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Evidence-Based Practice: The Importance of Developing a Comprehensive Fall Prevention ProgramAmanda Brunner, Sarah Caudle, Stephanie Cheers, Jazzarae Dozier, and Lesslie Duncan UNCW School of Nursing Nursing 415AbstractPatient falls are one of the most frequent adverse events in an acute care setting, and are a significant area of concern for healthcare providers.? In-hospital falls can potentially cause life-threatening injuries, increased length of stay, and significantly raise treatment costs. The five phases of the Stetler Model were used for research utilization and facilitation of evidence-based practice.? During the preparation phase the issue at hand and the desired outcomes were established.? Peer-reviewed research articles were analyzed during the validation phase, and the evidence was determined to be reliable.? The third phase of the Stetler Model allocated a comparison of the evidence, and a decision was made that a comprehensive fall prevention program is the best solution to decreasing the rate of patient falls.? During the final phases of the Stetler Model the evidence was translated into applicable procedures for utilizing the research within the hospital setting. Single nursing interventions that are used to prevent falls are not as effective as a program that uses multiple interventions.? Preventing falls in the hospital setting should be top priority, and hospital administration need to implement evidence-based practice in policy and procedure.? The evidence proves that a comprehensive fall prevention program needs to be in place.Keywords: fall prevention, hospital falls, fall interventionsIntroductionPatient falls are a significant area of concern for healthcare providers, primarily nurses. The American Nurses Association has created the National Database of Nursing Quality Indicators identifying patient falls as a specific measure directly related to the structure and process of nursing care (NDNQI, 2012). Patient falls are one of the most frequent adverse events in an acute care hospital setting. According to Shorr et al. (2012), patient falls pose many problems including potentially life-threatening injuries, increased length in hospital stay and raise treatment cost by more than $4,000 per patient. In fact "the length of stay increases by an average of 6.27 days" due to fall-related complications (Butcher, 2013, p.27). In order to create positive patient outcomes, this nurse sensitive indicator has been given high priority in nursing research to determine effective interventions for the prevention of patient falls. While current research does suggest an increase in the incidence of patient falls, it also highlights the impact nurses have on preventing them through continued research and implementation of effective interventions. Promising research and approaches exist, but better implementation and intertwining of necessary interventions is critical to successful prevention of patient falls while hospitalized. Using the Stetler model, this research review seeks to determine how a comprehensive fall prevention program is more beneficial at reducing patient falls, then a single intervention when implemented on high risk hospitalized patients.Validation StepThe validation phase of the Stetler Model, various articles were identified for analysis related to the prevention of patient falls. Given the popularity of the research topic and the various areas of interest within the group, a large body of research was identified. Article SelectionTo identify these articles, each member engaged in an integrative review of existing scholarly, peer-reviewed research publications. As a group, several database searches were utilized including, the University of North Carolina Wilmington’s Randall Library search engine, Consumer Health Complete, and Google Scholar. This search was fine-tuned using Medline, the National Institutes of Health collection, SAGE Journals, OVID database and Ebscohost. Key words used during this search included “bed alarm”, “fall prevention”, “hospital”, “inpatient”, “elderly”, “nursing interventions” and “hourly rounding”. Additionally, care was given to research within the last 10 years. Summary of the ArticlesThe article, “Effects of an Intervention to Increase Bed Alarm Use to Prevent Falls in Hospitalized Patients” used a cluster-randomized trial to examine whether an intervention aimed at increasing bed alarm use decreases hospital falls and related events (Shorr et al., 2012). The study was conducted at Methodist Healthcare University Hospital. The hospital’s 16 units were divided into two groups – the control group and the intervention group. Those units that were in the control group had bed alarms available, but were not made, told or encouraged to use them. The units that comprised of the intervention groups were all given extensive education and training on the bed alarms. They were also encouraged to use the alarms. The results disclosed that “randomized trial of an intervention to increase bed alarm use in hospital nursing units showed that increased use had no statistically significant effect on the number or rate of falls, injurious falls, or patients restrained on intervention compared with control units” (Shorr et al., 2012, p. 697). ?The study concludes that the bed alarms may prove useful with a well-established fall prevention program, although they are not a simple fix to reduce falls. The research article, “Fall Prevention in Acute Care Hospitals” is a study to determine the “effectiveness of the fall prevention tool kit (FPTK) on patient fall rates in 4 short-stay hospitals” (Dykes et al., 2010, p. 1913). Four hospitals in