BMJ Quality Improvement Programme

ABSTRACT
Inpatient falls (IF) are the most commonly reported
safety incidents. The high rate of inpatient falls was
reported in a newly built hospital, within Aneurin Bevan
University Health Board, Wales (UK). The aim of the
project is to reduce the incidence of IF and associated
adverse clinical outcomes in a hospital with 100%
single rooms.
The key mechanism for improvement was education
and training of nursing staff around falls risk factors. A
Plan-Do-Study-Act methodology was used and a
geriatrician-led, systematic nurse training programme
on the understanding and correct use of existing
multifactorial falls risk assessment (FRA) tool was
implemented in April 2013.
Pre-training baseline data revealed inadequate falls
assessment and low completion rates of the FRA tool.
Subsequent, post-training data showed improvement in
compliance with all aspects of FRA. Concurrent with
nurse training, the actual falls incidence/1000 patientbed-
days fell significantly from the baseline of 18.19
±3.46 (Nov 2011-March 2013) to 13.36±2.89
(p<0.001) over next 12 months (April 2013-March 2014) and remained low (mean falls 12.81±2.85) until November 2015. Improved clinical outcomes have been observed in terms of a reduction of length of stay and new care home placements, making total annualised savings of £642,055. PROBLEM Ysbyty Ystrad Fawr (YYF) is the newly built, local general hospital providing 100% single rooms with an ensuite facility within Aneurin Bevan University Health Board (Wales, UK). The hospital replaced two previous hospital sites which were mostly comprised of multibedded wards (MB-W) in November 2011. The new hospital (YYF) has a medical assessment unit, an acute medical ward, one general medical ward and three care of the elderly (CoTE) wards in addition to an adult and old age Psychiatry, adult Psychiatry, and elective surgical unit. The quality and patient safety team noticed increased incidents of inpatient falls (IF) in the new hospital and the report was shared with medical and nursing teams. The immediate response was to analyse the IF data for five general medical and CoTE wards with a total of 144 beds providing acute/general medical care and/or geriatric rehabilitation. Most patients admitted to these five wards were older adults (mean age = 72 years). The mean incidence of IF in the new hospital over a period of 12 months was 16.79/1000 patient-bed-days. This IF incidence in the new hospital was high when compared to the two previous multi-bedded hospitals where falls rate was 6.75/1000 patient-bed-days.1 A similar falls rate (6.7 falls/1000 patient-days) has been reported from a 300 traditional multi-bedded hospital providing both acute medical care and geriatric rehabilitation.2 Both the previous and new hospital sites continued to admit acute and sub-acute patients. There was no change in demographics, size, and characteristics of the population except the change in the geography of the new hospital. The new hospital has 144 medical beds and all are single rooms as compared to the previous two hospitals which had 124 medical beds and only 10 were single rooms. Therefore, the new hospital with 100% single rooms provided enhanced dignified and personalised care but this was at the expense of an IF rate almost 2.5 times higher as compared to the two previous hospitals. This was clearly a quality and patient safety issue in the new hospital and action in terms of a hospital falls prevention program was Singh I, Okeke J. BMJ Quality Improvement Reports 2016;5:u210921.w4741. doi:10.1136/bmjquality.u210921.w4741 1 Open Access BMJ Quality Improvement Programme by copyright. BMJ Qual Improv Report: first published as 10.1136/bmjquality.u210921.w4741 on 29 July 2016. Downloaded from http://bmjopenquality.bmj.com/ on September 9, 2019 by guest. Protected urgently needed to prevent harm. Current evidence does not support the use of the fall risk prediction tools in the hospital setting,3 therefore, a team comprised of a consultant geriatrician, ward sister, nurses, and managers were established to explore alternate options to reduce the incident of IF. The initiative used were quality improvement methods to test, implement, and measure the impact of systematic nurse training on falls risk assessment (FRA). The FRA is a nursing tool to assess and mitigate the multiple factors that pose a risk of IF in the hospital setting. The FRA is part of the Health Board Falls Policy and all inpatients above the age of 65 should have falls risk assessment completed on admission. The primary aim of this quality initiative was to reduce the incidence of falls by 25% in the next 12 months. The secondary aim was to reduce any associated adverse outcomes related to falls in the new hospital with 100% single rooms. BACKGROUND Worldwide populations are ageing.4 The prevalence of falls increases with age, from 35% in older adults (>65
years) to 45% in adults over the age of 80.5–6 Older
patients admitted to hospital are at greater risk of
falling.7 IF are a major concern for patient safety and a
marker of care quality and account for almost two-fifths
of the patient safety incidents reported to the National
Reporting and Learning System.8
In literature, the falls rate among hospitalised older
adults has varied from 2% in an acute setting9 to 12.5%
in a rehabilitation setting.10 Overall, the intensity of
falls/1000 patient-bed-days can vary depending on the
ward type and hospital population11 and it has been
reported as 2.2 in acute setting,12 9.2 at the geriatric
rehabilitation wards,13 and 17.1 in the psychogeriatric
ward setting.13
Falls among those in the hospital also tend to result in
more serious complications; with 10 – 25% of such falls
resulting in fracture or laceration.14 Inpatient hip fractures
have higher mortality when compared to those
from the community.15 After adjustment for age and
gender, the odds of inpatient mortality was 2.25 times
higher for inpatient hip fracture and the odds ratio was
raised for both 90-day and one-year mortality.15 IF in
single rooms has been associated with a significantly
higher incidence of hip fracture in a hospital design
with single rooms as compared with a multi-bedded facility.
