Using the article posted below, discuss your individual critical analysis of the posted article with in-text referencing to support your thoughts a

P R A C T I C E I M P R O V E M E N T

Nicole S. C Improvemen ORCID iden

Brittany J. Ko Services, Wa

Michael S. U Professor, Ea

For correspo WakeMed H Raleigh, NC

J Emerg Nur Available onl 0099-1767

Copyright � All rights rese https://doi.or

666 JO

DO NO HARM: A MULTIFACTORIAL APPROACH TO PREVENTING EMERGENCY DEPARTMENT FALLS—A QUALITY IMPROVEMENT PROJECT

Authors: Nicole S. Cook, BSN, CEN, CCRN, TCRN, Brittany J. Komansky, MHA, BSN, RN, CEN, and Michael S. Urton, DNP, APRN, AGCNS-BC, Raleigh and Greenville NC

Earn Up to 8.0 Hours. See page 722.

Contribution to Emergency Nursing Practice

� The current literature indicates that emergency depart- ment falls may be difficult to prevent and predict, how- ever there is a significant gap in available research on this topic.

� This article contributes to the existing literature by describing a unique, multifactorial approach to emer- gency department fall prevention to include data review, fall risk assessment, remote video monitoring, exit alarm strategy, fall prevention culture, and communication.

� Key implication for emergency nursing practice found in this article: a multifactorial fall prevention program is necessary, as no single intervention can address all po- tential causes of patient falls in the emergency depart- ment.

Abstract

Introduction: Patient falls in the emergency department are a unique patient safety issue because of the often challenging nature of the environment. As there are a variety of potential causative factors for patient falls in the emergency department,

ook, Member, Cardinal Chapter-446, is Trauma Performance t Coordinator, WakeMed Health & Hospitals, Raleigh, NC. tifier: http://orcid.org/0000-0001-6672-1546.

mansky, Member, Cardinal Chapter-446, is Director, Emergency keMed Health and Hospitals, Raleigh, NC.

rton is CNS Concentration Director and Clinical Assistant st Carolina University, Greenville, NC.

ndence, write: Nicole S. Cook, BSN, CEN, CCRN, TCRN, ealth and Hospitals, Trauma Services, 3000 New Bern Ave, 27610; E-mail: [email protected]

s 2020;46:666-74. ine 4 June 2020

2020 Emergency Nurses Association. Published by Elsevier Inc. rved. g/10.1016/j.jen.2020.03.007

URNAL OF EMERGENCY NURSING

this project employed a multifactorial approach to prevent pa- tient falls in a Level 1 trauma center emergency department (adult only) in an urban tertiary care teaching hospital.

Methods: This project was a single-unit quality improvement intervention that compared postintervention monthly unit-level data to historic monthly rates on the same unit. The intervention was multifaceted with patient-level, nurse-level, and unit-level interventions employed. A task force was convened to review and identify specific departmental gaps related to fall preven- tion, complete a retrospective review of departmental patient falls to determine causative factors, and implement interven- tions to reduce ED falls. A comprehensive program consisting of an ED-specific fall risk assessment tool, remote video moni- toring (RVM), stretcher alarms, and a robust patient safety cul- ture, among other interventions, was implemented. Patient falls and falls with injuries were tracked as an outcome measure.

Results: After data driven analysis of causation, selection of key interventions, staff education, and sustained focus for 2 years, the department experienced a 27% decrease in falls and a 66% decrease in falls with injuries.

Discussion: A multifactorial approach was an effective strat- egy to decrease patient falls in the emergency department.

Key words: Emergency; Fall; Multifactorial; Remote video monitoring; Safety

Introduction

Patient falls are a safety concern for emergency departments across the country. These events contribute to hospital ad- missions, increased patient morbidity and mortality, and in addition, to increased health care costs.1,2 High patient volumes and the wide variety of patient acuities in the emer- gency department make it difficult to predict and prevent patient falls. Additional factors that have been implicated in ED falls include long distances to restrooms, acute illness

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Baseline adult emergency department falls and falls with injuries, October 2014 to September 2016. Rate ¼ events/(Adult ED Visits/1000). FWI, falls with injuries; Q1, quarter 1; Q2; quarter 2; Q3; quarter 3; Q4, quarter 4; FY, fiscal year.

