Abstract TP329: Patient Transfer Check Off Decreases Fall Rate on Stroke Unit

Abstract

Background and Issues: Protecting stroke patients from falls and injury is fundamental to providing exceptional care. An increased risk for falls has been recognized among persons with diagnoses of stroke and other neurological disorders. Our Stroke Unit’s comprehensive fall prevention program, while helpful, did not adequately identify stroke patients who would fall. While instituting video monitoring of patients at high risk for falls provided a 20% reduction in fall rate, stroke patients evaluated at low and moderate risk continued to fall. Purpose: The purpose of our practice change was to determine if implementing high risk measures on all patients admitted to a stroke unit until demonstration of five safe transfers would decrease the number of patient falls. Methods: Utilizing a shared responsibility model, our Stroke Unit engaged all staff members in the falls prevention program. Each patient was evaluated using the current falls risk assessment tool. If the patient was scored high risk, full falls prevention measures were maintained. For patients scoring low to moderate risk, a safe patient transfer check off procedure was implemented. Each patient was monitored five times to ensure independent demonstration of all aspects of transfer without support. Upon five safe transfers, the patient’s bed alarm could be shut off and general fall preventative measures maintained. Unit secretaries checked the bed alarm system twice a day to monitor proper activation of alarms. A report was created representing the retrieved information for the charge nurse. The charge nurse followed up with nurses whose patient alarms were not on and ensured proper activation. Results: Since implementation of the safe patient transfer check off, we have seen an additional 33% reduction in fall rate compared to our post-implementation of video monitoring rate (3.48/1000 patient days compared to 5.20/1000 patient days). There were zero falls for patients who were successfully checked off on safe transfers. Conclusion: Implementing a safe transfer check off for mild to moderate fall risk patients on a Stroke Unit may be a successful strategy to prevent falls and fall related injuries. Engaging all staff members in the program increased awareness of the importance of falls prevention.