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Please use the fall prevention doc titled "Hourly rounding in a high dependency unit" to fill in the grid, follow the examples already provided to fill out the grid. The other portion of the grid will be done by my partner. ONLY DO 1N

Running Head: REDUCING FALLS IN THE HOSPITAL SETTING Reducing Falls in the Hospital Setting David Arnquist and Brittany Mayfield Texas Tech University Health Sciences Center NURS 4342-003 February 6, 2018 1 REDUCING FALLS IN THE HOSPITAL SETTING 2 Reducing Falls in the Hospital Setting According to The Joint Commission’s National Safety Goals, we must “prevent residents from falling” (2018). In this paper we will discuss the consistencies and gaps of information among three articles of study relating to reducing falls in the hospital setting. We have developed a question based this safety goal, developed by The Joint Commission, to focus our research. We will utilize this research to validate policies and help change those which may need to be readdressed. By evaluating evidence and applying it to our practice, we can help promote patient safety in our places of work. REDUCING FALLS IN THE HOSPITAL SETTING 3 For patients in the hospital setting, will lower nurse to patient ratios be more effective in reducing falls? P (Population of Interest): Patients over 18 years of age I (Intervention of Interest): Staffing, alarms, and rounding to reduce falls. C (Comparison of Interest): Nurse to patient ratios O (Outcome of Interest): Reduce falls T (Time): Patients during hospital stay Articles (level of evidence/evaluation of strength of the evidence) Protecting Patient Safety: Can Video Monitoring Prevent Falls in High-Risk Patient Populations? Level = 3 Strength = A Who Involved (sample size, sampling method, population) Size = 1508 cases Sampling method = targeted sample Population = hospitalized patients at high risk for falling What Occurred (qualitative, quantitative) Where Completed (type of agency, state, country) Quantitative Agency = West Virginia University School of Nursing Country = USA When (year research done) 2013 Why (research question) Does the use of centralized video monitoring reduce patient falls and injuries associated with falls and reduce the use of observational sitters for fall prevention? How (data collection, tool used with validity and reliability, statistical tests, qualitative control) Data collected = Number of patient falls, injuries resulting from falls, observational sitter usage, videomonitoring technician records, and sitter data for each of the four units. Tool used = Hendrich II Falls Risk Assessment with validity and reliability not provided. Consistencies (how addresses the PICOT question, how alike with other studies reviewed) Gaps (how does it not address the PICOT question, what did the researchers state still needed to be studied) Video monitoring significantly reduced the number of patient falls, which is consistent with similar studies. This study addressed the population, intervention, and outcome of our PICOT. This study did not address nurse to patient ratios. There were not enough video monitoring devices for each patient who met the criteria, due to a high volume of patients and few available rooms. The study states that further research should be conducted for other high-risk populations, such as selfharm patients. REDUCING FALLS IN THE HOSPITAL SETTING Missed Nursing Care, Staffing, and Patient Falls Level = 3 Strength = A Size= 124 patient units in 11 hospitals Sampling method = convenient Population = RN, LPN, nursing assistants, and patients Quantitative Agency = University of Michigan School of Nursing State = 11 hospitals across two states Country = USA 4 November 2008 to August 2009 Do nurse staffing levels predict patient falls? Does missed nursing care mediate the effect of staffing levels on patient falls? Data collected = The average amount of missed care for each unit and the relationship between staffing, case mix index, missed nursing care, and patient falls. Tool used = MISSCARE survey with a content validity index of 0.89 (Kalisch & Williams, 2009) I believe this study addresses all parts of our PICOT question, but that further studies must be conducted to compare across a wider sample size. This study found similar consistencies among studies which have associated falls with missed nursing care. This study explains how further analysis is necessary to develop interventions to prevent a lack of care, which may lead to a fall. (Boswell & Cannon, 2017) REDUCING FALLS IN THE HOSPITAL SETTING 4 Summary of Findings (consistencies and gaps from all articles): Application of findings to evidence-based practice which validates/changes policies and procedures (what policies and procedures does this information directly address and why): REDUCING FALLS IN THE HOSPITAL SETTING Individual discussion of Application of Evidence to Own Practice (name). -One page discussion that’s going to help you in your practice -Finding and reading articles? -Which parts of this course is going to help you in your practice? 6 REDUCING FALLS IN THE HOSPITAL SETTING Individual discussion of Application of Evidence to Own Practice (name). 7 REDUCING FALLS IN THE HOSPITAL SETTING 8 References Nursing Care Center National Patient Safety Goals. (2018, January 1). In The Joint Commission. Retrieved February 6, 2018, from https://www.jointcommission.org/ncc_2017_npsgs/ Kalisch, B. J., & Williams, R. A. (2009, May). Development and Psychometric Testing of a Tool to Measure Missed Nursing Care. Journal of Nursing Administration, 39(5), 211-219. doi:10.1097/NNA.0b013e3181a23cf5 Kalisch, B. J., Tschannen, D., & Lee, K. H. (2012, January). Missed Nursing Care, Staffing, and Patient Falls. Journal of Nursing Care Quality, 27(1), 6-12. doi:10.1097/NCQ.0b013e318225aa23 Sand-Jecklin, K., Johnson, J. R., & Tylka, S. (2016, April). Protecting Patient Safety: Can Video Monitoring Prevent Falls in High-Risk Patient Populations? Journal of Nursing Care Quality, 31(2), 131-138. doi:10.1097/NCQ.0000000000000163
Art & science If you would like to contribute to the Art & science section, email gwen.clarke@rcnpublishing.co.uk The synthesis of art and science is lived by the nurse in the nursing act Josephine G Paterson Hourly rounding in a high dependency unit Lowe L, Hodgson G (2012) Hourly rounding in a high dependency unit. Nursing Standard. 27, 8, 35-40. Date of acceptance: June 25 2012. Abstract The Leeds Teaching Hospitals NHS Trust is one of the many organisations that have signed up to Safety Express, a pilot programme of the Department of Health’s Quality, Innovation, Productivity and Prevention safe care coalition. Its aim is to reduce avoidable harm to patients in four areas: trips and falls, pressure ulcers, catheter-associated urinary tract infections and venous thromboembolism. Hourly rounding (hourly checks on patients) has been identified as a means of reducing harm to patients. This article describes the preparation needed to introduce hourly rounding in a high dependency unit. Authors Lynsey Lowe Band 6 sister, high dependency unit, St James’s University Hospital, Leeds. Gillian Hodgson Nurse consultant, infection prevention and control, The Leeds Teaching Hospitals NHS Trust. Correspondence to: lynsey.lowe@leedsth.nhs.uk Keywords Falls, hourly rounding, high dependency units, patient safety, pressure ulcers, venous thromboembolism Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software. Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above. © NURSING STANDARD / RCN PUBLISHING p35-41w8.indd 35 Safety Express, a pilot programme of the Department of Health’s Quality, Innovation, Productivity and Prevention (QIPP) safe care coalition (Patient Safety First 2011), identified hourly rounding as a method of keeping patients free from harm, for example by reducing the risk of falls and pressure ulcers (Ford 2010). Hourly rounding requires that nurses check on patients at set times to ensure that their essential care needs are being met (Mason 2012). A trial was undertaken at The Leeds Teaching Hospitals NHS Trust to assess whether hourly rounding could be used in a general high-dependency unit (HDU) to reduce patient harm. The unit has 14 beds, with a staffing ratio of one nurse to two patients. The unit provides care for a variety of patients, including post-operative patients and those who have been transferred from intensive care. The average age of patients is 62 years, with ages ranging from 15 to 96 years. The unit operates an incident reporting method to measure incidence of pressure ulcers, falls and patient complaints. However, patient harm from catheter-associated urinary tract infection (CAUTI) or venous thromboembolism (VTE) incidents are not measured routinely. Background A review of the literature was undertaken to identify the benefits of hourly rounding and how to introduce such a model in an HDU. A search was conducted using CINAHL (Cumulative Index to Nursing and Allied Health Literature), Medline and Google. Initially a narrow date range of 2010-2012 was used. However, few primary research articles were retrieved, and the date range was extended to include articles published between 2001 and october 24 :: vol 27 no 8 :: 2012 35 19/10/2012 12:09 Art & science patient care 2012. The search terms used were ‘hourly rounds’, ‘intentional rounding’, ‘patient safety’, ‘falls’ and ‘pressure ulcers’. The authors located and read four articles that described hourly rounding and its benefits, and seven studies in which rounding had been piloted. However, little information was found in relation to hourly rounding in a critical care environment. The only hourly rounding study identified in critical care was a pilot project in an army medical centre where this method was successfully introduced to reduce the incidence of falls (Weisgram and Raymond 2008). D’Alessio et al (2010) described hourly rounding as a proactive nursing intervention used to meet patient needs. According to McEwen and Dumpel (2010), rounding should use a pre-determined set of questions or checks, referred to as the ‘four Ps’: Pain:  patients’ pain score. Potty:  patients’ toileting needs. Position:  patients’ need for help with repositioning. Possessions:  proximity of patients’ possessions. The aim of the four Ps is to reduce the incidence of falls and pressure ulcers by ensuring that patients are not trying to get out of bed without assistance to go to the toilet or get a drink, and that they receive help to change position. Bates (2011) suggested that rounding is a new term for the traditional ‘back round’, which consisted of two nurses going around each patient ensuring that the bed was tidy, washing the patient’s hands and face when necessary, and massaging their pressure areas. During this traditional back round many of the factors that are addressed in modern rounding, such as hydration, pain relief, elimination and skin condition, were attended to as a task-orientated process. The new method of hourly rounds usually involves a tickbox-style checklist where the type of check and frequency can be adjusted to meet patient needs. The Patients Association (2010a) highlights that patients place a lot of emphasis on the quality of care they receive. In November 2011, the association and Nursing Standard launched the Care campaign. This campaign focuses on the main aspects of care that frequently do not meet expected standards, but form the fundamentals of nursing care (Patients Association 2010b): C  – Communicate with compassion. A  – Assist with toileting, ensuring dignity. R  – Relieve pain effectively. E  – Encourage adequate nutrition. Woodward (2009) suggested that hourly