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July-August 2013 • Vol. 22/No. 4246

Kimberly Foisy, MSN, RN, CMSRN, is Clinical Educator/Administrative Nursing Supervisor, Orthopedic-Neurological Medical/Surgical Unit, North Shore Medical Center (NSMC), Salem Hospital, an affiliate of Partners Healthcare System Inc.; and Assistant Professor, Massachusetts College of Pharmacy and Health Sciences, School of Nursing, Boston, MA.

Acknowledgment: The author gratefully acknowledges Kathy Clune, MSN, RN, Nurse Manager, Phippen 6 and 7; and Taryn Bailey, MSN, RN-BC, Executive Director, Professional Practice and Patient Education Services, for their advice and guidance in the development of this article.

Thou Shalt Not Fall! Decreasing Falls In the Postoperative Orthopedic

Patient with a Femoral Nerve Block

N orth Shore Medical Center (NSMC), Salem Hospital, an affiliate of Partners Health –

care System Inc., is a 250-bed acute care teaching hospital located in Salem, MA, near Boston. The hospital serves a diverse patient population with 12,000 inpatient admissions per year. The hospital’s 32-bed orthope- dic-neurologic inpatient unit, which is split between the 6th and 7th floors of the Phippen Building, has an average daily census of 30 patients. Unit leadership includes a nurse manager, clinical educator, unit coordinator, and one day-shift charge nurse assigned to both floors. Average daily staffing consists of three nurses, two nursing assistants, and a service associate for each 16- bed unit; staff can be assigned to either floor.

Improvement Needs Decreasing patient falls is a

patient safety priority for direct-care nurses. Many regulatory and govern- mental agencies, such as the Centers for Medicare & Medicaid Services (CMS), have set standards and pay- ment incentives to reduce or elimi- nate falls in the health care setting. For example, CMS (2011) no longer reimburses for hospitalization if a patient has an injury as a result of an inpatient fall. Some health care providers suggest falls cannot be avoided (Muraskin, Conrad, Zheng, Morey, & Enneking, 2007). However, staff members for the involved units at NSMC were determined to count- er this view by taking action to address a recent increase in patient falls on the unit.

Phippen 6 and 7 house postoper- ative orthopedic and neurological

surgical patients. Each floor has 16 private beds. A group of multidisci- plinary professionals and unlicensed staff from the two units convened to form a team under the Transitioning Care at the Bedside (TCAB) model (Rutherford, Moen, & Taylor, 2009). The team set a goal to eliminate falls on the unit and started analyzing falls data to determine the rate and cause of falls that were occurring. Data revealed as many as three falls per month associated with femoral nerve blocks (FNBs), with two patients sustaining injury from January to July 2009. The unit had a fall rate of 5.2 per 1,000 patient days, compared with a fall rate of 3.43 per 1,000 patient days for the facility. Further data analysis showed 5 of 30 falls reported during that time occurred in patients with a femoral nerve block in place following knee arthroplasty.

A process flow analysis revealed the nursing practice protocol recent- ly had been replaced by a standard computerized nursing order set that did not include assessment parame-

ters for the patient or a plan of care. Furthermore, the signs at the head of the patients’ beds stating “Fall Risk Femoral-Nerve Block” were being removed as soon as the FNB was dis- continued. A learning needs assess- ment demonstrated nursing assis- tants did not have adequate knowl- edge of the definition, purpose, and precautions needed in caring for a patient with a current or recently discontinued femoral nerve block. In addition, patients and families were not aware of the safety risks needed during and after the use of a contin- uous femoral nerve block.

Literature Review Two searches of the CINAHL data-

base were performed to identify best practices (June 2009; May 2011) for literature of the preceding 6 years. The terms searched included femoral nerve block, falls, and orthopedic sur- gery. The search revealed no pub- lished nursing literature that demon- strated a decrease in falls in persons with femoral nerve blocks after an

Advanced PracticeAdvanced Practice

Kimberly Foisy

A Transforming Care at the Bedside model was used to decrease falls in the femoral nerve block (FNB) patient population on a 32- bed orthopedic/neurologic unit in a community hospital setting. A multifaceted, strategic practice and educational bundle was implemented, resulting in a 75% decrease in falls among patients with FNB.

July-August 2013 • Vol. 22/No. 4 247

educational intervention was imple- mented to nursing staff. Results of two medical studies are described in the following paragraphs.

Sharman, Iorio, Specht, Davies- Lepie, and Healy (2010) reported patients with a FNB have a shorter length of stay. According to these authors, patients ambulate earlier as a result of the comfort maintained with the block. A large percentage of postoperative falls among this group of patients have quadriceps weak- ness as a contributing factor.

Continuous FNB provides effec- tive pain management as an anal- gesic adjunct to other modalities for orthopedic patients. A FNB reduces the required doses of general anes- thetic agents and hence their side effects, including nausea, vomiting, drowsiness, and respiratory depres- sion. The FNB also confers superior pain management, decreases opioid requirements, and enables earlier ambulation and hospital discharge (Atkinson, 2008). The use of FNB with general anesthesia also places the patient at a higher risk for falls.