Cook et al/PRACTICE IMPROVEMENT

states, intoxication, and departmental crowding.1,2 As there are a wide variety of factors potentially leading to ED falls, it stands to reason that there could be a wide variety of inter- ventions that may aid in preventing ED falls. Unfortunately, most fall prevention literature is related to inpatient falls, with limited ED-related literature and available screening tools.

The purpose of this article was to provide an example of how a comprehensive, ED-based fall preven- tion initiative was created and implemented, including the following components: triage-based fall risk assess- ment, application of new monitoring technologies, improved post event analysis, and awareness and recog- nition activities.

Background

The National Database of Nursing Quality Indicators de- fines a patient fall as a sudden, unplanned descent to the floor (or other unintended surface), with or without injury.3

The organization tracks and reports both falls and fall- related injuries to National Database of Nursing Quality In- dicators as part of its quality improvement efforts. In the inpatient setting, both falls and falls with injury (FWI) rates are reported as the number of events per 1,000 patient days (number of events/patient days x 1,000).3 In the emergency department, fall and FWI rates are reported as the number of events per 1,000 patient visits.3

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This quality improvement project was conducted in an adult emergency department, Level 1 trauma center in an urban tertiary care teaching hospital that sees approximately 89,000 adults (aged 18 years and older) per year. It is part of a 3-hospital system with 3 additional stand-alone emergency departments and a separate children’s emergency depart- ment. As the largest emergency department within the sys- tem, this emergency department’s policies and clinical practices serve as the basis for much of the entire organiza- tion’s ED operations.

Although systemwide efforts to eliminate preventable hospital-acquired adverse events had resulted in some suc- cess in reducing patient falls and FWI, a unit-level analysis identified emergency departments as a significant contrib- utor of fall events for the organization. From October 2014 through September 2016 (Figure 1) the adult emer- gency department averaged 62 falls per year for a rate of 0.75 falls per 1,000 visits with approximately 15% of these falls resulting in injury (FWI rate 0.09 injury falls/1,000 visits). During this time, falls from patients in emergency departments across the organization contributed 8.4% of the total system falls.

Reducing the number of ED falls was identified as a crit- ical focus for reducing overall system falls and improving pa- tient safety outcomes. Given the relative size and patient volume of the adult emergency department in comparison to the other emergency departments within the system, unit-level leadership decided that initiating a quality improve- ment project within the adult emergency department would

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provide the best opportunity for program implementation and evaluation of outcomes.

Review of Key Evidence

In emergency departments, falls may be difficult to predict and prevent with the acute nature of patient visits and the brief, episodic encounters.4-6 A review of the current literature surrounding ED fall incidence and ED fall prevention revealed a significant gap in the research surrounding this topic. Most of the research done on the topic of fall prevention has been focused on inpatient hospital settings, including the design of fall risk assessment tools and recognition of fall prevention interventions.2,5,7 In many hospitals, these inpatient tools have been applied to the ED setting despite lack of valida- tion in these populations owing to lack of an ED-specific alternative.8 It has only been in the last few years that small-scale and retrospective studies have been conducted in ED populations resulting in new insight and potential screening tools specifically for the ED setting.8,9

Recommendations for effective fall prevention pro- grams generally include key elements such as (1) population identification, (2) risk factor screening, and (3) an individu- alized, comprehensive plan of care.8,10,11 In addition, pro- grams are encouraged to incorporate a multifactorial approach, working to address individual risk, environmental considerations, and staff knowledge and engagement along with policies and equipment that support fall prevention ac- tivities.10,12