the state of Massachusetts conducted a random study to test the fall prevention tool kit.? “Qualitative inquiry was used to?identify barriers and facilitators to fall risk communication and interventions” (Dykes et al., 2010, p. 1913). The FPTK was then developed using the Morse Falls Scale risk factors that developed customized interventions to meet the individual needs of the patient (Dykes et al., 2010). Once this information was evaluated, patient information handouts and nursing plan of care was produced.? Four medical units from two separate hospitals met the criteria of having a higher than normal fall rate. Each unit was randomly assigned to the intervention unit or control unit (Dykes et al., 2010).? This research study received approval from the Institutional Review board prior to beginning the study.? It was found that there was fewer falls on the units using the fall prevention tool kit in comparison to the control units.? The study also “found that patients aged 65 or older benefited most from the FPTK…although fewer falls occurred overall in intervention units, this difference was noted only for patients aged 65 years or older” (Dyke et al., 2010, p. 1915).? This study shows that using a fall prevention plan that identifies specific needs of each patient as well as implementing patient education will benefit in the reduction of falls in the hospital setting. “Nurses’ Solutions to Prevent Inpatient Falls in Hospital Patient Rooms” addressed extrinsic risk factors relating to inpatient falls, and used findings from nurse interviews to come up with twenty-four solutions to reduce falls within the hospital setting (Tzeng & Yin, 2008). In 2005 the Joint Commission put together five main causes of falls, which are inadequate caregiver communication, inadequate staff orientation and training, inadequate assessment and reassessment, unsafe environment of care, and inadequate care planning and provision. The nurses interviewed were asked to give their perspective on how to remedy, or find solutions to, the Joint Commission’s five causes of falls. The Joint Commission focused on caregiver’s capabilities and efforts as the reason for falls, and the nurses interviewed focused on unsafe care environment. The conclusion was that prevention of fall-related injuries should be a hospital design principle and hospital administrators should be able to incorporate the research study’s results into their hospital renovation projects or in new hospital building designs.The research as a whole is very important for the healthcare community since the cost of falls is very significant not only to the hospital, but also to the patient and the patient’s family. The research utilizes the largest asset that the healthcare community has, which is the invaluable nursing force. Nurses are on the front lines so to speak, and are the best resource for hospital policy and procedure implementation.The article “Falls Prevention in Hospitals: An Integrative Review” presented a comprehensive review of existing successful hospital falls programs (Spoelstra, S., Given, B., and Given, C., 2011). This study of eleven articles was designed to drive nursing administrators to create falls prevention programs and policies in other facilities. “The articles included adults 18 years of age or older, in various types of hospital units (e.g., rehabilitation, psychiatric, older adult care, or long-term stays)” (Spoelsta et al., 2011, p.97). Using a meta-analysis of existing programs, clinical trials and case-control studies, a wide range of results were reported from 19% to 57%. These results supported implementation of multi-faceted falls prevention program which include: 1) a culture of safety 2) a fall risk assessment tool 3) interventions 4) post fall follow-up and quality improvement. Additional suggestion includes integration with technology and electronic records. The article “Outcomes and Challenges in Implementing Hourly Rounds to Reduce Falls in Orthopedic Units” is a qualitative study to evaluate the effectiveness of hourly rounding and the reduction of falls. The setting for this study included two 29-bed postoperative orthopedic units in a large academic medical center in the Midwest of the United States. The aim of this study was to compare patient falls rates prior to implementing hourly rounding, during the initial hourly rounding and one year following the rounding implementation (Tucker, 2012).?During the study hourly rounding, which includes checking on the patient, every hour to offer toileting assistance and assess position and comfort was implemented. Prior to leaving the room the nurse would make sure the patient has everything they may need including their call bell, remote and bedside table. The patient would be reminded they will be checked on hourly, and to call for assistance if anything is needed before the next round. ?The results show a reduction in falls after hourly rounding was implemented. Fall rates went from 1.8% to 0.8% three months after implementation of hourly rounding. Unfortunately they were back up to 1.1% at the one-year follow up, however when hourly rounding was monitored and charted these rates declined. Not only did hourly rounding reduce patient falls, it also increased patient satisfaction. Article Analysis The strength of the article “Effects of an Intervention to Increase Bed Alarm Use to Prevent Falls in Hospitalized Patients” was that it was completed over an 18-month period, included over 26,000 patients, and the participants were blinded to the study. A notable weakness was that it was conducted at a single site. After the Methodist Healthcare Institutional Review Board looked over the study protocol, they decided