Safety: Interdisciplinary Quality Improvement Initiative Results in 63% Reduction in Patient Falls
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.
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.
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%.