16 In multivariate analyses, IF had been independently
correlated with significantly higher length of stay
(LoS) and substantially increased utilization of resources
following injurious falls.17 The extra cost of caring to
NHS for patients who have suffered a fall amounts to an
estimated £2.3 billion/year.18 Falls also result in pain,
distress, loss of independence and confidence, in addition
to affecting the patient’s family and carers.
Over the last decade, there has been a trend of constructing
single rooms in many parts of the world to
deliver a high level of patient care whilst minimizing
hospital-acquired infections.19–20 The proportion of
single-occupancy rooms in NHS hospitals is rising and
new hospital design includes greater ratios of singlebedded
accommodation, in some cases 100% single
rooms.21 However, adverse outcomes of single rooms
including reduced social interaction, less surveillance by
the staff, and increased IF have been reported.1 11 22
Multi-bedded wards (MB-W) are often in the line of
vision of the staff and there is added benefit of increased
surveillance by other patients or relatives, thus preventing
IF. In comparison, the observed significant increase
of IF rate in single rooms could be due to several
factors: room size, easy access to ensuite toilet facility,
patients being less visible from nursing stations, delay in
responding to call bell due to increased walking distance
in corridor, or inability to safeguard patients who fall
due to hospital design.16
Currently, nurses are caring for more adults over 65
than any other patient population and hospital admission
is associated with increased risk of falls.1 In order to
provide safe, affordable, and patient-centred care,
nursing education needs to be enhanced fundamentally.
23 Nursing education is available in most health care
settings, but it can be difficult to participate in such
training events due to time and service constraints. The
inability to keep up to date with training and development
not only results in high-stress levels but also compromised
patient care.24–25 Nurse education has also
been shown to reduce work-related stress.26
Falls could be prevented by 18-31% through multifactorial
assessments and interventions.27 A Cochrane
review (2010) on interventions for preventing falls in
older people, suggested that multifactorial interventions
resulted in a statistically significant reduction in the rate
of falls and risk of falling in the hospitals.28 Recent
studies on falls prevention initiatives in acute care/tertiary
hospitals have shown effectiveness in reducing falls
and fall-related injury rates significantly.29–30 However,
there is a dearth of studies exploring falls reduction in
the single room setting.
BASELINE MEASUREMENT
The main outcome measures employed in this project
included the incidence of falls expressed as a rate per
1000 patient-bed-days. Data around the incidence of falls
was gathered using standard hospital data for critical
incidents where IF is recorded on Datix. Datix is webbased
patient safety software for healthcare risk management
which provides a comprehensive oversight of risk
management activities and includes incidents of IF or
adverse events.
The U-control chart (figure 1) shows the falls incidence
per 1000 patient bed days immediately after the
new hospital was opened in November 2011. This
2 Singh I, Okeke J. BMJ Quality Improvement Reports 2016;5:u210921.w4741. doi:10.1136/bmjquality.u210921.w4741
Open Access
by copyright.
BMJ Qual Improv Report: first published as 10.1136/bmjquality.u210921.w4741 on 29 July 2016. Downloaded from http://bmjopenquality.bmj.com/ on September 9, 2019 by guest. Protected
demonstrates a stable but high rate of IF of 19.4/1000
patient-bed-days over 10 months. This was higher than a
very similar elderly care unit in the UK comprised of
eight single rooms and four four-bedded wards (13.3/
1000 patient-bed-days).11 The falls rate observed in the
new hospital was even higher than a psychogeriatric
ward (17.1/1000 patient-bed-days).13
DESIGN
The team including a ward manager, two registered
nurses, a healthcare support worker, geriatric medicine
registrar, senior nurse, hospital manager, and consultant
geriatrician met to discuss the root cause for the high incidence
of IF in the new hospital with 100% single rooms.
The new hospital and two previous hospitals provided care
to the same geographic and demographic population.
The permanent nursing and medical firms from the two
previous hospitals were transferred to the new hospital
site, and new nursing staff and healthcare assistants were
recruited to provide similar 1:7 nurse/patient ratio.
