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Beth Israel Deaconess Medical Center Will Collaborate in Two Additional Federal Innovation Grants

Beth Israel Deaconess Medical Center will collaborate in two additional federal innovation awards announced last week: one with Dartmouth-Hitchcock Medical Center as part of the High Value Healthcare Collaborative (HVHC) and one with Mayo Clinic.

These awards were announced as part of the second and final round of Innovation Grants awarded by the federal Center for Medicare and Medicaid Innovation.

The collaborations come in addition to the $4.9 million Innovation award received in May to launch a Post-Acute Care Transitions program designed to improve patient outcomes and prevent avoidable cost in the high-risk 30-day period following acute care hospitalization.

BIDMC is one of 15 large health systems across the nation to come together as the High Value Health Collaborative convened and facilitated by the Dartmouth Institute for Health Policy and Clinical Practice. The $26.2 million grant will fund a program to engage and implement shared decision-making for patients facing hip, knee or spine surgery, and for patients with diabetes or congestive heart failure across the HVHC member systems.

The bulk of the funding will be used to hire and train Patient and Family Activators at the 15 member organizations. Over the three-year grant period, 1,845 health care workers will be trained and an estimated 48 PFA positions will be created to engage in shared decision making with patients and their families, focusing on preferences and supplying sensitive care choices.

"The goals of this project are fully in keeping with our own efforts to create a truly patient-centered care experience where patents and their families work closely with their caregivers," says Ken Sands, MD, BIDMC's Senior Vice President of Health Care Quality and one of the principal investigators on the grant.

CMMI estimates the project will result in savings of $64 million over three years, largely due to reduced utilization and costs that have been shown to occur when patients are engaged and empowered to make health care decisions based on their own values and preferences.

Other members of the HVHC include Baylor Health Care System, Beaumont Health System, Denver Health, Intermountain Healthcare, Mayo Clinic, North Shore-LIJ Health System, MaineHealth, Providence Health and Services, Scott and White Healthcare, Sutter Health, UCLA Health System, University of Iowa Health Care, and Virginia Mason Medical Center.

HVHC members collectively serve 50 million patients in health systems across the United States. The Collaborative was founded in 2010 and identified nine high volume, high cost, high variation clinical areas to focus on, with the goal of improving care and outcomes, reducing variation, and lowering costs.

For the second award announced, BIDMC will be collaborating with the Mayo Clinic, the US Critical Illness and Injury Trials Group and Philips Research North America, in an effort to improve critical care performance for Medicare/Medicaid beneficiaries in intensive care units.

Daniel Talmor, MD, vice chair for critical care in the Department of Anesthesia, is one of three principal investigators, including Ognjen Gajic, MD, from the Mayo Clinic and Michelle Gong, MD, from Montefiore Medical Center in New York.

Data shows that 27 percent of such Medicare beneficiaries face preventable treatment errors due to information overload among ICU providers. The Mayo Clinic model will enhance effective use of data using a Cloud-based system that combines a centralized data repository with electronic surveillance and quality measurement of care responses.

"We believe this will reduce ICU complications and costs," says Talmor, adding BIDMC's role will be to lead the clinical and economic evaluation of the intervention.

One of the clinical sites to take part in the trial is BIDMC-affiliated Lawrence General Hospital, and the medical center will collaborate with Tufts University in the evaluation.

The $16 million grant will train 1,440 existing ICU caregivers in four diverse hospital systems over three years to use new health information technologies effectively in managing ICU patient care. CMMI estimates the efforts will generate $81.3 million in savings.

Beth Israel Deaconess Medical Center is a patient care, teaching and research affiliate of Harvard Medical School, and currently ranks third in National Institutes of Health funding among independent hospitals nationwide. BIDMC is clinically affiliated with the Joslin Diabetes Center and is a research partner of Dana-Farber/Harvard Cancer Center. BIDMC is the official hospital of the Boston Red Sox. For more information, visit www.bidmc.org.