to waive the informed consent allowing for this to be a blinded and randomized trial, which authenticates it.A significant weakness of the article “Fall Prevention in Acute Care Hospitals” was the results only showed a decrease in falls when the FPTK was implemented with?adults age 65 or older. An additional weakness was that the study had a short duration, and only lasted approximately six months. Strengths include the study was randomized and had a large sample size of over 10,000 patients from four different hospitals.The strengths of “Nurses’ Solutions to Prevent Inpatient Falls in Hospital Patient Rooms” are the large body of results, and the significance. The weaknesses are the small sample of nurses used, and the possible biases of the two researchers conducting the study. Strengths of “Falls Prevention in Hospitals: An Integrative Review”, include the large body and variety of literature reviewed. Additionally, thousands of patient days were considered in this review. Limitations of this study may account of the variation in results as well as the diversity of in-patient units and variety of interventions implemented on each unit. Additionally, reporting of results was neither standardized nor consistent.Strengths of the study, “Outcomes and Challenges in Implementing Hourly Rounds to Reduce Falls in Orthopedic Units” include planned patient care that is delivered and assessed by nurses by a nursing model that “emphasizes the nurse patient relationship as the foundation of nursing care” (Tucker, 2012). The nursing staff included registered nurses, licensed practical nurses and nurse aids. Limitations to this study include no random assignment or a control parative EvaluationResearch on patient falls has been a continued area of focus due to the overwhelming evidence related to the devastating effects of patient falls.? Theoretically, nursing staff wants to provide the safest environment by maximizing benefits and minimizing possible harm.? Thus, this research was designed to help nursing administration develop policies and programs to prevent patient falls. Our research concludes that single interventions to reduce falls, should be combined into a comprehensive fall prevention plan consisting of multiple interventions. In all the research articles both the characteristics of the sample populations and the setting of the study are very similar to the population and setting that we plan to aim our comprehensive fall prevention program towards. The various studies were conducted at assorted hospitals throughout the country, on all units including general medical, surgical, psychiatry and specialty units. The fact that study results were obtained from multiple units and not one specific unit is appreciated since we intend to make this a hospital-wide project. The patients that participated in the study were of various ages, ranging from 18 years and older. The patient population in the studies is the same population that would benefit from our comprehensive fall prevention program, those that are hospitalized and are considered to be high risk for falls. All hospitals already have some sort of fall prevention interventions in place, rather it be theory or evidence practice based. An example of an evidence base practice intervention would be hourly rounding. An example of a theory based intervention is reminding the patient to call for assistance. This has been a nursing practice for a long time, and it is believed if you tell the patient to call for assistance, they will. Unfortunately, this is not always the case - hence why more than one nursing intervention to prevent falls should be implemented on high fall risk patients.Current research has been conducted in various environments from hospital wide to unit based.? While the standard of current practice stems from the negative effects of patient falls, a gap exists between knowledge of fall risk factors and causes and practices to prevent them.?Effective fall prevention in the hospital setting must include every layer of the organization. Admittedly, implementing change is a complex undertaking. After gaining the proper evidence to implement policy change the next step to institutionalize change, involves a long term plan that must start with gaining the support?and the approval of the CEO or top administrative personal and management. Once our idea has the backing of management it must be presented to the hospitals policy, budget and practice review board. Next, organizations must create a culture of safety with a focus on falls prevention by providing adequate educational and material resources. ?Not only should clinical staff be knowledgeable of fall risk factors and ways to prevent it, nurse managers should facilitate organizational resources and encourage unit staff to implement organizational standards and strategies. ?Nursing staff should assess all patients, utilize hospital resources and develop strategies to best implement falls reduction.??Finally, unit staff, managers, and hospital administration should collect data on falls within the organization to facilitate on-going assessment of the falls prevention program?Most hospital organizations already have some sort of fall prevention intervention in place, but key to preventing falls is a comprehensive fall prevention plan – one that includes multiple interventions intertwined in order to reduce patient falls. Hospital resources are a vital element needed to create a successful falls prevention program. With that being said, most hospitals probably already have the means of developing a proper comprehensive fall prevention program; it is just a matter of developing and formalizing it. An obvious necessary resource