Evidence Based RUA

Chamberlain College of Nursing

NR452: Capstone

Evidence Based RUA

Although The Joint Commission (JACHO) has seemed to disappear behind the curtain in

light of recent events with COVID-19, preventing falls in the hospital continues to be one of the
top safety goals for the accreditation and certification committee. Hospitals care a great deal

about earning accreditation and certification from The Joint Commission as they set the standard

for what patient quality of care and safety of care should be. It should also be mentioned that

accreditation [from The Joint Commission] builds confidence in the community that they will

receive competent care (The Joint Commission, n.d.).

Patient falls, when resulting in serious injury or death, are considered “sentinel events”.

In other words, something that is preventable and should never happen. Although a patient fall is

considered a never event, falls do still happen in the hospital setting. The purpose of this paper is

to explore the importance of fall prevention along with a proposed solution and goal. With any

proposed solution and goal there are barriers and benefits that will be encountered. Barriers

being staff knowledge and lack of motivation, and benefits for both the health care team and

patients alike. This is where healthcare thrives as working as a team to accomplish a common

goal in the benefit of our patients. In relation to what NCLEX-RN category this falls under, the

clinical problem this is drawn from is client needs with the subcategory being safety and

infection control (National Council of State Boards of Nursing, 2019)

Importance

On average 1.3 to 8.9 falls happen per 1000 patients. Although this may not seem like a

significant number of patients, it is one of the leading negative events recorded against hospitals

accounting for approximately 70% of inpatient incidents and could lead to even more if left

unresolved. This is an issue for patients and hospitals because patient falls lead to increased cost

that quickly adds up (averaging $4200 per fall), and reduction of resources (increased length of

hospital stay uses up a bed that otherwise would have been available and need for additional

skilled nursing staff) (Ashok & Khyathi, 2019). The lost funds could have gone to a range of
things the hospital needs. Such as: purchasing staff valuable PPE, purchasing equipment, giving

staff raises, and the list goes on and on.

Yes, limited funds and resources are becoming a greater concern to hospitals as the

COVID-19 pandemic in The United States worsens. Ethically, however, it is more important not

to forget who is the center of this issue. The patient and their families. The more serious injuries

include fractures, and subdural hematomas that have led to excessive bleeding and death. Injuries

or deaths that could have been prevented (Ashok & Khyathi, 2019).

Patient Population

The population this paper is focusing on is the older adult patients who are admitted in an

acute care healthcare facility. They considered the patient an older adult if they are 65 years old

or older. The study had both male and female participants. The common medical risk factors seen

in this patient population are cognitive impairment, confusion, dementia, neurological disease,

cardiovascular disease, urinary and bowel incontinence, musculoskeletal issues, visual and

hearing impairments (Zhao & Kim, 2015). The non-medical risk factors that the patient had are

lengthy stay at the facility, had a previous fall, and not being able to care for themselves. Taking

a psychotropic or antidepressant medication was also one of the risk factors.

The study reviewed different data from healthcare facilities in different counties

including the United States, Europe, and Australia. However, the risk factors among patients in

Europe may not be directly comparable to those patients in the US and Australia due to the

different policies and regulations in their own respective countries. Despite the diverse

population sample, they found that “Hispanics patients were likely to have less falls in the

hospital compared to African American, Caucasians, and Asian patients” (Zhao & Kim, 2015).

Despite all the information they had, there was no consistent data that shows cultural background
as a risk factor.

Two of the ethical considerations for this population is autonomy and beneficence. The

healthcare team caring for the patient must advocate for patients right by allowing them to make

their own decisions and be involved in planning their care. It is advisable that patients’

independence is promoted to respect their dignity. The patients should also be provided a fall risk

assessment upon admission and a safe environment during their stay to prevent harm.

Proposed Solution

Raising awareness of fall risk factors by educating all staff to do something as simple as

responding to call lights (from janitor to primary care provider), and educating family/visitors to

ask for help with their loved one when ambulating, lays the foundation of the solution. This

fosters an environment of safety and includes participation from all parts of the healthcare team.

It upholds the ethical principle of beneficence, to do no harm. Taking an interdisciplinary

approach to fall prevention, which includes strong administrative support, makes everyone

responsible and cultivates an environment and attitude of preventing falls (Ayton et al., 2017).