A continuous FNB is used as an anesthetic. A catheter is placed just below the skin surface, next to the femoral nerve. The catheter coats the nerve with anesthetic, blocking transmission of neuronal messages and creating a feeling of localized numbness for the patient (Kasibhatia & Russon, 2009). This block allows the patient to achieve more effective pain management. The block does not alleviate the pain on the posteri- or portion of the knee. An adjunct therapy, such as patient-controlled analgesia, often is prescribed for this reason. Because the block causes a weakness of the quadriceps muscle, the patient needs assistance with every transfer (Atkinson, 2008).

One of the cases analyzed by the team involved a patient who was ambulating with a nursing assistant. The continuous femoral nerve block had been discontinued 2 hours earli- er. The patient’s knee buckled, and he proceeded to fall to the floor. The nursing assistant hit the door and sustained a minor back injury. The patient’s knee wound opened as a result of the fall, requiring minor suturing. Fortunately, the patient’s

length of stay did not increase as a result of this fall.

Continuous Quality Improvement Model

After reviewing the data, the team developed a multifaceted plan to educate unit staff on the safety and care of patients with femoral nerve block, as well as standardize the process for patient care following femoral nerve block. The Nerve Block Bundle included developing and implementing a: 1. Patient and family education

sheet to engage patients in their care (see Figure 1).

2. Revised nursing protocol to standardize the process for care.

3. Nursing education plan. 4. Fall prevention signage specific

to this population (see Figures 2 & 3).

5. Tip sheet for unlicensed assistive personnel (UAP) to reinforce the care and safety needs of the patient with a FNB (see Figure 4).

The education plan and bundle were presented at the NSMC Nursing Professional Practice Council, ac –

cepted into practice, and imple- mented August-October 2009.

Patient/Family Education Sheet

Patient and family education are vital in preventing falls (Agency for Healthcare Research and Quality, 2010). The patient/family education sheet (see Figure 1) includes informa- tion related to pain management, duration of the femoral nerve block, sensation of the lower extremity, and safety guidelines to reinforce the patient’s need to call for assistance to get out of bed.

Nursing Protocol Sharma and co-authors (2010) rec-

ommended hospitals develop proto- cols addressing decreased quadriceps function as a result of a continuous FNB. Prolonged nerve blockade can last up to 30 hours after termination of the continuous femoral nerve block (Atkinson, 2008). This study recommended the implementation of a postoperative evaluation that included proprioceptive function.

FIGURE 1. Femoral Nerve Block Patient Information Sheet

• The femoral nerve block is a regional anesthetic technique used in con- junction with general anesthesia for pain relief.

• It is an effective block that provides both safe and excellent surgical anesthesia and postoperative pain control.

• Your leg will feel numb, but you can still move your leg • You will have little or no pain in the front of your leg or knee. However,

you will probably have some discomfort behind your knee. That is expected.

• Remember to discuss your pain plan with each nurse. • REMEMBER: Ring your call bell for assistance. • You MUST NOT get out of the bed or chair, or off the commode without

assistance. • Your therapist and/or nurse will instruct you on the safest ways to move. • The numbness and weakness from the block usually lasts 8-20 hours

and occasionally more than 24 hours once it is removed from your groin.

• As the block begins to wear off, you should start your pain medicine that was prescribed by the surgeon. REMEMBER: Ask the nurse for your pain medication. The nurse will be offering you pain medication, but you need to ask as well.

Thou Shalt Not Fall! Decreasing Falls in the Postoperative Orthopedic Patient with a Femoral Nerve Block

July-August 2013 • Vol. 22/No. 4248

Based upon this evidence, a nurs- ing protocol was written to include the following: 1. Assess the sensory, motor, and

vascular condition of the extremity every 4 hours during and after removal of the femoral nerve block until the patient obtains full sensation and motor function returns.

2. Maintain fall precautions for the duration of the patient stay, regardless of assessment of

FIGURE 2. Fem Block Stop Signage

STOP

Do Not Get Out of Bed Call for Help

FIGURE 3. Fall Prevention Signage

Fem-Block High Risk for Falls!

Patient: Room: Date/Time Stopped:

return of motor function and sensory function.

3. Maintain fall risk signage for the duration of the patient stay.

4. Place signage at the head and foot of the bed to reinforce mes- saging for the patient, family, and staff (see Figures 2 & 3).

Fall Risk Signage Patients typically have the FNB

removed on postoperative day 2 in

the early morning. Patients generally are discharged on postoperative day 4 either to home or a rehabilitation facility. To im prove patient safety, the team decided signage would remain for the entire length of stay.

UAP Education/Tip Sheet Based on findings from the litera-

ture, a one-page educational sheet was developed for all UAP (see Figure 4). The tips were developed by the

FIGURE 4. Safety in Caring for the Patient with a Femoral Nerve Block

A femoral nerve block is a peripherally inserted catheter that delivers a numbing medicine to cover the femoral nerve. A TKR patient usually has the catheter in place for 48 hours.

