Intervention Plan Design for Patient Falls.
Submit your 20–25-page final capstone project that synthesizes the work you completed in the previous four assessments
Note: Each assessment in this course builds on the work you completed in the previous assessment. Therefore, you must complete the assessments in this course in the order in which they are presented.Intervention Plan Design for Patient Falls.
All papers uploaded below. This paper is a summary of all the papers and use the references from those papers as well.
Congratulations! The finish line is in sight for both the capstone project you have been working on all quarter and your Master\’s of Science in Nursing program. Take a moment to appreciate all you have accomplished and give yourself a pat on the back; you have earned it!Intervention Plan Design for Patient Falls.
Your final submission for your capstone project will bring together all of the sections you have worked on throughout this course, as well as the relevant revisions you have made to those sections based on feedback from your instructor, as well as feedback you have received or observations you may have made during your practicum experience. Intervention Plan Design for Patient Falls.True professionals can learn to strive for continuous improvement in their work and incorporate feedback from colleagues and leaders to help scaffold improvement efforts. As a master\’s-level nurse you will be expected to create and implement plans and evaluate their outcomes. Being able to envision a pathway for a project to move from the idea phase all the way through the evaluation phase is a critical skill. By successfully synthesizing the various sections of this project together into one final artifact, you will have demonstrated your competence in this essential skill.Intervention Plan Design for Patient Falls.
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
Note: You will also be assessed on two additional criteria unaligned to a course competency:
Note: The assessments in this course are sequenced in such a way as to help you build specific skills that you will use throughout your program. Complete the assessments in the order in which they are presented.Intervention Plan Design for Patient Falls.
For your final capstone project submission you will synthesize the work you completed in the previous four assessments. Please make sure that you have made relevant revisions as suggested by your instructor, as well as relevant additions that you uncovered during your practicum experience. The only brand-new content that you will need to create for this assessment is an Abstract and an Introduction.Intervention Plan Design for Patient Falls.
This final submission will be graded using the seven program outcomes (POs) for the Master\’s of Science in Nursing program. As a reminder they are:
In addition, you will be assessed on how well you incorporated the feedback you received from your instructor on your previous work in this course via the following criterion:Intervention Plan Design for Patient Falls.
You will also be assessed on the completion of hours toward your practicum experience.
See the scoring guide for specific grading criteria related to these requirements.
Please carefully review the outline below to see which parts of the final submission will align to which program outcomes. (Note: The bullet points in the outline correspond to the grading criteria from your previous assessments. It may be worth putting in some extra revisions on the material related to criteria on which you did not previously score as well as you would have liked. You may also wish to read the Guiding Questions: Final Project Submission document to better understand how each aspect of your submission will be assessed.) It is important to remember that if you do a quality job addressing the points below, you will meet all of the program outcomes. The alignment is provided for transparency, but do not become preoccupied with how each point will feed into the scoring guide.Intervention Plan Design for Patient Falls.
Reminder: these instructions are an outline. Your heading for this this section should be Problem Statement and not Part 1: Problem Statement.
Part 1: Problem Statement
Population and Setting
Comparison of Approaches
Initial Outcome Draft
Part 2: Literature Review
Intervention Plan Components
Stakeholders, Policy, and Regulations
Ethical and Legal Implications
Part 4: Implementation Plan
Management and Leadership
Delivery and Technology
Stakeholders, Policy, and Regulations
Part 5: Evaluation of Plan
Part 6: Discussion
Reflection on Leading Change and Improvement
Address Generally Throughout
Attached below: paper guidelines, all papers uploaded below to summarize this final paper.
Implementation Plan Design for Patient Falls
Patient falls has been categorized as one leading factor for morbidity and mortality rates, especially for patients in specialized care and centers that accommodate elderly patients. As such, an intervention methodology that is effective for the prevention of patient falls at a skilled nursing rehabilitation center for older patients encompasses the hourly rounding, staff education, and use of bed alarms. Implementation of the intervention plan requires a proper design that places into account the care settings, including the culture variances, availability of the resources, existing policies, stakeholders present as well as the need urgency (Rahi & Ahmad, 2020). In our case, this paper will give a detailed overview of the design implementation purely based on the project aims and expected outcome of reducing the incidence of patient falls among the elderly residing in skilled nursing facilities.Intervention Plan Design for Patient Falls.
Management and Leadership
Management and leadership aspects are important in any given design implementation plan. A proper strategy implementation that puts into consideration the professional nursing practices and encourages the interprofessional collaboration during the implementation of an intervention plan must be well thought to ensure the success of the same. In our case on the implementation of the design plan for preventing patient falls, the nurse charge within a skilled nursing rehabilitation center will be the leader of an implementation committee that will comprise of interprofessional members drawn from the various departments that are crucial in supporting the overall skills and resources requirements for the design implementation.Intervention Plan Design for Patient Falls. The team will be responsible in overseeing the existing policies, both at the institution level and the healthcare industry level that are potential in impacting the design implementation (Saade & Nijher, 2016). Furthermore, the team will also be responsible for ensuring that professional nursing practices are adhered to,in order to give room for collaboration with other professionals. Apart from saving time and service quality improvement, interprofessional collaboration also gives room for information sharing that is crucial for the overall care by identifying the health care issue root causes beyond just the observation of the symptoms.Intervention Plan Design for Patient Falls.
Nevertheless, the established team under the nurse charge leadership will be expected to apply the proposed design plan by engaging everyone on board first to understand the need for change and the expected outcome of the implementation. As such, this will ensure the reduction of conflict and as well, enable smooth communication and action whenever the need arises during the implementation period (Saade & Nijher, 2016). Interprofessional collaboration can sometimes be tedious or may further deteriorate the service delivery if proper leadership and coordination is not present which may a times result in duplication of duties, negligence, as well as conflict among the team members which may result in jeopardizing the much-needed care for the overall benefit of the patient at hand.Intervention Plan Design for Patient Falls.
Change implementation comes with its own challenges, which may emanate fromthe scarcity of the resources, stakeholders influence or the need urgency (Rahi & Ahmad, 2020). As such, to implement this design plan for preventing the patient falls, these elements must be put into consideration beforehand to ensure that the implementation runs smoothly and whenever there emerges a challenge, then it is resolved in the earliest time possible to avert any downfall for the planned changes. Interprofessional collaboration has been known to reduce costs and saving time in that it reduces the diagnosis period and as well, when information sharing is encouraged, the team can resolve the treatment or intervention methodology at speed, which may drastically reduce the associated costs.Intervention Plan Design for Patient Falls. For the patient falls prevention, especially in the elderly, the patient care management involves a variety of professionals whom most of them from the physicians, therapist, nurses, councilors as well as non-medical staffs such as cleaners, physically visit the bed sites within the facility. As such, when these professionals are made aware of the implementations expected, they can each play a part in the implementation process, a move that will reduce costs of hiring new nurses or overburdening nurses who are present within the facility when left alone to watch the patients. Through training as well as incorporation of technology such as bed alarm systems, the interprofessional collaboration will become a success and the expected outcome will be viable to realize within the set period of six months to one year (Saade & Nijher, 2016).Intervention Plan Design for Patient Falls.
Delivery and Technology
With the implementation design revolving around three main elements of hourly rounding, staff education, and use of bed alarms, the proposed interventions and methodological applications will take into considerations the quality of the project based on set assumptions. For the hourly rounding, the nurses on duties in conjunction with other professionals involved within the care process will conduct the set rounds to ensure that the patients are in the right position on their bed and any obstacles that can hinder their mobility are dealt with to eliminate the increased possibility for the falls (Shin & Park, 2018). Furthermore, they will listen to patient needs if they are in a position to express themselves and place the patient items at reach to avoid the need to stretch, which may result in a possible fall that is preventable by such simple actions from the concerned team (Leone & Adams, 2015).Intervention Plan Design for Patient Falls.
On staff education, this will be done on both the physical training attendance, as well as virtual training. This will enable flexibility of the professionals from their normal duty to avoid any gaps that may result in decreased surveillance as well as attending to the patient care needs. Practical lessons where they will be subjected to mock drillsthat involve patient fall situations will be crucial after which the trained professionals will be subjected to responding to real situations involving real life patients within the facility. This will improve the professional’s knowledge of prevention and management when it comes to the patient falls leading to the overall reduction of patient falls that the plan intends to achieve.Intervention Plan Design for Patient Falls.
Finally, on the bed alarms, this is a combination and application of the modern technology with that of the human skills. Technological application should never eliminate the human ethical considerations or the physical intervention as sometimes technology may fail, leading to catastrophic results that may jeopardize the whole care process. Bed alarms are set either for the patients to notify the concerned staff that they are in need of assistance or to notify the concerned profession of an attempt to leave bed in time for the appropriate action. As such, bed alarms will be set to work hand in hand with the concerned professions and as such they will be set with appropriate time to notify and give room for quick intervention. With this in mind, the professionals will be trained on how to respond to the alarms and the intervention protocols concerning the same. The alarm system must also be accurate not to mislead the professionals on duty through false alarms. To ensure quality, the defaults will be rechecked on a weekly basis and whenever they are available, the technical team will rectify accordingly.Intervention Plan Design for Patient Falls.
