Evidence based practice review

January-February 2016 • Vol. 25/No. 1 17

CPT (R) Gwendolyn Godlock, MS-PSL, BSN, RN, AN, CPHQ, is Field Representative Nurse Surveyor, The Joint Commission, Oakbrook, Terrace, IL. CPT Mollie Christiansen, BSN, RN, AN, CMSRN, is Clinical Nurse Officer in Charge, Burn Progressive Care Unit, United States Army Institute of Surgical Research, Joint Base San Antonio Fort Sam Houston, TX. COL Laura Feider, PhD, RN, is Dean, School of Nursing Science and Chief, Department of Nursing Science, Army Medical Department Center and School, Health Readiness Center of Excellence, Joint Base San Antonio Fort Sam Houston, TX. Acknowledgments: The team would like to thank nursing leaders COL (R) Sheri Howell, for- mer Deputy Commander of Nursing and Chief of Staff; and COL Richard Evans, Assistant Deputy Chief Army Nurse Corps, for their support. A special acknowledgment for the former Chief, Medical Nursing Section, COL Vivian Harris, who remained a staunch supporter, advo- cate, and cheerleader, the Medical Section nursing staff, and the Center for Nursing Science and Clinical Inquiry. Note: The view(s) expressed herein are those of the authors and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, Department of Defense, or the U.S. Government.

Implementation of an Evidence-Based Patient Safety Team to Prevent Falls

in Inpatient Medical Units

T he Centers for Medicare & Medicaid Services identified falls as a preventable health

care acquired condition (DuPree, Fritz-Campiz, & Musheno, 2014). A large portion of the medical-surgical inpatient population is aging, and therefore at high risk for falls (Boltz, Capezuti, Wagner, Rosen berg, & Secic, 2013). Falls have physical and emotional implications for patients, as well as increased financial costs for facilities. Nationally, medical units have the highest rates of falls (Bouldin et al., 2013). Most notably, falls can cause significant injuries resulting in increased length of stay, unexpected surgeries, and even death (Williams, Szekendi, & Thomas, 2014). Historically medical-surgical nurses care for a mix of complex patients with an array of comorbidi- ties and patient needs (Carter & Burnette, 2011).

Literature Review The literature search was limited

to keyword searches on falls, team- work, patient safety, nursing, hourly rounding, and communication. Data – bases included PubMed, EBSCO, Agency for Healthcare Research and Quality, CINAHL, and The Joint Commission for years 2008-2014. Use of fall prevention teams was an emerging evidence-based practice (EBP) intervention to decrease the incidence of inpatient falls (Graham, 2012). Consistently, the evidence demonstrated ineffective communi- cation, situation awareness, team-

work, assessment, hourly rounding, and environmental challenges as key factors related to preventable inpa- tient falls.

Collectively, researchers have shown improving teamwork through successful integration of standard EBP tools proved most efficient in reducing preventable inpatient falls. Successful falls prevention strategies included staff education about the fall-injury risk assessment tool, post- fall assessments, alarm device usage, side effects of medications, hourly rounding, and offering toileting fre- quently (Tzeng & Yin, 2012). Re – search also suggested hourly round-

ing positively impacts patient fall rates, call bell usage, and patient satisfaction (Olrich, Kalman, & Nig – olian, 2012).

The focus of the literature review was to identify strategies for improv- ing collaborative care, with empha- sis on teamwork at the microsystem level. Engaging clinical nurses is key in the creation of an effective falls prevention team. Teams include champions on each nursing unit. Unit champions are responsible for educating staff on all incident trends and the latest preventions strategies (Graham, 2012).

This project examined the use of

Continuous Quality ImprovementContinuous Quality Improvement

Gwendolyn Godlock Mollie Christiansen

Laura Feider

Falls are a patient safety priority among hospital inpatients. The creation of a Patient Safety Team engaged frontline staff in patient safety and falls prevention. This intervention decreased the fall rate from 1.90 to 0.69 falls per 1,000 occupied bed days.

