Reducing Falls in the Hospital Setting Paper. Running Head: REDUCING FALLS IN THE HOSPITAL SETTING Reducing Falls in the Hospital Setting David Arnquist and Brittany Mayfield Texas Tech University Health Sciences Center NURS 4342-003 February 6, 2018 1 REDUCING FALLS IN THE HOSPITAL SETTING 2 Reducing Falls in the Hospital Setting According to The Joint Commission’s National Safety Goals, we must “prevent residents from falling” (2018). In this paper we will discuss the consistencies and gaps of information among three articles of study relating to reducing falls in the hospital setting. We have developed a question based this safety goal, developed by The Joint Commission, to focus our research. We will utilize this research to validate policies and help change those which may need to be readdressed. By evaluating evidence and applying it to our practice, we can help promote patient safety in our places of work. REDUCING FALLS IN THE HOSPITAL SETTING 3 For patients in the hospital setting, will lower nurse to patient ratios be more effective in reducing falls? P (Population of Interest): Patients over 18 years of age I (Intervention of Interest): Staffing, alarms, and rounding to reduce falls. C (Comparison of Interest): Nurse to patient ratios O (Outcome of Interest): Reduce falls T (Time): Patients during hospital stay Articles (level of evidence/evaluation of strength of the evidence) Protecting Patient Safety: Can Video Monitoring Prevent Falls in High-Risk Patient Populations? Level = 3 Strength = A Who Involved (sample size, sampling method, population) Size = 1508 cases Sampling method = targeted sample Population = hospitalized patients at high risk for falling What Occurred (qualitative, quantitative) Where Completed (type of agency, state, country) Quantitative Agency = West Virginia University School of Nursing Country = USA When (year research done) 2013 Why (research question) Does the use of centralized video monitoring reduce patient falls and injuries associated with falls and reduce the use of observational sitters for fall prevention? How (data collection, tool used with validity and reliability, statistical tests, qualitative control) Data collected = Number of patient falls, injuries resulting from falls, observational sitter usage, videomonitoring technician records, and sitter data for each of the four units. Tool used = Hendrich II Falls Risk Assessment with validity and reliability not provided. Consistencies (how addresses the PICOT question, how alike with other studies reviewed) Gaps (how does it not address the PICOT question, what did the researchers state still needed to be studied) Video monitoring significantly reduced the number of patient falls, which is consistent with similar studies. This study addressed the population, intervention, and outcome of our PICOT. This study did not address nurse to patient ratios. Reducing Falls in the Hospital Setting

Reducing Falls in the Hospital Setting Paper. There were not enough video monitoring devices for each patient who met the criteria, due to a high volume of patients and few available rooms. The study states that further research should be conducted for other high-risk populations, such as selfharm patients. REDUCING FALLS IN THE HOSPITAL SETTING Missed Nursing Care, Staffing, and Patient Falls Level = 3 Strength = A Size= 124 patient units in 11 hospitals Sampling method = convenient Population = RN, LPN, nursing assistants, and patients Quantitative Agency = University of Michigan School of Nursing State = 11 hospitals across two states Country = USA 4 November 2008 to August 2009 Do nurse staffing levels predict patient falls? Does missed nursing care mediate the effect of staffing levels on patient falls? Data collected = The average amount of missed care for each unit and the relationship between staffing, case mix index, missed nursing care, and patient falls. Tool used = MISSCARE survey with a content validity index of 0.89 (Kalisch & Williams, 2009) I believe this study addresses all parts of our PICOT question, but that further studies must be conducted to compare across a wider sample size. This study found similar consistencies among studies which have associated falls with missed nursing care. This study explains how further analysis is necessary to develop interventions to prevent a lack of care, which may lead to a fall. (Boswell & Cannon, 2017) REDUCING FALLS IN THE HOSPITAL SETTING 4 Summary of Findings (consistencies and gaps from all articles): Application of findings to evidence-based practice which validates/changes policies and procedures (what policies and procedures does this information directly address and why): REDUCING FALLS IN THE HOSPITAL SETTING Individual discussion of Application of Evidence to Own Practice (name). -One page discussion that’s going to help you in your practice -Finding and reading articles? -Which parts of this course is going to help you in your practice? 