In early 2014, a patient on a medical-surgical/telemetry unit at Medina Hospital had a fall with fracture. A team of caregivers and managers performed all the required post-fall protocols, including a root cause analysis and post-fall huddle. When they discovered that certain environmental factors may have contributed to the fall, a duo of nurses took action: Nursing Quality Program Manager Ann Marie Flannery, RN, and Clinical Instructor Karen Theodore, BSN, RN, created a 30-minute interactive fall prevention class entitled “Ready for Take Off”. Initially conducted on the unit where the fall occurred, it later was offered to the entire hospital and turned into a system-wide class throughout the Cleveland Clinic health system.
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“The class is an eye opener for nurses,” says Theodore. “It makes them question whether they are taking into account everything that contributes to a fall, and it stresses the importance of educating patients and families on fall risks.” Medina Hospital offered the falls prevention program 28 times during July and August to nearly 125 caregivers, exceeding its goal by 25 percent.
The main component of the training is enactment of a potential fall scenario. First, participants alter a clean patient room to create hazards. They raise the bed, dim the lighting, place bedside tables near the side of the bed, drape call light cords and intermittent pneumatic compression device cords over the bed, add clutter to the room and so on. Then one participant takes on the role of either an elderly patient with atrial fibrillation or a postpartum mom who has received blood. Others work as a team to safely assist the patient. For instance, they activate bed/chair alarms, talk the patient through every step of a transfer, use a gait belt, and bring IV poles and other connected devices closer to the patient.
After the scenario, attendees discuss the risks in various patient care settings and the steps to take when a patient falls. The “Ready for Take Off” initiative encourages nurses and other caregivers to:
- Utilize standard risk awareness tools and assistive devices.
- Assess patients for drift prior to moving.
- Stage the patient environment for a safe lift off.
- Focus on the task at hand as it is a high-risk safety situation when a patient is preparing to move.
- Operate as a team by getting help when one caregiver is not enough.
- Identify the elements and responsibilities of the post-fall protocol.
Flannery presented the program to the enterprise-wide Quality Committee, which created an “education-in-a-box” guide for Cleveland Clinic’s main campus and eight other hospitals to use. The guide, called “Fall Into Action,” provides instructions for nurses to run the 30-minute interactive training session at their facilities.
Theodore says nurses at Medina Hospital have “embraced the training and taken off with it.” During one session, nurses from the emergency department realized that bed/chair alarms would make their unit safer. They recently requested and received alarms, and Theodore will offer education on using them.