Boston Medical Center Nurses Teach Pressure Ulcer Prevention

Three nurses at Boston Medical Center are taking a proactive rather than reactive approach to skin care.  The skin team RNs - two full time and one part time - constantly emphasize the importance of assessing patients' skin from head to toe.

Because ongoing documentation of pressure ulcers is necessary to ensure Medicare reimbursement, the nurses review with staff on a regular basis how to properly report finding pressure ulcers and whether a patient already has one on admission.  If patients fall at home but are not found for several days, for example, they often are admitted with pressure ulcers because of lack of hygiene and position changes.

If a pressure ulcer is noted by a nurse on assessment, that nurse puts in a consult for a nurse from the skin care team to examine the wound.  To provide the best skin care possible for each patient, the skin care team collaborates with dietitians, CNAs, nursing directors, nurse managers and doctors.

One way the skin team reminds staff about proper skin assessment and care is through a mannequin referred to as "Uncle Ulcer", which features interchangeable wound and ostomy parts.  The mannequin, purchased with grant funds, has proved to be a great hands-on teaching tool, says Lauren H. Laubenstein, RN, BSN, CWON, wound/ostomy nurse, because it helpf staff learn to recognize and care for different stages of pressure ulcers in the classroom setting.  A skin Web site also is under development to reinforce what the nurses already know, says Siobhan Nevin, RN, BSN, CWOCN (NE Nurse.com, January/February 2010, p. 13).

Pressure Ulcers

A pressure ulcer or bedsore is an injury to the skin or underlying tissue usually over a bony protruding area of the body.  Pressure ulcers can range in severity from minor skin reddening to deep wounds.  Factors that cause pressure ulcers are unrelieved pressure on the skin, or slight rubbing or friction on the skin.

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Boston Medical Center Tackles Alarm Fatigue and Noise

Hospitals around the country are grappling with the issue of alarm fatigue. The concern is that the constant noise of equipment alarms on hospital inpatient floors is so overwhelming that nurses can become desensitized, thereby creating potential patient safety risks. This issue is so pervasive that the Joint Commission--the accrediting body for hospitals nationwide--is implementing a new national standard aimed at reducing alarm fatigue.

BMC is tackling the issue head on, where a multidisciplinary team of BMC physicians, nurses and clinical engineers has designed a new approach to increase patient safety by reducing the number of clinically insignificant alarms. Their work is already getting national attention.

The approach was piloted on a unit that cares for cardiac patients and uses telemetry equipment to monitor heart rate, blood pressure, oxygen level and other vital signs. The alarm noise on the unit was constant. Many of the alarms indicated clinically insignificant events that required no action by staff, yet they competed with alarms indicating life-threatening conditions like critical heart rhythms.

"The warning alarms for clinically insignificant events were constantly going off and creating unnecessary background noise, causing us to struggle with alarm fatigue," says Deborah Whalen, NP, BMC Clinical Service Manager, Cardiology.
The team reviewed alarm data and developed a list of safe changes that would decrease the total number of alarms, while still ensuring that alarms continued for all events that required immediate attention.

During the six-week pilot, the number of alarms dropped from 87,823 to 9,967 per week - a stunning 89 percent decrease in audible alarms. Patient satisfaction rose. Staff satisfaction increased, too, with many nurses remarking on the quietness of the unit and noting that they could spend more time caring for patients than answering clinically insignificant alarms. Physicians indicated that patient alarm histories now were more meaningful and there was unanimous agreement that care was safer and better. The results were so successful that the program has been implemented in all inpatient adult general medical surgical units at BMC.

"We observed that while the number of alerts dropped drastically, we also had greater response to alerts because those that sounded were all actionable, and now the staff were keenly listening for alarms," says James Piepenbrink, director of the department of clinical Engineering at BMC.

Meanwhile, the novel approach of the pilot and the significant improvement in both patient care and patient and staff satisfaction is proving of interest to care providers nationwide, and in May, the BMC team presented their work in a Joint Commission webinar viewed by more than 1,000 health care institutions with more than 5,000 participants.