Recent ED-based studies and improvement projects seem to indicate that modified versions of inpatient fall pre- vention tools and policies can be effective in the ED setting but there is a strong need for high-quality research on (1) at- risk populations in the emergency department, (2) ED- specific fall risk prevention activities, and (3) application of new technologies for screening, monitoring and prevent- ing falls in the emergency department.4,7

Methods

This project was a single-unit quality improvement inter- vention that compared postintervention monthly unit- level data to historic monthly rates on the same unit. The intervention was multifaceted with patient-level, nurse- level, and unit-level interventions employed. Statistical anal- ysis of the pre and postintervention fall rates was conducted to establish if the changes were statistically significant

668 JOURNAL OF EMERGENCY NURSING

(a ¼ 0.05). As this work was consistent with a quality improvement project and was not considered research, the work was exempt from Institutional Board Review.

At the start of this project, a fall prevention task force was convened, composed of emergency management, emer- gency nurses, and other emergency staff. The objectives of the task force were to (1) conduct a comprehensive review of adult ED falls to identify trends, (2) identify the ED- specific gaps/needs related to fall prevention, and (3) imple- ment interventions to reduce ED falls and FWI. The team worked with a clinical nurse specialist (CNS) with expertise in patient safety and fall prevention to provide consultation and to assist with the improvement initiative.

The ED fall prevention task force met biweekly in addi- tion to several small group meetings with ED clinical staff to better understand the unique challenges and current gaps in the ED fall prevention practices. An in-depth, retrospective review of fall data helped the task force to better identify the specific characteristics of the ED falls (eg, age, sex, diagnosis, timing, fall risk). A tour of the adult emergency department was conducted with the task force and CNS consultant to review concerns and challenges related to the environment and workflow. These findings were summarized and presented to ED leadership, the system falls committee, and adult ED nursing staff as an initial step to generate in- terest in the topic and encourage engagement from clinical staff.

The key fall prevention barriers identified by the task force were (1) departmental volume and acuity, (2) unit layout and flow (eg, line of sight, shared bathrooms), and (3) the lack of an ED-specific fall risk assessment tool. In addition to these challenges, the task force recognized the need for a strong fall prevention culture on the unit, backed by an engaged and supportive leadership team. Given the varied factors identified and recommendations found in fall prevention literature, a multifactorial approach to preventing falls, including risk assessment, unit culture, electronic medical record (EMR) updates, and novel patient monitoring interventions was initiated.

Interventions

DATA REVIEW

Although chart review and data analysis may not be thought of as an intervention, the success of this fall prevention initiative depended heavily on the initial analysis of ED falls data. Though many patients are identified as being “high risk” for falling, the reality is that most do not fall. Having additional information may aid staff to better predict falls.

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FIGURE 2

KINDER 1 fall risk assessment tool, reprinted with permission from Alexander et al.22

Cook et al/PRACTICE IMPROVEMENT

In addition to establishing baseline fall rates for the adult emergency department, chart reviews were completed to identify common factors and trends related to the falls. Where appropriate, findings were used to guide changes to care and operations based on identified factors. For example, although no significant time-of-day trends were noted, it was found that a disproportionate number of intoxicated patients had fallen, which highlighted the need for changes to the monitoring and bed assignment for these patients.

FALL RISK ASSESSMENT

During the retrospective chart review it was calculated that the Morse Fall Scale (MFS)13 had a specificity of 91% (low rate of false negatives) but only a 23% sensitivity (high fall risk score and went on to fall). Given the poor sensitivity of

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the MFS for patients in this emergency department, a litera- ture search was conducted by the CNS to identify available ED-specific fall risk assessment tools. At the time, only 2 vali- dated fall screening tools had been created for the ED envi- ronment—the KINDER 18 (Figure 2) and the Memorial ED Fall Screening Tool.9 There were no published studies reporting the sensitivity or specificity of either tool, but adult ED leadership and key clinical staff reviewed both tools for potential use in the organization and the KINDER 1 was selected as a potential replacement for the MFS for adult pa- tients in emergency departments across the system.