January-February 2016 • Vol. 25/No. 118

EBP TeamSTEPPS® to enhance com- munication and teamwork. Prior to this EBP project, clinical nursing staff were not aware of environmen- tal risk factors contributing to inpa- tient falls. Patient education regard- ing fall risks varied across the depart- ment and preventive strategies were not standardized. EBP TeamSTEPPS provided clinical nursing staff with a simple, yet structured approach to identify fall risk factors and apply patient-specific interventions. Most notably, this project emphasized shared accountability and adher- ence to a standardized process. This was a departmental approach be – cause inpatient falls were considered the nurse executive’s patient safety priority.

Methodology Throughout the first half of

2013, medical nursing section lead- ers noted an increase in inpatient falls. The section chief tasked a clin- ical nurse to work with the nursing services patient safety officer to address this emerging problem. Based on their outstanding clinical skills, nursing judgment, and com- mitment to patient safety, section chiefs nominated fall team mem- bers. All nominees agreed to partic- ipate in the group. Because all train- ing, education, and interventions were completed during the nurses’ working day, no additional funding was required to start the group. Staff in the Department of Hospital Education Simulation Center partic- ipated with strong support from hospital leaders.

Continuous quality improve- ment guided this EBP project specif- ically using the FOCUS-PDCA model (Shugdar, n.d.). This model is commonly used in health care as a systematic method to analyze and improve processes (Peer & Rakich, 2000). FOCUS-PDCA has been used throughout the project facility for process improvement. The team discussed various components of the project using the FOCUS-PDCA model. Leaders are responsible for managing quality improvement projects by maintaining open dia- logue with clinical staff.

FOCUS-PDCA methodology con- sists of nine-steps:

• Find a process to improve. • Organize a team. •� Clarify current process. •� Understand variations in cur-

rent process. •� Select process improvement. •� Plan the improvement. •� Do the improvement. •� Check for results. •� Act to hold the gain (Peer &

Rakich, 2000, pp. 188-193)

To align with the Partnership for Patient Outcome measure, the pri- mary quality indicator used for this project was inpatient falls per 1,000 bed days. These numbers were calcu- lated using patient safety reporting (PSR) and the Workload Manage – ment System for Nursing.

The pre-intervention average fall rate for the medical nursing section was 1.90 falls per 1,000 bed days. All inpatient actual and near-miss falls were reported by nursing staff through the PSR system, and the fall rate was calculated at the end of every month by project leaders. The main components during the implementation phase of the Patient Safety Team included a Patient Safety Stand-down Week, identifying Safety Team Cham – pions, Patient Safety Journal Club, completion of the Perfect Storm Falls Simulation training, and trending fall incident rates before and after implementation.

During the Medical Nursing Section Patient Safety Stand-down Week, the Fall Safety Team evi- dence-based project was launched. Over a 1-month period, all team members of the medical section (N=6 inpatient nursing units) received safety-specific training with a focus on fall prevention, team goals, and purpose. Licensed nursing personnel received training on critical thinking in falls preven- tion and all team members received training on bed mechanics (bed alarms, side rails, locks, etc.). Classes were offered over 5 days during day and night shifts, to achieve a goal of 85% trained.

Formation of Fall Safety Team

The medical section Fall Safety Team included registered nurses (RNs), licensed vocational nurses (LVNs), and certified nursing assis- tants (CNAs), and included identi- fied champions from each shift of the medical inpatient units. Unit champions were identified, trained on fall preventions and interven- tions, and used as instructors dur- ing the Patient Safety Stand-down Week. An on-duty, on-call roster was created each month using the current work schedule so one team member was on-call around the clock to respond after a patient fall. This roster was posted in the charge nurse room on each unit. If a fall occurred, the Fall Safety Team member went to the location of the fall as soon as possible, completed a post-fall checklist (see Figures 1a- 1b), and facilitated a safety huddle with the nursing staff, patient, and family. During this safety huddle, evidence-based interventions were discussed and recommendations made to continue to keep the patient safe. Additionally, unit staff were alerted to potential causes for the fall and encouraged to check the safety of all other patients on the unit. Nursing vigilance was seen as paramount if increased falls were noted across a section.