CDC: Hospitals Continue Progress in Preventing Infections

The Centers for Disease Control and Prevention today announced significant gains in hospitals' efforts to prevent healthcare-associated infections in 2010. These include a 33% reduction in central line-associated bloodstream infections, 18% reduction in healthcare-associated invasive MRSA (methicillin-resistant Staphylococcus aureus), 10% reduction in surgical-site infections, and 7% reduction in catheter-associated urinary tract infections, according to data submitted to the CDC's National Healthcare Safety Network. Data on Clostridium difficile infections and MRSA bloodstream infections will be available from the network next year. "Today's news reflects the enormous amount of work and effort by hospitals, physicians, nurses and other caregivers," said John Combes, M.D., AHA senior vice president and senior fellow at the Health Research and Educational Trust. "We applaud their efforts to improve quality for patients."

>> Full Press Release

Cooley Dickinson Hospital’s Positive Culture Led to Pressure Ulcer Improvements

In the past eight quarters since the end of 2007, Cooley Dickinson Hospital - a 140-bed facility in Northampton, Massachusetts - has had three quarters with zero incidents of pressure ulcers (bed sores).

It's impressive because even under the best circumstances, bedsores "happen." That is, patients enter hospitals with their skin severely compromised from long illnesses. Or their treatment is so stressful on their bodies - either because they are on ventilators or constrained to their beds - that energy is diverted from the largest organ (skin) to where it is most needed.

It takes constant focus to combat pressure ulcers, and in the case of  Michele Craig, Cooley Dickinson's Wound and Ostomy Nurse, a large measure of good will.

"I'm kind of relentless," she says, adding with a laugh, "and I try not to be too grumpy."

Because of the financial pressures under which many Massachusetts hospitals are operating, Craig's staff was cut; she's now the sole wound care practitioner on staff. But she's quick to point out, she's not solely responsible for Cooley Dickinson's good pressure-ulcer-reducing numbers; it's a team effort that involves everyone from the nursing staff, through nutrition, physical therapy, and even housekeepers, since an improperly made bed can cause the shearing and friction forces that aggravate skin.

"I post the results of my audits on each floor and I try to be as positive as I can," Craig says. "I often write on the reports, 'Down 3%! Great job!' or 'Keep Up the Good Work!' " 

Each patient admitted to the hospital is checked for pressure ulcers. Each pressure ulcer is photographed upon admission. Craig surveys every unit, except childbirth, quarterly. Each pressure ulcer is charted to record whether it is facility-acquired or not. If it is the result of the hospital stay, Craig writes a case study and brings it to a meeting of the caregivers on the floor where it occurred. What could have been done differently? How did it occur?

"If I wasn't consulted, I need to know why," she says. "I need to look back on the chart to see who noticed it. Did the staff document precautions correctly? Did they miss the assessment at admission?"

Craig says that while she is relentless in getting to the bottom of the issues, she is never judgmental, and sees no need for pointing fingers at staffers.

"It's not about assigning blame," she says. "It's about improving the process."

After the issue is identified, Craig assesses the patient, and has a physician sign the orders for the wound care. Then Craig works with another main component of the care team in many cases - the family of the patient to ensure that once the patient leaves the hospital the pressure relief measures continue.

"People who are on prednisone, who are diabetic or who have low albumin levels - they're at risk," she says. "Sometimes there are people who are just experiencing skin failure." She stresses that some patients just require more care than others to prevent pressure ulcers and that in some cases preventing them is extraordinarily difficult.

Craig regularly assesses the lotions that Cooley Dickinson uses to prevent wounds and she has a say on one of the most important wound-fighting tools - the beds the hospital has bought and rent.

"Right now the newest thing is a 'micro-climate' covering," Craig says, explaining that it's a top layer on the mattress that doesn't trap moisture or heat.

But lotions, beds and other tools, such as waffle boots and chair cushions, all ultimately depend on the staff overseeing their use. The human connection is where Michele Craig finds herself focusing more and more attention.

"I try to be available to the nurses. I try to be positive because, let's face it, direct patient care is difficult and labor intensive, and people respond well to praise," she says.

