I chose to examine an article in MedSurg Nursing on decreasing falls with purposeful hourly rounding. I’m currently working on an acute rehabilitation and transitional care unit within the local hospital. Our facility trained staff on implementing purposeful hourly rounds a few months ago and the nursing leaders of this change are collecting data to determine the relationship of hourly rounding to Press Ganey survey results. My unit is also the pilot unit for a study on integral bed alarm use. This research article combines both topics of interest. I’m supportive of hourly rounding to promote safety, physiological, and psychological comfort to patients, but this study has some problems. This has piqued my interest enough for me to dig further into the literature on this topic since the research article leaves me with many questions.
The researchers examined data on falls, call bell use and response times, and Press Ganey survey results for a month prior to hourly rounding implementation and a month after hourly rounding was implemented. During the month after implementation, construction was occurring on the unit and researchers note that nurses were encouraging patients to use their call bells as a result, possibly confounding results. The researchers found no significant statistical difference in fall rate before and after implementing the hourly rounding but considered a decrease in falls “clinically significant”, though they never operationalized that term and they used data showing the largest drop in patient falls occurred in the months prior to implementing hourly rounding. This drop was larger than the drop that occurred after implementation of rounding. Journal Club Critique Form fishbone_template
I was interested in this research topic because my mother had knee surgery on both knees last week. After two days during her inpatient acute stay at the hospital, she fell. She did not want to “bother” the nurses when she needed to use the restroom. My mother was moved closer to the nurse’s station so that they can keep an eye on her. Bed alarms were used as well. She was discharged the next day to a rehab facility. One solution is for nurses to take the time to educate their patients about using the call light for assistance and informing patients that they are required to have assistance when they are out of bed.
One article, Forrest et al. (2012), stated that patients with admission diagnosis of stroke, brain injury, amputation, neurologic disorders (Parkinson’s disease, multiple sclerosis, Guillain-Barre, myopathy, peripheral neuropathy), and spinal cord injury are at higher risk for falls than patients whose admission diagnosis related to orthopedic, cardiac, pulmonary disorders, prolonged stay on medical or surgical units, or trauma without spinal cord injury or head injury.
The universal fall precautions are applied at my hospital:
Familiarize patient with the environment.
Have patient demonstrate call light use.
Maintain call light within reach.
Keep patient’s personal possessions within patient safe reach.
Have sturdy handrails in patient bathrooms, bed, and hallway.
Place hospital bed in low position when a patient is resting in bed.
Raise bed to a comfortable height when patient is transferring out of bed.
Keep hospital bed brakes locked.
Keep wheelchair wheel locks in “locked” position when stationary.
Keep nonslip, comfortable, well-fitting footwear on the patient.
Use night lights or supplemental lighting.
Keep floor surfaces clean and dry.
Clean up all spills promptly.
Keep patient care areas uncluttered.
Follow safe patient handling practices.
Patient education is key. Make sure patients understand that they are not to be ambulating on their own. Letting patients know that they are not an inconvenience to the nurse is important. Taking time to talk with patients is critical. If patients can sense that you are in a hurry or are trying to rush through tasks, they will just nod their head and let you walk out the room and an incident could occur afterwards. Take the extra time to get to know your patients. This will help prevent further problems down the line.
The construction might have distorted the study of your article. It would be beneficial for them to do another study once all the construction is completed. I agree with you that hourly rounding is crucial.
Forrest, G., Huss, S., Patel, V., Jeffries, J. Myers, D., Barber, C. & Kosier, M. (2012). Falls on an inpatient rehabilitation unit: risk assessment and prevention. Rehabilitation Nursing, 37(2), 56-61. https://www.ncbi.nlm.nih.gov/pubmed/22434614
I really think the study was confounded by construction during a comparison month. I think it’s odd that the researchers used this data rather than gathering from a later month. It leaves the study open to arguments of being invalid. Not to mention the strange use of data from well before interventions were even started. At the very least, it is misleading unless you look very closely at the information in their analysis.
