Keeping patients from falling has become a priority for all manner of health care providers, partly because falls and fall prevention are often factored into quality scores. Death or serious injury from a fall in a health care facility is considered a “never event.” But falls are common. The Agency for Healthcare Research and Quality estimates that somewhere between 700,000 and a million American hospital patients take a tumble each year. Clearly, all the well-intentioned fall-prevention efforts have accomplished only so much.
A program at Virginia Mason Medical Center in Seattle could be an example of a better approach. Rather than focus on falls, it travels upstream to treating and preventing delirium, one of the main causes of falls in the hospital. And the authors of a paper in the July–September issue of the Journal of Nursing Care Quality about the program and its results describe it as “nursing driven.”
A multidisciplinary team at the 336-bed not-for-profit hospital designed and implemented the program. It included nursing executives, nurses and other types of providers, a psychiatrist, and members of the quality-improvement staff. The program started with a “nursing-focused, evidence-based prevention bundle.” The interventions included efforts to minimize sensory deprivation and disruption of patients’ sleep. Patients also were assessed for delirium risk when they were admitted; the risk factors include being older than 65, a prior history of delirium, and cognitive impairment. The families of at-risk patients were asked to fill out a form identifying a family member’s baseline cognitive abilities to help keep tabs on any worrisome changes in the person’s mental status.
A second phase of the program focused on patients experiencing delirium. They were evaluated for metabolic abnormalities, infections, substance withdrawal, and other possible causes of delirium.
Nursing leaders and clinical quality nurses reviewed every fall in the hospital to check whether it was related to delirium. Root-cause analysis was used to identify how and why the delirium-related fall occurred. Nursing leaders created and implemented action plans.
The program was associated with a near halving of the delirium-related fall rate. Before the program, the rate of delirium-rated falls was 0.91 per 1,000 patient days at Virginia Mason. Afterward, it was 0.50 per 1,000.
Now the caveats. Historical controls are never the optimum comparison group. Delirium is a clinical syndrome and, therefore, there’s some unavoidable subjectivity to the diagnosis. Staffing at Virginia Mason increased on a per-patient basis during the delirium-fall intervention. The increased staffing might have had an effect on the delirium-rated falls, separate and apart from the program targeting the problem.
Putting those limitations aside, lead author Alice Ferguson and her colleagues make a convincing case that the nurses were central to the success of the program. Nurses performed real-time delirium assessment and were given the authority to take nonpharmacological steps to prevent and treat delirium. “Our results,” they wrote, “show that implementation of a hospital-based delirium program should include nurses in this critical role.”