6 REDUCING FALLS IN THE HOSPITAL SETTING Individual discussion of Application of Evidence to Own Practice (name). 7 REDUCING FALLS IN THE HOSPITAL SETTING 8 References Nursing Care Center National Patient Safety Goals. (2018, January 1). In The Joint Commission. Retrieved February 6, 2018, from https://www.jointcommission.org/ncc_2017_npsgs/ Kalisch, B. J., & Williams, R. A. (2009, May). Development and Psychometric Testing of a Tool to Measure Missed Nursing Care. Journal of Nursing Administration, 39(5), 211-219. doi:10.1097/NNA.0b013e3181a23cf5 Kalisch, B. J., Tschannen, D., & Lee, K. H. (2012, January). Missed Nursing Care, Staffing, and Patient Falls. Journal of Nursing Care Quality, 27(1), 6-12. doi:10.1097/NCQ.0b013e318225aa23 Sand-Jecklin, K., Johnson, J. R., & Tylka, S. (2016, April). Protecting Patient Safety: Can Video Monitoring Prevent Falls in High-Risk Patient Populations? Journal of Nursing Care Quality, 31(2), 131-138. doi:10.1097/NCQ.0000000000000163 Art & science If you would like to contribute to the Art & science section, email gwen.clarke@rcnpublishing.co.uk The synthesis of art and science is lived by the nurse in the nursing act Josephine G Paterson Hourly rounding in a high dependency unit Lowe L, Hodgson G (2012) Hourly rounding in a high dependency unit. Nursing Standard. 27, 8, 35-40. Date of acceptance: June 25 2012. Abstract The Leeds Teaching Hospitals NHS Trust is one of the many organisations that have signed up to Safety Express, a pilot programme of the Department of Health’s Quality, Innovation, Productivity and Prevention safe care coalition.Reducing Falls in the Hospital Setting

Reducing Falls in the Hospital Setting Paper. Its aim is to reduce avoidable harm to patients in four areas: trips and falls, pressure ulcers, catheter-associated urinary tract infections and venous thromboembolism. Hourly rounding (hourly checks on patients) has been identified as a means of reducing harm to patients. This article describes the preparation needed to introduce hourly rounding in a high dependency unit. Authors Lynsey Lowe Band 6 sister, high dependency unit, St James’s University Hospital, Leeds. Gillian Hodgson Nurse consultant, infection prevention and control, The Leeds Teaching Hospitals NHS Trust. Correspondence to: lynsey.lowe@leedsth.nhs.uk Keywords Falls, hourly rounding, high dependency units, patient safety, pressure ulcers, venous thromboembolism Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software. Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above. © NURSING STANDARD / RCN PUBLISHING p35-41w8.indd 35 Safety Express, a pilot programme of the Department of Health’s Quality, Innovation, Productivity and Prevention (QIPP) safe care coalition (Patient Safety First 2011), identified hourly rounding as a method of keeping patients free from harm, for example by reducing the risk of falls and pressure ulcers (Ford 2010). Hourly rounding requires that nurses check on patients at set times to ensure that their essential care needs are being met (Mason 2012). A trial was undertaken at The Leeds Teaching Hospitals NHS Trust to assess whether hourly rounding could be used in a general high-dependency unit (HDU) to reduce patient harm. The unit has 14 beds, with a staffing ratio of one nurse to two patients. The unit provides care for a variety of patients, including post-operative patients and those who have been transferred from intensive care. The average age of patients is 62 years, with ages ranging from 15 to 96 years. The unit operates an incident reporting method to measure incidence of pressure ulcers, falls and patient complaints. However, patient harm from catheter-associated urinary tract infection (CAUTI) or venous thromboembolism (VTE) incidents are not measured routinely. Background A review of the literature was undertaken to identify the benefits of hourly rounding and how to introduce such a model in an HDU. A search was conducted using CINAHL (Cumulative Index to Nursing and Allied Health Literature), Medline and Google. Initially a narrow date range of 2010-2012 was used. However, few primary research articles were retrieved, and the date range was extended to include articles published between 2001 and october 24 :: vol 27 no 8 :: 2012 35 19/10/2012 12:09 Art & science patient care 2012. The search terms used were ‘hourly rounds’, ‘intentional rounding’, ‘patient safety’, ‘falls’ and ‘pressure ulcers’. The authors located and read four articles that described hourly rounding and its benefits, and seven studies in which rounding had been piloted. However, little information was found in relation to hourly rounding in a critical care environment. The only hourly rounding study identified in critical care was a pilot project in an army medical centre where this method was successfully introduced to reduce the incidence of falls (Weisgram and Raymond 2008). Reducing Falls in the Hospital Setting