Stakeholders, Policy, and Regulations
Stakeholders are an important element in the overall success of the design implementation of the proposed plan. In this case, the medical professionals, the facility management, patients, non-medical staff, local healthcare authorities, as well as the surrounding community forms the better part of the stakeholders that must be considered during the implementation of the design plan (de Camargo et al., 2019).Intervention Plan Design for Patient Falls. Both the existing or emerging policies must be put into account to provide the legal and ethical effects of the implementation process. As such, Centers for Disease Control and Prevention (CDC) has developed a tool for guiding the professions during the development of fall prevention projects as well as the implementation of the same. Through Stopping Elderly Accidents, Deaths and Injuries (STEADI) guidelines, the professionals and the management together with other stakeholders are entitled to follow the laid down guidelines to ensure that the established implementation process is in line with the requirements of the American Geriatrics Society’s clinical guideline for fall prevention (Leone & Adams, 2015).Intervention Plan Design for Patient Falls.
On the other hand, it will be assumed that the management will come up with full support, especially in providing the required resources and expertise to implement the project. On the professionals’ side, their collaboration will be key as they stand at the center of the implementation process as they are the ones being involved with patients on a daily basis. Other non-medical staffs, must adhere to the institution’s policy on the implementation process to be guided accordingly. The patients must also be made aware of the risks associated with falls as well as how to prevent such occurrences if they are in a position to communicate. A new policy should be developed especially in guiding the interprofessional teams. The leadership, composition as well as communication lines are important aspects in teams that will promote the much-needed collaboration to deal with the patient falls as well as strengthen teams in the long-run (de Camargo et al., 2019).Intervention Plan Design for Patient Falls.
This section proposes a timeline to implement an intervention plan with reference to specific factors that influence the timing of implementation.
|Team formation and working protocols development||1st month||This will involve the development of teams through the leadership of the charge nurse including putting in place the required policies for the proper guidelines of the plan implementation|
|Training and development||1st and 2nd month||The 1st month will involve virtual and class attendance for the training sessions. The second month will incorporate practical lessons in terms of drills as well as physical placement in the patient’s environment. This will be done at first under supervision and this will reduce as dictated by the professional performance as time progresses.|
|Full time placement||From 3rd month to 1 year||After the training and development is over, and the policies are in place, the next activity will be to make full time placement of the interprofessional team. This will be done by the implementation committee under the chair of the nurse charge within the facility.|
|Evaluation||Weekly for the alarm system
Monthly for the team performance and the recorded fall rate
|Evaluation is important as it establishes the existing gaps during implementation and it gives room for improvement whenever the need be. The weekly alarm system evaluation is necessitated by the fact that the system acts as a support system, especially for the nurses to be aware of the patient movements and therefore, requires a regular checkup to make sure that it is in the right condition. The patient fall rate is also an important indicator of the project outcome and whether it is meeting the expectations.|
|Final report||After lapse of the 1-year period||As project implementation time lapses, it is well advised to come up with a comprehensive report that performs a postmortem on the overall implementation process. This is crucial in establishing whether the project was a success or failure and what can be done differently next time (Miklosik & Janovska, 2015).|
The project implementation process is a long journey that requires proper planning and allocation of time and resources. Nevertheless, the leadership and management play a central role in the coordination of the project implementation processes and are therefore a major indicator of the failure or success of the project. In this case, the patient fall prevention is a delicate process that requires training, interprofessional collaboration as well as technological intervention. The resources, leadership and timeline are therefore crucial in ensuring that the project meets the expectations of decreasing the falls’ incidence among the elderly populations within a skilled nursing rehabilitation center for older patients.Intervention Plan Design for Patient Falls.
The high incidence of patient falls among the elderly is a quality improvement need. In hospital settings, the elderly are at an increased risk of patient falls. As individuals advance in age, the possibility of accumulating health problems and subsequent medications increases. Similarly, their risk of falling also increases. Aging is also associated with numerous changes in gait, including decreased limb strength and gait velocity. Ultimately, these factors place older adults at a high risk of patient falls. As indicators of frailty and immobility, and chronic health impairment among older persons, falls significantly diminish functioning by limiting activity for older persons, causing injury, and loss of mobility. According to Kenny et al. (2017), most injuries among seniors result from falls. These include hip and forearm fractures, pelvis, and humerus.Intervention Plan Design for Patient Falls.
Addressing patient falls is incredibly crucial, given their imminent health burden. Patient falls are linked to high rates of morbidity and mortality. McCarthy (2016) highlight that falls is the leading cause of death resulting from injury among the elderly above the age of 65 in the United States. One in every four US citizens dies from fall-related causes. Also, fall-related injuries are highly prevalent among the elderly. Mainly, hip and wrist fractures, pelvis, and osteoporosis are among the factors that increase vulnerability to patient falls. Other severe injuries resulting from patient falls are laceration, joint dislocation, disabling tissue injury, and sprain. Notably, even falls that do not result in physical injury have negative impacts such as self-imposed activity limitations, anxiety, and trauma.Intervention Plan Design for Patient Falls.
Additionally, patient falls lengthen hospital stays and increase healthcare costs. The Centers for Disease Prevention and Control (2020) asserts that the cost of treating patient falls approximates to $67.7 billion annually. As patient falls are linked to subsequent hospital readmissions, addressing the issue is incredibly crucial.Intervention Plan Design for Patient Falls.
Population and Setting
Nursing staff in a skilled nursing facility comprise the target population for a quality improvement program targeting patient falls. Nursing staff practicing in these facilities are well trained and specialized in providing round-the clock-assistance to the elderly on the activities of daily living (ADLs). It is incredibly crucial to address patient falls within this population as these nursing staff care for individuals at a high risk of patient falls. They, therefore, play a fundamental role in falls prevention among the elderly, especially residents of skilled medical facilities.
This project targets skilled nursing facilities as the setting. Skilled nursing facilities are a type of nursing home acknowledged by Medicare and Medicaid to meet the long-term health needs of the elderly. The setting is crucial in addressing patient falls among the elderly as skilled nursing facilities house seniors who have limited potential to function independently and who require assistance with daily living activities. Frailty is acknowledged as a significant risk factor for patient falls (Kojima et al., 2015). As a result, skilled nursing facilities are likely to record a higher incidence of patient falls as they contain frail adults.Intervention Plan Design for Patient Falls.
Several interventions are effective in addressing patient falls. These are hourly rounding, coupled with nursing staff education and the use of bed alarms. Research has demonstrated that the integration of hourly rounding protocols in nursing practice is an efficient evidence-based strategyfor patient falls (Goldsack et al., 2015). Hourly rounding reduces the occurrence of falls and can be used in tandem with other fall prevention interventions to enhance patient safety. Staff education is another intervention to minimize the occurrence of falls among seniors in skilled nursing facilities. Staff training promotes a culture of safety in the organization (Hill et al., 2016). Staff participating in the education program should be those who interact with patients daily, and this has broader experience in patient behavior and falls prevention. These two interventions should be combined with the use of bed alarms for effective falls prevention. The above interventions align well the target population, project setting, and the identified need.Intervention Plan Design for Patient Falls.
Another alternative to the interventions discussed above is the use of bed alarms only for falls prevention. While the use of bed alarms are effective in decreasing falls by notifying healthcare personnel when high-risk patients try to leave their bed without nursing assistance, the approach is not highly effective when used solely. It should be combined with other fall prevention bundles to be highly effective.Intervention Plan Design for Patient Falls.
Initial Outcome Draft
The main aim of the project is to reduce the incidence of patient falls among the elderly residing in skilled nursing facilities. It is incredibly reflective of the project’s intention, which is to decrease falls’ incidence among the elderly populations. This outcome further illustrates what the project intends to achieve by establishing a framework for patient safety and quality improvement in healthcare settings. Preventing patient falls improves patient safety and is an indicator of high-quality patient care.Intervention Plan Design for Patient Falls.
Implementing a falls prevention bundle encompassing hourly rounding, staff education, and use of bed alarms is estimated to take six months to one year. During this period, staff will be educated on the importance of falls prevention among the elderly as well as the benefits of hourly rounding. Education will also comprise a prompt response to patient bed alarms. While the time frame is realistic, several potential challenges are likely to be encountered during this period. These include time constraints, staff shortages in the facility, and budgetary limitations.Intervention Plan Design for Patient Falls.
According to the CDC, residents in skilled nursing facilities who frequently fall sustain injuries with a higher potential to cause permanent disability and reduce the patient’s quality of life. Falls in these facilities result from person-centered and environmental factors such as effects of aging or gait imbalance, underlying medical conditions, side effects of drugs, low lighting, wet floors, and inaccessibility of personal items prompting patients to reach them without assistance. While various interventions have been proven to be effective, a falls prevention bundle is found to be more successful in preventing falls, compared to the use of a single intervention (Guirguis-Blake et al., 2018). Successful prevention of patient falls requires healthcare professionals to manage underlying risk factors for patients and modify risks within the environment that contribute to patient falls. Given the complexity of these factors, a combination of interventions is necessary.Intervention Plan Design for Patient Falls.