REMOTE VIDEO MONITORING

Although still a relatively new technology, video monitoring has been effective in reducing falls in the inpatient setting.14-17 Remote video monitoring (RVM) was

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identified as a potential means to address the department’s challenging layout and to assist with the high volume and acuity. The organization had recently introduced 36 RVM devices to the inpatient setting, and following discussions with nursing leadership, 2 were assigned to the adult emergency department. These devices (Avasys TeleSitter, Avasure, Belmont, MI) were nonrecording, mobile video cameras that were monitored remotely by hospital staff (max 12:1 monitor-to-staff ratio). The devices had the capability to communicate directly with the patient or staff via a speaker in addition to the ability to sound a local alarm if needed. RVM could be initiated without physician order on any patient that was identified at high risk for falling. The 2 RVM devices allowed for monitoring 400 to 450 patients per month (20%-25% of high fall-risk patients). Patient selection was based on the KINDER 1 score along with evaluation of the clinical team and nursing leadership and consideration of patient risk factors (eg, age, diagnosis, bed placement), staffing, and department acuity.

EXIT ALARM TECHNOLOGY

Bed (or stretcher) alarms are an intervention with mixed fall prevention effectiveness18 and can contribute to alarm fa- tigue.19 However, with the bay-based nature of the ED layout and challenges with patient monitoring, bed alarms were identified as a potential benefit for a comprehensive fall prevention program. At the time of this improvement project, the organization was in the process of purchasing new stretchers (Stryker Prime Series, Stryker, Kalamazoo, MI) and integrated bed exit alarm technology was a feature that was considered and ultimately purchased. Following equipment introduction and staff education, bed alarms were then incorporated into the plan of care for those pa- tients identified as a fall risk during triage.

FALL PREVENTION CULTURE

Although a successful fall prevention program requires policies and resources, it is the engagement, knowledge, and commit- ment of the staff and leadership that will sustain improvement. There were a variety of actions that were used to engage staff and generate buy-in and excitement regarding fall prevention. One activity was the creation of the “Catch a Falling Star” recognition program to recognize staff who had played a vital role in preventing a patient fall or injury.Staff were nominated by their peers or management team and were recognized on a unit display board, presented with a certificate, and given a small token of appreciation. In addition, milestone celebra- tions were held on the unit and signage that indicated the

670 JOURNAL OF EMERGENCY NURSING

date of the last fall event was placed in the department and visible to staff, patients, and families.

COMMUNICATION

Poor communication is one of the most common contribu- tors to adverse patient safety events.20 Documentation of the KINDER 1 began the communication about fall risk between the triage nurse and the primary nurse and trig- gered a fall prevention plan of care. In addition, changes were made to the existing EMR to better communicate fall risk and fall history. Flowsheets were created for docu- menting the specifics of a patient fall, which then triggered an alert within the EMR in the form of a red banner across the top of the chart alerting staff that the patient had fallen during their current encounter. On subsequent encounters, the alert would populate to notify staff that the patient had fallen during a previous encounter.

Results

With regard to fall risk assessment, screening of patients was consistent at more than 95% compliance using both the MFS (preimprovement) and the KINDER 1 (postimprove- ment). These assessments were all completed during the initial triage or by the primary registered nurse in the case of a direct ED admission. During the year following the change to KINDER 1, more than 80,000 patients were assessed with KINDER 1 with 31% reported as positive (ie, high fall risk). This was compared to the 10% of MFS screens that resulted in a high-risk assessment. Using these results and the patient fall data, the organization’s KINDER 1 sensitivity was calculated at 68% (pre-MFS ¼ 23%) and the specificity 68% (pre-MFS ¼ 91%).

Outcome measures included both the adult ED fall rate (adult ED falls per 1,000 patient visits) and the adult ED FWI rate (adult ED injury falls per 1,000 patient visits). Baseline data were reported for the 8 quarters (January 2015 to September 2016) before the project’s implementation. The implementation timeframe was identified as January 2017 to June 2017. The postimple- mentation time period was identified as July 2017 to June 2019. A t test (equal variance, 2-tailed) was conducted on the pre- and postintervention data (fall rate and FWI rate) to determine the statistical significance (a ¼ 0.05) of the changes in fall rates following the improvement program.