Pressure Ulcers

A pressure ulcer or bedsore is an injury to the skin or underlying tissue usually over a bony protruding area of the body.  Pressure ulcers can range in severity from minor skin reddening to deep wounds.  Factors that cause pressure ulcers are unrelieved pressure on the skin, or slight rubbing or friction on the skin.

Read More »

Cooley Dickinson Hospital: Better-than-National Infection Rate Drops Further Following UV Room Disinfection

In America's hospitals, approximately one in 20 patients will contract a hospital-acquired infection (HAI). At Cooley Dickinson Hospital last year, one in 129 patients got an HAI. Now, those better odds of avoiding an infection at Cooley Dickinson have improved even further, as the hospital has documented a groundbreaking 82 percent drop in one type of infection, Clostridium difficile (C. diff), a nasty germ that can cause diarrhea, sepsis and even death.

"This decrease translates to many more people leaving the hospital safer and with better outcomes," said Joanne Levin, MD, CDH's Medical Director of Infection Prevention.

Read the full story here. 

Heywood Hospital Addresses Falls with Injury

Falls in Hospitals Happen

Recognizing the issue, the Joint Commission has stepped in to require hospitals to implement falls-reduction programs as a requirement of accreditation, and the Centers for Medicaid and Medicare Services will no longer reimburse hospitals for the cost of care that results from inpatient falls. Hospitals have addressed the problem with initiatives that involve all staff, from trustees to caregivers to facility managers and housekeepers, among others. Yet, falls continue to occur. 

The Agency for Healthcare Research and Quality estimates that somewhere between 700,000 and 1,000,000 people in the U.S. fall in a hospital each year. Because all patients, but especially elderly patients, are often taking several medications, have many medical risk factors, are stressed, and vulnerable it's easy for them to lose their balance as they attempt to rise from a bed or a chair.
While a common method for preventing falls is to "alarm" chairs and beds so that a patient shifting position or is beginning to stand on their own sets off a warning to nurses that a patient is on the move, a fall can often happen before an intervention takes place. And unlike other hospital initiatives to fight patient harm - such as relatively simple checklists that are proven to stem the tide of infections - fall mitigation strategies are less definitive.  That is, there are many interventions for stemming falls - from exercises to in-depth patient education, to bedrails, non-slip footwear, safety "huddles", and more - but it's up to nursing administrators and their teams to sort through the strategies to find the right combination for each individual patient.

Heywood Hospital in Gardner, MA - a 134-bed community hospital - has assembled a team to deal with the falls issue, which at Heywood is made even more difficult by the presence of an in-facility geriatric psychiatric unit. Elderly patients, often with dementia, cycle from that unit into general hospital units when a medical issue arises.  Because geriatric psych patients often cannot remember cautions ("Call us if you need to use the restroom") and because they often wander or become frustrated, their fall risk soars. "The challenge is around the population you serve, the environment you are in, and the screening tools you use," says Tina Santos, R.N., M.S.N., M.B.A., Heywood's Chief Nursing Officer and V.P., Operations. "There's a lot of human factor in there to address the issue."

Christine Basil, R.N., Director of Acute Care Case Management, said the hospital's multidisciplinary team re-approached all aspects of the falls issue beginning with the assessment tool that is used for all patients admitted to the hospital. "We're moving from the Hendrich model to the Morse Fall scale," Basil said noting two of the main tools that caregivers use to rate patients on a scale of their likelihood to fall. Patients are "ranked" based on the medications they are taking, if they have hypotension, or if they are frail, are likely to wander and, most importantly, if they have a history of falls - among many other factors.
"Everyone is at risk of falls in the hospital," Basil says. "But you stratify patient risk based on the assessment." Then you work with your team to undertake patient-specific interventions. For instance, at Heywood, a very high-risk patient may be placed in a room nearest the nursing station. The dietary staff will be informed about a particular patient's special needs.  Even the cleaning staff is aware that patients with red socks are fall risks, so if the staffer is in the room and sees a red-socked patient attempting to get out of bed, that person can alert the nursing staff or advise the patient to wait for help from a staff member.
There is extensive falls-prevention literature that focuses on the optimum height for a patient's bed. Obviously, a bed that is too high could result in a patient falling as he or she attempts to get out. But research has shown that a too-low bed may result in weak patients losing their balance as they attempt to raise themselves up to stand. Heywood uses adjustable beds to ensure the height is optimum for the safety of each patient.

