Patient falls have been a problem in hospitals for quite some time.
Nancy Donaldson, RN, DNSc, FAAN, clinical professor and director of the Center for Research and Innovation in Patient Care at University of California San Francisco School of Nursing, took the impact of and attention paid to patient falls into account when she began a project to reduce the incidence of patient falls and the severity of fall-related injuries.
Donaldson was able to begin her project with the help of the Collaborative Alliance for Nursing Outcomes Partners for Quality (CALNOC), formally known as the California Nursing Outcomes Coalition, and information gathered from 33 acute care hospital CALNOC members that identified 77 medical-surgical units to serve as project sites.
Coaches and linkers collaborate
The project, which began in 2002 and lasted through the fourth quarter of 2006, used a telephone-based coaching tactic to collaborate with "linkers," or fall prevention champions, located throughout the CALNOC system.
The idea of a linker was crafted by Donaldson using Havelock's Linkage Model, which emphasizes the transfer of knowledge from knowledge generators to users. In this case, it was the coaches' knowledge being shared with the linkers, who in turn shared their information with a CALNOC hospital.
"In the field of education, coaching is effective, not only for facilitating changes in practice, but also for building individual and organizational capacity for continuous improvement," says Donaldson.
The linker was the facilitator between the CALNOC hospital and the coach. Every three to six weeks, the coach talked with the linker on the phone for 30 to 60 minutes.
The coaching team was made up of six registered nurses with specialized knowledge and skills related to research utilization, evidence-based practice, nursing services administration, and fall prevention strategies.
"We used the telephone because it was too expensive to hold monthly visits," says Donaldson. "We did try to regionalize the calls and most of our coaches made at least one site visit."
From there, participating hospitals were asked to fill out a self-assessment tool to take inventory of policies and procedures related to fall risk assessment, prevention, and performance.
Once staff members at the CALNOC hospitals filled out this self-assessment tool, the coaches were assigned to linkers in each facility. The coaches' main purpose was to help linkers develop and implement improvements in fall-related organizational policies. Coaches were also encouraged to:
- Monitor, listen, assess progress, and elicit feedback
- Provide information and support
- Identify action, help with planning, and clarify next steps
- Provide referrals
- Identify resources in the form of individuals, information, and energy
Also, each coach's work was customized to a specific hospital culture and focused on targeted areas of priority work.
Like the coaches, linkers were encouraged to:
- Develop an understanding of the organization's fall patterns
- Report on fall incidents monthly
- Enter fall-related data in an event-reporting system
Mixed results
After the linkers and coaches collaborated for two years, CALNOC distributed another self assessment to determine if there were any improvements in the rate of patient falls from when the project first began.
Although the data showed that little change had been made in preventing patient falls, there was an increase in how often hospitals reported on such events.
Prior to the initiative, 53% of CALNOC hospitals were not evaluating fall prevention equipment, but after the initiative, the percentage climbed to 89% of hospitals.
Also, hospitals that reported fall rates monthly or more often increased from 3% prior to the initiative to 39% after taking part in the initiative, or quarterly from 18% to 57%.
Overall, hospital responses to a fall incident became more systematic, incorporating more elements that would help improve fall prevention in the future.
In addition to improving these percentages on reporting and evaluating fall preventions, the CALNOC hospitals also took away some valuable practices.
The hospitals learned that they must build in a sufficient timeframe for assessing performances along with a leadership commitment. The best performing sites had strong commitment to falls reduction at the top levels along with focusing on the initiative for a minimum of two years.
Also, many sites discovered it was better to customize fall prevention strategies to individual patient needs and to thoroughly investigate each fall.
Continuing to focus on falls
As a follow-up to the patient falls initiative, CALNOC is looking at the difference between the best performers and the worst performers in the project by looking at the data from 2006.
"We look at the data and see who was the best for falls, and look a year later, half the best are no longer the best and half that were the worst are no longer the worst. There is a lot of shifting going on, which is interesting," says Donaldson.
Donaldson wants to see if any parallels can be drawn between the factors that make the best performers the best, and if any of those factors can be found in the worst performers as well.