Abstract WP461: Stop in the Name of Falls

Abstract

Background and Purpose: One of OhioHealth’s strategic priorities includes improving patient safety by eliminating preventable patient harm. The Integrated Stroke Unit (ISU) at Riverside Methodist Hospital worked to achieve this goal by reducing falls by 20%. The ISU consistently experienced a higher fall rate compared to like units across the nation. The ISU averaged over 7 falls per month with injury falls steadily increasing. The ISU experienced inconsistencies related to fall risk assessment and fall prevention interventions. As a result, a Fall Risk Scorecard was created to streamline interdisciplinary team work, increase patient safety, and improve safe patient handling and mobility. Methods: A multidisciplinary approach was used to improve patient safety and determine the root cause for patient falls. A team of nurses, rehab therapist, and patient support assistants was established. Inconsistencies were identified related to recognition of patients at risk for falls, types of fall interventions in place, and bed alarm knowledge and utilization. A need for visual management to standardize practice was seen. A Fall Risk Scorecard was created to help identify fall risk patients, standardize fall prevention interventions, and provide knowledge to staff regarding the patient’s activity level. The PDSA cycle was used to create standard work for the care team. Educational materials were developed and one-on-one training was provided to staff. The multidisciplinary approach helped to create a standardized process for each therapist coming to the ISU. The Fall Risk Scorecard was piloted for 3 months. Results: During the pilot, the unit saw a 57% reduction in falls. Current state, the ISU has continued to utilize the Fall Risk Scorecards and has sustained a 57% reduction in falls. With the utilization of lean methodology, members of the care team were able to ensure the right patient received the right intervention at the right time. With these results, the pilot has been selected for a system-wide roll-out over 11 different care sites. Conclusion: By taking a collaborative approach, utilizing lean methodology, and real-time problem solving, the ISU has successfully reached their goal to increase patient safety and improve safe patient handling and mobility.