Structures Seen on Ultrasound in Left Femoral Space (viewed from foot)

The catheter is placed just below the skin surface, next to the femoral nerve. The catheter coats the nerve with numbing medicine; this allows for blocking of the painful sensations from the hip down the patient’s leg.

The medicine will numb the patient’s leg. The thigh muscle, or quadriceps, will be very weak.

The leg will be warm, and may be slightly warmer than the non-affected leg.

The patient will always need two assists when getting out of bed with this catheter in place and for a certain period of time after removal.

Maintain the patient on The Falling Star Program.

After removal of the femoral nerve block, the same safety precautions will remain until the patient has regained complete sensation in the leg. You need to check with the nurse before moving the patient to determine if the patient has feeling back in his/her leg and identify if the patient can be transferred with one assist.

Source: Reprinted with permission from Vander Beek, J. (2005).

Advanced Practice

July-August 2013 • Vol. 22/No. 4 249

Atkinson, H.D. (2008). Postoperative fall after the use of the 3-in-1 femoral nerve block for knee surgery: A report of four cases. Journal of Orthopaedic Surgery, 16(3), 381-384.

Centers for Medicare and Medicaid Services (CMS). (2011). Medicare fact sheet: Proposals for improving quality of care during inpatient stays in acute care hospi- tals in the fiscal year 2011 notice of pro- posed rulemaking. Retrieved from http:// www.cms.gov/Medicare/Medicare-Fee- for-Service-Payment/AcuteInpatientPPS/ downloads/FSQ09_IPLTCH11_NPRM04 1910.pdf

Kasibhatia, R.D., & Russon, K. (2009). Femoral nerve blocks. Journal of Perioperative Practice, 19(2), 65-69.

Muraskin, S.I., Conrad, B., Zheng, N., Morey, T.E., & Enneking, M.D. (2007). Falls associated with lower-extremity-nerve blocks: A pilot investigation of mecha- nisms. Regional Anesthesia and Pain Medicine, 32(1), 67-72.

Rutherford, P., Moen R., & Taylor, J. (2009). TCAB: The “how” and the “what.” American Journal of Nursing, 109(11), 5- 17.

Sharma, S., Iorio, R., Specht, L.M., Davies- Lepie, S., & Healy, W.L. (2010). Compli – cations of femoral nerve block for total knee arthroplasty. Clinical Ortho paedics and Related Research, 468(1), 135-140.

Vander Beek, J. (2005). Finding the femoral nerve. Retrieved from http://www.neurax iom.com/html/finding_the_femoral.php

ADDITIONAL READINGS Schulz-Stubner, S., Henszel, A., & Hata, J.S.

(2005). A new rule for femoral nerve blocks. Regional Anesthesia and Pain Medicine, 30(5), 473-477.

Turjanica, M.A. (2007). Postoperative continu- ous peripheral nerve blockade in the lower extremity total joint arthroplasty population. MEDSURG Nursing, 16(3), 151-154.

FIGURE 5. Falls Associated with Femoral Nerve Blocks per Month

(January 2009 – September 2010)

TCAB team in collaboration with physical therapists. This education guide was reviewed with and sup- plied to all UAPs, and has been incorporated into new hire orienta- tion for employees on these units. The educational process consisted of either 1:1 education or group ses- sions. The educator continued to contact UAPs individually to vali- date understanding of the informa- tion provided.

Nursing Implications In the calendar year 2009, Phippen

6 and 7 had a reported falls rate of 5.2 per 1,000 patient days. Following implementation of the FNB educa- tion plan and bundle, the unit fall rate decreased to 2.9 per 1,000 patient days, with a facility reported rate of 3.52 per 1,000 patient days (see Figure 5). The bundle was effective in decreasing falls among patients with FNB, also contributing to the im – proved overall fall rate.

The team has been able to sustain the gains, in large part because of the interdisciplinary and multifaceted approach to analyzing the issue, pro- viding education, and implementing necessary practice changes. The sig- nage has continued to have a posi- tive influence on the fall prevention project as it serves as a helpful visual reminder for staff, patients, and fam- ilies. Education, audits, and re mind –

ers to keep signs in place are ongo- ing. Staff members now utilize the two-person assist method with all affected patients during the duration of the FNB as well as after the block is removed, until sensation and motor function have returned as determined by the nurse. Patients are more aware of the need for assis- tance now due to the signage and education sheet. Patients and fami- lies have identified the value of the information. All newly hired staff members review the bundle during the orientation period. Fall data also continue to be evaluated.

Conclusion The TCAB approach engaged unit

leaders, clinicians, and patients to improve the quality and safety of patient care on two orthopedic- neurologic units. There was only one recorded fall in patients with FNB after implementation of the FNB bundle, from September 2009 to December 2010. It is amazing what a little bit of knowledge and education can accomplish!

REFERENCES Agency for Healthcare Research and Quality.

(2010). The falls management program: A quality improvement initiative for nurs- ing facilities. Retrieved from http://www. ahrq.gov/research/ltc/fallspx/fallspxman ual.htm

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Thou Shalt Not Fall! Decreasing Falls in the Postoperative Orthopedic Patient with a Femoral Nerve Block

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