I am currently working at a Rehabilitation and Memory care facility and falls are the most common problem in the memory care unit. Elderly patients fall regularly which can result in various injuries such as fracture, head injuries or death. I am also a supporter of hourly rounding, but health care providers and nurses need to take time out and find out what is the root cause of these falls. My health care center implemented many safety measures to prevent falls, but for some reason, we are not maintaining the goal of a fall free environment. We need to take everything into consideration such as chronic health conditions, impaired eyesight, impaired hearing, polypharmacy, and dehydration. These are just a few triggers, and if healthcare providers do not fix these causes then the problem will remain the same. Although we use call bells, alarm to bed and chair, low beds and other preventable measures to reduce falls, we cannot overlook the patient’s health issues. Another article, (Poor Sleep and Risk of Falls in Community-Dwelling Older Adults) show that insomnia is also a contributing factor. The article continues to say, “approximately 50% of independently living adults aged 65 years or older in the United States report chronic sleep complaints.” Once our health care facilities understand how dangerous falls are to older adults, they will better understand preventive measures need to be taken. Great job.
Slattum, P. W. (n.d.). Poor Sleep and Risk of Falls in Community-Dwelling Older Adults: A Systematic Review – Yaena Min, Patricia W. Slattum, 2018. Retrieved from https://journals.sagepub.com/doi/abs/10.1177/0733464816681149
I was talking about this to the director of an independent and assisted living facility. She was talking about the number of falls they have at those levels of care because residents are becoming weaker or more confused but this isn’t fully recognized yet by the resident or their family.
This is a great topic. Fall prevention is a very important aspect of patient care. Several studies have shown that there is no one specific intervention that could prevent or reduce all falls. An individualized comprehensive assessment is vital to determining the appropriate interventions. For example, bed alarms can be very effective if used for a short time for a patient with cognitive impairment or when used as part of a comprehensive plan of care. “Overall, it seems that alarm use can assist in the care and safety of nursing facility residents. When used as one piece of a comprehensive care plan, they can be quite effective devices in ensuring resident safety” Mileski et al., 2019).
Michael Mileski, Matthew Brooks, Joseph Baar Topinka, Guy Hamilton, Cleatus Land, Traci Mitchell, . . . Rebecca Mcclay. (2019). Alarming and/or Alerting Device Effectiveness in Reducing Falls in Long-Term Care (LTC) Facilities? A Systematic Review. Healthcare, 7(1), 51.
I completely agree. The use of alarms has to be combined with all the other factors in a fall prevention bundle. I wish there was one magical answer to getting patients to remember to call the nurse and to get them to wait for assistance. Sometimes, no matter how quickly you answer their bell and arrive to their room, they are still getting up without assistance.
Most nurses routinely complete the fall risk assessment and develop a fall prevention plan for all patients. Engaging patients and families can help reduce falls. I can’t count how many times a family member has came out to the desk and said that the patient was getting out of bed. Instead of trying to redirect the patient and hit the call light they took time to come out to the desk and left the patient at high risk for a fall. According to the American Nurse today, to engage patients and families in a three-step prevention process to reduce the risk of falls. Step 1: Fall risk screening and assessment. Fall risk screening should be done at every patient admission and with each status change, which in acute- care settings may require screening every day or even every shift. Fall risk screening scales would be the Morse Fall Scale, Schmid Fall Risk Assessment Tool and Stratify Fall Risk Assessment Tool. Step 2: Tailored fall prevention care planning. After completing the fall risk screening, collaborate with the patient and family to develop a personalized plan to address each identified risk factor. A common mistake is prescribing interventions based on a patient’s level of fall risk (low, medium, or high), rather than tailoring interventions based on patient-specific risk factors. Step 3: Consistently carrying out the fall prevention plan. Consistent implementation of the fall prevention plan requires communicating the patient’s risk factors and plan to the healthcare team (including the patient and family). Direct-care team members, such as nurses and patient care assistants, reinforce the plan with the patient and notify you of any change in the patient’s risk status. You then reassess the patient and update the plan as needed. Another tool I read about in this article was The Fall TIPS (Tailoring Interventions for Patient Safety) Toolkit developed by the Fall TIPS Collaborative can be used to engage patients and family members in the three-step fall prevention process and communicate and reinforce the fall prevention plan at the bedside. What’s neat about it is it is specifically tailored to each patient. I looked up this tool and the signs have the patients name, his fall risk and what to do not only for the medical staff but the families at bedside too.