At monthly meetings, represen- tatives brought all post-fall check- lists so team members could discuss recent falls throughout the section. The team made recommendations to nurse leaders for process im – provement and targeted evidence- based interventions. Unit champi- ons were responsible for educating staff about trends, safety alerts, and current safety issues. Also, members participated in a Patient Safety Journal Club at monthly meetings to examine evidence-based inter- ventions from the literature. Finally, the Fall Safety Team participated as coaches and mentors in different falls training events throughout the hospital, including TeamSTEPPS simulation and the semiannual nursing skills validation fair.

Continuous Quality Improvement

January-February 2016 • Vol. 25/No. 1 19

Implementation of an Evidence-Based Patient Safety Team

FIGURE 1A. Falls S.A.F.E.T.Y Team (FST) Post-Fall Checklist (1 of 2)

Directions: Please respond to unit within 30 minutes after fall and complete the checklist. Once completed, scan to Falls S.A.F.E.T.Y Team Folder and keep original. This information will be used and discussed at next FST meeting.

Falls S.A.F.E.T.Y Team (FST) Representative Name: Nurse, technician, and LVN caring for fallen patient Full Names and Title:

Date and time of fall/discovery Date Time Date and time FST response Date Time Fall location, room, and unit Fall witnessed? Yes or No If yes give name: Circle one: After fall, patient assisted to: Bed Chair Floor Primary nurse description of environment and patient when arriving to scene

Patient or family (if at bedside) description of fall

Please ask the following questions:

1. What was the patient trying to accomplish at time of fall? 2. Report from patient regarding injury (e.g., “my head

hurts”)

What was different this time compared to all other times you did this activity without incident?

Any change in patient condition or injuries? Yes or No. If yes, please explain in detail. Describe injuries and location:

Have there been any changes to patient condition or plan of care in last 24 hours? (e.g., new medications ordered, received sedation)

Was provider notified? Yes or No If yes, what time? If no, why not? What was the patient’s activity order at the time of the fall? Was this being followed?

What was the patient’s last assessed fall risk prior to the fall? Were all corresponding nurse-initiated orders in place (NIO), active, and signed off in treatment plan? (especially hourly rounds)

MR#______________________

Fall Safety Team Simulation Training

The Fall Safety Team worked with unit leaders and the nursing services patient safety officer to create and facilitate an all-day TeamSTEPPS sim- ulation training event titled “The Perfect Storm: Falls Prevention using EBP TeamSTEPPS.” Training includ-

ed an inpatient fall simulation sce- nario in which participants conduct- ed a bedside huddle, updated the white board, and identified falls risk factors. Participant surveys were completed to evaluate the training, and observers scored the use of dif- ferent TeamSTEPPS principles in the simulation. The 30-minute training was completed by 17 groups of three

RNs, LVNs, and CNAs (military and civilian). Feedback from the training will serve as a baseline for future TeamSTEPPS training and be used to focus staff education on the most common deficiencies seen in fall simulation.

The Perfect Storm simulation sce- nario was based on PSR data of fac- tors contributing to falls. For exam-

January-February 2016 • Vol. 25/No. 120

ple, the most common event leading to a fall was either the patient being on the commode or transferring to the toilet. The simulation empha- sized the need to place a bedside commode in the patient’s room, stay with the patient while he or she was on the toilet, and perform hourly rounding. This was a key component pertaining to PSR data utilization and application with an evidence- based approach, innovation, and intervention. The TeamSTEPPS sim- ulation feedback included critical

safety tasks missed in simulation as well as evaluation of how well partic- ipants demonstrated TeamSTEPPS principles (see Table 1).