The team undertaking the quality improvement
project also acknowledge the fact that single rooms have
been associated with higher falls risk based on the incident
reporting but no clear mechanism for single rooms
causing falls has either been reported or researched.
Further brainstorming using fish bone analysis highlighted
issues with lack of nurses’ awareness of falls,
insufficient falls training, and knowledge; poor compliance
with completion of the multifactorial FRA; lack of
engagement with therapists; increased work related pressure
with single rooms.
The team agreed to implement an intervention to
raise the nurses falls awareness by introducing opportunistic
informal falls teaching on completing the multifactorial
FRA tool. The decision of the team to raise
nurse awareness through training was justified on the
basis of health board guidance recommending reliable
completion of the FRA tool, availability of resources,
time constraints, and no extra cost was involved.
The statistical process control (SPC), also known as
control chart was used to plot the data in time order to
demonstrate the evidence of improvement. An SPC
chart has a central line for the mean values, an upper
line for the upper control limit (UCL) and a lower line
for the lower control limit (LCL).
STRATEGY
The project team used Plan-Do-Study-Act (PDSA) cycles
to test the effects of the interventions employed. The
initial PDSA cycles tested opportunistic informal falls
awareness in one ward. The initial structure for repetitive
testing of change was ‘a reminder to complete FRA
during weekly multidisciplinary meeting’. This was
studied by four weeks and team agreed to implement a
reminder on daily ward manager led ‘patient status at a
glance board rounds’. This was implemented on a
small-scale to test in the same ward but no change in
reduction of incidents of IF was noted. The team tested
to include ‘a prompt for completion of the FRA during
nurse’s handover’ in the morning and evening. The
results showed inconsistency among nursing staff and
the team agreed to introduce ‘registrar led weekly teaching’
on falls awareness. The teaching was well received,
raised the falls awareness amongst nurses, and some
reduction of recurrent falls was observed. However,
teaching sessions were missed due to other on-call and
training commitments of the registrar. All the PDSA
were studied and agreed action was to commence the
‘consultant led weekly teaching’ and invite nursing staff
from all the five medical wards to spread and drive the
improvement.
The data was plotted on an annotated U-control chart
in order to demonstrate progress over time. Despite
observing a slight reduction in the incidence of IF over
initial 16 months, it started regressing towards the mean
(Figure 2).
Following evaluation of the initial repetitive PDSA
cycles and learning achieved through interventional
experiments, the team agreed that the intervention has
shown some improvement on initial small scale testing
but further changes should be made.
The project team met several times to gain an understanding
of staff perception, attitude, and factors leading
to the high rate of IF in the new hospital. Whilst
Figure 1 Baseline statistical
process U-control chart displaying
incidents of inpatient falls over 10
months.
Singh I, Okeke J. BMJ Quality Improvement Reports 2016;5:u210921.w4741. doi:10.1136/bmjquality.u210921.w4741 3
Open Access
by copyright.
BMJ Qual Improv Report: first published as 10.1136/bmjquality.u210921.w4741 on 29 July 2016. Downloaded from http://bmjopenquality.bmj.com/ on September 9, 2019 by guest. Protected
numerous solutions were explored such as having a day
room or modifying the FRA, the prevailing issue agreed
was the lack of systematic and structured nurse training
around understanding and mitigation of risk factors
leading to falls in the hospital setting. The team
acknowledged the challenges to deliver training sessions
to all grades of nursing staff but this decision was justified
based on inadequate audit findings on the compliance
with the use of the FRA tool and the fact that
nurses are the first point of contact with patients and initiate
FRA. These challenges were overcome through
team commitment to a shared agenda to prevent falls
and improve patient safety.
The new strategy was to introduce ‘formal systematic
structured nurses training on falls’ every two weeks from
April 2013. A consultant geriatrician with a special interest
in falls, senior nurses, and ward managers were consulted
to develop the structure of falls training. All
nurses on the CoTE and general medical wards were
enrolled in the falls training and it was agreed to commence
formal teaching in the education centre.
Teaching was done based on the national UK guidelines
published by NICE around prevention of falls and
National Service Framework for older people.
The structured teaching was delivered by a consultant
geriatrician (IS) with a special interest in falls or a geriatric
medicine trainee (SA, MK, JO) at regular intervals
(fortnightly) in small groups. This was done to ensure
each staff member attended at least one teaching
session.
Each training session lasted 45 minutes and included
discussion on the definition of falls, understanding complications
of in-patient falls, interactive case-based discussion
to underpin falls, risk factors from nurse’s
experience, and reflective practice. Each session ended
with formal teaching on falls risk factors including
dementia, delirium, nutrition and continence, and guidance
on completion of the formal health board document:
A multifactorial FRA tool.