Abstract 3585: Improved Fall Prevention Outcomes Utilizing a Fall Kit, New Products, and Standardized Process on a Neurology Stroke Unit

Abstract

Background: Nurses are responsible for identification of patients who are at fall risk, and development of a plan of care to minimize risk in the hospital setting. Therefore, fall rate indicators can be positively influenced by nursing driven safety interventions using an interdisciplinary approach. Barriers to fall prevention and increased fall rates were validated through an assessment of unit nursing practice. Detailed assessment revealed: 1) an inconsistent fall prevention process, 2) lack of fall prevention products and alarm devices, and 3) increased time needed gather fall prevention forms/equipment. This resulted in increased potential risk for harm to patients, and reduced staff compliance. Purpose: The purpose was to implement a comprehensive fall prevention program with goals of 1) reduction in patient fall rate and 2) improvement in nursing compliance through use of fall prevention kits, and access to products/alarm devices. We also want to estimate the effect for a larger study and implementation on other nursing units. Methods: Methodology included the development of: 1 an interdisciplinary team, 2) the contents of a “fall prevention kit” which contained all necessary products and forms (i.e. room/hall signs, patient color-coded socks, patient and family contract/agreement, fall prevention checklist, and patient fall risk identification band) and 3) a standardized fall prevention process including education for all caregivers, patients and families, and 4) a process to improve access to fall prevention items and purchase of new prevention products. The pre- and post-implementation analyses included monthly fall rates, compliance of fall prevention, improved access and use of products, and staff satisfaction with fall prevention processes. Results: Fall Rate with injury pre-implementation defined as # of falls/bed-day x1000 was 1.16 and showed overall improvement post-implementation at a rate of 0.77 (≤.39). Improvement was also shown in compliance of caregivers with the standardized process (100%), reduction in time to access to products/devices reduced by 10 minutes per daily fall assessment episode (avg.10 pts/day= 100 minutes) and staff satisfaction with the new process (95.5%). Conclusion: Prevention in patient falls is critical to reduce risk of injury, cost of hospitalization, prolonged length of stay, disability, and/or death. A collaborative team approach utilizing a standardized process and improved access to products/devices was imperative to improve fall prevention strategies, diminish risk for injury, as well as improve nursing compliance on the stroke unit.