Results The fall rate after the interven-

tion decreased to 0.69 falls per 1,000 bed days. A year after imple- mentation, the average was 1.63 falls per 1,000 bed days (see Figure 2). These numbers were calculated using PSR data and Workload

Management System for Nursing. The current year-to-date falls rate for the section was 1.63 falls per 1,000 bed days. This represents lim- ited 3-month post-implementation data; however, the change is clini- cally relevant and continues to trend downward. Attaining stake- holder support, identifying unit- level fall champions, and using interactive and innovative educa- tion platforms, creative marketing, and leadership rounds minimized project limitations.

Continuous Quality Improvement

FIGURE 1B. Falls S.A.F.E.T.Y Team (FST) Post Fall Checklist (2 of 2)

FST Rep: ___________________________________ Date and Time: _____________________

Bed alarm on? Yes or No Was zone set for middle zone (Zone 2)? Yes or No Was iBed in use? Yes or No

Comments:

Lines, tubing, drains present? Yes or No Comments: Did patient have a mobility aid? Yes or No If yes, was it being used? Do patient have a sensory aid (hearing aids, glasses)? Yes or No

If yes, was it being used.

Did patient’s clothes drag on the floor? Yes or No Did patient have footwear? Yes or No Comments: Restraint in place prior to fall? Yes or No If yes, was it being used? Is in non-slip? Bed in low position? Yes or No Comments: Bed wheels locked? Yes or No Comments: Wheelchair locked? Yes or No Comments: Floor dry? Yes or No Comments: Lighting adequate? Yes or No Comments: Call light in reach? Yes or No Comments: Bedside table, telephone, water container in reach? Yes or No

Comments:

Area free of clutter and other items? Yes or No Comments: Side rails in use? Yes or No How many in use? 1 2 3 4 How many on bed? 1 2 3 4

Comments:

Were NIO’s being followed? Yes or No Comments: If applicable, was mobility aid (e.g., walker, cane) working properly? Yes or No

Comments:

Any environmental or safety issues? Yes or No Comments: # Staff on duty? RN_____________ LVN_____________ CNA____________________ Tech__________________

Comments:

Did nurse complete a Patient Safety Report? Yes or No Unit census and turnover for day ___ Recommendations from primary staff regarding possible strategies to prevent this fall

Comments:

January-February 2016 • Vol. 25/No. 1 21

The Perfect Storm Simulation Results

Observers scored the use of TeamSTEPPS principles on a Likert scale (1=completely ineffective, 5=very effective). Two observations were made about four different princi- ples; for example, in assessing lead- ership, observers determined if the leader and participant roles were well defined. Forty-nine individuals participated in the Perfect Storm Simulation and were asked to com- plete surveys before and after train- ing (see Figures 3 & 4). The pre-sur- vey was completed by 49 individu- als, of whom 85% (n=42) reported receiving TeamSTEPPS 3.5 hour training. Additionally, 95% (n=47) indicated their respective inpatient units demonstrate effective commu-

Implementation of an Evidence-Based Patient Safety Team

TABLE 1. TeamSTEPPS Simulation Feedback and Evaluation

Key Principle Tools and Strategies Outcomes

Communication SBAR, call-out, check-back, handoff Reduction in inpatient falls Increase patient engagement

Adaptability Team orientation Collaborative care Team performance

Increased staff confidence Leadership Brief, huddle, debrief

Situation Monitoring STEP, I’M SAFEShared Mental Model Patient-specific care plans Advocacy and assertion Facilitates patient trust

Mutual Support CUS, Two-Challenge Rule, task assistance, feedback, DESC

TABLE 2. Survey Results

Participant Pre-Simulation Survey Percentage of Yes Responses Have you received TeamSTEPPS training? 85 Do you understand your role on the team when a patient falls on your unit? 95 Do members of your work unit mutually support one another? 95

Participant Post-Simulation Survey Mean Participant Score 3 = Strongly Agree

2 = Neutral 1 = Disagree

The team conducted a debrief after the fall simulation. 2.97 The team leader oriented (SBAR) the team prior to patient engagement. 2.93 Team members mutually supported one another during the fall simulation. 2.93 Team members used closed-loop communication during the simulation. 2.84

