Kevin G. Smith, RN Felipe Gutierrez, RN, MSN, FNP Judy Davidson, RN, MS, CCRN, FCCM

2. Identifying and Eliminating Nursing Practice Barriers within an existing Evidenced Based, Multidisciplinary Inpatient Fall Prevention Protocol Kevin G. Smith, RN Felipe Gutierrez, RN, MSN, FNP Judy Davidson, RN, MS, CCRN, FCCM

3. Evidence Based Practice Institute • Identify best practice standards • Install evidence-based practice • Evidence Based Practice Institute Project • Journey to Magnet • Agent of change: Fall champion

4. PICO? • P: inpatients determined to be at high risk for falling while hospitalized • I: identifyingand modifying practices determined to beobstructive to implementation of a multidisciplinary evidenced-based fall prevention practice • C: when compared to current practice? • O: measurably reduce the occurrence of falls

5. Scripps Investigational Review Board • Starting point: Define “falls” • Plan: • Convenience study of patients • Multidisciplinary Practice Survey • Implement Best Practice • Goal: reduce fall related negative outcomes

6. Background • D.O.U. with nursing scope of practice that includes high acuity medical/surgical and cardiac patients in telemetry setting. • Very high professional nursing practice standard with practice autonomy within multidisciplinary patient care setting.

7. Background • Practicing a nursing centered multidisciplinary inpatient falls prevention plan of care, utilizing nationally recognized protocols. • Occurrence rate of falls continues to be problematic, above California Nursing Outcome Coalition (CalNOC) benchmark of hospitals of similar size within California.

8. Background • Rhetorically, why hasn’t a proven plan of care netted the expected results? • Falls are a “nursing sensitive quality indicator”.

9. “Falls” Literary Review • After initial review of over 100 publications related to falls, 22 were selected for thorough review. • The 22 articles selected for critical review spanned the “hierarchy of evidence”. Although, most evidence was from studies conducted without randomization.

10. Review Findings • Points of saturation: • Etiology of falls are multifactorial • Regular rounding reduces falls • Interventionally multidisciplinary • Falls are a nursing quality indicator • Educational oversight

11. Project Plan • Specialty Adult Focused Environment (S.A.F.E.) Unit – Constant rounding • Fall Champions – Plank owners • Team Nursing /Rotational assignments • Educational oversight - Daily inservicing • Fall occurrence – Intense review

12. Project Findings • Champions = change • Resources = results • Staff driven educational oversight works (eventually)

13. First Phase: n = 59 55% of RN’s surveyed said they had a patient fall within the last year 81% of rooms had “call don’t fall sign” 27% of RN’s reported fall risk in change of shift report Second Phase: n = 34 No surveys conducted in second phase, focus on rounding 88% of rooms had “call don’t fall sign” 35% of RN’s reported fall risk in change of shift report Baseline Data/Results

14. First Phase: n = 59 75% of RN’s charted the correct Morse Score 81% of RN’s ordered low bed/bed alarm or were NA 91% of rooms were free from clutter Second Phase: n = 34 82% of RN’s charted the correct Morse Score 71% of RN’s ordered low bed/bed alarm or were NA 94 % of rooms were free from clutter Baseline Data/Results

15. First Phase: n = 59 91% of patients had call light; urinal; commode; water within reach 35% of patients were unable to communicate/confused/dementia 60% of patients /families were educated on fall risk Second Phase: n = 34 85% of patients had call light; urinal; commode; water within reach 19% of patients were unable to communicate/confused/dementia 71% of patients/ families were educated on fall risk Baseline Data/Results

16. First Phase: n = 59 66% of the time PT/OT worked with patient if ordered 51% of patients had a written plan to prevent falls 72% of charts had a “ticket to ride” updated as needed Second Phase: n = 34 64% of the time PT/OT worked with patient if ordered 44% of patients had a written plan to prevent falls 74% of charts had a “ticket to ride” updated as needed Baseline Data/Results

17. Results • In summary, many of the process outcomes that we were measuring did not improve. • But what happened to falls?

18. Research Data Findings

19. Conclusion • Addressing literature review saturation points has yielded tangible results. • Staff championed best practice integration works. • Educational oversight yields practice change (inservice, inservice, inservice).

20. Implications for Future Change Strategies • Unit Collaborative Practice Council propose practice improvement • Champions for change recruited for each new project • Use literature to identify best practice • Staff champions implement culture change • Journey to Magnet