Figure 3 displays the results of the adult ED fall rate over these time frames. Figure 4 displays the adult ED injury fall rate for the same time. Following implementation of the

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FIGURE 3

Adult ED fall rates pre and post improvement. Rate ¼ falls/(adult ED visits/1000). Improvement activities included: ED task force (Q2-17), data analysis (Q2-17), staff recog- nition program (Q2-17), KINDER 1 tool implementation (Q2-17), remote video in emergency department (Q3-17), and new ED stretcher with bed alarms (Q3-17). Q1, quarter 1; Q2; quarter 2; Q3; quarter 3; Q4, quarter 4; FY, fiscal year.

Cook et al/PRACTICE IMPROVEMENT

improvement project, the fall rate decreased from 0.73 falls per 1,000 visits (pre) to 0.55 falls per 1,000 visits (post), representing a 25% decrease (t ¼ 1.41, P ¼ 0.18). The injury rate decreased from 0.09 FWI per 1,000 visits (pre) to 0.03 FWI per 1,000 visits (post), which was a 66% decrease in injuries (t ¼ 2.29, P < 0.05). These decreases represented 27 fewer falls and 10 fewer injuries over the 24-month postimplementation period despite a 3% increase in adult ED volume over this time frame.

Discussion

As previously noted there has been a distinct lack of litera- ture related to ED-specific fall prevention programs and in- terventions. Available fall risk assessment tools have either been inpatient-specific (not been validated for use in the emergency department) or ED-specific tools that have not been fully validated. As a result of this lack of evidence, this patient safety initiative incorporated interventions that were previously studied for use in the inpatient setting. However, by incorporating these interventions into a multi- factorial fall prevention program to address the unique nuances of the ED setting we hope to fill this need for ED-specific fall prevention literature.

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Understanding the underlying trends and patient safety gaps found in the fall events was a crucial initial step in this initiative. This knowledge laid the foundation for an effec- tive fall prevention program. Once the key implicating fac- tors were identified, interventions were chosen from the existing literature and implemented.

The use of RVM, although not new to the organization, was a new approach in the emergency setting. The utilization of RVM provided nurses with an additional means of ensuring that high-risk falls patients were still visibly monitored and communicated with, and that the nurse was alerted when needed. Use of RVM was encour- aged for patients determined to be at risk for falling, such as intoxicated or altered patients or any patient who might benefit from continuous monitoring. If all RVMs were in use, exit alarms were available on all ED stretchers as were constant-observer staff, providing nurses with multiple monitoring strategies.

Implementation ofthe KINDER1 notonlyenabled staff to assess patients with an ED-specific tool, but also contrib- uted to the overall fall prevention culture. Staff appreciated the fact that the KINDER 1 allowed for nursing judgment, and it reinforced the belief that staff were empowered to assess for and prevent patient falls. By selecting “nursing judgment” on the KINDER 1, triage staff were able to identify patients

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Adult ED injury fall rates pre and post improvement. Rate ¼ injury falls/(adult ED visits/1000). Improvement activities included: ED task force (Q2-17), data analysis (Q2-17), staff recognition program (Q2-17), KINDER 1 tool implementation (Q2-17), remote video in emergency department (Q3-17), and new ED stretcher with bed alarms (Q3-17). Q1, quarter 1; Q2; quarter 2; Q3; quarter 3; Q4, quarter 4; FY, fiscal year; FWI, falls with injuries.

PRACTICE IMPROVEMENT/Cook et al

who they felt were most in need of additional monitoring during their visit. By implementing this methodology, nurse leaders were able to keep the RVM in use and prioritize the needs of patients with the highest risk for falling.

