Whether it’s low tech signs or high tech computer systems, falls prevention efforts can take many different forms in the inpatient rehabilitation setting. What links programs together is the role the rehab nurse plays in educating both patients and fellow staff members.
At Schwab Rehabilitation Hospital in Chicago, falls risk education begins at the time of admission, when the patient education packet is reviewed with both patients and their family members. Previously, with other competing priorities at the time of admission, fall risk education was not always a priority.
At admission, Schwab patients, which consist mainly of the diagnoses of stroke, TBI, SCI, and amputees, undergo a fall risk assessment. The nurses use the popular Hendrich II Fall Risk Model to determine each patient’s risk level. “We have the advantage of using an assessment tool based on patients’ deficits,” said Melanie Corr, RN, CRRN, staff nurse.
Factors like previous falls history, age, impaired memory, sensory deficits, certain medications, and more are assigned point values, with the patient earning a total score. Those with certain diagnoses, like stroke, have a heavier falls risk. The scores are not static and patients are re-evaluated throughout their stay to see if their number goes up or down.
The Hendrich II is not the only tool available to rehab nurses to determine their patients fall risk level. Staff at MemorialCare Rehabiliation Institute at Long Beach Memorial Medical Center in California evaluates patients using The Johns Hopkins Hospital Fall Assessment Tool. That multi-factoral protocol weighs similar factors and also considers the presence of any equipment that tethers a patient in place and whether the patient needs assistance for transfers.
The rehab patient population at the facility is similar, with stroke, TBI, SCI, medically complex patients and complex orthopedic patients. Paddy Garvin-Higgins, MN, RN, CRRN, CNS, PHN, rehab clinical nurse specialist explained, “Every patient that comes through the door is considered to be a fall risk.”
Rehab nurses use the Johns Hopkins Fall Assessment Tool and their own clinical judgment to give their patients a score. Nurses can independently assess if patient is at a higher risk than the test indicates. Long Beach Memorial Medical Center developed an algorithm to help nurse determine if a patient is low or high risk and whether they are prone to injury. Garvin-Higgins said, “The nurse is responsible for making sure falls prevention measures are documented.” Once the assessment is complete, the next step at both facilities is to set up the appropriate interventions.
At Schwab Rehabilitation Hospital, risk management protocols for all patients include having the call light within reach, having the bed side rails up, hourly rounds,and falls education calls for patients. Corr noted, “We revised policy and added fall prevention to hourly rounding.” Nurses or nursing assistants check to see if patients have what they need within reach. Those at moderate risk have the addition of a bed or chair alarm and an evaluation of their room location, to possibly move them closer to the nurses’ station. High risk patients get all the previous precautions, plus an evaluation of the need for restraints and spot checks every two hours. Standard measures at Long Beach Memorial include having the call light in reach, side rails up, hourly intentional rounds, and well-lit rooms.
Communicating the Risk
Schwab Rehab illustrates fall risk using the stoplight model-green for low, yellow for moderate and red for high. “We communicate the fall risk in a visual way,” explained Naomi Seef, MSN, CRRN, Sinai Health System patient officer. Physical signs are attached to both the bed and the patient’s wheelchair, so anyone who comes into contact with them, not just nurses, will know their falls status. Call Don’t Fall signs are also placed in rooms.
“One of the key successes was education,” noted Seef. It was not simply a nursing initiative.Rehab nurses met with representatives from therapy, dietary, environmental services, anyone who would be in a patient care area. “We wanted them to be aware of the traffic alarms so they can help us keep the patients safe,” said Seef. They trained other workers to get a nurse when a patient with a red light wanted to get of bed or move from chair to bed.
The rehab nurses at Long Beach Memorial Medical agree with the need for a multidisciplinary approach. “The biggest success is getting the word out there to all staff as it is everyone’s responsibility, not just nursing,” Garvin-Higgins remarked. Indeed, the facility won an award for its interconnected falls prevention models, which consistently put patients and families at the center. Additionally, their risk management efforts won them recognition from the American Excess Insurance Exchange.
Besides a fall risk wristband, which all staff can see, fall risk scores and prevention measures are added to patients’ electronic health records. Whenever any clinician accesses a record, a banner notifies them of the patients’ risk level. It is part of an all-out effort to train the entire staff, not just nurses, training that includes mandatory online education on falls prevention.
For an additional technological intervention, Long Beach Memorial recently tested a telesitter. A portable monitoring device is placed within the patient’s room, with a second monitor at the nurses’ station. If the patient moves, the nurse can see and use two-way audio to tell them to sit down. “There’s a real connection between how we balance human behavior and technology,” explained Garvin-Higgins.
Success has come to both facilities after ramping up falls prevention measures. Long Beach has seen a 50% falls reduction in the previous six months as compared to the prior six month period. Schwab Rehabilitation Hospital reduced their fall rate per 1000 patient days from 7.86 to 3.9 over the course of one year. “We thought it was just phenomenal,” Seef remarked.
No matter the interventions, when it comes to falls prevention, “It’s been helpful to have the rehab nurse at the table,” Garvin-Higgins said. Rehab nurses play an instrumental role in getting the word out and implementing critical measures. Their advanced knowledge of patient injuries and functional loss can help develop care plans.
While preventing all falls is impossible, strives have been made to lower the frequency. With rehab nurses at the helm of efforts, the downward trend, at least at these facilities, will hopefully continue.
Danielle Bullen is on staff at ADVANCE. Contact: [email protected]