The process of hourly rounding has been identified as a successful evidence-based approach to reduce patient falls. It encompasses purposefully checking in on every patient every hour and recording the contact. A purposeful hourly rounding comprises checking the 5Ps of the patient. These are pain, position, personal needs, periphery, and potty (Daniels, 2016). When assessing for pain, nurses should determine the patient’s pain level and administer medication when necessary. They must also ensure that patients are placed in a comfortable position and reposition immobile patients to prevent the occurrence of pressure ulcers. Additionally, nurses must assist the patient with personal needs such as hydration, nutrition, and using the toilet while ascertaining that their individual items are within reach.Intervention Plan Design for Patient Falls.
Linehan and Lihehan (2018) assert that hourly rounding decreases the occurrence of patient falls and light usage while enhancing the perceptions of patients on nurse responsiveness. It is, therefore, a vital tool in improving care outcomes and improving patient safety. Notably, the concept of hourly rounding has been met with some form of resistance from nurses, with opponents most citing increased documentation, over-regulation of nursing activities, and loss of adequate time as major concerns behind intentional hourly rounding. However, evidence-based research has highlighted that hourly rounding improves efficiency, decreases documentation, and significantly improves patient safety. It is, therefore, a quality improvement strategy that increases patient safety as well as satisfaction.Intervention Plan Design for Patient Falls.
Attending nurses and patient care technicians are responsible for purposeful hourly rounding (Shin & Park, 2018). Although hourly rounding is a standard of care, the frequency of the strategy should be dependent on patients’ needs. Stable patients can be allowed to rest, with less hourly rounding while patients requiring nursing attention should be rounded after every hour. During hourly rounding, the nurses should ask questions and document their interactions with patients to determine the patient’s health needs that should be prioritized. Notably, hourly rounding significantly improves nurse responsiveness as nurses promptly attend to acknowledged patient needs.Intervention Plan Design for Patient Falls.
According to Leone and Adams (2015), structured, purposeful hourly rounding is linked to positive outcomes such as patients’ confidence in their care, improved satisfaction, reduced use of call bells, and decreased incidence of patient falls. However, several barriers to purposeful hourly rounding have been identified. Time constraints, competing priorities, and increased workloads have been noted to interfere with the process of hourly rounding. Most staff also perceive that increased documentation associated with hourly rounding is irrelevant. Lack of sufficient staff engagement thus hinders the successful execution of hourly rounding.Intervention Plan Design for Patient Falls.
As an intervention to prevent patient falls among the elderly, purposeful hourly rounding should be used together with other strategies such as staff education and use of bed alarms, in the form of a bundle (Morgan et al., 2016). Ensuring that nurse staff are engaged in falls prevention programs in skilled nursing facilities requires the health organization to provide a comprehensive educational program and training on falls prevention among the elderly. Educating both clinical and non-clinical staff, is an integral approach that allows the organization to reach all professionals, including night shift and weekend nurses. Fall prevention training should also be extended to disciplines beyond nursing staff, such as medical residents, nurse assistants, technicians, and rehabilitation specialists. Education ensures that staff are aware of the crucial roles they play in fall prevention. Staff roles relating to fall prevention will be accurately defined.Intervention Plan Design for Patient Falls.
According to Heng et al. (2020), the majority of falls prevention programs focus on patient education. These processes focus on educating hospitalized patients as well as those in nursing homes. The authors, however, note that staff education on fall prevention is equally essential as patient education. Intervention Plan Design for Patient Falls.Various education modalities can be used during staff education, such as face to face meetings, handouts, fall prevention posters, and handouts. Notably, combining these approaches is more effective than using single education provision modalities. Staff education allows nurses to classify patients at high risk of falls and execute patient-centered strategies aimed at falls prevention. Group training education sessions on falls prevention among nursing staff in skilled nursing facilities are effective in enabling nurses to remember and understand the presented information. Fall prevention education for resident care nurses is mostly done by a fall prevention expert, a specialized individual with adequate knowledge on fall prevention acquired through education, training, and experience. Physical therapists also play a crucial role in educating nurse staff on mobility optimization, which is an essential component of falls prevention programs. Self-efficacy has been noted as a critical aspect that allows nurses to transition from education to practice.Intervention Plan Design for Patient Falls.
Use of bed alarms is another intervention used in combination with hourly rounding and staff education in the identified fall prevention bundle among seniors in skilled medical facilities. Bed alarm systems work to minimize patient falls by notifying healthcare personnel when high-risk patients endeavor to leave their beds or chairs. Among hospitalized patients, most falls result from patients ambulating from the bed, chair, or toilet without adequate assistance from nurses. Alarm systems designed on patients’ bed or chairs have the potential to minimize the potential for physical restraints that contribute to patient falls. Doubts exist on the reliability of bed alarms in preventing patient falls. While the approach is effective in improving nursing responsiveness, the strategy is not effective when used alone. Gavaller et al. (2019) highlight that bed and chair alarms among patients in the long term and acute care settings have been proven ineffective strategies for fall prevention and have satisfied the criteria as a physical restraint according to the Centers for Medicare and Medicaid (CMS).Intervention Plan Design for Patient Falls.
A study conducted by Mileski et al. (2019) revealed that the use of bed alarms alone as a strategy for preventing falls is inadequate as an intervention. For alarms to be effective in preventing patient falls, they must be used as a component of a comprehensive bundle executed for residents at a high risk of patient falls. The above authors assert that no single intervention is effective in fall prevention. In all healthcare facilities, patient falls are reduced by a multifaceted comprehensive and prolonged approach that focuses on maintaining patient safety and improving the quality of care. Overall, the use of bed alarms is useful in long-term healthcare facilities while utilized as a component of a comprehensive care plan.Intervention Plan Design for Patient Falls.
An example of health policy related to patient falls is the CMS No-Pay Policy for hospital-acquired patient falls. In 2008, the Centers for Medicare and Medicaid (CMS) stopped compensating healthcare organizations for costs linked to patient falls (Fehlberg et al., 2017). This policy increased the likelihood of nurses to implement strategies for fall prevention within healthcare facilities. This policy will impact how the skilled nursing facility will address fall prevention among residents in the organization. As the CMS no longer reimburses costs related to patient falls, the nursing resident facility will have to implement approaches to fall prevention, among them purposeful hourly rounding, staff education, and use of bed alarms. These interventions will be used together to in form of acomprehensive bundle aimed at improving patient safety and enhancing the quality of health outcomes among the elderly populations. These interventions will be made at the individual and organizational level and will directly influence nurses’ delivery of patient care.Intervention Plan Design for Patient Falls.
Intervention Plan Design for Patient Falls
Patient falls especially among elderly patients is a major healthcare service quality concern in the US healthcare system. For this reason, evidence-based quality improvement (QI) strategies need to be implemented to lower the rates of patient falls in this particular patient population. This is what will enable the achievement of the best patient outcomes in this patient population. A particular need in this regard has been identified in the elderly patient population in skilled nursing facilities carrying out in-patient rehabilitation for this elderly population. The limited mobility, joint stiffness, and normal tissue degeneration that occurs with age place these older patients at a higher risk of falling in these facilities and sustaining injuries or even dying (McCarthy, 2016; Kojima et al., 2015). Most of the injuries sustained by the elderly in skilled nursing facilities and nursing homes such as fractures of the pelvis or hip fractures/ dislocation are the result of preventable falls (Kenny et al., 2017). The incidence of accidental patient falls in the US hospital system is between 3.3 and 11.5 patient falls per 1,000 hospital stays. And make to make this quality matter even more of a concern to the financial welfare of the organization, the Centers for Medicare and Medicaid Services (CMS) as a rule no longer reimburses for services rendered to victims of hospital falls.Intervention Plan Design for Patient Falls. This is because they are deemed as preventable and a result of laxity in the quality of care (Fehlberg et al., 2017; Bouldin et al., 2013). This intervention plan design is a follow-up to the PICOT investigation that identified the need for the prevention of falls among the elderly patients at skilled nursing rehabilitation centers. The population of target for the quality improvement was identified as the registered nurses working in these skilled nursing centers which provide the setting. The three-pronged intervention strategy for the reduction of patient falls in this setting was nurse education, doing hourly rounds, and the use of bed alarms (Hill et al., 2016; Goldsack et al., 2015). The comparison was the use of bed alarms alone, while the expected measurable outcome was to decrease the patient falls in the skilled nursing care center to 3.4 falls per 1,000,000 patient days or zero defect (Rastogi, 2018). The timeframe for the intervention was set at six months.Intervention Plan Design for Patient Falls.