Evaluator Survey of TeamSTEPPS Principle Score (1-5) Leadership 4.22 Mutual support 4.50 Situation monitoring 4.20 Communication 4.15

Critical Safety Task Percentage of InterventionCompliance Checked for non-skid socks 100 Updated white board 93 Activated falls response team 80 Used assertive communication: “Please do not get out of bed without assistance.” 67 Checked call bell function 70 Completed falls risk education 47 Requested patient call bell use return demonstration 48 Used two patient identifiers 30

January-February 2016 • Vol. 25/No. 122

nication, mutual support, and situa- tion awareness regarding prevention fall strategies. Forty-five individuals (92%) completed the post survey and were asked to evaluate team member use of TeamSTEPPS princi- ples during the simulation. Co – incidentally, observers and partici- pants scored closed-loop communi- cation the lowest at 2.84. Overall communication, situation back- ground assessment recommenda-

tion (SBAR), closed-loop, and thoughts post fall scored a 2.90. Participants scored themselves the highest in leadership (debriefing score mean=2.97), with mutual sup- port and SBAR communication a close second (mean=2.93).

The Fall Patient Safety Team has been active since August 2013, with plans to expand throughout the surgical section. TeamSTEPPS simu- lations are completed quarterly,

with the focus on replicating the falls simulation training in other sections throughout the organiza- tion (e.g., critical care, periopera- tive, surgical). The greatest chal- lenge in completing simulation training has been coordinating staff schedules. Identification of two runners, who went back to the identified floor and escorted the staff, facilitated timely simulation training with a targeted team approach. Additionally, each unit received a schedule time to com- plete the scenario.

Nursing Implications This project suggests teamwork

and situational awareness are useful in mitigating risk for falls and improving patient safety in inpatient clinical settings. Substantial evi- dence supports EBP TeamSTEPPS and its positive impact on patient safety. The use of simulation training for other patient safety and quality improvements (e.g., medication error prevention) can be replicated for any patient care setting using a team approach (team communica- tion and teamwork). The EBP TeamSTEPPS model can be used as an intervention for any patient safe- ty concern that requires hands-on training. Authors recommend teams and/or facilities identify the top three patient safety events and casu-

Continuous Quality Improvement

FIGURE 2. Medical Section Falls per 1,000 Bed Days

Fa lls p er 1 ,0 00 B ed D ay s

4.5

4

3.5

3

2.5

2

1.5

1

0.5

0

CY 2013 Jan Feb Mar Apr May June July Aug Sept

Medical Section falls per 1,000 bed days

Average pre-intervention

Average post-intervention

FIGURE 3. Participant Surveys

Pre-Simulation Survey Please circle Yes or No

1. Have you received TeamSTEPPS training? Yes or No 2. Do you feel empowered to communicate concerns on your unit? Yes or No 3. Do you participate in huddles and/or briefs at the beginning of every shift? Yes or No 4. Do you understand your role on the team when a patient falls on your unit? Yes or No 5. Do members of your work unit mutually support one another? Yes or No

Post-Simulation Survey Please answer the questions below via the scale: 3 = Strongly Agree, 2 = Neutral, 1 = Disagree

1. Team members effectively communicated their thoughts and the plan following a fall. 3 2 1 2. The team leader oriented the team prior to patient engagement using SBAR. 3 2 1 3. Team members used closed-loop communication during the simulation. 3 2 1 4. The team conducted a debrief after the fall simulation. 3 2 1 5. Team members mutually supported each other thrughout the simulation. 3 2 1

January-February 2016 • Vol. 25/No. 1 23

al factors. For example, if one of the top three problems is falls then the event and possible cause should be reviewed (e.g., walking to the rest room, using the commode, demen- tia, incontinent bladder, continuous intravenous fluids). Team members should collaborate to identify evi- dence-based interventions to include in simulation training.

