Quality Improvement Project Eliminates Falls in High Volume Endoscopy Unit

Abstract

Purpose: Our high volume endoscopy unit began a concerted effort to track complications associated with our endoscopic procedures in January of 2008. A result of this effort was the identification of a surprising number of patient falls in our recovery area. In response to this finding, we created and implemented a quality improvement project to eliminate patient falls in the recovery area. Methods: We analyzed each patient fall to try to identify the root cause in each case. We found that most patients that fell were elderly or ambulated with the help of an assistive device and fell while changing clothes in the bathroom unaccompanied. As an improvement project, we utilized a series of questions to ask patients that would help us identify those who are at risk of falling. Once patients were identified as being a fall risk, they would have a special wrist band placed that stated “fall risk” and their chart was highlighted with the same information. Any patient identified as a fall risk would then be accompanied to the bathroom to change by one of our allied health staff and they would leave the recovery area in a wheelchair. We used descriptive statistics to analyze age, gender, use of an assistive ambulatory device, and total number of endoscopic procedures. We used Fisher's exact test to compare the proportion of procedures that were complicated by patient falls before and after the quality improvement intervention. Results: In 2008, we completed 38,370 sedated endoscopic procedures and had 8 patient falls (0.02%). 3 patients were female and the average age was 67 (range 40 - 96). Five of the eight patients that fell were over the age of 70 and/or used an assistive device for ambulation. All patients sustained injuries that required additional medical attention. Three of the 8 patients were taken by ambulance to the ER and one was admitted overnight to the hospital. The remaining five patients were evaluated, treated and released from the recovery room by a physician staff. Our fall prevention initiative started January 23, 2009. In the first 18 weeks of our process change, we have performed 13,857 procedures and have had no falls (p=.056 compared to the same 18 weeks in 2008). Conclusion: These data demonstrate that a simple, low cost intervention in a high volume endoscopy center can completely eliminate patient falls.