Table 1: Summary of the elements of the PICOT statement
|P||Problem or population||Registered nurses working in skilled nursing care rehabilitation centers|
|I||Intervention bundle||Hourly rounds, nurse education, and bed alarms|
|C||Comparison or alternative||The use of bed alarms alone|
|O||Outcome expected||Reduction of elderly patient falls to insignificant levels (zero defect or 3.4 falls per 1 million hospital stays)|
|T||Timeframe||A period of six months|
Intervention Plan Components
The PICOT investigation above provides enough evidence to support a three-pronged approach to the solution of the problem of patient falls among the elderly patients in a skilled nursing rehabilitation center. The use of a falls prevention bundle in comparison to a single intervention such as the use of bed alarms alone has been found to be more effective. This is the evidence-based finding that informs the use of this approach in this intervention plan design (Guirguis-Blake et al., 2018; Morgan et al., 2016).The components of this patient fall prevention and improvement bundle are (AHRQ, 2018):Intervention Plan Design for Patient Falls.
The concept of hourly rounding in this intervention plan/ bundle is to identify a potential fall before it happens. It is a purposeful round that is planned and documented. During the round, the nurse checks for the so-called 5Ps namely position, personal needs, pain, potty, and periphery (Daniels, 2016). During these rounds, patients who report pain are given pain-relieving interventions. Pain is one of the reasons that may make the elderly patient attempt to get up so as to get the attention of the nurse. Immobile patients are also positioned properly during these rounds. The patients are also assisted with toileting and other personal needs. Lastly, the rounds give the nurses the opportunity to place within reach any items that the patient may want to use (Linehan & Linehan, 2018; Shin & Park, 2018; Leone & Adams, 2015).Intervention Plan Design for Patient Falls.
Nurse Education and Training/ Patient Education
Training nurses and educating them on how to recognize and prevent imminent patient falls is a very important part of the falls prevention bundle (AHRQ, 2018). This training addresses knowledge gaps and gives the opportunity for the nurses to have grey areas addressed. It is in this same sense that the nurses who have been trained should also educate their patients on the dangers of getting out of bed without assistance, especially if the particular elderly patient is a fall risk (Heng et al., 2020).Intervention Plan Design for Patient Falls.
The Use of Bedside Alarms
Bedside alarms are a technological solution to the notification system that nurses can rely on. The alarm is set to sound after a particular time lapse following the departure of a patient from their bed.Usually, the nurse is required to set he alarm to sound just seconds after the patient attempts to leave their bed. This could be 3-5 seconds, giving no time for the patient to fall. Education on the consequences of ignoring the alarm by the nurses is paramount (Mileski et al., 2019). This is the role that technology plays in the reduction of patient falls.
The criteria that can be used to assess for the success of the above fall prevention bundle is a tangible, verifiable, quantifiable, and numerical reduction in the frequency of patient falls after the six months of intervention. This calls for the documentation of the baseline fall statistics before implementation of the bundle, followed by monthly monitoring to assess progress and lastly the final value after the six months.Intervention Plan Design for Patient Falls.
Impact of Cultural Needs and Characteristics of the Target Population and Setting on the Development of the Intervention Plan Components
In order for the intervention plan above to be successful, the characteristics of the target population of registered nurses working in skilled nursing rehabilitation centers and the setting of the intervention must be taken into account. Also to be taken into account are the cultural needs of the target population. What could be considered as the most important cultural need for the nurses impacting the plan is the provision of a conducive working environment that is defined by empowerment and psychological safety to facilitate delivery of quality nursing care. The characteristics of registered nurses in skilled nursing rehabilitation centersthat impacted the plan include that:
The characteristics of the skilled care centerimpacting the intervention plan include being a temporary home for the inpatients during rehabilitation and being a care center designed for old people with mobility problems. These characteristics favor the above plan. The assumptions on which the above explanation is made are that there will be no nurse turnover for the six months of the plan implementation and that the skilled care center will also be in operation for the entire duration.
The PICOT model is used to generate evidence for best practice. After the successful dissemination of the recommendations of the PICO clinical inquiry, what remains is translation into practice (White et al., 2016). This is where the above intervention plan comes in. In this case, the theoretical nursing model on which this intervention plan will be based is the Roger’s Diffusion of Innovation Theory (Pashaeypoor et al., 2016). One of the strengths of this theoretical model is that the innovators who are 2.5% of the organization’s human resource act as agents for change influencing the search for evidence and adoption of the recommendations for best practice (in this case it is doing hourly rounds, staff education and training, patient education, and making use of bedside alarms). The other strength is that early adopters (13.5%) and early majority (34%) will also quickly embrace the practice change to reduce patient falls. Together with the innovators, these two groups of nurses at the skilled nursing center forms a critical mass for effective change adoption (50%) s a QI initiative. On the other hand, the weakness of the model is that the late majority (34%) and the laggards (16%) will slow down adoption by being sceptical of the evidence-based intervention pan.
The strategy from other disciplines in this case will be drawn from the goods manufacturing sector in which Six Sigma quality paradigm governs QIs. For this, the strategy will be to have “zero defects”. This means having virtually zero falls or a ratio of 3.4 falls per million hospital stays (Rastogi, 2018). Finally, the healthcare technology relevant to the intervention plan is artificial intelligence or AI in the form of intelligent bedside alarms (Mileski et al., 2019).Intervention Plan Design for Patient Falls.
The relevant contemporary evidence for the intervention plan as outlined above comes from several authoritative peer-reviewed studies on the effectiveness of a falls prevention bundle in the reduction of patient falls as a QI initiative. These studies are by Linehan & Linehan (2018), Shin & Park (2018), Daniels (2016), and Leone & Adams (2015) for hourly rounds.For staff training and education as well as patent education the study evidence is from Heng et al. (2020) and the evidence-based toolkit for falls prevention by the AHRQ (2018). The conflicting data, however, is provided by the study by Gavaller et al. (2019) who found that bedside alarms in themselves are ineffective as a prevention strategy for patient falls. This apparent ineffectiveness is however mitigated by including it in a bundle instead of using it alone (as in this case).Intervention Plan Design for Patient Falls.
Stakeholders, Policy, and Regulations
The impact of stakeholder needs, healthcare policy, regulations, and governing bodies on the intervention plan is immense. The patients as stakeholders expect to receive quality care. Falls cannot guarantee this. The hospital/ organization as another stakeholder also needs a good rating and classification by the Joint Commission on Accreditation of Healthcare Organizations or JCAHO. Healthcare policy such as the rule by the CMS of not reimbursing for services rendered to hospital fall victims has a major impact on the intervention since the hospitals stand to lose money through care and even possible litigation. Lastly, governing bodies such as state boards of nursing expect nurses to provide the highest quality of care devoid of negligence. The assumption on which the above analysis is made is that the organization values its reputation and that nurses at the centers are professional and qualified.Intervention Plan Design for Patient Falls.
Ethical and Legal Implications
The ethical issues related to practice is that nurses must observe the bioethical principle of nonmaleficence or primum non nocere (Santhirapala&Moonesinghe, 2016). This means they should never harm to befall a patient, such as in the case of injuries resulting from a fall. Legally, then nurse owes the patient a duty of care. When breached as in the case in which the patient falls and gets injured, the nurse can be sued for Civil Negligence under Tort Law (Walker, 2011). Organizational change may also be inspired if the organization is sued along with the nurse on vicarious liability grounds. The unknowns or missing information in this case is the state of the working environment in the skilled centers for the nurses. An environment of victimization and intimidation by nurse managers will make the nurses effuse to report cases of patient falls.Intervention Plan Design for Patient Falls.
Patient falls as a quality issue in healthcare has drawn significant attention. The falls are responsible for preventable morbidity and mortality. Any organization that values its reputation and ratings will implement evidence-based QI initiatives to curb this issue. This is the content of this paper, with regard to prevention of falls in a skilled nursing rehabilitation center for older patients.
Evaluation Plan Design for the Implemented Intervention for the Reduction of Patient Falls in a Skilled Nursing Facility for the Rehabilitation of Older Adults
The quality improvement (QI) problem that had been identified in skilled nursing facilities rehabilitating older or elderly adult residents was that of accidental patient falls. The statistics mirrored this problem in that in US hospitals, 3.3-11.5 accidental patient falls in every 1,000 hospital stays are reported. The importance of this issue being that the Centers for Medicare and Medicaid Services or CMS no longer reimburses hospitals for care given to patients who have suffered accidental falls in their careIntervention Plan Design for Patient Falls.. This means that these organizations risk losing money caring for these fall cases as well as through possible litigation (Fehlberg et al., 2017; Bouldin et al., 2013). It had been observed that these falls are indeed preventable if appropriate evidence-based strategies and interventions are put into place by the registered nurses working in those facilities. The subsequent intervention plandesign then proposed three evidence-based measures to prevent these patient falls in skilled nursing facilities for the aged. These were (i) hourly rounding; (ii) nurse education and training followed bypatient education; and (iii) intelligent bed alarms as the technological support (Mileski et al., 2019; Linehan & Linehan, 2018; AHRQ, 2018). The implementation plan design afterwards proposed and outlined an implementation period of one year, broken into specific tasks. This paper outlines the evaluation plan for that particular implementationdesign for the above interventions aimed at reducing patient falls in skilled nursing facilities.Intervention Plan Design for Patient Falls.