rounding ensures that patients know that a member of staff will be available to help them with their immediate needs. Halm (2009) stated that the benefits of hourly rounding include a reduction in patients’ anxiety about their needs being met 36 october 24 :: vol 27 no 8 :: 2012 p35-41w8.indd 36 because they learn to trust the process, prevention of falls, pressure ulcers and unrelieved pain, and improvement in patient satisfaction. Conversely, in mental health care settings, Moran et al (2011) suggested that patients experiencing psychotic symptoms or deep depression may find hourly visits too intrusive or stimulating, and that two-hourly visits may be more appropriate. Rounding log A trial was undertaken at The Leeds Teaching Hospitals NHS Trust to assess whether hourly rounding should be introduced routinely in HDU. The trial was carried out over a two-week period between March and April 2011 and included all patients on the unit at that time. The principles of the Plan, Do, Study, Act (PDSA) cycle were used to assess the effect of hourly rounding (NHS Institute for Innovation and Improvement 2008). This tool can be used to test a change by trialling the idea for a set period then assessing and evaluating it. The NHS Safety Thermometer is an improvement tool for measuring, monitoring and analysing patient harms (NHS Information Centre 2012). It was used to measure patient harm caused by pressure ulcers, falls, VTE and CAUTI in the unit. Measurement began before the rounding trial period commenced and carried on during the trial period. Data were collected once a week on all patients (12 on average) on the unit. Data from incident reports were also used to measure incidence of pressure ulcers, falls and patient complaints. A rounding log was devised that addressed the factors associated with the four Ps described earlier, without duplicating the factors that are already addressed routinely as part of the unit’s 24-hour observation chart. This proved challenging because common factors such as pain and patient positioning reduce pressure damage (National Institute for Health and Clinical Excellence 2005) are monitored and documented on the 24-hour chart every hour, as part of routine patient care in HDU. Various rounding logs provided through Safety Express were examined and a decision was taken to retain the core factors even though there would be some duplication. For example, dehydration can result in pressure damage and increases a patient’s risk of falling. Although oral intake is documented hourly on the unit’s 24-hour chart, it was included in the rounding log because hydration is crucial in reducing patient harm, promoting comfort and enhancing the hospital experience (Kelly et al 2010). This section of the rounding log also included a prompt to remind © NURSING STANDARD / RCN PUBLISHING 19/10/2012 12:09 staff that if a patient is not allowed to drink or is nil-by-mouth, equipment must be placed near the patient; otherwise he or she may have to get out of bed to get a drink, increasing the risk of falls. The rounding log used in the unit is shown in Figure 1. It was decided to complete the log hourly during the day and every two hours at night to promote rest and sleep for patients. Patients cared for on the unit have several constraints on their mobility, such as invasive monitoring devices, surgical drains and urinary catheters. Because of the severity of their illness patients are weak and unsteady on their feet. These factors may increase the risk of falling when attempting to get out of bed to reach glasses or a tissue, for example. For these reasons a section on possessions was included in the log to remind staff to ensure that all such items are within the patient’s reach. Asking patients if they require the toilet and addressing their toileting needs were included in the rounding log because attending to patients’ comfort and safety may reduce the risk of falls (Halm 2009). The log also prompts nurses to check the position of the urinary catheter bag in catheterised patients. This was to check that the catheter bag was not touching the floor, which could lead to contamination, and that the catheter was positioned below the level of the bladder to promote drainage and to prevent reflux and CAUTI (Department of Health 2007). Patients are sometimes reluctant to ask for assistance or interrupt nurses because they are uncertain whether the nurse is available to help (Woodward 2009). For this reason, wellbeing was included in the rounding log. Asking patients how they feel or if anything else can be done for them gives individuals an opportunity to express any other need or concern without feeling they are interrupting the nurse. Patient safety At The Leeds Teaching Hospitals NHS Trust, various risk assessments are required to ensure patients receive a high standard of safe individualised care. It was decided that the rounding log should not only be a tool for implementing hourly rounding, but should also be used to check that other risk assessments pertinent to patient safety had been completed. To achieve this, two columns were added to the log so that staff could sign to say that they had checked that all the risk assessments had been completed and updated for the patient on each shift (Box 1). The addition of safety checks to be completed during each shift was to assist in ensuring that the log would be applicable to other areas of patient © NURSING STANDARD / RCN PUBLISHING p35-41w8.indd 37 safety, such as malnutrition, which also contributes to pressure ulcer development (Royal College of Nursing 2001), and to give assurance that practices related to the prevention of healthcare-associated infections were being completed. Implementation All staff in the unit were informed of the hourly rounding process to optimise effective implementation. This included sending an email to all nurses and providing informal verbal training that discussed hourly rounding, the documentation required, and the anticipated benefits for patients and staff. This information was kept in a single file on the unit for all staff to refer to and included an information sheet that staff could take away for their own use. At the start of the morning shift, the nurse in charge would hand out the rounding logs. These were kept on the easel at each patient’s bed space so that it was easy to see and ensure the round was completed. The nurse at the bedside caring for the patient was responsible for carrying out the round and completing the log. On discharge, the log was to be filed in the patient’s notes. It was the responsibility of the nurse at the bedside to start a new log on receiving a new patient admission. To give assurance that the rounding log was being used effectively, several informal checks were conducted over the two-week period. The checks consisted of making sure that each patient had a rounding log in use and that the log had been completed each hour. The checks did not include confirmation that any action required had been taken. Results Rounding logs for 44 out of a possible 51 patients were completed. The patients who did not have a rounding log in use had been admitted to HDU after the logs had been distributed. When auditing the logs, only 25 patients had ticks to say the checks had been done every hour. As there was some duplication of information recorded for both the log and the 24-hour chart, this could have influenced the result. Because of time constraints some nurses may have chosen to document the information on either the log or the 24-hour chart and not both. The columns to check completion of risk assessments were only completed in 29 of the logs. The data collected using the Safety Thermometer showed that between February 17 2011 and the beginning of the trial on March 21 2011 two incidents of patient harm were recorded: a new urinary tract infection and a new category 2 october 24 :: vol 27 no 8 :: 2012 37 19/10/2012 12:09 Art & science patient care 4am Beginning of each shift Malnutrition Universal Screening Tool completed Food chart commenced and completed if required Day Rounding log 2am Every 2 hours Midnight FIGURE 1 4pm Every hour 3pm Hospital No: ......................... Name: ................................... DoB: ....................................... DATE: Position ‘Are you comfortable?’ Move the patient up the bed. Rearrange pillows. Offer extra blankets. Turn patients at high risk of pressure ulcers. Patient needs ‘Do you need to use the toilet?’ Assist the patient to the commode or the bed pan. Check catheter position and bag. Visual skin assessment undertaken, check under thromboembolic stockings Venous thromboemolism risk assessment completed Antibiotic review date and indication documented Meticillin-resistant Staphylococcus aureus risk assessment and decolonisation complete © NURSING STANDARD / RCN PUBLISHING 38 october 24 :: vol 27 no 8 :: 2012 Drink/mouth care ‘Would you like a drink?’ Assist the patient with a drink or oral care if nil-by-mouth. Possessions Move tissues and glasses within reach. Arrange bedside table. Ensure water or mouth care is available. 2pm 19/10/2012 12:09 p35-41w8.indd 38 Wellbeing ‘How are you feeling? Is there anything else I can do?’ Staff member’s initials 9am 10am 11am Noon (Adapted with permission from Safety Express Northern Team) 8am 1pm 5pm 6pm 7pm, 8pm 9pm 10pm 6am Night pressure ulcer (NHS Information Centre 2012). In this context, ‘new’ refers to harm that resulted in the unit. Safety Thermometer data collected during the two-week trial from March 22 2011 to April 5 2011, showed that no incidents of patient harm were recorded. Safety Thermometer data collected during the period following the trial, from April 6 2011 to June 14 2011, showed that there were three records of patient harm: a new category 2 pressure ulcer, a new pulmonary embolism and a new VTE. It is difficult to compare the significance of the data as the time periods of the information collected before, during and after the study are not the same. It is likely that the data collection before and after the study would capture more records of harm because these time periods were longer than the two weeks where rounding occurred. Also, Safety Thermometer data were only collected once a week capturing patient harms on that day at that time. Therefore the Safety Thermometer may not have captured every incident of patient harm that occurred on the unit. There were no patient falls during the two-week trial, but there were no patient falls during the two months before or following the trial either. Therefore it was not possible to say whether the implementation of hourly rounds and the use of a rounding log had any effect on falls or whether it was because in a critical care environment hourly rounds are routinely undertaken. There were no patient complaints during the two-week trial. However, as there were no patient complaints during the two months before or after the trial, it is not possible to conclude whether a formal approach to rounding and the use of a rounding log reduces the number of patient complaints in HDU. Discussion Without further audit it is not possible to conclude whether the poor completion of the log was as a result of the log not being signed, or whether the assessments had not been done. This may also demonstrate that hourly rounding is not achievable on a busy unit, but it is more likely to indicate poor compliance with completing the log. Patients in HDU have contact with a nurse at least once an hour and this is demonstrated by audits that are completed as part of Releasing Time to Care (NHS Institute for Innovation and Improvement 2009). These audits have shown that the 24-hour observation chart is consistently