Inpatient Falls - A Hospital Wide Approach to Prevention

South Eastern Sydney Illawarra Area Health Service

Abstract

Inpatient falls prevention is a key priority area for hospitals, Area Health Services and State Health. Evidence exists in the literature that it is possible to prevent falls in hospital. This program describes what has essentially been a two year journey using evidence based approaches both in falls prevention and change management techniques that has ultimately led to a significant reduction in the commonest reported hospital adverse event.

 Download the presentation given at the 2008 NSW Health Expo (887 KB).

Aim

To combine research generated evidence with the known principles of change management science to reduce the incidence of falls across a hospital.

Nature of the Problem

Falls in older people are a common problem associated with significant morbidity and mortality as well as substantial costs to health care. Evidence exists to support specific approaches to falls prevention and this includes strategies to prevent falls occurring in hospitals. One of the biggest challenges facing health care is how to take evidence derived in a research setting and apply it in a real life context. This program, targeting inpatient falls, set out to take the evidence from the research setting and combine it with proven change management approaches to put in place a generalisable and sustainable program of falls reduction.

Extent of the Problem

Inpatient falls are the commonest reported adverse event occurring in hospitals in NSW (CEC Annual Report 2006).  Whilst most falls do not result in serious harm, each year approximately 350 people die or sustain a serious injury as a result of a fall occurring in hospital in NSW. All hospital falls are recorded on the Incident Information Management System. Prior to this program of change, data was entered by clinical staff but the information rarely came back to a ward or team in a format that could be used to inform and change practice. Timely sharing of data in a user friendly format has allowed clinical teams to analyse the extent of the problem of falls across the hospital and has shaped the interventions that teams have put in place to prevent falls. On-going regular provision of data has also been a core component of the evaluation process.

Strategic Importance

Falls prevention is a key priority area at Commonwealth and State level. NSW Health launched its Falls Policy in 2004 with implementation plans and linked performance indicators at Area Health level. Inpatient falls prevention is a target area for the Australian Council on Healthcare Standards - EQuIP and the Clinical Excellence Commission. Inpatient falls are on the dashboard at hospital, Area Health, State and Commonwealth level.

Planning and Implementing Solutions

Key to the success of the work has been the combination from the outset of executive level support, clinical leadership and dedicated support from the Clinical Practice and Improvement Unit.

Stage 1 of the program involved setting up the Falls Advisory and Implementation Group (FAIG) which has representation from all medical and surgical wards and includes consumer representation. IIMS data was used at a ward level to develop an understanding of why falls were occurring and common themes emerged across the wards which formed the basis for planned interventions - toileting, management of acutely confused older people, use of night sedation etc.  Wards were actively encouraged to report all falls on IIMS.

Stage 2 saw wards being provided with falls and prescribing data on a monthly basis in a format that is visually easy to interpret. Data is now displayed on every ward in an area that can be easily seen by all staff and is updated monthly. Wards have essentially been given ownership and accountability for their falls as well as being empowered with both the knowledge and skills to change practice. An on-going program of education which has taken the FAIG to a number of existing forums in the hospital has ensured that falls prevention has become and remained a high profile area in the hospital.

Stage 3. Having focused on falls at a ward level, Stage 3 has moved on to try and tackle some of the more complex system level issues that contribute to falls and injury in hospital. Whilst previously only SAC1 events triggered a further investigation, now a template has been devised to ensure that all SAC2 events are investigated by clinical teams and the results of the investigation shared in a constructive manner at the FAIG. Examples include design and layout of certain clinical areas, bed and ward moves for patients, the impact of delays in procedures, use of assistants in nursing, provision of a number of lo-lo beds etc.  The FAIG has also taken a report from a previous death from a fall and turned it into a case scenario which has proved to be a very effective tool for teaching.

Outcomes and Evaluation

Over the last two years there has been a statistically significant reduction in falls across the hospital (r= -.391, p=0.036) (Fig 1a). This has been accompanied by a dramatic reduction in use of night sedation (r= -.740, p<0.001) (Fig 1b) and an increase in the use of Vitamin D  (r= .907, p<0.001).(Fig 1c). The rate of people who fall recurrently has also decreased.

Figure 1a. Falls per 1000 occupied bed days

Figure 1b. Sedatives dispensed per month 

Figure 1c. Vitamin D tablets dispensed per month

At our organisation wide survey in 2007, the work on falls prevention was one of only 5 areas awarded the category of Extensive Achievement by the ACHS survey team. This was at a stage where a significant reduction in falls had yet to be reached but there was recognition that the building blocks were in place for change to occur. 

Sustaining Change

It has taken 2 years to achieve significant change. A heavily resourced project may well have produced results much faster. However, without taking into account the human dimension of change – e.g. attitudes, cultures, and beliefs – it is likely that a project would have produced short terms benefits only. This program has provided staff with the necessary head space to shape and change their own practice. Change has come from within the clinical teams and interventions have been slowly incorporated into routine clinical care in the hope of creating a sustainable change over time.

Future Scope

The approach used in this program is easily reproducible and can be applied to prevent falls in other hospitals in NSW. The principle of combining research generated evidence with change management science can also be applied to many aspects of health care delivery in both the acute and community setting.

References

Contact

This project was entered in the 2008 NSW Health Awards, Making Prevention Everybody's Business category.