Evaluation of Plan
Definition of Outcomes
The intervention plan that was implemented in this case was concerned with quality improvement in healthcare with regard to patient falls. As a result, its expected outcomes align with the so-called Quadruple Aim objectives that were formulated to guide quality improvement in healthcare. The Quadruple Aim objectives are (i) improvement of the health of patient populations (like that of the older adults in the skilled nursing facility); (ii) improvement in the care experience of patients; (iii) reduction in the cost per capita of healthcare; and (iv) creation of a conducive work environment for the healthcare employees to motivate them to deliver (Feeley, 2017; Sikka et al., 2015). The outcomes that were the goals of this intervention plan and that are aligned to the above Quadruple Aims are:Intervention Plan Design for Patient Falls.
The above expected outcomes were the goal of the implemented intervention plan of hourly rounding, nurse education and training, and the use of intelligent bed alarms. Having zero falls reported is the ultimate goal desired, and it refers to the Six Sigma quality measurement paradigm that places emphasis on having just 3.4 defects per one million opportunities (DPMO) or virtually no defect (Williams, n.d.). After completely implementing hourly rounding, nurse education and training, and the use of bedside alarms for a period of one year; the skilled nursing facility should report zero incidents of accidental patient falls. Successful implementation is also expected to bring about less spending by the patient on healthcare costs. When a patient falls, even if the hospital takes the responsibility of paying for their care (since CMS will not reimburse for the same), the patient and their family will still spend some money on the extended hospital stay. This of course is tied to the outcome of shorter hospital stays. Without accidental falls affecting the elderly patients, they will have shorter stays at the skilled nursing rehabilitation facility. This will help them save on healthcare expenditure.Intervention Plan Design for Patient Falls.
The other outcome that will improve the care experience for the skilled nursing facility residents will be less readmissions caused by morbidity as a result of the accidental fall suffered at the care facility. Less readmissions means the patient will spend less, will get fewer disturbances from rest, and will be more satisfied. Of course greater patient satisfaction with the quality of care received will lead to better reviews and more prominence of the skilled nursing facility as a center of excellence in nursing care. Lastly but not least, presence of a conducive, comfortable, and welcoming work environment will be the other expected outcome. It aligns well with the Quadruple Aim objectives in that staff that are empowered and motivated find it easier to deliver quality healthcare services due to the presence of psychological safety at the workplace.Intervention Plan Design for Patient Falls.
This is the plan that will be put in place to assess the success and impact of the intervention plan to prevent accidental patient falls. It will involve:
The ICT department together with the nurse informaticist at the facility will undertake a weekly review of how the bedside alarm system will be functioning and if it will be sounding promptly. They will also be assessing how fast the nurse response to the alarm will be. The nurse informaticist will also enforce a strict reporting system within the facility’s electronic health record (EHR) system for any patient fall. This will indicate the time of the fall, the patient’s diagnosis, the interval between notification and response, and the name of the nurse making the report. The Quality Improvement Committee will also be having monthly meetings to review the past month’s fall data and make necessary recommendations for adjustment for the following month. Performance of every nurse at the skilled care facility will also be assessed quarterly to find out competence and compliance. At the same time (quarterly), a questionnaire instrument will be used to gather data on patient satisfaction with the quality of care. Lastly, at the end of the year (end of the implementation period), there will be a summative evaluation of the quantitative data collected throughout the year. This will show whether the fall rate has declined to zero or not.Intervention Plan Design for Patient Falls.
The nurses’ role in leading the evidence-based practice change for quality improvement is central to the success of the implementation of the intervention plan for reduction in patient falls. First and foremost, the nurse is by default and training a patient advocate. This means that the nurse must be at the forefront in ensuing no harm befalls the patient at all times and that the patient’s safety is assured at all times. The nurse is also the chief implementer of the interventions aimed at reducing the patient falls. It is the nurse who will do the hourly rounds.Intervention Plan Design for Patient Falls. It is also the nurse who will undergo training and education on recognizing patients at a fall risk and how to prevent falls. Nurses will also be the ones responding to the bedside alarms when a patient attempts to leave their bed. Lastly but not least, the nurses’ role is also to be receptive of the practice change. This they will do by making sure they are among the innovators, early adopters and early majority according to Roger’s Diffusion of Innovations (DOI) Theory (Pashaeypoor et al., 2016).Intervention Plan Design for Patient Falls.
The intervention plan affects nursing and interprofessional collaboration in that it enriches evidence-based practice (EBP) in nursing and fosters close cooperation between bedside nurses, the nurse informaticist, ICT staff, nurse managers, and physiotherapists. The plan forces cooperation among the different professionals with the sole aim of benefiting the patient by improving the quality of care that they receive. The healthcare field gains from this in that EBP is entrenched in nursing practice. This ensures that only those interventions that are backed by scholarly evidence are used in the care of patients and facilitation of patient safety.Intervention Plan Design for Patient Falls.
The current quality improvement initiative or project could be improved to create an even bigger impact in the target population of nurses working in skilled care facilities for the rehabilitation of older adults. This can be achieved by publishing the outcome of this quality improvement initiative in peer-reviewed EBP journals, giving presentations in conferences and symposia organized by professional nursing organizations on the process of this quality improvement initiative, and seeking JCAHO (Joint Commission on Accreditation of Healthcare Organizations) certification to ensure that the quality improvement is preserved for posterity and the benefit of future nurses.Intervention Plan Design for Patient Falls. There are several EBP journals in which one of the innovative nurses at the skilled facility can publish the outcome of this quality improvement initiative to reduce patient falls. By doing this, the successful process of reducing patient falls (clinical inquiry, intervention, its implementation, and evaluation) will be disseminated to a wide cross-section of nurses working in similar skilled care facilities across the country. A similar effect can be achieved by the nurses who are members of professional nursing organizations such as the American Nurses Association (ANA). These nurses can make presentations at symposia and conferences (organized by the professional organization) of this quality improvement initiative to reduce patient falls. Many of their colleagues can thus benefit from this and go on o implement the same at their places of work. Lastly but not least, accreditation by JCAHO will mean that the quality improvement is maintained and sustained thereby creating a bigger impact. The organization can also indulge the services of software engineers to improve the artificial intelligence (AI) component of the bedside alarms. This will take advantage of the latest in AI technology for the betterment of care and patient safety.Intervention Plan Design for Patient Falls.
Leading Change and Improvement
This project has greatly impacted me positively insofar as my ability to lead change and improve my personal practice is concerned. I have come to appreciate the importance of quality improvement in healthcare through the use of evidence-based interventions. As a registered nurse, this has made me acquire competencies that place me in a better position to be a clinical nurse leader and nurse manager. Given the opportunity, I can no comfortably lead change in quality improvement in a leadership position. The completed intervention, implementation, and evaluation can only be transferred into my personal practice by me using the process in my practice. I have started to practice the same and intend to continue doing so even in other organizations that I may work for in the future.Intervention Plan Design for Patient Falls.
Patient falls are a significant quality issue in the nursing care of elderly patients in residential skilled care facilities. Patient falls cause significant morbidity and mortality in this patient population. Because of this, there is need for evidence-based interventions that can address this issue for better patient experience and outcomes. This paper has outlined such an intervention, its implementation, and evaluation in a skilled nursing facility for older adults undergoing rehabilitation.Intervention Plan Design for Patient Falls.
The purpose of this capstone project was to come up with evidence-backed strategies that can be used to prevent accidental patient falls that are a big quality issue in healthcare. Accidental patient falls are commonplace among the elderly patient population, especially in those above the age of 65 years. This project adopted the approach of clinical inquiry, which yielded three evidence-based intervention components effective in reducing patient falls.Intervention Plan Design for Patient Falls. Used together, these three components form an effective nurse-led bundle that has the potential to prevent patient falls completely. When used separately, however, evidence shows that the separate intervention components may not be as effective as when they are used as a bundle. In implementing the intervention, the role of the nurses working at the skilled care centers for the rehabilitation of elderly patients stands out. Apart from being the patient advocate, the nurse is also the one who implements each and every of the three intervention components.Intervention Plan Design for Patient Falls.