completed hourly and therefore the patient would have had hourly contact with a member of staff. In the critical care environment, there is direct contact and communication continually with patients and at a minimum every hour. There are © NURSING STANDARD / RCN PUBLISHING p35-41w8.indd 39 many elements in hourly rounding that are already being monitored and recorded hourly in HDUs, including observations, fluid input and output, and pain and sedation scores. Although it is not officially known as rounding it could be argued that critical care nurses are already doing this and that the 24-hour chart could also be used as a rounding log. The belief that making hourly rounds has limited value in critical care units is incorrect because targeted outcomes may not improve if the four Ps are not addressed (Halm 2009). One of the benefits of hourly rounding is that nurses anticipate and attend to patients’ needs proactively rather than reactively (Halm 2009). The patient experience is also improved as patients know that they will have contact with a nurse at least every hour. User feedback All staff were given the opportunity to comment and provide feedback on the use of the rounding log. An evaluation questionnaire was devised, which all staff involved in the rounding process were asked to complete. The questions asked were: Was  it was possible to complete the log hourly? Was  it possible to complete the once-per-shift checks? How  easy was the log to understand? How  easy was the log to use? How  beneficial is rounding to your patient group? There was also a section at the bottom of the form for inclusion of any additional comments. Feedback from staff suggested that hourly rounding in HDU was already being carried out and that another check list was not required. It was suggested that the questions were patronising to nurses because they imply that if there is no checklist then essential care is not carried out. This echoes the work of McEwen and Dumpel (2010) who also found that some nurses considered rounding schemes to be patronising. During the feedback, it was noted that although the inclusion of risk assessment checks in the rounding log was useful, it generated more paperwork which was unnecessary. There was also the suggestion that the log could be of benefit on ward areas such as medical wards for BOX 1 Risk assessments and screenings related to patient safety Nutrition screen using the Malnutrition Universal Screening Tool (MUST). Food chart, if required. Visual Infusion Phlebitis (VIP) score for all invasive catheters. Visual skin assessment, including removal of thromboembolic stockings to assess the patient’s heels. Venous thromboembolism risk assessment. Meticillin-resistant Staphylococcus aureus risk assessment. Review of antibiotics, where applicable. october 24 :: vol 27 no 8 :: 2012 39 19/10/2012 12:09 Art & science patient care older adults and medical admission units where the nurse to patient ratio is much lower. This supports Mason’s (2012) suggestion that in clinical areas with a lower nurse to patient ratio it is often the more acutely ill or the ‘louder’ patients who dominate nurses’ time, whereas hourly rounding helps to ensure that all patients are cared for equally. Limitations and future recommendations Patient harm identified by the Safety Thermometer cannot be prevented by hourly rounding alone. Other attributable causes need to be considered, such as maintaining aseptic technique during urinary catheter insertion to prevent CAUTI, and the appropriate use of prophylaxis to prevent VTE. The evidence suggests that trips, falls and pressure ulcers can be reduced significantly through the process of hourly rounds (Ford 2010). However, they may not be eradicated if other factors such as medication reviews, comfortable footwear and safe staffing levels are not addressed. A longer trial period may have meant that completion of the rounding log and addressing targeted outcomes became part of routine practice, potentially reducing the number of hourly rounding omissions. Because hourly observations are already monitored in HDU, more time may be required to provide more reliable outcomes. The number of logs audited was small, and therefore no generalisations could be derived. A study including several critical care areas would provide a larger patient sample and more reliable data. Regular patient surveys are conducted on HDU to ensure patients’ needs are being met and to identify where improvements are required. However, a specific patient survey was not conducted during the trial and therefore no evidence was generated to support the literature linking rounding and patient satisfaction. ‘Possessions’ and ‘wellbeing’ are not addressed in the 24-hour chart, and therefore it has been suggested that these two areas could be included, enabling it to be used as a more structured rounding log as well as an observation chart. Conclusion The process of reviewing patient observations hourly already exists in HDU. However, this does not include the patient experience. Evidence from other clinical areas demonstrates that hourly rounds reduce the incidence of falls and pressure ulcers; however, the effect on VTE and CAUTI has not been documented. It is unclear whether the same effect would be seen in HDUs, where it might not be appropriate to introduce hourly rounding. Despite this, incorporating the principles of hourly rounding in existing observation processes will contribute to reducing patient harm NS References Bates J (2011) Round again. Nursing Standard. 25, 27, 2-8. D’Alessio E, Magsalin M, Neville KL, Patten C (2010) Evidence-based nursing. Enhancing nursing’s presence. Nursing Management. 41, 12, 16-18. Department of Health (2007) Saving Lives: Reducing Infection, Delivering Clean and Safe Care. High Impact Intervention No. 6. Urinary Catheter Care Bundle. The Stationery Office, London. Kelly T, Timmis S, Twelvetree T (2010) Review of the evidence to support oral hygiene in stroke patients. Nursing Standard. 24, 37, 35-38. Mason M (2012) More than a checklist. Nursing Standard. 26, 20, 20-21. McEwan D, Dumpel H (2010) Scripting and rounding: impact of the corporate care model on RN autonomy and patient advocacy. National Nurse. 106, 9, 20-27. Ford BM (2010) Hourly rounding: a strategy to improve patient satisfaction scores. MEDSURG Nursing. 19, 3, 188-191. Moran J, Harris B, Ward-Miller S, Radosta M, Dorfman L, Espionosa L (2011) Improving care on mental health wards with hourly nurse rounds. Nursing Management. 18, 1, 22-26. Halm MA (2009) Hourly rounds: what does the evidence indicate? American Journal of Critical Care. 18, 6, 581-584. NHS Information Centre (2012) NHS Safety Thermometer. www.ic.nhs. uk/services/nhs-safety-thermometer (Last accessed: October 4 2012.) 40 october 24 :: vol 27 no 8 :: 2012 p35-41w8.indd 40 National Institute for Health and Clinical Excellence (2005) Pressure Ulcers: Prevention and Treatment. tinyurl.com/9ze7nm8 (Last accessed: October 4 2012.) Patient Safety First (2011) Safety Express – Guide to Programme Delivery. tinyurl. com/9sqvest (Last accessed: October 4 2012.) NHS Institute for Innovation and Improvement (2008) Quality and Service Improvement Tools: Plan, Do, Study, Act (PDSA). tinyurl. com/25pvog5 (Last accessed: October 4 2012.) Royal College of Nursing (2001) Pressure Ulcer Risk Assessment and Prevention. tinyurl. com/2a8hv6s (Last accessed: October 4 2012.) NHS Institute for Innovation and Improvement (2009) Releasing Time to Care: The Productive Ward. tinyurl.com/6r7nl2 (Last accessed: October 4 2012.) Patients Association (2010a) Patient Voice. tinyurl.com/8k2zpsw (Last accessed: October 4 2012.) Patients Association (2010b) CARE Campaign. tinyurl.com/cpsjztt (Last accessed: October 4 2012.) Weisgram B, Raymond S (2008) Military nursing. Using evidence-based nursing rounds to improve patient outcomes. MEDSURG Nursing. 17, 6, 429-430. Woodward JL (2009) Effects of rounding on patient satisfaction and patient safety on a medical-surgical unit. Clinical Nurse Specialist: Journal for Advanced Nursing Practice. 23, 4, 200-206. © NURSING STANDARD / RCN PUBLISHING 19/10/2012 12:09 Copyright of Nursing Standard is the property of RCN Publishing Company and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
LWW/JNCQ JNCQ-D-15-00113 January 30, 2016 16:5 J Nurs Care Qual Vol. 31, No. 2, pp. 131–138 c 2016 Wolters Kluwer Health, Inc. All rights reserved. Copyright  Protecting Patient Safety Can Video Monitoring Prevent Falls in High-Risk Patient Populations? Kari Sand-Jecklin, EdD, RN, AHN-BC; Jennifer Ray Johnson, BSN, RN, CNRN; Sharon Tylka, BSN, RN Despite implementation of many prevention strategies, patient falls in hospitals continue to be a significant safety problem, causing nursing staff and administrators to seek innovative means to further reduce falls among hospitalized patients. This article describes the feasibility and impact of implementing centralized video monitoring on the safety of patients identified as high risk for falls, as well as implications of video monitoring in the acute care setting. Key words: centralized video monitoring, falls, fall prevention, patient video monitoring O NE of the top priorities of health care organizations is to establish ways in which inpatient falls can be reduced or eliminated.1 Since 2007, The Joint Commission’s National Safety Goals2 have emphasized the need to reduce the risk of patient injuries from falls, and more recently, the Centers for Medicare & Medicaid Services has identified that it will no longer reimburse for complications related to falls.3 Although some progress is being made to identify the most effective interventions to reduce falls, the reality of the problem remains. The purpose of this article is to describe the process of implementing centralized video monitoring (CVM) as a fall preven- Author Affiliations: West Virginia University School of Nursing, Morgantown (Dr Sand-Jecklin); and Neurosciences Unit (Ms Johnson) and Trauma/General Surgery Unit (Ms Tylka), West Virginia University Healthcare, Morgantown. The authors declare no conflict of interest. Correspondence: Kari Sand-Jecklin, EdD, RN, AHN-BC, Department of Nursing, West Virginia University, PO Box 9640 HSS, Morgantown, WV 26506 (ksandjecklin@ hsc.wvu.edu). Accepted for publication: August 8, 2015 Published ahead of print: October 28, 2015 DOI: 10.1097/NCQ.0000000000000163 tion strategy and to document the outcomes as they relate to patient falls, video-monitoring technician (VMT) behaviors, and use of patient sitters. BACKGROUND From 3% to 20% of inpatients experience a fall during their hospital stay, with the potential for injury, additional medical intervention, and increased length of stay. Hospitals also face the risk of malpractice lawsuits and unreimbursed charges for care resulting from falls.3 Dunne et al4 found that any inpatient hospital fall was correlated with a longer length of stay and an increase in cost of care. According to the Centers for Disease Control and Prevention,5 in 2010, the direct medical costs related to falls were $30 billion, which is expected to increase to near $54.9 billion by 2020. In addition to other fall prevention strategies, many organizations use bedside staff sitters (or one-on-one observation) to assist in keeping patients safe in an effort to reduce inpatient falls; however, this intervention often removes caregivers from providing direct patient care and contributes to both staffing strains and cost of providing care. The costs related to sitter use are a major concern for 131 Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. LWW/JNCQ 132 JNCQ-D-15-00113 January 30, 2016 16:5 JOURNAL OF NURSING CARE QUALITY/APRIL-JUNE 