"Another tool we have is the 'scoot chair'," says Nora Salovardos, R.N., Director of Psychiatric Services. The chairs allow patients to propel themselves forward with their feet  (which allows mobility and freedom to get around) but they are slightly reclined (which makes it difficult for the patient to stand up - and fall). "With the scoot chair, we can promote independence with the patient, which is what they want and which is also important to their recovery," Salovardos says.
But no matter what tools are used, falls are likely to occur. And when that happens, Heywood, like many other hospitals, immediately forms a "huddle". Says Basil, "As immediate to the fall as possible, nursing leadership and all staff involved gather around to ask pertinent questions: 'What were the contributing factors? How did it happen? What are all the factors that contributed to the fall?' Then we do immediate coaching with staff while supporting and mentoring them, as well as ensuring that the care plan is changed if necessary and additional interventions are included."  Families are also notified about any fall that may occur and educated about the new plan of care.

"We're very transparent and look at ourselves closely," says Anne E. Hamm, RN, CRM, Director of Patient Care Assessment, Risk Management, and Patient Safety Officer. "We report everything. Our goal is not only to reduce falls but to eliminate injuries from falls." It's a hard task but one that Santos says her team is dedicated to by "embedding best practices into our workflow" every day.
"There isn't a one-size-fits-all way to address falls," Santos says. "Our success at Heywood so far is in really approaching the problem in a varied fashion and keeping our focus away from just tunnel vision. Rather we focus on the needs and interventions appropriate for each individual patient."

BID-Plymouth (formally Jordan Hospital’s) Great Success in Combating Infections

Over six consecutive months in 2013, Jordan Hospital in Plymouth has not recorded a single catheter-associated urinary tract infection (CAUTI) in its Critical Care Center- an impressive statistic that has required intensive, shift-by-shift persistence by caregiving teams throughout the hospital and a wholesale change in the hospital's culture.

By eliminating incidences of CAUTI, a common infection in hospitals throughout the U.S., Jordan has created a safer environment for patients and reduced the length of time patients stay in the hospital, incurring additional healthcare costs.

But achieving the success has not been easy.  An intensive education program involving the hospital's Board of Trustees and personnel in the Emergency Department, Critical Care Center (CCC) and other units throughout the hospital, has been followed by daily and even hourly assessments of patients with catheters.  The surveillance, discussion, and effort to curb infections are unending and are now ingrained within the hospital's culture.

"We began with the premise that anytime you insert anything into a person's body that they didn't come into the hospital with, it increases their susceptibility to infection," says Kathleen M. Mercurio, R.N., infection preventionist at Jordan. Foley catheters, which are thin flexible tubes that are passed through the urethra and into the bladder to drain urine, are, in effect, "ladders" that bacteria can use to climb into the patients' bladder, potentially causing an infection.

Inserting a catheter into compromised patients was standard operating procedure in all hospitals up until five years ago.  It is estimated that about 20% of patients in acute care hospitals are catheterized, with the percentage higher for Medicare patients. Because catheters drain urine (as opposed to having to move a patient to a bathroom or bedpan), the general thinking was that a patient could remain more stable in a bed as they were treated and recuperated. But infections became persistent and the Centers for Medicare and Medicaid Services (CMS) determined that CAUTI was a preventable occurrence. CAUTI was then named a complication for which hospitals would no longer receive additional payments as of October 1, 2008.

The American Recovery and Reinvestment Act of 2009 authorized $50 million to fight infections, including CAUTI. The Health Research & Educational Trust, through a contract with the Agency for Healthcare Research and Quality, coordinates the national CUSP (Comprehensive Unit Based Safety Program) CAUTI initiative, while the Massachusetts Hospital Association (MHA) and similar state associations coordinate "On the CUSP: Stop CAUTI" initiatives within 35 states around the country.  Jordan's effort is part of the state initiative involving 15 Massachusetts hospitals that in June 2012 started the "On the CUSP Stop CAUTI" project, which will continue through February 2014.