Keywords: quality improvement, accidental falls, elderly patient, prevention
Final Project Submission – Patient Falls
This project was about patient falls in healthcare institutions, especially among older adults. The identification of this need was the result of the realization that patient falls among the aged has remained a serious quality improvement issue in healthcare to date. With ageing and the normal deterioration in bodily functions associated with it, many older adults find themselves vulnerable to falls which result in preventable morbidity and mortality. As a matter of fact, among this population most injuries among suffered result from falls (Kenny et al., 2017). In the United States, the frequency of patient falls in healthcare institutions is reported to be between 3.3 and 11.5 patient falls out of 1,000 hospital stays. Apart from the cost in morbidity and mortality to the patients, this quality issue also costs the healthcare institution involved in not only reputation but also finances. This is because the Centers for Medicare and Medicaid Services or CMS has a policy of not reimbursing for services rendered to victims of accidental falls in hospitals (Fehlberg et al., 2017; Bouldin et al., 2013). Of course, the healthcare institution involved may also get sued in a court of law for the tort of negligence. To establish the best evidence-based strategies to prevent the occurrence of falls among older adults in skilled nursing facilities for rehabilitation, this project adopted the PICOT method of clinical inquiry (Melnyk & Fineout-Overholt, 2019). This led to the discovery of evidence supporting three strategies of hourly rounds, staff education and training, and the use of bed alarms (Heng et al., 2020; Mileski et al., 2019; Linehan & Linehan, 2018; Shin & Park, 2018; AHRQ, 2018; Daniels, 2016; Leone & Adams, 2015). The target population was all nursing staff working in skilled care facilities. The implementation would take a year with the evaluation of effectiveness taking both a continuous (e.g. monthly Quality Improvement Committee meetings) and summative (end-of-year quantitative survey) approach at the end of the year. This summative paper is about the statement of this quality problem and clinical inquiry, the intervention plan, the implementation of the intervention plan, and the evaluation of the implemented intervention.Intervention Plan Design for Patient Falls.
As mentioned in the introduction above, the identified need in the case of this project was a quality improvement need. The need was identified as that of addressing the high numbers of patient falls occurring among the elderly patient population. It was found that this was especially rampant in skilled nursing care facilities established for the rehabilitation of older adults away from the home environment. With a rapidly ageing population and longer lifespans attributed to better healthcare, the number of elderly adults seeking skilled nursing care at aged care facilities has been rising.Intervention Plan Design for Patient Falls. However, this population of older adults is vulnerable to accidental falls by the fact that they are experiencing age-related reduction in physical functionality. The risk of patient falls in this patient population is also exacerbated by the fact that it is also this same patient population that mostly suffers from other multiple pre-existing chronic medical and mental conditions such as heart disease, diabetes, arthritis, hypertension, and Alzheimer’s dementia amongst others. For instance, heart disease increases the likelihood of syncope if the elderly patient were to leave their bed suddenly without help. If diabetic, the occurrence of hypoglycemia is an ever present risk for an accidental fall is such older patients are not monitored constantly and made to only leave their beds when necessary and with assistance. In this patient population, chronic musculoskeletal conditions such as osteoarthritis also make them vulnerable to gait disturbances, restricting the range of their movements and predisposing them to falls. Of course, the presence of neurocognitive disorders such as Alzheimer’s dementia will make an elderly patient in these skilled nursing care facilities not realize the danger they are putting themselves in when they suddenly leave their beds without help.Intervention Plan Design for Patient Falls.
Kenny et al. (2017) state that the majority of reported cases of physical injuries among the elderly patient population are related to accidental falls that can be prevented if the necessary proactive measures were put in place. But physical injuries are not the only cost of falls in the elderly population. These accidental falls also result in deaths. As a matter of fact, it is reported that in the US, the highest number of deaths caused by injury in older adults over the age of 65 years can be directly attributed to accidental falls (McCarthy, 2016). All these facts point to the urgent need to address this issue as it puts the safety of older patients at risk and tarnishes the quality of care given to this patient population. Falls will invariably lead to future readmission which is an important quality benchmark for healthcare organizations. It is estimated by the Centers for Disease Prevention and Control or the CDC that treating the consequences of accidental patient costs approximates to almost USD 68 billion every year. In the case of patient falls, therefore, both the patient and the care facility lose in terms of physical injury/ death and expenditure or costs.Intervention Plan Design for Patient Falls.
Population and Setting
This clinical inquiry aims the intervention(s) that will be arrived at through clinical inquiry at the population of skilled care nurses working in skilled nursing rehabilitation centers for elderly adults. Nurses working in aged care facilities and skilled nursing homes for the rehabilitation of elderly clients are expected to be fast, professional, intuitive, pre-emptive, and concious of patient surroundings. Above all, they are supposed to be critical thinkers who can take stock of a situation and identify potential dangers to the patient.Intervention Plan Design for Patient Falls. This means that they should be able to appreciate the fact that they are caring for a patient population that is vulnerable and that may not have their full cognitive capacity in place. For this reason, it is expected that these nurses must possess special competencies. This is because they not only take care of the medical and nursing needs of the elderly, but also assist them with their activities of daily living or ADLs.Intervention Plan Design for Patient Falls.
Nurses in skilled care nursing homes for the rehabilitation of elderly patients are registered nurses who are highly trained. For this reason, they are receptive of new ideas that are aimed at improving the care delivered to their target patient population. They are aware of evidence-based practice or EBP by virtue of their education and training as well as its importance in improving patient outcomes. As nurses, they are the patient advocates who are in the forefront in ensuring that the rights of the patient are respected and the patient is treated according to the dictates of the bioethical principles of autonomy, beneficence, nonmaleficence, and justice.Intervention Plan Design for Patient Falls. Being registered nurses, they are also expected to be in possession of the competency of clinical nurse leadership. This means that through the use of the nursing process, they must be able to assess the needs of their elderly patients, make appropriate nursing diagnoses, and come up with appropriate interventions that they then implement to address the identified needs of the individual patient. In this case, the overriding nursing diagnosis will be ‘the risk of an accidental fall secondary to old age and infirmity’.Intervention Plan Design for Patient Falls.
In looking at the target population for this clinical inquiry, it is also crucial to appreciate that the environment in which they work is demanding and stressful. For this reason, a conducive working environment that is welcoming and warm is a significant prerequisite for them to be able to provide quality nursing care that improves the patient outcomes after implementing the EBP recommendations. This means that psychological safety is an important component of successful implementation of the evidence-based strategies to reduce the incidence of patient falls. A nurse who is scared of being reprimanded or victimized will not be willing to report a case of an accidental patient fall. They will try to hide this out of fear of the repercussions. However, this is not helpful for the patient. Transformational nursing leadership is therefore required to make this target population empowered and to win their buy-in for the successful translation into practice of the interventions backed by evidence from the clinical inquiry.Intervention Plan Design for Patient Falls.
The setting of the interventions, as had been alluded to in the introduction, is the skilled nursing care facility for the rehabilitation of older adults. These are basically residential aged care facilities that take care of elderly patients undergoing rehabilitation after suffering from surgery, injuries, or any other kind of therapy. Clearly, this is a setting that is challenging from the very fact that the patients being taken care of are not only frail from old age, but also sickly from chronic conditions (Kojima et al., 2015).Intervention Plan Design for Patient Falls.
The intervention to the identified problem of patient falls in the elderly patient population in skilled care nursing facilities takes a bundled approach. According to the evidence gathered from peer-reviewed research during the clinical inquiry, it comprises of:
Comparison of Approaches
The practice alternative that was considered in this case in place of the bundled approach described above is the use of bedside alarms alone in addressing patient falls. This is a technological solution to the quality problem of frequent falls in the population of elderly patients. However, the technology still relies on human cooperation for it to work effectively. This is because the nurse must respond promptly to the bedside alarm. In the event that the nurse feels tired/ lazy/ bothered and ignores the alarm, the patient will still suffer a fall. Also, the other pitfall is in the possibility that the nurse may silence the alarm such that it fails to sound when the patient leaves their bed. They may also reduce the volume of the alarm sound so as not to be disturbed by the frequently sounding alarm.Intervention Plan Design for Patient Falls.
Initial Outcome of Draft
The expected outcome for the above intervention is a reduction in accidental patient falls in the elderly patient population in skilled nursing care facilities to insignificant levels. Borrowing from the Six Sigma quality measurement tool, this would be virtually no falls recorded or just 3.4 falls per one million hospital stays (zero defects). The concept of zero defects in Six Sigma states that only 3.4 defects are permissible per every million opportunities or DPMO (Williams, n.d.).Intervention Plan Design for Patient Falls.
The estimated timeframe for the completion of the implementation of the bundled nursing intervention to prevent patient falls in elderly care facilities is between six months to one year. This will give ample time for staff training and implementation of the new knowledge and competency gained. The extended period also deliberately allows for adjustments necessitated by resource limitations, notably financial and human resources.Intervention Plan Design for Patient Falls.
There is no paucity of literature on the matter of prevention of accidental patient falls in healthcare institutions such as hospitals and nursing homes. According to Guirguis-Blake et al. (2018), implementing a nurse-driven falls prevention bundle is more effective than having a single intervention such as bedside alarms. This, they posit, is drawn from the fact that minimizing the risks for falls in the immediate environment of the patient requires a multifaceted approach from many fronts. There is no single system that is optimally effective at all times. All interventions have a degree of efficacy but also a chance, however slim, that they may fail at times. Intervention Plan Design for Patient Falls.For this reason, having a single intervention has been shown by research to predispose to catastrophe when that single intervention does not work as expected. A case in point is the use of bedside alarms alone. The very fact that this intervention is technology driven makes it prone to malfunction that may spell the difference between safe patients on the one hand and an injured patient and negligence suit on the other. The other factor to take into account is that the alarm can be tampered with or set according to what the nurse wants (i.e. the interval between the time the patient leaves their bed and the sounding of the alarm). This, therefore, illustrates the need for a bundled approach such that the failure of one component of the intervention is mitigated by the other components of the bundle (Guirguis-Blake et al., 2018).Intervention Plan Design for Patient Falls.
