourly rounds on reducing the rates of patient falls. The study was a retrospective pilot study where two units were used to implement the intervention. Data was obtained pre and post implementation of the intervention to determine its effectiveness. The nurse leaders as well as champion staff in unit one were involved in the whole process of project implementation. The staff and nurse leaders in unit two were introduced to the project at the training level prior to project implementation. The results of the study revealed that there was a decline in patient fall rate in unit one by 1.3 falls/1000 patient days. This was lower when compared to the 2.5 falls/1000 patient days on unit two. The study revealed that hourly rounds are highly effective in preventing patient falls when there is active stakeholder engagement. One of the strengths of this study is its inclusion of a control and intervention group. This allowed for a better understanding of the effectiveness of the intervention. However, it is associated with a weakness of being a retrospective study. The results of the study could have been influenced by other confounding factors beyond the scope of the project. This article supports the PICOT statement for the research by showing the effectiveness of the intervention in reducing patient falls.

The second article that provides insights into the proposed project was published by Leone and Adams (2016). This research is a retrospective review of quality improvement projects that focused on reducing rates of patient falls by using an organizational culture of safety in rehabilitation units. The authors reviewed a quality improvement project that investigated the effectiveness of multiple fall interventions in promoting patient safety. A retrospective review of falls in the inpatient rehabilitation units was done. The quarterly fall rates were then compared with the dates in which fall prevention interventions of hourly rounding, signage, and safety huddles were implemented. Safety scores on culture were also obtained to determine the effectiveness of a safety culture on lowering the rates of patient falls. The results of the study revealed that the utilization of a culture of safety with hourly rounding had the largest decline in fall rate among patients. The research is associated with the strength of comparing the effectiveness of different interventions that can be utilized to prevent patient falls. This comparison provides a better understanding of the efficacy of the different fall prevention methods used in the clinical settings. The researchers also linked the outcomes of fall prevention with organizational culture. As a result, a correlation between safety culture and patient falls can be obtained. However, it is associated with a weakness of being a review of a quality improvement project. It failed to show the impact of project deliverables on reduction in patient falls.

Another research that was selected for this summary is the one conducted by Brosey and March (2015). This research investigated the effectiveness of using structured hourly nurse rounds on clinical outcomes and patient satisfaction. The researchers utilized evidence from articles that were obtained from databases that included PubMed, CINAHL, Nursing & Allied Health Collection and Cochrane Database of Systematic Reviews. Analysis of the data from the articles led to a solution that entailed the utilization of two hours structured nurse rounding in a large tertiary hospital. Obtained data was analyzed using methods that included descriptive statistics and Cox-Stuart trend analysis to determine changes in patient falls following the adoption of the intervention. The results of the study revealed that a clinical and statistical significance in the reduction of patient falls was recorded. There was also a corresponding improvement in the rate of patient harm. The reduction in patient harm was witnessed for a period of one year after the implementation of the intervention. This study has the strength of monitoring the intervention for three years to determine its effectiveness. Its utilization of the best intervention from the selected articles also strengthened the effectiveness of the selected intervention. However, it has a weakness of failing to control confounding factors that might have affected the domain scores of the healthcare providers.

In a retrospective descriptive study, Anderson, Postler, and Dam (2016) examine the epidemiology of patient falls in a hospital system. “The objective of this retrospective descriptive study was to describe the locations and characteristics of hospital-related falls. Data on patient characteristics, including locations and fall circumstances, were collected from incident reports and medical records” (Anderson, Postler & Dam, 2016, p. 423). The results of the study revealed varied outcomes on the risk of patient falls and identified 1,822 falls, within one year, at a 921-bed facility located in an urban hospital center. From the research, 97.0% (1,767) of the falls were reported in the inpatient units while 3% (55) occurred during the provision of ambulatory care. In the research, 73.5% of the patients who fell were aware of the fall prevention protocol before the fall happened. However, to the authors surprise, the youngest age group recorded the highest rates of falls and this raised concerns about the effectiveness of the falls prevention protocol in the facility.

An article by Bhise et al. (2018) describes how an electronic trigger can be used to recognize preventable adverse events that happen to hospitalized patients. “We refined the methods of the Institute of Healthcare Improvement’s Global Trigger Tool (GTT) application and leveraged electronic health record (EHR) data to improve detection of preventable adverse events, including diagnostic errors” (Bhise et al., 2018, p. 241). The research examined preventable adverse events in 42 cases. The outcome revealed 7 cases (7.6%) were related to diagnostic errors while 34 (37.0%) represented cases of patient care management events. 24 cases (26.1%) were due to adverse drug events, 4 (4.3%) were attributed to patient falls, 4 cases (4.3%) were linked to procedure-related complications and 2 cases (2.2%) were due to hospital-associated infections. From the results, it is evident that patients were subjected to potential hospital harm with 37.0% being attributed to errors in patient care management. Limitations were however identified with regard to the use of electronic triggers in specifying preventable harms to hospitalized patients.

The article by de Souza et al. (2019) explores the concept of inpatient hospital falls occurring in a large hospital. A database was generated by the authors from a hospital in the South of Brazil to examine patient falls in a hospital setting. Information collected were those published from January 1, 2012 through December 2017. The data set for the research was based on information about the level of risk for falls, type of injuries sustained, the implemented fall prevention protocol in the facility, and the reasons for falls. In a descriptive methodology, the study reveals that the risk of falls in a care facility depends entirely on the implementation of a fall prevention protocol such as nursing rounds. Interventions such as nursing rounds improve safety to patients, regardless of the type of falls they are exposed to, in an effort to optimize quality outcomes for patients. However, the study does not reveal the level of association between medications administered and the risk of falls for hospitalized patients.