2016 organizations and have been reported to be as high as $1.3 million in some US hospitals.6 Use of CVM may reduce the need for bedside sitters while providing constant observation to more effectively prevent patient falls. Review of literature A literature search revealed that CVM is a relatively new concept that has not been well researched. Twelve articles were found that mentioned the subject, but of those, only 5 described CVM specifically as an intervention to reduce patient falls. Hitcho et al7 identified that patient falls were most commonly associated with ambulation, with half being elimination-related and a large majority (79%) being unobserved and unassisted. Both Hitcho et al7 and Graham8 suggested CVM as a potentially effective means of fall prevention, as an at-risk patient is constantly observed for fall risk behavior, and assistance can be immediately summoned to prevent a fall. Goodlett et al9 initiated a fall reduction plan that included 24-hour camera surveillance. A comparative cost analysis showed that using video surveillance was more cost-effective than observational sitters.9 Four rooms that were adjacent to the nurse’s station were chosen for the camera rooms, with at-risk patients assigned to those rooms. Patients were chosen for the study if at high risk for falls based on historical data, which included cognitive dysfunction or nonadherence to safety instructions. Patients were excluded if in restraints or on suicide precautions. The project reduced the mean annual unit fall rate by 6%, but the difference was not statistically significant when comparing the patients in the entire unit with those in the camera rooms. Over the 12-month period, only 1 fall occurred in the 417 patients admitted to the camera rooms. This fall was attributed to poor staff response. Sitter costs were reduced from $960 to $240 for 4 patients, which helped support the cost-effectiveness and continuation of camera surveillance.9 Hardin et al10 reported results of an interventional study comparing inpatient falls on acute care units with and without inroom webcams and CVM at the nursing station. The CareView system used real time and recorded CVM along with “virtual bedrails,” which alarm when patients move across the defined border. The acute care units of 10 hospitals were randomly assigned to either an intervention group or a control group. Over the 6-month data collection period, 185 falls occurred, with 84 in the interventional units and 101 in control units. Three injuries occurred on the control units related to falls while only 1 injury occurred on the interventional units. When both the webcams and virtual bedrails were on, there were no falls on the intervention units.10 The difference in falls per 1000 patient-days between control and interventional groups was not significant; however, the difference between rates of falls per 1000 admissions was significant (P ≤ .05). Study limitations included a low patient monitoring consent rate, 20.6% overall for intervention units; issues with reliability of the equipment; and the negative effect of limited patient privacy.10 Jeffers et al11 performed an interventional study to examine use of CVM and operational expenses. The authors reported an immediate and significant impact on operations. Staffing savings exceeded the original investment within the first quarter after implementation and after 18 months; deferred cost saving was estimated at more than $2.02 million.11 The authors also described a decrease in overall trend of acute care falls per 1000 patient-days, and in the third quarter postimplementation, 75% of the nursing units met or exceeded the National Database of Nursing Quality Indicators (NDNQI) national benchmark.11 Some unexpected benefits were observed, such as decreases in patients pulling out intravenous catheters and removing oxygen therapy devices. Authors identified that other factors such as a more structured fall prevention program may also have contributed to improved outcomes. Of the 3 articles that presented specific data on CVM, all reported positive results in reducing falls,9-11 and 2 of the 3 also reported cost Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. LWW/JNCQ JNCQ-D-15-00113 January 30, 2016 16:5 Protecting Patient Safety reduction.9,11 Thus, although the literature on this intervention is not abundant, the positive results provide support for implementation of CVM as an additional tool for inpatient fall reduction. PROBLEM The practice change described in this article took place at a large academic medical center in the mid-Atlantic region. In 2007, a comprehensive fall prevention program was instituted, including the development of a performance improvement team to address inpatient falls and the implementation of the Hendrich II Fall Risk Assessment Model. The Hendrich II Fall Risk Model applies a scale in which risk factors12 are assessed by the nurse when patients are admitted to the hospital and reassessed every 8 hours thereafter. Patients determined to be at risk for falls were identified with a purple arm band, nonskid purple socks, and a purple “falling star” sign outside the patient room. The nurse then implemented appropriate fall prevention strategies on the basis of the patient’s individual risk factors as well as observed behaviors. Strategies included the use of an evidencebased fall risk assessment, visual identification of patients at risk for falls, manipulating the environment for greater safety (reducing clutter, eliminating tripping hazards, and moving patients into rooms closer to the nurses’ station), purposeful hourly rounding, patient and family education, individualized care plans, padded floor mats, low bed position, bed alarms (or other type of patient sensor alarms), and the use of sitters at the bedside. All of these options were available and used by nurses to assist in fall prevention; however, these options had not proven successful in significantly reducing patient falls. Studies have shown that these types of interventions can be effective, but the problem lies with the fact that interventions are not often standardized and outcomes are not consistent.13 Despite significant efforts to ensure nurse staff competency and consistency in imple- 133 menting a comprehensive fall prevention program, patient falls remained at higher than target numbers. To further reduce fall incidence, an innovative approach was necessary. Nursing leaders at the hospital proposed the implementation of CVM to reduce patient falls, injuries, and hospital costs on the basis of the positive outcomes reported by the Denver Health System as a result of CVM.11 An interdisciplinary group developed a proposal to implement CVM on 2 pilot units, including a mixed neurosciences and medicine unit. These 2 units had the highest incidence of falls in the organization. The intent of the pilot was to demonstrate a reduction in falls and based on the results to eventually expand the use of CVM to all other high-risk patient fall areas in the hospital setting. The study questions were as follows: Does the use of CVM reduce (1) patient falls and injuries associated with falls and (2) reduce the use of observational sitters for fall prevention? METHODS Study design This practice change study used a quasiexperimental pre-post design with a targeted sample of hospitalized patients at high risk for falling. The patient population included patients identified via the Hendrich II Falls Risk Assessment as being at high fall risk or having already experienced a fall. Practice change implementation The CVM program began in January 2013. It was implemented as an addition to other established fall prevention strategies, including constant observation of the highest-risk patients by a dedicated sitter. Prior to implementation, fixed (vs mobile) video cameras were permanently installed in 14 private rooms on each unit, with monitor screens installed in a centralized monitoring room. The monitor cameras were able to capture only “real-time” video—there was no capability to record and save the images. This provided assurance for patients that no person would be able to access the recording at a later date. Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. LWW/JNCQ 134 JNCQ-D-15-00113 January 30, 2016 16:5 JOURNAL OF NURSING CARE QUALITY/APRIL-JUNE 2016 A job description for a VMT was developed, and the VMTs were hired and trained. There was no requirement for health care experience; the VMTs were considered nonlicensed nursing employees and were supervised by one of the hospital nursing directors. Videomonitoring technicians work either 8- or 12hour shifts and at least 2 VMTs observe patients at all times. Camera views from 4 patient rooms are visible on 1 monitor screen, and monitor technicians may observe from 10 to 12 patients at once. Video-monitoring technicians can shift patient camera views between monitor banks, allowing them to alter their “patient assignments” so that 1 technician is not watching multiple patients displaying frequent high-risk behaviors. Video-monitoring technicians have the ability to call nursing units, individual nurses, and the hospital supervisor if assistance is needed in the technician CVM room. An algorithm was developed to determine the high fall risk patients for whom video monitoring would be appropriate, and all nursing staff on the pilot units were trained in use of the algorithm and purposes and procedures of CVM. In July 2013, the CVM program was expanded to 2 additional medical-surgical units, bringing the total number of monitor-capable beds to 56. Education was provided to nursing staff on the additional 2 units about the monitoring algorithm and protocol. It is important to note that only about one-third of the rooms on each unit were equipped with CVM capability. A physician’s order was not required for implementing the CVM intervention. When CVM was selected by the nurse as a fall prevention intervention, the patient and the family were educated about its purpose (although no signed consent for monitoring was required), and signage was placed both inside and outside the room to alert staff and visitors that CVM was in use in the patient’s room. Patients and family members can refuse CVM, although refusal of CVM has been rare. If they refused CVM or a room with CVM capability was not available, other fall prevention strategies were implemented. Once patients and families were educated and appropriate signage posted, the patient’s nurse phoned the VMT to provide background on the patient’s risk for falling and type of risk behavior the VMT should be alert to, the camera was turned on, and the VMTs continually observed the monitored patient, documenting any significant observations or interventions in a log. The only times the VMT was not able to observe the patient was when the patient was in the bathroom, a staff member paused the camera for patient privacy, or the VMT blocked a portion of the screen to allow for privacy (such as during bathing, catheterization, or other interventions requiring exposure of sensitive areas). When at-risk behaviors for falling were observed such as attempts to get out of bed, the VMT had the ability to redirect the patient via communication into the room, make a telephone call to the nurse or the nursing assistant, or use the patient call bell system to sound an alarm. An additional VMT intervention of overhead paging for staff assistance to the room was implemented at the time the medical-surgical units joined the pilot study. Implementation of the CVM program progressed smoothly, aside from the issue that often there were more patients who met the algorithm criteria for monitoring than available monitor