The evidence for the use of a nurse-led care bundle for the prevention of accidental falls to patients in the long term care facilities is supported by the work of Morgan et al. (2016). They support the use of hourly rounding in addition to other components like bedside alarms and staff training in a multifaceted care bundle. In particular, these authors reiterate the important role that staff training plays in the prevention of patient falls. Intervention Plan Design for Patient Falls.The suggestion they put forward is that it should not be only nurses that are trained, but also other healthcare staff cadres such as nurse practitioners, physician assistants, physiotherapists, physicians, and nurse assistants among others. This ensures that nurses are not left to shoulder the burden alone, when the task is supposed to adopt an interprofessional collaborative approach (Morgan et al., 2016).
Daniels (2016) on his part posits that purposeful and strict hourly rounding by the nurses is an evidence-based approach to reduce accidental patient falls in the hospital. While doing it, the nurses set out to perform five key functions aptly christened the five ‘P’s. This means that they will perform strict hourly rounds by checking on each and every patient to make sure that they (i) are free of pain; (ii) are taken care of in terms of any personal needs that they may have (need for drinking water, food, and so on); (iii) are positioned in a comfortable way to ease the pressure on the pressure points; (iv) are placed within reach of any item near the bed that the may need for their own use, such as a book or a phone; and (v) are taken care of in terms of bowel movements (Daniels, 2016).Intervention Plan Design for Patient Falls.
The position of Daniels (2016) is supported by Linehan and Linehan (2018) who also state and observe that hourly rounds by the nurses are effective in lowering the incidence of accidental patient falls in healthcare institutions. In their scholarly work published in the Journal of the American Medical Directors Association, the two authors are categorical that patient outcomes in long term care facilities such as skilled nursing homes for rehabilitation of elderly adults are greatly improved by hourly nursing rounds. They also however observe that despite this effectiveness of the intervention in improving the quality of care (effectiveness, efficiency, patient-centeredness, timeliness, safety, and equitability), the intervention is often resisted by nurses since it is labor-intensive and demanding. The authors state that nurses feel that it overburdens them with workload and leaves them no time to rest or carry out other nursing duties such as documentation (Linehan and Linehan, 2018).Intervention Plan Design for Patient Falls. This is however a problem that could be easily resolved by the organization if it is committed to excellence in patient care. This means that the organization will have to spend more resources and increase the number of nurses on a given shift so that no single nurse does every consecutive hourly round without resting. With adequate numbers, a nurse can rest for three hours before doing the next hourly round. This will increase motivation and prevent burnout. Such organizational commitment to make the working environment conducive and motivating will be in line with the fourth Quadruple Aim of making the healthcare work environment psychologically safe for staff for quality care to be provided (Sikka et al., 2015).Intervention Plan Design for Patient Falls.
The intervention of hourly rounding to reduce the incidence of patient falls is also supported by the work of Shin and Park (2018). They also aver that carefully planned and thorough hourly rounds by nurses in long term care facilities will be effective in preventing patient falls and guaranteeing patient safety. They however advise nurses to exercise their discretion and criticality in the performance of the hourly rounds. In particular, they advise that nurses may leave those patients they deem to be stable to rest without having to disturb them every hour while they are resting. On the same note, they may then concentrate on the more needy patients such as those who are bed-ridden for strict hourly rounding. In essence, what then authors advocate for is the nurse’s assessment of each patient and documentation of their risk status. The authors also reiterate the importance of the nurses interacting with and documenting their interactions with the patients during these hourly rounds (Shin & Park, 2018). Intervention Plan Design for Patient Falls.
Still adding to the available evidence in support of hourly rounding by nurses in the prevention of patient falls are Leone and Adams (2015). They posit that when nurses carry out or implement careful and strategic hourly patient rounds, there is a reduction in the number of accidental falls. More importantly, there is measurable improvement in patient satisfaction with the quality of care as well as the confidence of the patients in the ability of the nurses to care for them sufficiently. But as has been observed above, these authors noted that if the nurse-patient ratios are not addressed by the organization the strategy of hourly rounds will not work. They note that the increased workload brought about by the hourly rounds will wear out the small number of nurses per shift and reduce efficiency by causing burnout and disgruntlement. For this reason, adequate staffing is a crucial element in the success of the nurse-led fall prevention care bundle in long term care facilities such as skilled nursing rehabilitation homes. There may also be need for the organization to come up with strategic incentives to get the buy-in of the nursing staff in the implementation and integration into organizational policy of the fall prevention bundle. This is because these two authors also note that the resistance of nurses to the notion of hourly rounds is significant (Leone & Adams, 2015). Maybe having changes such as shorter shifts and more rest days may motivate the nurses to embrace this quality improvement intervention that can save patents’ lives as well as resources for the organization. In the end, however, what is clear is that each organization will have to handle the implementation according to their unique situation.Intervention Plan Design for Patient Falls.
Heng et al. (2020) on their part have posited that as much as staff education is important, it should not be done alone without patient education if the intervention is to be fully effective. On staff education, they suggest or recommend the use of different teaching aids to facilitate the retention of the knowledge and skills taught. Of importance, the authors recommend that such training of staff be done by someone who is an expert in fall prevention and quality improvement. In addition, the authors state that ancillary professionals in the long term rehabilitation care centers such as physical therapists (physiotherapists) should also be included in the training of the nurses. This is because they are more knowledgeable about appreciation of the mobility dynamics of a patient and can therefore teach the nurses how to recognize a patient who may be at a heightened risk of falls. As mentioned, they recommend that the hospitalized older adults also be educated on fall prevention to the extent to which they can process the information (in the abscence of cognitive disability) (Heng et al., 2020).Intervention Plan Design for Patient Falls.
The ineffectiveness of a singular approach to preventing patient falls is aptly illustrated by Gavaller et al. (2019). They state that research has shown that using bedside and chair alarms alone does not prevent accidental patient falls in long term care facilities. This conclusion is drawn from the fact that for the alarm system to be effective, the cooperation and availability of the nurses has to be guaranteed. This is not possible because in a setting that has few nurses per shift due to staff shortage, an alarm may sound when the nurses are occupied with another patient and hence go unattended. The result will be that the patient on whose bed the alarm was sounding to warn the nurses will suffer a fall. This position on inadequacy of bedside alarms alone as a fall prevention strategy is shared by Mileski et al. (2019). Research carried out by them showed that using bedside alarms alone will not prevent patient falls in a setting such as a skilled nursing care facility for the aged. Just like Guirguis-Blake et al. (2018) and Morgan et al. (2016), Mileski et al. (2019) recommend that a bundled approach be adopted to ensure effectiveness of any fall prevention intervention.Intervention Plan Design for Patient Falls.
One of the health policies that could greatly impact the implementation of the above nurse-led fall prevention bundle is the policy regulation by the Centers for Medicare and Medicaid Services (CMS) that prohibits reimbursement for care given to fall victims in hospitals. This policy will positively inspire organizations to want to implement these prevention strategies because they will save the organization financial resources that would be used to treat the fallen patients (Fehlberg et al., 2017).
It has been seen above that available evidence favors the use of a multifaceted interventional strategy or bundled approach in the prevention of accidental patient falls (Mileski et al., 2019; Guirguis-Blake et al., 2018; Morgan et al., 2016). The evidence-based intervention strategy that has been found to effectively prevent patient falls in long term care facilities as well as other healthcare settings is a combination of hourly rounds by nurses, the use of intelligent bedside alarms, and indiscriminate staff education (AHRQ, 2018).Intervention Plan Design for Patient Falls.
Intervention Plan Components
The development of the above intervention plan components was impacted by some cultural needs and characteristics of the target population and setting (skilled registered nurses in long term rehabilitation care facilities). The cultural need (from an organizational cultural standpoint) for the target population that significantly impacted the formulation of the above interventional plan components is that of empowerment and psychological safety at the workplace. The target group of nurses working at these skilled rehabilitation care facilities for the aged require that the working environment be conducive and motivating for them to be able to implement these interventional components of the fall prevention bundle.Intervention Plan Design for Patient Falls. This means that the nurse leaders in the skilled centers must exercise transformational leadership to inspire the translation into practice of these evidence-based strategies for fall reduction. The characteristics of the target population of nurses on the other hand include being patient advocates, being lifelong learners ready to be educated on evidence-based practice or EBP, being governed by professional standards of practice, and being directed by the ethical principle of primum non nocere or not harming the patient. The most important characteristic of the care setting in this case is that it is a temporary home for these older adults undergoing rehabilitation before reintegration into their families. The significance of this is that this setting cannot replace or rival the home environment, making it stressful to adjust to the setting for the elderly patients being taken care of there.Intervention Plan Design for Patient Falls.