GETTING RESULTS AT JORDAN

Mercurio says that the challenge at Jordan was threefold - to reduce catheter associated urinary tract infections in the Critical Care Center (which is what Jordan calls its ICU); to decrease the number of days a Foley catheter stays in a patient (hence decreasing the chance for infection); and to promote alternatives to Foleys that are non-invasive.

The main component for achieving those goals, says Lisa Bergendahl, Jordan's director of Critical Care and Respiratory Therapy, is simply talk, talk, talk among the nurses, Managers, and personnel throughout the CCC and the hospital.

"We're always discussing, 'Why do [patients] have the catheter? Do they need it? What's the risk-benefit? And can it come out?' " she said.  "As to 'why' a patient has a catheter, that comes down to strict criteria from the CDC [Centers for Disease Control and Prevention]."

CDC currently has six reasons for allowing insertion of a urinary catheter, ranging from the patient having a bladder obstruction, to the need for accurate measurements of urinary output in critically ill patients, to improving comfort in end-of-life patients.

"It's not wishy-washy criteria," said Mercurio. "There's not a lot of wiggle room. So there's a lot of talking between team members every shift. We have begun to see very productive conversations between nurses and physicians such as: 'It's day three and I don't think it [the catheter] should be in there any longer.'"

Nurses on each shift have to enter computerized documentation, answering, among other items: When was the catheter inserted? Where was it put in? (In the ED, CCC or on a med/surg floor) and why was it inserted.  To answer the "why," a nurse has to check off on the computer screen one of the CDC-approved guidelines.  Those same questions are answered for each patient when a new shift begins, demonstrating that for a quality-improvement strategy to work, repetition of many tasks is imperative.

ALTERNATIVES TO CATHETERS

Connie Schmidt, Jordan's manager, Infection Prevention and Control, says that an  ultrasound-like device called a bladder scanner has been a great help in cutting down on the use of Foley catheters. The hand held bladder scanner can precisely measure the amount of urine in the bladder, allowing a nurse to consider if alternative treatment is required to remove urine, as opposed to the older method of inserting a catheter to measure urine retention. Other alternatives Jordan Hospital uses include bedside commodes to allow patients quicker access, and externally placed condom catheters for male patients. 

The use of super absorbent padding under patients is being employed as another strategy to fight CAUTI.  That is, if a patient does not have an indwelling urinary catheter and can't get to the bathroom on their own, the padding helps wick away moisture from the skin - which means less potential for skin breakdown for patients.

"We had to create new strategies and processes easy for everyone involved. Using and incorporating a new process into their daily workflow requires a systematic, sensible approach," Mercurio says, drawing a parallel to the initiative to enforce regular hand washing. That directive was clearly understood by all involved, but it wasn't until Purel canisters were set up at virtually every doorway and every sink that hand washing rates increased dramatically.  The same is true for bedside commodes, different sized "condom" catheters, and the prevalence of absorbent pads.  "If it's there for people to use, they'll use it."

CHANGING THE CULTURE

"Anytime you want to change a person's habits, you have to give that person a reason for the change - a reason that hits something inside of them that makes them value the change," Mercurio says.  For the different cultures throughout the hospital, the reasons she gave varied.

For most, the number of patients nationally that die from CAUTI - up to 13,000 annually - was enough of a reason.  "I told others, 'This is how much longer a patient - perhaps your grandmother - will have to stay in a hospital if she has an infection'," Mercurio says, adding that the increased costs associated with Hospital Acquired Infections- by some estimates up to $500 million annually throughout the U.S. - also resonated with some.

But the biggest reason for the change that occurred at Jordan is that everyone realized that the evidence-based strategies the infection team was promoting were the right thing to do to make the hospital's patients more comfortable and safe.