capable rooms. In addition, the hospital’s typically high census sometimes prevented moving patients at high fall risk to a room with monitoring capabilities. Unfortunately, the frequency of these 2 issues was not tracked quantitatively. Data collection and analysis Approval from the institutional review board was obtained prior to data collection. Baseline data were collected on the number of patient falls, injuries resulting from falls, and observational sitter usage for 6 months prior to the implementation of CVM on all of the 4 units in which the technology was installed. After implementation of video monitoring, 6 months of data were collected related to falls, injuries, VMT records, and sitter data for each of the 4 units. Data were Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. LWW/JNCQ JNCQ-D-15-00113 January 30, 2016 16:5 Protecting Patient Safety entered into the SPSS version 21.0 software (IBM, Armonk, New York) and cleaned prior to analysis. RESULTS There were a total of 1508 cases of video monitoring on all units during the study periods, 697 for the first 2 units and 811 for the second units implementing CVM. The average number of monitored days per patient was 3.3 (median 1.0), with a positive skew, indicating that a very small number of patients were monitored for many days, while most were monitored for only about 1 day. During the baseline period for the first 2 units implementing video monitoring, there were 40 patient falls. During the postimplementation period, there were 30 patient falls, with only 12 falls documented for monitored patients. During the baseline period for the second 2 units implementing video monitoring, there were 34 falls. After implementing video monitoring, there were only 19 falls, and only 3 of those falls occurred in monitored patients (Table). The calculation of a standardized fall rate per 1000 patient-days for both baseline and postimplementation periods was performed. There were 74 falls over 19 021 patient-days at baseline for all units combined, reflecting 3.9 falls per 1000 patient-days. Data for all 4 135 units after implementation of video monitoring indicated 51 falls per 18 323 patient-days, reflecting 2.8 falls per 1000 patient-days, a significant reduction of 28.5% (Z = 1.85, P = .032). It is important to note that the majority of patients who fell during the postimplementation period were not video monitored, indicating that the fall rate for monitored patients may have been even lower than that reported during the postimplementation time frame. It was not possible to calculate falls per patient-day for monitored patients only, as these data were not collected. In addition, no data were available about whether unmonitored patients who fell met the criteria for video monitoring (high risk) or whether those patients were not able to be monitored because of lack of availability of an appropriate room with monitoring capability. Data collected after implementation of video monitoring indicated that there were no injuries documented for any of the patients who fell while on monitoring, while 6 unmonitored patients who fell sustained some type of injury. In addition to falls, documented VMT interventions were analyzed in relation to patient behaviors identified as potentially resulting in a fall. In both postimplementation data collection periods, VMTs called staff an average of 7 times per patient (range: 0-346). Overhead pages were less common, with medians of 0 for both data collection periods and means of Table. Comparison of Falls Pre- and Postimplementation of CVM Post No. of falls (1st 2 units with CVM) No. of falls (2nd 2 units with CVM) Injuries Standardized fall rate Pre Monitored Unmonitored 40 12 18 34 3 16 3.9 falls/1000 patient-days 0/15 2.8 falls/1000 patient-days (monitored and unmonitored patients) 6/34 Abbreviation: CVM, centralized video monitoring. Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. LWW/JNCQ 136 JNCQ-D-15-00113 January 30, 2016 16:5 JOURNAL OF NURSING CARE QUALITY/APRIL-JUNE 2016 1.5 and 2.4 (range: 1-320). Video-monitoring technicians redirection of the patient via the camera microphone occurred less often, with a mean of 1.2 and 0.5 (range: 0-124). There was a positive skew to all of these data, indicating that for a small number of patients, there were a large number of staff calls, overhead pages, and redirections. The number of observational sitter shifts were compared between the baseline and postimplementation of video-monitoring measurement periods. At baseline, there were 1082.8 sitter shifts per 19 021 patient-days or 56.9 shifts per 1000 patient-days. After implementation of video monitoring, the number of sitter hours was 800.6 per 18 323 patientdays or 43.7 shifts per 1000 patient-days. This equates to a 23.2% reduction in sitter shifts, with a significant Z score of 5.84 (P < .001). Only 5% of video-monitored patients also required the constant monitoring of a sitter. We were not able to accurately determine the number of sitter hours for monitored patients versus nonmonitored patients, or whether the need for an observational sitter was due to fall risk or other risk for injury (self-harm or other behavioral issue). In addition, we could not determine whether patients may have required a sitter because of lack of availability of a CVM room. It is likely that the reduction in required sitter hours would be greater if these data were available and could be included in calculations of sitter time. The initial data from CVM implementation indicate cost savings in terms of sitter hours, but the reduction in sitter shifts was not equal to the number of monitor technician shifts required for monitoring—reduction of 282 sitter shifts for the postimplementation period versus 1092 VMT shifts to staff the monitoring room. However, the potential cost savings in prevented patient falls is not measurable but could be sizable. DISCUSSION The implementation of CVM as an additional component of the comprehensive fall prevention program was successful on a num- ber of fronts. The process was well accepted by nursing and other hospital personnel, as well as by patients and families. Because the video cameras are “real time” only, patients do not need to be worried about anyone viewing a video recording of them. In addition, nursing staff are able to pause the camera to protect patient privacy, and VMTs can block a portion of the screen to protect patient privacy during procedures or bathing. Finally, the central monitoring area is in a private room outside the visual field of hospital staff, patients, or visitors. The implementation of CVM capability in approximately one-third of patient rooms on 4 medical-surgical units significantly reduced patient falls, with the majority of the documented falls postimplementation occurring among nonmonitored patients. In addition, no patients who fell while being monitored sustained any physical injury. After video monitoring was implemented, required observational sitter hours were also significantly reduced. These data indicate success of the video-monitoring program, particularly considering that most of the patients who fell were not being monitored at the time of the fall. These results support findings in the literature, which suggest that video-monitoring surveillance for patients at high risk for falls does reduce falls, injuries, and patient care costs associated with falls.10,11 In addition, this program also reduced the number of required observational sitter hours. Although the reduction in sitter costs was offset by the increase in costs for VMT shifts, the organization experienced the benefit of having more assistive staff available for direct patient care. A prior study (not CVM based) was able to document a reduction in sitter hours, but no significant reduction in patient falls.14 Video-monitoring technician interventions for high-risk patient behaviors included directly phoning nursing staff, overhead paging staff to the patient room, and redirecting the patient verbally. Most recently, overhead paging staff to the patient room has been determined to be the most efficient Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. LWW/JNCQ JNCQ-D-15-00113 January 30, 2016 16:5 Protecting Patient Safety means of response to high-risk patient behaviors. As a result of this study, a total of 77 cameras have been installed on high-risk medicalsurgical units, and there are plans to purchase “mobile” cameras to ensure that any patient who is high risk for falling can be monitored, regardless of room placement. In addition, CVM is being expanded to monitor patients who are at risk for self-harm, controlled medication diversion, and elopement. There also are plans to gather additional data related to video monitoring. We believe a formal evaluation of the CVM process itself is needed, particularly as this intervention represents innovative use of technology to promote patient safety, and there are few guidelines for best practices in terms of implementation. In addition, further data related to patient outcomes and costs are needed once CVM is available to all patients who have safety risks (falls, selfharm, drug diversion). Limitations One of the limitations of this study is the lack of data related to patients who fell while not on video-monitoring surveillance. Data were not collected to determine whether these patients had been identified as at high risk for falling as CVM was not available, had not been identified as at high risk, or had refused video monitoring (although this occurred rarely). In addition, no data were collected about staff response time to VMT notifications of risky patient behavior and the need to check on the patient or the impact of staff response time on the incidence of falls. It also was not possible to calculate falls per 1000 patient-days specifically for pa- 137 tients who were monitored. Finally, the education of the patient and the family about CVM and fall prevention was not studied apart from the CVM intervention itself. One published study has indicated that providing patients and families education about fall prevention itself leads to a reduction in fall incidence.15 CONCLUSIONS New technology is now available to assist acute care facilities in preventing patient falls. Through implementing a CVM system, patients can be better protected, and falls can be reduced while decreasing the costs associated with caregiving. Because of the physically weakened state of hospitalized patients, side effects of medications, and the impact of illness and treatments on safety and mobility, it is likely not possible to completely prevent falls in the hospital. However, CVM of high-risk patients has been demonstrated as an effective intervention to significantly reduce the incidence of patient falls as well as the likelihood of injury if a patient does experience a fall. Additional studies that examine the implications of CVM utilization need to be conducted to assist organizations with reducing patient falls, controlling costs, and creating a safer patient environment. In addition, standardized procedures for training of VMTs and for actions to implement when patients demonstrate high fall risk behaviors should be developed. Finally, studies documenting the use of CVM for other high-risk populations, including patients at risk for self-harm, controlled substance diversion, and flight risk, are needed. REFERENCES 1. Bechdel B, Bowman C, Haley C. Prevention of falls: applying AACN’s health work environment standards to a fall campaign. Crit Care Nurse. 2014;34(5):75– 79. 2. The Joint Commission. National patient safety goals— facts about the 2007 national patient safety goals. http://www.jointcommission.org/PatientSafety/ NationalPatientSafetyGoals/07 npsg facts.htm. Published 2007. Accessed November 14, 2013. 