Specialized assessment tools, as many of the patients who enter the hospital have unique

needs (different sets of comorbidities), is another solution to address this issue. An example is to

provide assistance in using the toilet especially to those who are incontinent as most of the falls

are related to elimination (Zhao & Kim, 2015). The patients can also benefit from environmental

modifications such as providing clean, clutter-free room and hallways. The use of interventions

for nurses like using assessment tools (MORSE fall scale, and Braden scale assessment tool) and

hourly rounding (Nuckols et al., 2017) can be used to prevent falls as well as using exercise for

the patients (Fuzhong, Hanner, & Fitzgerald, 2016).

Goals
 The long-term goal would be to reduce falls in the hospital by fifteen percent within the

first six months of implementing intervention bundles such as education and awareness of fall

prevention, specialized assessment tools, and hourly rounding. In order to assess this goal, the

first step would be to perform a systematic review. This is when the data is analyzed, and a

number of falls is definitively established through an appraisal of the company’s documentation.

This will be the benchmark we use to compare the data gathered during the first six months of

implementing the new guidelines. Using a randomized controlled study, we would assign half of

the hospitals units to implement these changes, and half to serve as the control group for this

study by computer randomization (Guerrera et al., 2017). When informing the units of these

changes make sure to use a democratic approach and allow for staff to vocalize concerns.

Staying on site to observe the staff performing these new protocols on the unit during their

normal work shift to ensure the integrity of the study. Then after six months of the new protocol

another appraisal of the unit’s data will be compiled, compared to the control group and

benchmarks set at the beginning of the study. The goal of the study will be to show that

implementing intervention bundles such as education and awareness of fall prevention,

specialized assessment tools, and hourly rounding lead to at least a fifteen percent decrease in

documented falls.

The short-term goal is to make sure that staff is willing and capable of adhering to the

units fall reduction protocol three weeks into the study. To measure this, we will use a survey

which is a cross-sectional research method (Jacobs et al., 2012). The staff will have education on

new fall protocols if they are in the independent variable group of the study. In order to do this a

survey with appropriate questions must be developed. The questions on the survey would inquire

about how long these new protocols take to complete, if they feel they are easily integrated into
their work routine and any suggestions. These surveys will be anonymous to encourage the staff

to be transparent about their answers (Jacobs et al., 2012). This will help evaluate how adaptable

these new protocols have been for the staff and enhance the evidence-based research trial (Jacobs

et al., 2012).

Barriers

There are several barriers that can prevent implementation of fall prevention programs such

as: staff knowledge, education, and motivation; organizational and leadership skills; healthcare

workers workloads; proper equipment access; audits and feedback (Ayton et al., 2017). Face-to-

face education programs for nurses can improve their knowledge for skills practice to prevent

falls and enhance their motivation to prevent future occurrence of falls. Implementation of the

educational programs can save many complications following falls, such as trauma injuries, local

or systemic infections and even deaths. Another convenient option for education nursing staff is

e-learning systems, which is easily accessible through computers or mobile devices. Education

can enhance a nurse's motivation to prevent falls. Lack of motivation is another barrier among

healthcare personnel. One of the main motivation factors for nurses is following utilitarian

ethical principles when taking care for patients, which refers to doing the best care for each

patient, so emphasizing the benefits for preventing falls among patients can increase nursing

motivation to prevent future complications from falls. Organization and developing a system of

audit and feedback for fall prevention can also affect nursing motivation. Creating a benefits

system is a strategy that can enhance nursing motivation and lower the rate of falls

Fall prevention requires development of nursing care plans with proper and achievable

goals with successful implementation of the nursing interventions that can prevent future

occurrence of the falls. For example, patients who have altered mental status and those who take
strong pain medication often require supervision and the occurrence of falls among these patients

are often anticipatory. In addition, nurses have to develop a plan of care for each patient with

recognizing patient’s major health problems and creating goals and interventions that can prevent

future falls. On the other side, unanticipated falls or often accidental events happen with patients

who are in low risk. The problem in developing care plans is often connected with a low nursing

workload and not enough time for nurses to develop and implement fall prevention plans.

Multiple patients’ care and shortage of healthcare personnel can be challenges for nurses. Those

are time consuming and lead to lowering attention for fall prevention. Implementation of fall risk

assessment tools such as MORSE Fall Scale can help for early recognition of patients, who are at

risk for falls.