American Nurse Today official Journal of the American Nurses Association (ANA). (n.d.). Retrieved February 27, 2020, from https://dev01.americannursetoday.com/
The TIPS toolkit sounds great. I will look into that more closely. My personal wish is to put all confused patients near the nurse’s station where someone can see them all the time, but there aren’t enough of those rooms. Even when we do everything right, someone seems to decide that they really don’t need our help. I recently had a patient with us after an MI. He called to tell me he was going to the bathroom. I ran to his room and reminded him, all over again, that he needed to WAIT for assistance. Another man tried to kick me out of his bathroom before he had transferred to the toilet. He is with us after a CABG and has an old above the knee amputation. He honestly refused to transfer and get seated on the toilet with a female. I had to find a male PT assistant because his male nurse was at lunch.
Daniels, J. F. (2016, January). Purposeful and timely nursing rounds: a best practice implementation project. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26878929
Bedside report and hourly rounding really do improve patient care. Bedside report allows the previous nurse to terminate care, introduces patient to next RN, allows the patient to be involved in care, allows RN to assess who needs their care the most. Also, it helps prevent falls, helps staff organize tasks, and prevents RN from running back and forth, because you can address needs and come back with medications and ETC. The study I read stated patient’s pain management score went up 6%. Falls decreased by 50%. Staff responded to calls more quickly and patient satisfaction scores were increased. Hour roundly is horrible to chart – our facility print out evidence based practice articles about HR for us. I tried to keep an open mind – I realized the more I made myself present the less charting I had for falls, I was able to monitor pain better, and my patients were happier with their care. They felt like I was present and observant of their needs. I was able to walk in when patients were attempting to get up out of bed and I felt like I was able intervene with issues, because I recognized them more quickly such as – changes in status, pulling IVs, and confusion.
That decrease of 50% sounds hopeful! I’ll get that study and see what we can implement to create that sort of change. Our unit is doing well but there’s always room for improvement. We went 4 months with no falls and then had two falls in one week.
Fall prevention is always a great topic to discuss. Every year in the United States, hundreds of thousands of patients fall in hospitals, with 30-50 percent resulting in injury (Preventing falls, 2013). Fall prevention can be challenging and implementing preventative measures can be challenging. Fall prevention must be balanced with other priorities for the patient. Fall prevention is interdisciplinary. Fall prevention needs to be customized (2013).
Reference
Preventing falls and fall-related injuries in health care facilities. (2013). The Joint Commission, (55), 1–5.
Which fall prevention practices do you want to use? (n.d.). Retrieved January 2013, from https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk3.html
It really is challenging and occasionally frustrating. We have implemented bedside report and purposeful hourly rounds. We move the most confused patients nearest the nurses’ station, and still someone finds a way around us and “beats the system”. Our last fall was from the facility itself. There is a little ramp into the bathroom at the doorway. This was (brilliantly) placed there when the unit was remodeled. A patient lost her balance and the aid wasn’t able to keep her upright.
Falls are hard. Can they be prevented, sure, but sometimes it’s unavoidable. I’ve seen so many employee injuries related to falls. Mostly back and shoulder injuries from trying to prevent them. I’ve even seen sitters who are trying desperately to get a patient to get back in bed and end up getting bit or scratched for it.
We recently got a new device in our hospital that seems to be helping. It’s a bed/chair alarm that talks to the patient and tells them not to get up and it allows their family member to record the message, personalizing it to the patient. It’s proven to be especially effective in dementia patients. I don’t know a whole lot about them, but my understanding is that they are expensive and are for single patient use only. So far the expense seems to be worth it!
We have the Posey alarm pads and boxes that we can add to chairs. These talk to the patients and say “Please don’t get up. Sit back down and wait for assistance”. These plug into the call bell system to make the room indicator flash red above the door. I have seen a couple of occasions where the patient actually listened to the recorded voice and sat down again. We use the integral bed alarms on everyone right now, but use the Posey alarms on the recliners and wheel chairs of confused patients.