In­ter­dis­ci­plinary Qual­ity Im­prove­ment Ini­tia­tive Re­sults in 63% Re­duc­tion in Pa­tient Falls

Modern Healthcare - - REGIONAL NEWS -

Back­ground & Ra­tio­nale

Ac­ci­den­tal falls are a ma­jor pub­lic health prob­lem in the United States. This pub­lic health prob­lem ex­tends to pa­tients who fall ac­ci­den­tally dur­ing hos­pi­tal­iza­tion. In 2010, The Joint Com­mis­sion re­viewed the largest num­ber of non­fa­tal fall-re­lated events re­sult­ing in death or per­ma­nent loss of func­tion since 1996. Falls are as­so­ci­ated with in­creased mor­bid­ity and mor­tal­ity, de­creased qual­ity of life, and in­creased length of hospi­tal stay. Re­searchers es­ti­mate that non­fa­tal fall-re­lated costs range be­tween $16 and $19 bil­lion per year.


On the Fam­ily Prac­tice Unit at Huntsville, a nurs­ing man­ager and other clin­i­cal de­ci­sion mak­ers de­vel­oped an on­go­ing QI ini­tia­tive that in­te­grated ev­i­dence-based guid­ance on fall preven­tion with clin­i­cal care, and uti­lized ed­u­ca­tion and com­mu­ni­ca­tion to en­hance care­giver com­pli­ance as well as ac­count­abil­ity re­lated to fall preven­tion. In 2009, bed tech­nol­ogy was updated with the pur­chase of beds with bed-exit alarms and the en­hanced abil­ity to mon­i­tor 3 zones of pa­tient mo­bil­ity in the bed as well as bed con­fig­u­ra­tion.

Clin­i­cal Im­pli­ca­tions

Ef­fec­tive preven­tion of pa­tient falls re­quires an in­ter­dis­ci­plinary, team ap­proach. Well-de­signed QI ini­tia­tives that uti­lize ev­i­dence-based best prac­tices in com­bi­na­tion with tech­nol­ogy in­te­gra­tion can im­prove pa­tient qual­ity of care and out­comes.

Clin­i­cal Set­ting

Ef­fec­tive fall preven­tion re­quires a mul­ti­dis­ci­plinary, team ap­proach. Huntsville Hospi­tal in Huntsville, Alabama has fo­cused on pro­vid­ing high-qual­ity care to the community since 1895. It is one of the largest locally owned, not-for-profit hos­pi­tals in the coun­try, with 881 li­censed acute care beds. A qual­ity im­prove­ment (QI) ini­tia­tive fo­cused on fall preven­tion was im­ple­mented at Huntsville af­ter The Joint Com­mis­sion and other na­tional health ini­tia­tives high­lighted the im­por­tance of ag­gres­sive fall preven­tion.


Huntsville Hospi­tal uses the Stryker S3® Med/Surg Bed con­fig­ured to in­clude the Chap­er­one® Bed Exit Sys­tem with Zone Con­trol® and iBed® Aware­ness Smart Bed Mon­i­tor­ing Sys­tem. The Chap­er­one sys­tem tracks a pa­tient’s cen­ter of grav­ity through three con­cen­tric zones of sen­si­tiv­ity while the iBed Aware­ness sys­tem al­lows care­givers to se­lec­tively and ac­tively mon­i­tor cus­tom bed con­fig­u­ra­tions.


With updated bed tech­nol­ogy, updated poli­cies, on­go­ing ed­u­ca­tion, com­pli­ance mon­i­tor­ing, and on­go­ing root cause anal­y­sis, this QI ini­tia­tive re­sulted in a rel­a­tive re­duc­tion in to­tal falls of 63%.

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