3. Inouye S, Brown C, Tinetti M. Medicare nonpayment, hospital falls, and unintentional consequences. N Engl J Med. 2009;360(23):2390–2393. Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. LWW/JNCQ 138 JNCQ-D-15-00113 January 30, 2016 16:5 JOURNAL OF NURSING CARE QUALITY/APRIL-JUNE 2016 4. Dunne T, Gaboury I, Ashe M. Falls in hospital increase length of stay regardless of degree of harm. J Eval Clin Pract. 2014;20(4):396–400. 5. Centers for Disease Control and Prevention. www. cdc.gov/falls/statistics/state htm. Published 2013. Accessed January 6, 2014. 6. Rausch DL, Bjorklund P. Decreasing the costs of constant observation. J Nurs Adm. 2010;40(2): 75–81. 7. Hitcho EB, Krauss MJ, Birge S, et al. Characteristics and circumstances of falls in a hospital setting: a prospective analysis. J Gen Intern Med. 2004; 19(7):732–739. 8. Graham B. Examining evidence-based interventions to prevent inpatient falls. Medsurg Nurs. 2012;21(5):267–270. 9. Goodlett D, Robinson C, Carson P, Landry L. Focusing on video surveillance to reduce falls. Nursing. 2009;39(2):20–21. 10. Hardin SR, Dienemann J, Rudisill P, Mills KK. Inpa- 11. 12. 13. 14. 15. tient fall prevention: use of in-room Webcams. J Patient Saf. 2013;9(1):29–35. Jeffers S, Searcey P, Boyle K, et al. Centralized video monitoring for patient safety: a Denver Health Lean journey. Nurs Econ. 2013;31(6):298–306. Hendrich AL, Bender PS, Nyhuis A. Validation of the Hendrich II Fall Risk Model: a large concurrent case/control study of hospitalized patients. Appl Nurs Res. 2003;16(1):9–21. Trepanier S, Hilsenbeck J. A hospital system approach at decreasing falls with injuries and cost. Nurs Econ. 2014;32(3):135–141. Spiva L, Feiner T, Jones D, Hunter D, Petefish J, Vanbrakle L. An evaluation of a sitter reduction program intervention. J Nurs Care Qual. 2012;27(4): 241–245. Ryu YM, Roche JP, Brunton M. Patient and family education for fall prevention: involving patients and families in a fall prevention program on a neuroscience unit. J Nurs Care Qual. 2009;24(3):243–249. Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Grading Rubric Module C NURS4342 Incorporation of Evidence into Practice Evidence Based Practice Aspects Content/Criteria PICOT Question. One PICOT question based on a current issue (Joint Commission and/or IOM) will be developed. Research Article Review. Complete the provided grid with information concerning three research articles addressing the PICOT question. Summary of Findings. The group will provide a summary related to the strengths and weaknesses found from all three articles reviewed. Application of Findings to Policies and Procedures. What policies and procedure should be reviewed based on what was learned from the review of articles. Individual discussion of Application of Evidence to Own Practice. In one page discuss how you are going to use the information learned during this course in your own practice and how you can initiate a policy or procedure change within your practice setting based on what you have learned in this class. Scholarly Presentation Writing style allows for clear communication of thoughts through logical presentation of ideas with correct spelling, grammar, and punctuation. APA Style Citations/References A title page is required for this assignment. Assignment is to be submitted as one document. Narratives are supported by proper citation and use of references following APA guidelines. Total: Expert Proficient Competent Substantial Areas for Improvement Unsatisfactory The PICOT question does not identify key parts of the question. (1 points) Discussion of the research articles demonstrated more than 6 omitted parts requested within the grid. (43 points) Information given does not provide descriptions of the strengths and weaknesses of all 3 articles. (2points) No discussion of policies and procedures related to the topic are provided. (2 points) Minimal and nonspecific discussion related to using the information learned was provided. (10 points) The PICOT question effectively and clearly identifies all relevant parts of the question. (5 points) Three research articles were discussed in depth with clear and concise information provided with all of the information requested included within the grid. (53 points) Summary discussion results exceed objectives with clear and concise information descriptions of the strengths and weaknesses of all 3 articles. (6 points) Specific policies and procedures related to the topic that need review are identified. (6 points) Clear, individualized detailed discussion provided. Specific examples of using the information learned was provided. (15 points) The PICOT question identifies all relevant parts of the question. (4 points) Discussion of the three research articles met assignment objectives related to the information requested included within the grid. The PICOT question minimally identifies all relevant parts of the question. (3 points) Discussion of the research articles demonstrated 2 to 3 omitted parts requested within the grid. The PICOT question does not identifies all relevant parts of the question. (2 points) Discussion of the research articles demonstrated 4 to 5 omitted parts requested within the grid. (51 points) Summary discussion results met objectives with descriptions of the strengths and weaknesses of all 3 articles. 5 points) General discussion of policies and procedures related to the topic that need review are provided. (5 points) Individualized discussion provided on utilization of information learned was provided. (46 points) Summary discussion results provide minimal descriptions of the strengths and weaknesses of all 3 articles. (4 points) Less than one page of individualized discussion was provided on the utilization of EBP material into own practice. (45 points) Summary discussion results do not address both the strengths and weaknesses of all 3 articles. (3 points) Vague discussion of policies and procedures related to the topic are provided. (3 points) No individualization of how the learned content would be integrated into practice was provided. (13 points) (12 points) (11 points) Thoughts are logically organized without errors in spelling, grammar, or punctuation. (5 points) Thoughts are logically organized with no more than 3 errors in spelling, grammar, or punctuation. (4 points) Thoughts are logically organized with no more than 4 errors in spelling, grammar, or punctuation. (3 points) Thoughts show no logical organization. APA format used for all citations and reference listings with no errors. No more than 3 APA formatting errors noted. 4 to 5 APA formatting errors noted. Thoughts are logically organized with no more than 5 errors in spelling, grammar, or punctuation. (2 points) 6 to 7 APA formatting errors noted. (10 points) (8 points) (6 points) (4 points) (2 points) (4 points) Minimal discussion of policies and procedures related to the topic are provided. (0 points) More than 7 APA errors noted in both citations and reference listings. Comments: PLAGIARISM: Plagiarism is considered cheating and is a violation of academic integrity as outlined in the Student Handbook. Any student who plagiarizes any portion of the assignment may receive a grade of zero on the assignment. LATE ASSIGNMENTS: Unless prior faculty notification and negotiation of an extended deadline, ten points will be deducted per day if submitted late. Assignment will not be accepted if submitted more than 3 days late and assigned grade will be 0 (zero).
LWW/JNCQ NCQ200142 November 16, 2011 12:25 J Nurs Care Qual Vol. 27, No. 1, pp. 6–12 c 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright  Missed Nursing Care, Staffing, and Patient Falls Beatrice J. Kalisch, PhD, RN, FAAN; Dana Tschannen, PhD, RN; Kyung Hee Lee, MPH, RN Patient falls in hospitals continue to be a major and costly problem. This study tested the mediating effect of missed nursing care on the relationship of staffing levels (hours per patient day [HPPD]) and patient falls. The sample was 124 patient units in 11 hospitals. The HPPD was negatively associated with patient falls (r = − 0.36, P < .01), and missed nursing care was found to mediate the relationship between HPPD and patient falls. Key words: falls, missed nursing care, staffing U P to 12% of hospitalized patients experience at least 1 fall during their hospital stay.1 A fall is defined as any event in which patients are found on the floor (observed or unobserved) or an unplanned lowering of the patient to the floor by staff or visitors.2 In 2008, and 2010, falls were identified as one of the top 10 sentinel event categories by the Joint Commission.3 Fall rates in hospitals range from 4 to 14 falls per 1000 patient days.4 With the adoption of the Centers of Medicare and Medicaid rule, which no longer reimburses hospitals at the higher diagnosis related group for the care and treatment associated with patient falls that occur during hospitalization, a clearer understanding of what factors Author Affiliations: School of Nursing, University of Michigan, Ann Arbor, Michigan (Drs Kalisch and Tschannen and Ms Lee). This project was funded by the Blue Cross Blue Shield Foundation of Michigan and the Michigan Center for Health Intervention, University of Michigan School of Nursing, National Institutes of Health, National Institute of Nursing Research (P30 NR009000). The authors declare no conflict of interest. Correspondence: Beatrice J. Kalisch, PhD, RN, FAAN, Nursing Business and Health Systems, University of Michigan, School of Nursing, 400 N Ingalls St, Ann Arbor, MI 48109 (bkalisch@umich.edu). Accepted for publication: May 25, 2011. Published online before print: July 6, 2011. DOI: 10.1097/NCQ.0b013e318225aa23 influence fall rates among hospitalized patients is even more critical.5 The causes of patient falls and interventions to prevent them have received considerable attention.6,7 Yauk and colleagues7 identified ambulation assistance, disorientation, bowel control problems, and fall history as predictors of falls among hospitalized medicalsurgical patients. Ferrari and colleagues6 also found inattention and mobility to contribute to falls. Additional studies have examined the effectiveness of several fall prevention strategies. Results of 2 meta-analyses found a pooled effect reduction of 4% and 25% in falls for patients in the experimental groups after the implementation of a variety of fall-prevention strategies.4,8 Strategies aimed at prevention of falls have included identification wrist bands or stickers, greater vigilance through hourly or scheduled rounds, camera monitoring, use of alarms, and in some cases physical restraints. In a review of the literature, we found only 1 study that investigated the link between the extent to which standard nursing care is completed and patient falls. That study used nurse reported perceptions of patient falls as the measure.9 The aim of this study was to determine whether the omission of elements of nursing care (ie, missed nursing care) leads to a greater number of patient falls, using actual fall rates gathered from our study hospitals and controlling for nurse staffing (hours per patient day [HPPD]) levels. The related research 6 Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. LWW/JNCQ NCQ200142 November 16, 2011 12:25 Missed Nursing Care, Staffing, and Patient Falls questions were as follows: (1) Do nurse staffing levels (HPPD) predict patient falls? and (2) Does missed nursing care mediate the effect of staffing levels on patient falls? LITERATURE REVIEW Falls have adverse consequences for patients (eg, mortality, fractures, functional dependence, and fear