Location
Virtual
Start Date
1-3-2024 8:55 AM
End Date
1-3-2024 9:10 AM
Keywords:
california; plcmmc
Description
Background
Patient falls are the most common adverse events reported in hospitals and represent a persistent patient safety issue. Annually, roughly 700,000 to 1 million patient falls occur in United States hospitals, resulting in around 250,000 injuries and up to 11,000 deaths (LeLaurin et al., 2019). Nurses are responsible for the identification of high fall risk patients and development of a plan of care to minimize risk. Multifactorial strategies have been shown to reduce falls, but evidence of a sustainability team (fall champions) is lacking. Review of the National Database of Nursing Quality Indicators (NDNQI) data on a 33-bed progressive care step-down unit revealed that the average number of falls went from 1.13 falls/1000 days in 2021 to 1.27 falls/1000 days in 2022.
Purpose
The project aims to determine if the implementation of a Fall Ambassador Safety Team (FAST) program in combination with an evidence-based fall prevention bundle is associated with a reduction in the total number of inpatient falls. The primary goal is to reduce the patient fall incidents to meet the target of/1000 patient days per the NDNQI data over a period of 9 months.
Methods
This quality improvement project was conducted between December 1, 2022, to September 30, 2023, in a 33-bed progressive care step-down unit. All adult inpatients hospitalized between January 1 to September 30, 2023, were included in the analysis. Methodology included the development of 1) Fall Ambassador Safety Team (FAST), comprised of nurses, nursing assistants, and health unit coordinators, 2) Fall prevention kit (i.e., room signs, bed/chair alarms, and fall rounding checklist), and 3) FAST orientation manual for all members. Weekly fall rounding was conducted by a FAST member that assesses fall risk, interventions, and barriers among staff and patients. Additionally, nursing leadership coordinated monthly fall meetings to discuss practice, gaps, and trends. The pre- and post-implementation analyses included quarterly fall rates and compliance of fall prevention bundles through weekly fall rounding audits.
Results
Analysis suggested a significant decrease in fall rates from an average of 1.24 falls/1000 days (9 months pre-implementation) to an average of 0.37 falls/1000 days patients (9 months post-implementation). This project has reached sustainment, and the unit continues to see a low fall rate, well below the national average.
Conclusion
Implementation of fall champions, in conjunction with a fall prevention program, is a feasible intervention in reducing fall rates. The FAST program appeared to be beneficial in improving the safety of patients and creating a collaborative environment for nurses to conduct safe, quality patient care.
Implications
Fall champions led by nursing staff are promising and viable programs for preventing falls. A collaborative team approach utilizing FAST was imperative to improve fall prevention strategies, diminish risk for injury, as well as improve nursing compliance. Continued auditing and staff education will ensure a decrease in falls, striving towards the organization’s goal of zero harm.
Recommended Citation
Codilla, Jerome and Arraiza, Joanna, "Fall Prevention Quality Initiative: Implementation of Fall Ambassador Safety Team (FAST)" (2024). Providence Nursing Research Conference 2023 – Present. 6.
https://digitalcommons.providence.org/prov_rn_conf_annual/2024/podiums/6
Department
Quality
Department
Nursing
Included in
Fall Prevention Quality Initiative: Implementation of Fall Ambassador Safety Team (FAST)
Virtual
Background
Patient falls are the most common adverse events reported in hospitals and represent a persistent patient safety issue. Annually, roughly 700,000 to 1 million patient falls occur in United States hospitals, resulting in around 250,000 injuries and up to 11,000 deaths (LeLaurin et al., 2019). Nurses are responsible for the identification of high fall risk patients and development of a plan of care to minimize risk. Multifactorial strategies have been shown to reduce falls, but evidence of a sustainability team (fall champions) is lacking. Review of the National Database of Nursing Quality Indicators (NDNQI) data on a 33-bed progressive care step-down unit revealed that the average number of falls went from 1.13 falls/1000 days in 2021 to 1.27 falls/1000 days in 2022.
Purpose
The project aims to determine if the implementation of a Fall Ambassador Safety Team (FAST) program in combination with an evidence-based fall prevention bundle is associated with a reduction in the total number of inpatient falls. The primary goal is to reduce the patient fall incidents to meet the target of/1000 patient days per the NDNQI data over a period of 9 months.
Methods
This quality improvement project was conducted between December 1, 2022, to September 30, 2023, in a 33-bed progressive care step-down unit. All adult inpatients hospitalized between January 1 to September 30, 2023, were included in the analysis. Methodology included the development of 1) Fall Ambassador Safety Team (FAST), comprised of nurses, nursing assistants, and health unit coordinators, 2) Fall prevention kit (i.e., room signs, bed/chair alarms, and fall rounding checklist), and 3) FAST orientation manual for all members. Weekly fall rounding was conducted by a FAST member that assesses fall risk, interventions, and barriers among staff and patients. Additionally, nursing leadership coordinated monthly fall meetings to discuss practice, gaps, and trends. The pre- and post-implementation analyses included quarterly fall rates and compliance of fall prevention bundles through weekly fall rounding audits.
Results
Analysis suggested a significant decrease in fall rates from an average of 1.24 falls/1000 days (9 months pre-implementation) to an average of 0.37 falls/1000 days patients (9 months post-implementation). This project has reached sustainment, and the unit continues to see a low fall rate, well below the national average.
Conclusion
Implementation of fall champions, in conjunction with a fall prevention program, is a feasible intervention in reducing fall rates. The FAST program appeared to be beneficial in improving the safety of patients and creating a collaborative environment for nurses to conduct safe, quality patient care.
Implications
Fall champions led by nursing staff are promising and viable programs for preventing falls. A collaborative team approach utilizing FAST was imperative to improve fall prevention strategies, diminish risk for injury, as well as improve nursing compliance. Continued auditing and staff education will ensure a decrease in falls, striving towards the organization’s goal of zero harm.