Another barrier for implementation of fall prevention is not enough equipment or

environmental factors. Lack of proper equipment such as bed alarms, call lights, proper

lightening and etc., can increase the risk of patient falls. The problem can be connected with not

enough finance, poor management, and lack of resources. Managers can develop programs for

gathering equipment and improving the facilities environment which can help for lowering the

rate of falls occurrence. Implementation of interventions like posting a sign for fall alert, call

light within reach, personal belongings and walking aids within reach, bed in the lower position,

bed alarms are used in the healthcare system as useful universal precautions for fall prevention.

Benefits

Every patient and medical professional can benefit from fall prevention but not just from

using the standard precautions of yellow slipper socks, using the call light, assessing patients

with the MORSE fall scale, and identification of a fall risk on doorways (Nuckols et al., 2017).
Other interventions need to be researched and implemented to reduce falls for all patients and to

give medical professionals a peace of mind when caring for them.

One such intervention that benefited patients of community senior centers was

implementing an exercise program to improve balance (Fuzhong, Hanner, & Fitzgerald, 2016).

Formerly called Tai Chi, the Tia Ji Quan program was implemented in 32 senior centers with 392

participants for a one-year period. The patients were taught several movements to help with

balance and to remain functional for activities of daily living. Results of this intervention

produced a 54% reduction in falls, improved physical performance of the participants, and 17

senior centers continued to offer the program after the research was completed (Fuzhong et al.,

2016).

To help health care workers, hourly rounding has been implemented in many hospitals.

One specific study conducted hourly rounds for nurses with the implementation of training them

to think critically about fall risk using the 4P method (pain, personal needs, position, and

placement) (Nuckols et al., 2017). Another such study implemented several strategies within

their hourly rounding resulting in a 50% reduction of falls (Morgan et al., 2016).

One intervention that has assisted both the patients and health care workers combined is a

study which put together a team of health care workers and social care professionals to respond

to calls of older people who have fallen at home. Results showed that the “rates for patients to

hospital were lower during the hours that the falls ambulances were in service, than when only

general ambulances were running” (Pyer, 2014, p. 71). Patients filled out questionnaires which

they responded they were “respected as an individual, treated with dignity and consulted about

their care” (Pyer, 2014, p. 71).

Fall prevention is something to take very seriously for each person involved. It should
have benefits for the patients and for the health care workers who provide care not only to save

money, but to save lives and to give everyone a peace of mind.

Participants and Interdisciplinary Approach

Preventing falls is a safety issue that needs to be accountable to all those that are a part of

patient care. The best approach to preventing falls is an interdisciplinary one. While nurses are

the forefront for preventing falls, it takes a team approach to provide patient safety. Part of this

team includes physical therapists and physicians.

During a hospital stay an adult, despite level of independence, experiences a reduced

level of mobility (Johnson, Kuperstein, Howell, & Dupont-Versteegden, 2018). Physical

therapists are an integral part of the plan of care for an adult inpatient stay in preventing mobility

decline which reduces fall risk (Johnson et al., 2018). It has been proven that getting patients out

of bed and moving as soon as the first day has better patient outcomes and decreased length of

stay which in turn reduces cost (Johnson et al., 2018).

Establishing the level of patient mobility at admission and providing appropriate

interventions for maintaining or improving a patient’s mobility status throughout their stay will

reduce falls risk (Johnson et al., 2018). According to Morris and O’Riordan (2017), these

interventions include “balance, gait training, range of motion exercises, and strengthening”. It

should be stressed to the patient that these tools should continue to be utilized outside of the

hospital to maintain or improve level of agility.

The other integral part of this equation is the physician. One of the biggest contributors

to this problem is medication. All physicians involved in a patient’s care need to be diligent in

closely monitoring their medications and the potential side effects that contribute to increased
fall risk (Morris & O’Riordan, 2017). Medications that potentiate the problem include narcotics,

psychotropic, and blood pressure medications. By reducing the strength, providing alternative

medications, or removing the medications that contribute to orthostatic hypotension, drowsiness,

lethargy and altered mental status can lead to a large reduction of fall risk (Morris & O’Riordan,

2017).

Conclusion

In conclusion, falls are a preventable sentinel event if everyone does their part by placing

importance on preventing them. Knowing the patient population being cared for and the risk

factors they have is a key in identifying the appropriate action to protect them from such an

event. A team approach reduces hospital costs, length of stay and utilizes less resources.

Ultimately it prevents injury, harm, and promotes safety and quality care.
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