As part of the CUSP CAUTI project, Jordan Hospital participated in a Hospital Survey on Patient Safety Culture in August and September 2012.  The survey allowed Jordan to examine the staff's perspective on how safe they feel the environment is on each unit to accept change and improve patient safety.  Jordan will complete the survey again in October 2013 and compare the results to evaluate if its efforts have improved the hospital's safety culture.

THE RESULTS

In July and November of 2012 and January and February of 2013, Jordan Hospital had one patient in each of those months who developed a CAUTI.  That's not a terrible track record, but as Mercurio says, "One is too many. One is someone's dad getting an infection."

But from March through August 2013 (the latest full month recorded), Jordan Hospital has had zero CAUTIs. 

And, the number of Foley catheter days - that is, the number of days that patients had catheters - steadily dropped, evidence of the strategy of removing them as soon as possible. The decrease in Foley catheter days occurred even as patient days in the CCC increased. That is, more patients, less days with them having catheters, and less chance of them getting an infection.

"Sometimes, of course, a catheter is needed, according to the CDC directives and the medical needs of the individual patient, but we stay on top of the situation and take it out as soon as we can," Mercurio says, adding, "If it goes in today, it may very well be removed tomorrow, when the patient has stabilized."

BID-Plymouth – (formally Jordan) Making Strides to Reduce Falls

Lisa Litchfield Zani, Inpatient Service Line Administrator at Jordan Hospital, Plymouth Jordan Hospital in Plymouth, Mass., has undertaken an innovative strategy to deal with patient falls, which is a common problem that occurs just about everywhere that care is provided -- from hospitals to homes.

People who are ill, recovering from surgery, on new medications - to name just a few of numerous reasons - often fall down, causing serious injury. It's a phenomenon that has caused all hospitals to devote special attention to reducing falls.

Lisa Litchfield Zani, Inpatient
Service Line Administrator at
Jordan Hospital, Plymouth

PatientCareLink posts falls data for each hospital in the state. By using measures approved by the National Quality Forum (NQF), patients and their families can see how well a hospital is performing in reducing falls. The NQF "nursing-sensitive measures" provide a framework to measure the quality of nursing care and assess the extent to which nurses in hospitals contribute to patient safety and a professional work environment. They also help hospitals identify where they may be able to improve their care.

Lisa Litchfield Zani, RN, BSN is the inpatient service line administrator at Jordan Hospital. She served on the Massachusetts Organization of Nurse Executives' Management of Practice Committee, studying hospitals across the state and nation to see how they've combated falls.

What she found is that there's a pattern of uniformity to why people fall and a variety of strategies to prevent them.

For instance, women generally fall backwards and are often at risk for hip fractures. Men fall forward and have a higher incidence of head injuries.  She says the literature shows that "anyone taking more than three medications - no matter what they are - puts them in jeopardy of falling," adding, "Our culture is very accepting of medications and I think we're heading towards a greater incidence of falls."

The elderly patient presents special concerns for a variety of reasons. They may have muscle or skeletal issues that make them unstable. Or any form of dementia may result in elderly hospital patients forgetting that they just had surgery and may have trouble getting up from a bed or chair.

"Sometimes it's not that they are forgetful but that they remember how they get around at home, relying on certain pieces of furniture for stability," Litchfield Zani says. "But in a new setting in a hospital, those familiar touchstones are no longer there and they're at risk of falling."

Once an elderly person falls, it has serious consequences, she says. Following a tumble a senior citizen may have a fear of falling again; that fear leads to immobility, and the immobility leads to a deterioration of muscle strength. These deteriorations lead to an even more degraded state and the increased chance of another fall.

Even younger people who have injured themselves for the first time may not think they're hurt that bad, or may have trouble accepting that they're once athletic nature is compromised. That type of person is also at risk of falling.

"I wish I could say there's a fall prevention recipe that really works for everyone, but there's just not one category of people that fall," Litchfield Zani says.

So hospitals rely on some tried and true methods of screening to assess fall risk and then precautions to prevent them.