Reducing Falls in the Hospital Setting Paper. D’Alessio et al (2010) described hourly rounding as a proactive nursing intervention used to meet patient needs. According to McEwen and Dumpel (2010), rounding should use a pre-determined set of questions or checks, referred to as the ‘four Ps’: Pain: patients’ pain score. Potty: patients’ toileting needs. Position: patients’ need for help with repositioning. Possessions: proximity of patients’ possessions. The aim of the four Ps is to reduce the incidence of falls and pressure ulcers by ensuring that patients are not trying to get out of bed without assistance to go to the toilet or get a drink, and that they receive help to change position. Bates (2011) suggested that rounding is a new term for the traditional ‘back round’, which consisted of two nurses going around each patient ensuring that the bed was tidy, washing the patient’s hands and face when necessary, and massaging their pressure areas. During this traditional back round many of the factors that are addressed in modern rounding, such as hydration, pain relief, elimination and skin condition, were attended to as a task-orientated process. The new method of hourly rounds usually involves a tickbox-style checklist where the type of check and frequency can be adjusted to meet patient needs. The Patients Association (2010a) highlights that patients place a lot of emphasis on the quality of care they receive. In November 2011, the association and Nursing Standard launched the Care campaign. This campaign focuses on the main aspects of care that frequently do not meet expected standards, but form the fundamentals of nursing care (Patients Association 2010b): C – Communicate with compassion. A – Assist with toileting, ensuring dignity. R – Relieve pain effectively. E – Encourage adequate nutrition. Woodward (2009) suggested that hourly rounding ensures that patients know that a member of staff will be available to help them with their immediate needs. Halm (2009) stated that the benefits of hourly rounding include a reduction in patients’ anxiety about their needs being met 36 october 24 :: vol 27 no 8 :: 2012 p35-41w8.indd 36 because they learn to trust the process, prevention of falls, pressure ulcers and unrelieved pain, and improvement in patient satisfaction. Conversely, in mental health care settings, Moran et al (2011) suggested that patients experiencing psychotic symptoms or deep depression may find hourly visits too intrusive or stimulating, and that two-hourly visits may be more appropriate. Rounding log A trial was undertaken at The Leeds Teaching Hospitals NHS Trust to assess whether hourly rounding should be introduced routinely in HDU. The trial was carried out over a two-week period between March and April 2011 and included all patients on the unit at that time. The principles of the Plan, Do, Study, Act (PDSA) cycle were used to assess the effect of hourly rounding (NHS Institute for Innovation and Improvement 2008). This tool can be used to test a change by trialling the idea for a set period then assessing and evaluating it. The NHS Safety Thermometer is an improvement tool for measuring, monitoring and analysing patient harms (NHS Information Centre 2012). It was used to measure patient harm caused by pressure ulcers, falls, VTE and CAUTI in the unit. Measurement began before the rounding trial period commenced and carried on during the trial period. Data were collected once a week on all patients (12 on average) on the unit. Reducing Falls in the Hospital Setting

Reducing Falls in the Hospital Setting Paper. Data from incident reports were also used to measure incidence of pressure ulcers, falls and patient complaints. A rounding log was devised that addressed the factors associated with the four Ps described earlier, without duplicating the factors that are already addressed routinely as part of the unit’s 24-hour observation chart. This proved challenging because common factors such as pain and patient positioning reduce pressure damage (National Institute for Health and Clinical Excellence 2005) are monitored and documented on the 24-hour chart every hour, as part of routine patient care in HDU. Various rounding logs provided through Safety Express were examined and a decision was taken to retain the core factors even though there would be some duplication. For example, dehydration can result in pressure damage and increases a patient’s risk of falling. Although oral intake is documented hourly on the unit’s 24-hour chart, it was included in the rounding log because hydration is crucial in reducing patient harm, promoting comfort and enhancing the hospital experience (Kelly et al 2010). This section of the rounding log also included a prompt to remind © NURSING STANDARD / RCN PUBLISHING 19/10/2012 12:09 staff that if a patient is not allowed to drink or is nil-by-mouth, equipment must be placed near the patient; otherwise he or she may have to get out of bed to get a drink, increasing the risk of falls. The rounding log used in the unit is shown in Figure 1. It was decided to complete the log hourly during the day and every two hours