Creation of a unit-based culture of fall prevention in a high-volume, high-acuity emergency department can be difficult and requires commitment and constant vigilance and encouragement from the department’s leaders. With strong organizational and unit-based leadership support this project was implemented and ingrained into the culture of the adult emergency department. This culture was fostered and encouraged by the Catch a Falling Star Program, imple- mentation of the KINDER 1, and unit-based celebrations when milestones such as a year without FWI were achieved.

As the fall rate within the department began to decline, staff recognized that ED falls were indeed more preventable than they previously believed, which further reinforced the fall prevention culture. Although the reduction in falls (27 less falls, t ¼ 1.41, P ¼ 0.18) may not be statistically signif- icant, the impact of this program can be measured by other means. For example, without a fall, you cannot have a fall- related injury. Although it may be difficult to quantify, avoiding the associated legal and financial costs, in addition to the increased morbidity and mortality associated with fall-related injuries, is a significant and positive impact for this patient safety initiative.

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FINANCIAL CONSIDERATIONS

The purpose of this article was not to make a business case for a particular set of interventions but rather to explore a po- tential multifactorial approach to fall prevention in a setting not often studied. Two technologies (RVM and exit alarm technology) were included in this discussion, both represent- ing significant potential cost to an organization. In the case of RVM, organizations would need to consider the potential up-front cost of the video monitors, software licensing, and ongoing payroll for monitoring staff. Although exit alarms on stretchers may represent significant additional expense, there are a variety of companies that produce portable, single patient-use exit alarms that could be implemented in the emergency department. Regardless of the initial and ongoing financial investment, organization savings were found to be present in costs associated with reduction of falls and FWI21

in addition to far more significant savings related to reduced constant observer (or “sitter”) personnel costs.14,15

Limitations

There were limitations to this project that could restrict generalizability and replication in other organizations. The potential for unreported or unobserved falls, in addition

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Cook et al/PRACTICE IMPROVEMENT

to misclassification of fall events may affect data reliability. Staff education regarding the fall prevention initiative and interventions was disseminated, however no measurement of the effect of this education on staff perception of patient falls and project engagement was collected. The lack of vali- dated, tested ED-specific fall prevention tools and interven- tions was a limiting factor in the creation of this program. The type of emergency department (adult only Level 1 trauma center) may be a limiting factor in the generaliz- ability of the findings to other ED populations.

Key Implications for Emergency Nursing Practice

Patient falls in the emergency department can be difficult to anticipate and prevent owing to the challenging ED setting and patient population. In order to create an effective ED fall prevention program, a thorough investigation into unit-specific contributing factors is imperative. Once contributing factors are identified, appropriate interventions can be determined and implemented. Given the multiple factors present in most falls, a multifactorial approach to fall prevention is necessary. Fostering a robust fall preven- tion culture is of utmost importance to ensure staff buy-in and program sustainability. The continued success of this particular program is attributed to the fact that fostering a strong fall-prevention culture remains a high priority item for unit leadership, with continued emphasis on staff educa- tion and celebrations of unit successes.

Conclusion

Preventing falls and fall-related injuries in the ED setting is of high importance owing to the implications of increased admission rates, length of stay, health care costs, and morbidity and mortality rates.1,7,8,12 Patients present to the emergencydepartmenttogetbetter,nottoexperiencefurther injury or harm. However, nurses often consider patient falls in the emergency department to be an unavoidable occur- rence related to the unpredictable, fast-paced nature of the setting. A closer analysis of patient fall events shows that many of these events could have been prevented with the appropriate screening, staff knowledge, and available equip- mentand resources.This improvement projectdemonstrated that a multifactorial fall prevention approach may allow emergency departments to better address this complicated problem. By closely examining the existing adult ED fall data, targeted interventions were implemented to improve the staff and department capabilities related to patient safety

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and fall prevention. These efforts resulted in a 27% decrease in adult ED patient falls and a 66% decrease in FWI. Novel interventions and technologies such as RVM, stretchers with exit alarms, and EMR updates coupled with staff education and the creation of a culture of fall prevention awareness created a sustainable fall prevention program.

Author Disclosures

Conflicts of interest: none to re

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