of reoccurrence) and staff providing direct patient care (eg, feelings of guilt, apprehension). Although several national and professional organizations have developed evidence-based guidelines that set forth strategies for reducing falls,10,11 consistency in implementation of these strategies has been limited. Findings from 188 medical-surgical units in 48 hospitals across the United States found that risk-specific interventions (such as ambulation and medication management) are not being implemented consistently.12 This finding is in line with our research where we have identified that elements of nursing care are being regularly missed in acute care hospitals. We have conducted 3 studies of missed nursing care, the first being a qualitative focus group study on 5 patient units,13 the second a quantitative study in 3 hospitals,14 and the third, an expansion of the 3-hospital study in 10 hospitals with diverse characteristics (eg, size, teaching status).15 The results of these studies showed that a substantial amount of standard required nursing care is being left undone and that the patterns of missed care are similar across hospitals. Ambulation of patients 3 times per day (or as ordered) was the most frequently reported element of missed nursing care with 76% of nurses reporting this action being frequently or always missed. Similarly, Callen and colleagues16 found that 73% of patients did not walk during their inpatient stay on a medical-surgical unit. Previous studies have found that nurse staffing levels are predictive of patient falls.17-19 Lake and colleagues18 studied 5388 7 units in 108 Magnet and 528 non-Magnet hospitals and found that an additional registered nurse (RN) HPPD was associated with a 3% lower fall rate in intensive care units .18 Similarly, Dunton and colleagues17 discovered that higher fall rates were associated with lower HPPD and a lower percentage of RNs. This association held true for higher staffing levels up to 15 HPPDs on step-down, medical, and combined medical-surgical units; however, no evidence was found of this relationship above the 15-hour cutoff point. Although the evidence points to several effective strategies for fall reduction, fall rates and injuries from falls remain high. Interventions implemented to reduce falls still remain vague or general in nature with limited effect size. This may be related to (1) poor dissemination of the research findings to bedside clinicians or (2) the failure of staff to effectively implement evidence-based strategies for patient-specific risk factors. It also may be due to a practice of routinely missing aspects of nursing care and not addressing these errors of omission. CONCEPTUAL FRAMEWORK The conceptual framework for this study is the missed nursing care model, which hypothesizes that missing or not completing standard, required aspects of nursing care leads to poor patient outcomes. The missed nursing care model is based on the structure, process, and outcome framework, as described by Donabedian.20 In the missed nursing care model, structure variables are the characteristics of patient units and hospitals—such as staffing levels—while the process variable (what is in the “black box of nursing care”) is defined as missed nursing care. Finally, outcomes are both patient (eg, falls, hospital acquired infection rates) and staffrelated (eg, job satisfaction, intent to leave, turnover) outcomes. For the purpose of this study, we examined the relationship between nurse staffing (structure), missed nursing care (process), and patient falls (outcome). Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. LWW/JNCQ 8 NCQ200142 November 16, 2011 12:25 JOURNAL OF NURSING CARE QUALITY/JANUARY–MARCH 2012 METHODS Sample and setting This study used a cross-sectional, descriptive design. The study was conducted in 11 acute care hospitals ranging in bed size from 60 to 913. The number of participating patient care units in each of the hospitals ranged from 2 to 22 units, which included a total of 124 units. Unit inclusion criteria were (1) an average patient length of stay 2 days or more and (2) a patient population older than 18 years. Exclusion criteria were (1) short stay units (≤23 hours) and (2) pediatric, women’s health, perioperative, and psychiatric units. All patient care units in the hospitals that met the inclusion criteria agreed to participate in the study. The total nursing staff on these units who participated in the study was 3432 nurses (RNs and licensed practical nurses) and 980 nursing assistants. The overall return rate was 57.3%, with a unit response rate ranging from 34.4% to 99.6%. Study variables Missed nursing care Missed nursing care was measured by the MISSCARE survey that asks participants to identify how frequently elements of care (such as, ambulation, turning, patient assessment, teaching, discharge planning, medication administration) are missed, using a 4-point Likert scale, with anchors “rarely missed” (1) to “always missed” (4). The reliability and validity of the MISSCARE survey has been reported elsewhere.21 Because the missed care survey covers a wide range of nursing care interventions, we asked a panel of experts, nurses in acute care hospitals who hold quality improvement and/or risk management responsibilities, to identify which of the 24 elements of nursing care on the MISSCARE survey have the potential to impact fall rates if it is not provided. The 5 elements of nursing care on which the experts (n = 38) agreed were ambulation, patient assessments each shift, focused reassessment, response to call light, and assistance with toileting. The internal consistency measured by Cronbach α for the 5 elements of nursing care is 0.75. These elements are in line with previous literature identifying patient risk factors related to falls.6,7 Therefore, for the purpose of this study, missed nursing care refers to the frequency nurses reported these 5 fall-related elements as being missed. Hours per patient day Hour per patient day was defined in accordance with the National Database of Nursing Quality Indicator standards. The HPPD values were calculated as the number of productive hours worked by all nursing staff (RN, licensed practical nurse, nursing assistant) with direct patient care responsibilities divided by in-patient days. Fall rate Falls were defined as any event in which patients are found on the floor (observed or unobserved) or an unplanned lowering of the patient to the floor by staff or visitors. Fall rates were calculated as the number of falls per 1000 patient days. Procedures After institutional review board approval from each of the participating hospitals, study data were collected from November 2008 to August 2009. Data included (1) surveying the nursing staff on each of the study units utilizing the MISSCARE survey and (2) collecting HPPD and fall rate data by patient care unit from administrative data repositories. Packets containing a letter explaining the study, the MISSCARE survey, and a return envelope were placed in each staff member’s mail box. Nursing staff were asked to place completed surveys in locked boxes located on their respective units. For staffing data, hospitals were asked to provide the data in raw form (ie, Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. LWW/JNCQ NCQ200142 November 16, 2011 12:25 Missed Nursing Care, Staffing, and Patient Falls numerator and denominator) to ensure consistency in computation across hospitals. Administrative staff in each hospital were given a Microsoft Excel file with specific definitions and data requirements and were asked to input data into a template designed by the research team. Then, the research team computed all variables of interest. Fall rate data also were collected by administrative staff of each hospital after providing a specific definition of fall rate to the staff. The monthly fall rate was collected for each of the 2 months corresponding with survey administration in each hospital. Data analyses Data were analyzed with the SPSS 17.0 (Chicago, Illinois). The unit of analysis was the patient care unit. Because the fall rate is positively skewed (skewness = 1.43), square root transformations were performed to adjust for this. The square root of the fall rate was used for analyses. Although missed nursing care scores were collected at the individual level (n = 4412), they were aggregated to the unit level (as the dependent variable falls was a unit level variable). The unit level overall mean score of missed nursing care was the average amount of missed care identified for each unit. Correlation analyses were used to address the relationship between staffing, case mix index (CMI), missed nursing care, and patient falls. To examine the mediating effect of missed nursing care on the relationship between staffing (ie, HPPD) and patient outcomes (ie, fall rates), 3 regression equations were calculated. A variable functions as a mediator when it meets the following conditions: the independent variable must affect the mediator in the first equation; the independent variable must affect the dependent variable in the second equation; and the mediator must affect the hold in the predicted direction, and the effect of the independent variable on the dependent variable must be less in the third equation than in the second.22(p1177) 9 RESULTS Respondents in each of the units were primarily female (91%) and older than 35 years (54%). Most participants worked full time (81%) and 12 hours shifts (75%). In terms of education and experience, the average percentage of staff on the unit holding a BSN degree or higher was 47%, and 51% of employed staff had more than 5 years experience. Twenty-six percent of patient units were intensive care units and the others were medical-surgical, step-down, and rehabilitation units. The mean missed nursing score for participating units was 1.50 (SD = .18), with a range of 1.07 to 2.59. Hour per patient day values ranged from 6.46 to 31.99 with the mean being 11.12 (SD = 4.55). The mean score of fall rates on the units was 3.82 (SD = 2.74), with a range from a low of 0.00 (no falls) to a high of 17.80. Staffing, missed nursing care, and patient falls Bivariate Pearson correlations were calculated to examine the relationships among HPPD, CMI, missed nursing care, and patient falls (Table). Hour per patient day was negatively associated with patient falls (r = − 0.36, P < .01). The higher the overall missed nursing care score, the higher the patient fall rates (r = 0.30, P < .01). More patient falls were significantly related to the following missed nursing care elements: ambulation (r = 0.22, P < .05), each shift patient assessment (r = 0.19, P < .05), call light response (r = 0.22, P < .05), and toilet assistance (r = 0.30, P < .01). Focused reassessment was not significantly associated with patient falls. In addition, CMI was not significantly correlated with falls. Missed nursing care mediation of the effect of HPPD on patient fall Missed nursing care was hypothesized in this study as a mediating variable in the relationship between HPPD and patient falls. To Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. LWW/JNCQ NCQ200142 10 November 16, 2011 12:25 JOURNAL OF NURSING CARE QUALITY/JANUARY–MARCH 2012 Table. Staffing, Missed Nursing Care, and Patient Falls: Correlation Matrix Variables 1 2 3 4 5 6 7 8 9 1. Patient falls − − 0.36b − 0.19 0.30b 0.22a 0.19a 0.16 0.22a 0.30b b b b 2. HPPD − 0.64 − 0.26 0.00 − 0.01 − 0.15 − 0.38 − 0.41b 3. CMI − − 0.13 − 0.00 0.05 − 0.13 − 0.23a − 0.17 b 0.63b 0.70b 0.76b 0.86b 4. Missed nursing care − 0.66 b 5. Ambulation − 0.11 0.13 0.40 0.50b b a 6. Each shift patient − 0.71 0.22 0.45b assessments 7. Focused reassessment − 0.41b 0.50b 8. Call light response − 0.65b 9. Toilet assistance − Abbreviations: CMI, case mix index; HPPD, hours per patient day. a P < .05. b P < .01. satisfy the requirements for mediation, 3 variables were computed. To establish mediation, the following conditions must be satisfied: (a) HPPD must affect missed nursing care in the first equation; (b) HPPD must affect patient falls in the second equation; and (c) missed nursing care must affect patient falls in the third equation. Then, if these conditions are met, the effect of HPPD on patient falls must be less in the third equation than in the second equation, thus establishing mediation. In equation 1, missed nursing care, the mediator variable, was regressed on the predictor variable, HPPD. As noted in the Figure, results indicated that HPPD was significantly associated with missed nursing care (F1,120 = 8.46, P = .004). Hour per patient day explained 6.7% of the variance in missed nursing care. In equation 2, patient fall, the outcome variable, was regressed on the predictor variable, HPPD. Hour per patient day was significantly associated with patient fall (F1,115 = 17.20, P < .001). Hour per patient day explained 13.0% of the variance in patient falls. In the final equation, patient fall, the outcome variable, was regressed on both the predictor variable (HPPD) and the mediator variable (missed nursing care). Missed nursing care negatively affected patient falls (t = 2.49, P = .014), explaining 9.2% of variance in patient falls. With missed nursing care present, the proportion of variance of patient falls accounted for by HPPD was reduced from 13.0% (second equation) to 8.3% (third equation), and the standardized regression coefficient was decreased from − .36 to − .30 from the second to third equation. Thus, the reduced direct association between HPPD and patient falls when missed nursing care was in the model supported the hypothesis that missed nursing care was at least 1 of the mediators in the relationship between HPPD and patient falls. DISCUSSION The results of this study demonstrate that the level of nurse staffing predicted patient falls. This supports the findings of previous studies which have reported that higher staffing levels lead to fewer patient falls.16-18 It also reinforces our earlier findings that staffing levels predict the amount and type of missed care.23 Missed nursing care was also found to mediate the relationship between staffing levels and falls. The effect of staffing levels Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. LWW/JNCQ NCQ200142 November 16, 2011 12:25 Missed Nursing Care, Staffing, and Patient Falls 11 Figure. Test of the mediation model with regression analyses. on fall rates is lessened when standard nursing care is completed (ie, no missed care, specifically ambulation, patient assessments each shift, focused reassessment, call light response, and toilet assistance). This suggests that one method of preventing patient falls is to devise methods whereby nursing staff complete standard nursing care more so than adding staff. It also could indicate that the mindfulness of the staff (ie, completing standards of care) is a critical factor for achieving improved outcomes, as opposed to specific fall-prevention strategies, such as alert signs, wristbands, and/or signage above the bed. For example, ambulation has been found to correlate significantly with patient falls. One study by Fisher and colleagues24 found that exercise (ambulation) was highly correlated with patient falls.24 In addition, updated guidelines of the American Geriatrics Society and the British Geriatric Society on preventing falls in elderly patients include exercise for balance, gait, and strength training as a key recommendation.25 Early ambulation also has been shown to reduce length of stay.24 The fact that previous studies have identified ambulation as an element of care that is frequently missed suggests that this nursing action may be particularly critical to falls prevention.14 Further studies that examine the predictive relationship between specific elements of missed care elements and patient falls are needed to gain a better understanding of these relationships. Limitations This study is limited by the fact that it was confined to 11 hospitals in 2 states. This limits the generalizability of the study findings. However, this limitation is mitigated by the fact that we have found similar areas of missed care across hospitals. In addition, the measure of missed nursing care is based on perceptions of nursing staff. IMPLICATIONS The findings from this study underline the importance of ensuring that required care is completed (ie, limit missed care) on a daily basis, thus potentially minimizing patient falls. Although nurse staffing levels affect patient fall rates, the level of impact is reduced when care is completed in its entirety. Further work must be done to assist nurses in completing necessary tasks such as ambulation, toilet assistance, patient assessments, and call light responses, which may or may not mean additional staff members. Strategies for assisting staff to complete all aspects of nursing care include checklists, computer reminders, and patient engagement. Until we more fully understand the process of nursing care and its relationships to patient outcomes, we will not be able to develop successful strategies to prevent adverse events such as falls. Hospital nursing staff need to conduct root cause analyses to determine the reasons for missing this care and develop interventions to ensure that standard nursing care is completed. Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. LWW/JNCQ 12 NCQ200142 November 16, 2011 12:25 JOURNAL OF NURSING CARE QUALITY/JANUARY–MARCH 2012 REFERENCES 1. Coussement J, De Paepe L, Schwendimann R, Denhaerynck K, Dejaeger E, Milisen K. Interventions for preventing falls in acute- and chronic-care hospitals: a systematic review and meta-analysis. J Am Geriatr Soc. 2008;56(1):29-36. 2. Rutledge DN, Donaldson NE, Pravikoff DS. Fall risk assessment and prevention in healthcare facilities. Online J Clin Innov. 1998;1(9):1-33. 3. The Joint Commision. Summary data of sentinel events reviewed by the Joint Commission. http:// www.jointcommission.org/assets/1/18/SE_Data_ Summary_4Q_2010_(v2).pdf. Accessed January 6, 2010. 4. Oliver D, Hopper A, Seed P. Do hospital fall prevention programs work? A systematic review. J Am Geriatr Soc. 2000;48(12):1679-1689. 5. Centers for Medicare and Medicaid Services. Medicare and medicaid move aggressively to encourage greater patient safety in hospitals and reduce never events. http://www.cms.gov/apps/media/press/release.asp? Counter.= Published 2008. Accessed January 19, 2011 6. Ferrari MA, Harrison BE, Campbell C, Maddens M, Whall AL. Contributing factors associated with impulsivity-related falls in hospitalized, older adults. J Nurs Care Qual. 2010;25(4):320-326. 7. Yauk S, Hopkins BA, Phillips CD, Terrell S, Bennion J, Riggs M. Predicting in-hospital falls: development of the scott and white falls risk screener. J Nurs Care Qual. 2005;20(2):128-133. 8. Hill-Westmoreland EE, Soeken K, Spellbring AM. A meta-analysis of fall prevention programs for the elderly: how effective are they? Nurs Res. 2002;51(1):18. 9. Schubert M, Glass TR, Clarke SP, et al. Rationing of nursing care and its relationship to patient outcomes: the Swiss extension of the International Hospital Outcomes Study. Int J Qual Health Care. 2008;20(4):227237. 10. Gray-Micelli D. Preventing falls in acute care. In: Capezuti E, Zwicker D, Mezey M, Fulmer T, eds. Evidence-Based Geriatric Nursing Protocols for Best Practice. New York, NY: Springer Publishing; 2008:161-198. 11. Institute for Clinical Systems Improvement. Health care protocol: prevention of falls (acute care). http://www.icsi.org/falls_acute_care_prevention_of_ protocol_/falls_acute_care_prevention_of_protocol_ 24255.html. Published 2010. Accessed January 19, 2011. 12. Titler M. Impact of system-centered factors, and processes of nursing care on fall prevalence and injuries from falls. Presented at: Third annual meeting of Robert Wood Johnson Foundation’s Interdisciplinary Nursing Quality Research Initiative; July 16-17, 2008; Princeton, NJ. 13. Kalisch BJ. Missed nursing care: a qualitative study. J Nurs Care Qual. 2006;21(4):306-313. 14. Kalisch BJ, Landstrom G, Williams RA. Missed nursing care: errors of omission. Nurs Outlook. 2009;57(1): 3-9. 15. Kalisch B, Tschannen D, Lee H, Friese C. Hospital variation in missed nursing care. Am J Med Qual. 2011;26(4):291-299. 16. Callen BL, Mahoney JE, Grieves CB, Wells TJ, Enloe M. Frequency of hallway ambulation by hospitalized older adults on medical units of an academic hospital. Geriatr Nurs. 2004;25(4):212-217. 17. Dunton N, Gajewski B, Taunton RL, Moore J. Nurse staffing and patient falls on acute care hospital units. Nurs Outlook. 2004;52(1):53-59. 18. Lake ET, Shang J, Klaus S, Dunton NE. Patient falls: association with hospital Magnet status and nursing unit staffing. Res Nurs Health. 2010;33(5):413425. 19. Whitman GR, Kim Y, Davidson LJ, Wolf GA, Wang SL. The impact of staffing on patient outcomes across specialty units. J Nurs Admin. 2002;32(12):633639. 20. Donabedian A. The quality of care. JAMA. 1988;260(12):1743-1748. 21. Kalisch BJ, Williams RA. Development and psychometric testing of a tool to measure missed nursing care. J Nurs Adm. 2009;39(5):211-219. 22. Baron RM, Kenny DA. The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol. 1986;51(6):1173-1182. 23. Kalisch BJ, Tschannen D, Lee KH. Do staffing levels predict missed nursing care? Int J Qual Health C. 2011;23(3):302-308. 24. Fisher SR, Kuo YF, Graham JE, Ottenbacher KJ, Ostir GV. Early ambulation and length of stay in older adults hospitalized for acute illness. Arch Intern Med. 2010;170(21):1942-1943. 25. Panel on Prevention of Falls in Older Persons AGS, British Geriatrics S. Summary of the Updated American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons. J Am Geriatr Soc. 2010;59(1):148-157. Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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mariam90
School: University of Virginia

Below is the response. Please let me know what else you want me to fill. If I am not wrong I was supposed to fill in the table with information about the article on hourly rounding. I stand to be corrected.

Running Head: REDUCING FALLS IN THE HOSPITAL SETTING

Reducing Falls in the Hospital Setting
David Arnquist and Brittany Mayfield
Texas Tech University Health Sciences Center
NURS 4342-003
February 6, 2018

1

REDUCING FALLS IN THE HOSPITAL SETTING

2

Reducing Falls in the Hospital Setting
According to The Joint Commission’s National Safety Goals, we must “prevent residents
from falling” (2018). In this paper we will discuss the consistencies and gaps of information
among three articles of study relating to reducing falls in the hospital setting. We have developed
a question based this safety goal, developed by The Joint Commission, to focus our research.
We will utilize this research to validate policies and help change those which may need to be
readdressed. By evaluating evidence and applying it to our practice, we can help promote patient
safety in our places of work.

REDUCING FALLS IN THE HOSPITAL SETTING

3

For patients in the hospital setting, will lower nurse to patient ratios be more effective in reducing falls?
P (Population of Interest): Patients over 18 years of age
I (Intervention of Interest): Staffing, alarms, and rounding to reduce falls.
C (Comparison of Interest): Nurse to patient ratios
O (Outcome of Interest): Reduce falls
T (Time): ...

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