Conclusion Consistency has been the key to

hardwiring these concepts into day- to-day operation on the nursing units. The falls safety team has since become part of the Depart ment of Nursing Patient Safety Team and received extensive patient safety training (TeamSTEPPS Master Train – er Course [2.5-8 hour days] and Patient Safety Workshop [1-8 hours]). The Patient Safety Team will continue to respond to falls, complete the post-fall assessment checklist, make recommendations, and tailor interventions based on best evidence. The team also will continue to participate in depart- ment or section-level education and

training related to falls and other patient safety issues. Overall, the Patient Safety Team works to inte- grate TeamSTEPPS at the bedside to gain the trust of patients, family members, and fellow team mem- bers. Although all inpatient falls may not be preventable, impact can be made by raising situational awareness, increasing mutual sup- port, engaging leaders, encouraging open communication, and provid- ing frontline staff education and involvement. This EBP intervention has reduced the probability of patient harm and has made a notable clinical contribution to falls prevention. Timely frontline staff feedback; visible, engaged, and sup- portive leadership; and transparen- cy proved extremely valuable throughout the entire project.

REFERENCES Boltz, M., Capezuti, E., Wagner, L.,

Rosenberg, M.C., & Secic, M. (2013). Patient safety in medical-surgical units: Can nurse certification make a differ- ence? MEDSURG Nursing, 22(1), 26- 37.

Bouldin, E.L.D., Andresen, E.M, Dunton, N.E., Simon, M., Waters, T.M., Liu, M., &

Shorr, R.I. (2013). Falls among adult patients hospitalized in the United States: Prevalence and Trends. Patient Safety, 9(1), 13-17.

Carter, K., & Burnette, H. (2011). Creating patient-nurse synergy on a medical-sur- gical unit. MEDSURG Nursing, 20(5), 249-254.

DuPree, E., Fritz-Campiz, A., & Musheno, D. (2014). A new approach to preventing falls with injuries. Journal of Nursing Care Quality, 29(2), 99-102.

Graham, B.C. (2012). Examining evidence- based interventions to prevent inpatient falls. MEDSURG Nursing, 21(5), 267- 274.

Olrich, T., Kalman, M., & Nigolian, C. (2012). Hourly rounding: A replication study. MEDSURG Nursing, 21(1), 23-26.

Peer, K., & Rakich, J. (2000). Accreditation and continuous quality improvement in athletic training education. Journal of Atheletic Training, 35(2), 188-193.

Tzeng, H.M., & Yin, C.Y. (2012). Toileting- related inpatient falls in adult acute care settings. MEDSURG Nursing, 21(6), 372-377.

Shugdar, M. (n.d.) The FOCUS-PDCA methodology. Retrieved from http:// www.cbahi.org/rm/files/Standards/QM/ Teaching%20Samples/07.7%20QM%20 FOCUS%20Summry.pdf

Williams, T., Szekendi, M., & Thomas, S. (2014). An analysis of patient falls and fall prevention programs across academ- ic medical centers. Journal of Nursing Care Quality, 29(1), 19-29.

Implementation of an Evidence-Based Patient Safety Team

FIGURE 4. “The Perfect Storm” Evaluator Score Sheet

Leadership Notes/Comments:

1. How effective was the team in establishing a team leader clear throughout the scenario?

1 2 3 4 5

2. How effective was the team in defining and maintaining clear roles throughout the sce- nario?

1 2 3 4 5 Mutual Support Notes/Comments:

1. Did the staff remain calm, friendly, and sup- portive throughout the entire scenario?

1 2 3 4 5

2. How effective were team members in verbal- izing concerns and supporting each other throughout the scenario?

1 2 3 4 5 Situation Monitoring Notes/Comments:

1. How effective was the team in cross monitor- ing for each other (monitoring each other and sharing workload)?

1 2 3 4 5

2. How effective was the team in demonstrating situation monitoring and reacting appropri- ately?

1 2 3 4 5 Communication Notes/Comments:

1. How effective was the staff in repeating back information and making sure communication was complete?

1 2 3 4 5

2. How effectively did team members use SBAR to communicate with those entering the sce- nario?

1 2 3 4 5

1 = completely ineffective, 2 = ineffective, 3 = neutral, 4 = effective, 5 = very effective

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