The theoretical underpinning for the implementation of the above fall prevention bundle as EBP is Roger’s Diffusion of Innovation theory (Pashaeypoor et al., 2016). In this theory, the innovators are the change agents that inspire and drive the practice change towards implementation of the fall prevention bundle. These innovators (who are part of the skilled nurses working at the long term rehabilitation care centers) depend on the early adopters and the early majority for the successful acceptance and adoption of the intervention into practice and into the organization’s policies and regulations. Together, the innovators, the early adopters, and the early majority form 50% of all the nurse employees at any skilled care center.Intervention Plan Design for Patient Falls. This means that they can realistically influence the remaining sceptics who are the late majority and the laggards and get their buy-in. The strategy from other disciplines relevant to the intervention plan in this case is about quality control and is not from the service industry. It is from the goods manufacturing industry and is referred to as the ‘defects per million opportunities’ (DPMO) or ‘zero defects’. This quality control strategy comes from the Six Sigma quality control initiative that states that acceptable quality should allow virtually no defects, or just 3.4 defects per million opportunities. Extrapolated to this context of patient falls, that means that the only acceptable outcome would be no falls reported or just 3.4 falls per one million hospital stays (Williams, n.d.). Lastly, the health technology relevant to the above intervention pan, as has been seen, is that of artificial intelligence or AI. This is evident in the intelligent bedside alarms that will sound at any time the patient leaves their bed.Intervention Plan Design for Patient Falls.
There is no paucity of contemporary literature in support of the intervention plan components. For instance, evidence for hourly rounding comes from Linehan & Linehan (2018), Shin & Park (2018), Daniels (2016), and Leone & Adams (2015). For staff training and patient education, the evidence comes from Heng et al. (2020) and the AHRQ (2018); while conflicting findings for bedside alarms is found in the work of Gavaller et al. (2019).Intervention Plan Design for Patient Falls.
Stakeholders, Policy, and Regulations
The impact of stakeholder needs relevant to the intervention plan can be found in the needs of the patients and the healthcare organization. The former need quality care that is safe, timely, effective, efficient, patient-centered, and equitable. The latter needs better ratings and accreditation by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). On policy and regulations, the CMS no-pay policy for services rendered to fall victims in hospitals stands out as greatly impacting the implementation of the intervention. Lastly but not least, the state boards of nursing have disciplinary procedures for punishing errant nurses who demonstrate professional negligence. This, too, has an impact on the implementation of the fall prevention interventions. Intervention Plan Design for Patient Falls.
Ethical and Legal Implications
Ethically, the nurses working in the skilled care centers are supposed to practice nonmaleficence (not harming the patient), by not allowing them to suffer falls (Santhirapala & Moonesinghe, 2016). Legally, the nurse on the shift in which a patient suffers a fall owes a duty of care to them and may be sued for Civil Negligence under Tort Law and be liable to pay remedies. The organization may also be sued alongside the nurse(s) on the premise of vicarious liability (Walker, 2011).
Management and Leadership
Proper leadership and management are critical to the success of the implementation strategy for the fall prevention intervention. This role will fall to the nurse leaders or managers in the skilled care rehabilitation centers. To facilitate their work and to make it manageable, they would need to form a quality improvement implementation committee with an interprofessional collaborative outlook to direct the implementation of the nurse-led fall prevention bundle. This committee will examine the existing organizational policies and standard operating procedures with a view to revising them and aligning them with the evidence-based fall prevention intervention. They will also look at the industry standards that guide quality assessment with regard to patient falls (Saade & Nijher, 2016).Intervention Plan Design for Patient Falls. On this they may consult the Agency for Healthcare Research and Quality (AHRQ) toolkits as well as the JCAHO recommendations and guidelines. The implementation committee headed by the nurse manager will also enforce the strict adherence to nursing standards of practice. They will look for areas of possible conflict and address them to pre-empt the same. They will have to be excellent communicators to be able to impress upon and convince the nurses of the significance of translating the recommendations into practice. In other words, they have to find a way to ensure the achievement of maximum buy-in from the nursing and other allied healthcare workforce at the skilled care centers. Management and leadership will also be needed with regard to provision of the resources that will be needed to successfully implement the fall prevention intervention. All this while, interprofessional collaboration would be the guiding philosophy so that all professionals can contribute to the success of the implementation.Intervention Plan Design for Patient Falls.
The implications of change connected to the proposed quality improvement strategies are found in the need for recruitment of more nurses (to manage hourly rounding without creating burnout), expenditure on training and education of nurses, and the purchase and installation of bedside alarm technology. This means there will be significant demands on financial and human resources for successful implementation. Costs can therefore be controlled by carefully deploying nursing skill mix, having training conducted at the facility on-the-job, and going for the lowest but best bidder in the purchase of bedside alarms.Intervention Plan Design for Patient Falls.
Delivery and Technology
With the exception of the bedside alarms, the delivery of the other two intervention components (namely hourly rounding and staff training) will be fairly straightforward. Nurses on each shift will strategize and perform patient rounds every hour until the shift ends. In each round, they will concentrate on the patients who are at a higher risk of falls. They will position them, meet their needs, and document. Staff training on the other hand will be done on site to save on costs. Training will involve simulations, presentations, drills, role play, and practical demonstrations. As for the bedside alarms, this will be installed and integrated into the facility’s electronic health record (EHR) system first. Nurses will then be trained on its use after which they will be able to set the time lapse period between the time the patient leaves their bed and the time the bedside alarm sounds. They will then be required to promptly respond to the alarm when it sounds so that the patient does not fall.Intervention Plan Design for Patient Falls.
The current emerging technological solution to the fall prevention strategy is the use of artificial intelligence (AI) in intelligent bedside alarms. This technology will need to be made foolproof so that no nurse will be able to tamper with the set time lapse duration, prolonging response and endangering the lives of patients. It will need constant maintenance to avoid malfunction and catastrophic consequences.Intervention Plan Design for Patient Falls.
Stakeholders, Policy, and Regulations
There are many stakeholders that will impact the implementation of the fall prevention intervention. These include but are not limited to the elderly patients, their families, the nurses, the allied healthcare workforce (physical therapists, counselors, dieticians, nurse practitioners, physicians, occupational therapists, the organization, the local community, and the local healthcare authorities amongst others (De Camargo et al., 2019). One of the regulatory elements that may impact the implementation of the fall prevention bundle is a Centers for Disease Control and Prevention or CDC tool in the form of guidelines. It is the Stopping Elderly Accidents, Deaths and Injuries (STEADI) guidelines. Support is expected to be from the facility’s management, both morally and resource-wise. Existing policy considerations that would help with the implementation of the fall prevention bindle would be the need for accreditation by the JCAHO as a center of excellence that delivers quality care to older adults.
The timeline for the implementation of the fall prevention strategy will be one year, broken down by task as follows:
The expected outcomes that are the goal of the intervention strategy discussed above are aligned to the Quadruple Aim objectives (Sikka et al., 2015) and are as follows:Intervention Plan Design for Patient Falls.
The evaluation plan to find out the success or failure of the intervention for fall prevention is as follows:
The nurses’ role in leading change and driving improvements in this case encompasses patient advocacy as a whole. The nurse is the patient’s number one advocate and cares about their welfare. The nurse is also the chief implementer in this case. It is the nurse who will do hourly rounds, be trained on fall prevention, and respond to bedside alarms. The intervention affects nursing as a profession by facilitating EBP. Because it is multifaceted in approach, it also helps strengthen interprofessional collaboration by bringing together the expertise of different healthcare professionals. The healthcare field also gains from the fact that healthcare quality rises due to the use of EBP.Intervention Plan Design for Patient Falls.
Improvement of the current project to create an even bigger impact can be realized through (i) publishing the EBP intervention in a reputable journal (thereby reaching many more skilled care nurses); (ii) disseminating the intervention at conferences and symposia through presentations; and (iii) getting JCAHO quality certification. Updating the AI software of the intelligent bedside alarm system will also harness emerging technology and improve outcomes.
Reflection on Leading Change and Improvement
This project has made me realize the significance of quality improvement in healthcare. I am now in a position to lead change in any organization that I may work in; courtesy of the experience I have gained from this project. The completed intervention, its implementation, and evaluation plans can be integrated into my personal clinical practice and improve quality by constantly practicing the same.Intervention Plan Design for Patient Falls.
It is universally agreed that accidental patient falls in hospitals are especially rampant in the elderly patient population. This is brought about by their infirmity, age-related physiologic deterioration, and state of having many comorbid chronic illnesses as well as neurocognitive disorders. This being a quality improvement issue in healthcare, evidence-based interventions are required to prevent these falls. This project has demonstrated that this kind of intervention can be a nurse-led fall prevention bundle comprising of hourly rounding, staff training, patient education, and the use of intelligent bedside alarms. Intervention Plan Design for Patient Falls.