The literature reviews also incorporated the article by King, Pecanac, Krupp, Liebzeit, and Mahoney (2018) that reported a study conducted to identify the impact of fall prevention among the nursing staff and how care is administered to patients at risk of falls. The research was a qualitative study whereby the authors used the Grounded Dimensional Analysis (GDA) to establish the experience of nurses providing care to patients. Specifically, actions taken by nurses to prevent falls were identified and the approaches used by the hospital facility to respond to the consequences of falls were evaluated. 27 registered nurses were enrolled in the program and in-depth interviews were conducted to collect the data. The outcome of the study showed that hospital administration used intense fall prevention messaging with staff and interventions such as nursing rounds to achieve zero falls in the facility’s inpatient units. However, the results indicated that nurses developed immense fear for patient falls and were keen to protect the incidences just to meet the goals of the hospital.

Mitchell, Lavenberg, Trotta, and Umscheid (2014) examined how hourly rounds improved the response of nurses towards the falls of hospitalized patients. The study was a systematic review and compiled data retrieved from previous studies most of which were based on different methodologies. In the review, the authors focused on recently published materials that had the subject headings on how nurses reduce hospital falls to patients. Despite little consistency in the manner in which data was collected, the study revealed that hourly rounds by nurses yielded a moderate strength in the response of nurses to patient falls. The approach improved the perception of nurses towards patient care which also gave them time to evaluate the causes of falls for hospitalized patients.

Validity of Internal and External Research

The population characteristics of the selected studies were adequate to generate a bundle of evidence about the effectiveness of the articles. In most research materials, except for systematic reviews, the participants were those that represent the nurse and patient population to whom outcomes can be implemented in future nursing practice. For instance, the characteristics and perception of nurses with regard to patient falls were examined to establish how they respond to the risk of falls to patients. Nonetheless, the interaction between subject selection and the metrics of research were vividly explored by eight articles to affirm the effectiveness of the study in improving quality outcomes to patients. The research environment, on the other hand, was localized in care facilities and this is consistent with the area in which the study is yet to be implemented. However, except for systematic reviews, data collection methodology was applied in the context to generate both quantitative and qualitative data which are predictive in influencing the research outcomes prior to implementation. The effect of time was also checked as the articles used were those published between 2014 and 2018. The premise ensured the use of research materials that were up-to-date with the subject of study to ensure accurate information.

Conclusion

The review of the selected articles has shown that the use of nursing rounds is effective in reducing rates of patient falls. However, its effectiveness over the use of other methods such as call lights has not been explored. As a result, the proposed intervention seeks to establish this cause by investigating whether nurse rounds are more effective than call lights in preventing or reducing patient falls. Through this, it will inform the adoption of evidence-based interventions in clinical practice.

References

Anderson, D. C., Postler, T. S., & Dam, T. T. (2016). Epidemiology of hospital system patient falls: A retrospective analysis. American Journal of Medical Quality, 31(5), 423-428. Retrieved from https://doi.org/10.1177%2F1062860615581199

Bhise, V., Sittig, D. F., Vaghani, V., Wei, L., Baldwin, J., & Singh, H. (2018). An electronic trigger based on care escalation to identify preventable adverse events in hospitalised patients. BMJ Quality & Safety, 27(3), 241-246. doi10.1136/bmjqs-2017-006975

Brosey, L. A., & March, K. S. (2015). Effectiveness of structured hourly nurse rounding on patient satisfaction and clinical outcomes. Journal of Nursing Care Quality, 30(2), 153-159. doi: 10.1097/NCQ.0000000000000086

de Souza, A. B., Röhsig, V., Maestri, R. N., Mutlaq, M. F. P., Lorenzini, E., Alves, B. M., … Gatto, D. C. (2019). In hospital falls of a large hospital. BMC Research Notes, 12(1), 284. Retrieved from https://doi.org/10.1186/s13104-019-4318-9

Goldsack, J., Bergey, M., Mascioli, S., & Cunningham, J. (2015). Hourly rounding and patient falls: What factors boost success?. Nursing Management, 45(2), 25-30. doi:10.1097/01.NURSE.0000459798.79840.95

King, B., Pecanac, K., Krupp, A., Liebzeit, D., & Mahoney, J. (2018). Impact of fall prevention on nurses and care of fall risk patients. The Gerontologist, 58(2), 331-340. Retrieved from https://doi.org/10.1093/geront/gnw156

Leone, R. M., & Adams, R. J. (2016). Safety standards: Implementing fall prevention interventions and sustaining lower fall rates by promoting the culture of safety on an inpatient rehabilitation unit. Rehabilitation Nursing, 41(1), 26-32. doi:10.1002/rnj.250

Mitchell, M. D., Lavenberg, J. G., Trotta, R.L., & Umscheid, C. A. (2014). Hourly rounding to improve nursing responsiveness: A systematic review. The Journal of Nursing Administration, 44(9), 462-472. doi: 10.1097/NNA.0000000000000101

HCA 699 Section A: Problem Description