is the procurement of interventional equipment such as bed alarms, non-skid socks, identification bracelets, patient education materials, etc. The other fall reduction interventions are just a matter of education and training the staff to hourly round, bedside report, provide a well-lit uncluttered area, and ensure the patient’s call bell is in reach and reminding them to call for any type of assistance. Finally, data collection and evaluation would be crucial to program assessment; therefore, research would be a continued resource for investment.? While an effective falls prevention program would require the cultivation of personnel resources as well as the investment in material goods and information technologies, the potential for positive patient outcome would be a worthwhile and cost effective investment.?Decision MakingAs a group we have conducted high quality research, which has produced many outcomes that are relevant to preventing falls. Our research has led to the importance of establishing a comprehensive fall prevention program. Throughout our research on several different articles, pertaining to preventing falls and current interventions that are in place, we have been able to recognize the strengths and weaknesses of these single interventions. Most of the articles prove that multiple interventions are more effective than one single intervention at reducing falls. Using the research we have conducted, the Stetler model and Kotter’s phases of changes we would like to introduce either a change or modified change in practice in an environment that is similar to the research environment. All of the articles used in this research study took place in a hospital setting; therefore we would like to introduce a comprehensive fall prevention program in a hospital, focusing specifically on those patients that are determined to be high risk for falling as deemed by a fall risk assessment tool such as the Morse Fall Scale. In order to establish this change we will all need to act as an innovator, and develop a vision, communicate the vision, and empower action as suggested by Kotter. To begin to initiate this change in practice we should present our research findings along with our newly developed comprehensive fall prevention program to the hospital’s professional organization, such as nursing congress’s performance improvement board. If they like the idea and we can get them on board I believe they will help up fast track our idea to the top levels of the organization. Some monetary resources may be needed to invest in supplies such as bed alarms, gripper socks, fall bands and more if the organization does not already have these items readily available. ?It would be crucial to present our evidence to upper administration and have them institute policies and procedures related to the falls prevention program. We will also need to reach out to our fellow nurses and other staff members, and provide them with education on how the new comprehensive fall prevention program is designed to work – all interventions but be implemented together for this program to work as intended. Since this program would utilize a lot of resources, we could present a pilot program as an option. ?For example, start this program on one or just a few units, figure out what is most effective at this facility and use this data to make any adjustments before implementing throughout the organization. Introducing the fall prevention program by conducting an in-service to floor nurses and other staff members that provide direct patient care is vital.In order to evaluate the effectiveness of our comprehensive fall prevention program, the number of falls before and after implementation would be recorded and compared. We would expect to see a decrease in fall rates once the comprehensive fall prevention program is in place and implemented correctly. ?The data acquired throughout the program would be evaluated and quality improvement can be a continuous component of the program. Utilizing a collaborative fall prevention program would be valuable and cost-effective for any hospital organization to adopt. ReferencesButcher, L. (2013). The no-fall zone. Hospitals & Health Networks, 27, p. 26-30. Retrieved from , P. C., Carroll, D. L., Hurley, A., Lipsitz, S., Benoit, A., Chang, F., Meltzer, S., Tsurikova, R., Zuyov, L., Middleton, B. (2010). Fall Prevention in Acute Care Association, 304, 17, p. 1912-1918. Doi: 10.1001/jama.2010.1567National Database of Nursing Quality Indicators. (2012, March). Guidelines for data collection on the American nurses association’s national quality forum endorsed measures. Retrieved from NQF-Data-Collection-Guidelines.pdf Shorr, R. I., Chandler, A. M., Mion, L. C., Waters, T. M., Liu, M., Daniels, M. J., . . . Miller, a. S. (2012, November 20). Effects of an Intervention to Increase Bed Alarm Use to Prevent Falls in Hospitalized Patients. Annals of Internal Medicine, 157(10), 692-699. Doi: 10.7326/0003-4819-157-10-201211200-00005Spoelstra, S., Given, B., and Given, C. (2011). Falls prevention in hospitals: An integrative review. Clinical Nursing Research, 21(1), 92-112. Doi:10.1177/1054773811418106Tucker, S. J., Bieber, P. L., Attlesey-Pries, J. M., Olson, M. E., & Dierkhising, R. A. (2012). Outcomes and challenges in implementing hourly rounds to reduce falls in orthopedic units. Worldviews on Evidence-Based Nursing, 9(1), 18-29. Doi:10.1111/j.1741-6787.2011.00227.x Tzeng, H. M., & Yin, C. Y. (2008). Nurses solutions to prevent inpatient falls in hospitalpatient rooms. Nursing Economics, 26(3), 179-187. Retrieved from bc5a-4e8aa9550937%40sessionmgr4001&vid=2&hid=4114 ................
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