Litchfield Zani oversees an anti-falls regimen in just about every sector of the hospital. All patients are assessed on their current mobility, whether they've ever fallen before (which she says in the best indicator of future problems), and on the medications they're taking. Patients that are high risk for falling have difficulty transferring - that is, on how they move from a bed to a chair and how they get to the bathroom.  They may be on medications that cause dizziness or balance problems. All of that screening is put together to arrive at a fall protocol for the patient.

"The protocol educates our nurses about the risk factors," she says, and provides guidelines for proven interventions to prevent falls and injury.  Patients are given a special armband to denote their fall risk and a symbol is placed on their door signifying to their caregivers that they are at risk for falling.  Those at risk are noted on the whiteboard at the nursing station so that a clinician seeing an at-risk patient getting up without assistance can rush over and help. Patients are given slipper socks with no-skid treads and an assistive device is always at the bedside.  We also use bed alarms to notify staff when a patient is getting out of bed or a chair without assistance.

"Those are the things that everyone is doing or should be doing," Litchfield Zani says. "We're using evidence-based practice to do the best we can."

JORDAN'S SPECIAL UNIT

Where Jordan Hospital differs, Litchfield Zani says, is that "we've captured the population" most likely to fall. Jordan Hospital created an 8-bed "pod" unit that contains inpatients from the greater population of at-risk patients. Many are especially confused or have interrupted their medical treatment somehow (like pulling out an IV), or they experience "sundowning" - that tendency of some patients with dementia to get combative towards late afternoon/early evening.

Using a computer program that pulls out the most at-risk, Jordan Hospital's RNs meet every morning at 8 am where the unit's nursing director Melissa Kilham RN, BSN, screens patients house-wide that might meet the criteria for the fall prevention unit. Some highly at-risk patients are sedentary so they do not have to be moved. Others are mobile and are therefore considered good candidates.  Since there are so many patients in the hospital at any given time that are at high risk for falling, we make it our goal to keep the unit filled at all times.

"We have two nurses and two nurses aides in the unit so we have very good coverage," she says. Although the unit costs more to staff it saves cost by decreasing the patient care sitters.  The staff that are expert at caring for these patients engage in activities with the patient to keep them exercising and occupied.  Patients are up in a chair for meals and ambulating a couple of times per day if appropriate.

"We're very hands on, unbelievably so at times," she says. Jordan Hospital's RNs in the pod conduct 15-minute checks on patients, querying them as to whether they're too hot or cold, hungry or thirsty, in pain or needing to use the bathroom.  "We check with them to fulfill their basic needs so they don't have a need to get up without assistance."

Patients in the pod have their medications re-scheduled (if possible) so they do not have to be woken up in the night. The use of diuretics is scheduled so that they are assisted to the bathroom thereafter.

An added benefit is that Jordan Hospital's Vice President of Operations and geriatrician James Fanale, MD, is working with three geriatricians on staff to work with the unit.  They will provide training to other clinical staff, review policy and procedures, and evaluate using the Beer's Criteria, which is an evidenced-based system that lists certain medications a patient should or should not receive to reduce the risk of falls. They will also offer consultation on appropriate care.

Jordan Hospital looks for signs of post-prandial hypotension , meaning that there's a drop in a patient's blood pressure after meals, which increases the risk of falling.

"Now we do blood pressure screening after meals, and try to keep patients sitting during this time" Litchfield Zani says, "and we hope in the future we'll be able to do rounds with the doctors on recommendations for alterations in the patient's medication regimen."

The bottom line of the Jordan Hospital process improvement initiative is that come April 2010, the unit will have been existence for two years and has been the site of very few falls - much lower than the general population. At the same time, staff has developed new skills that they can use in other parts of the facility.

"It's constant work to perform screenings and follow ups and regular checks on patients, but the rewards are great," Litchfield Zani adds. "A fall, especially in an elderly patient, can be devastating to them. I think we're making some progress at Jordan Hospital."

Patient Falls

The National Quality Forum (NQF) defines a fall as an unplanned descent to the floor (or extension of the floor e.g., trash can or other equipment) with or without injury to the patient.

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