at night to promote rest and sleep for patients. Patients cared for on the unit have several constraints on their mobility, such as invasive monitoring devices, surgical drains and urinary catheters. Because of the severity of their illness patients are weak and unsteady on their feet. These factors may increase the risk of falling when attempting to get out of bed to reach glasses or a tissue, for example. For these reasons a section on possessions was included in the log to remind staff to ensure that all such items are within the patient’s reach. Asking patients if they require the toilet and addressing their toileting needs were included in the rounding log because attending to patients’ comfort and safety may reduce the risk of falls (Halm 2009). The log also prompts nurses to check the position of the urinary catheter bag in catheterised patients. This was to check that the catheter bag was not touching the floor, which could lead to contamination, and that the catheter was positioned below the level of the bladder to promote drainage and to prevent reflux and CAUTI (Department of Health 2007). Patients are sometimes reluctant to ask for assistance or interrupt nurses because they are uncertain whether the nurse is available to help (Woodward 2009). For this reason, wellbeing was included in the rounding log. Asking patients how they feel or if anything else can be done for them gives individuals an opportunity to express any other need or concern without feeling they are interrupting the nurse. Reducing Falls in the Hospital Setting

Reducing Falls in the Hospital Setting Paper. Patient safety At The Leeds Teaching Hospitals NHS Trust, various risk assessments are required to ensure patients receive a high standard of safe individualised care. It was decided that the rounding log should not only be a tool for implementing hourly rounding, but should also be used to check that other risk assessments pertinent to patient safety had been completed. To achieve this, two columns were added to the log so that staff could sign to say that they had checked that all the risk assessments had been completed and updated for the patient on each shift (Box 1). The addition of safety checks to be completed during each shift was to assist in ensuring that the log would be applicable to other areas of patient © NURSING STANDARD / RCN PUBLISHING p35-41w8.indd 37 safety, such as malnutrition, which also contributes to pressure ulcer development (Royal College of Nursing 2001), and to give assurance that practices related to the prevention of healthcare-associated infections were being completed. Implementation All staff in the unit were informed of the hourly rounding process to optimise effective implementation. This included sending an email to all nurses and providing informal verbal training that discussed hourly rounding, the documentation required, and the anticipated benefits for patients and staff. This information was kept in a single file on the unit for all staff to refer to and included an information sheet that staff could take away for their own use. At the start of the morning shift, the nurse in charge would hand out the rounding logs. These were kept on the easel at each patient’s bed space so that it was easy to see and ensure the round was completed. The nurse at the bedside caring for the patient was responsible for carrying out the round and completing the log. On discharge, the log was to be filed in the patient’s notes. It was the responsibility of the nurse at the bedside to start a new log on receiving a new patient admission. To give assurance that the rounding log was being used effectively, several informal checks were conducted over the two-week period. The checks consisted of making sure that each patient had a rounding log in use and that the log had been completed each hour. The checks did not include confirmation that any action required had been taken. Results Rounding logs for 44 out of a possible 51 patients were completed. The patients who did not have a rounding log in use had been admitted to HDU after the logs had been distributed. When auditing the logs, only 25 patients had ticks to say the checks had been done every hour. As there was some duplication of information recorded for both the log and the 24-hour chart, this could have influenced the result. Because of time constraints some nurses may have chosen to document the information on either the log or the 24-hour chart and not both. The columns to check completion of risk assessments were only completed in 29 of the logs. The data collected using the Safety Thermometer showed that between February 17 2011 and the beginning of the trial on March 21 2011 two incidents of patient harm were recorded: a new urinary tract infection and a new category 2 october 24 :: vol 27 no 8 :: 2012 37 19/10/2012 12:09 Art & science patient care 4am Beginning of each shift Malnutrition Universal Screening Tool completed Food chart commenced and completed if required Da …