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Clinical Consultation: Stroke Unit Fall Prevention: An Interdisciplinary, Data-Driven Approach
Situation: Frustration came over me as I shuffled through the file cabinet looking for the folder containing the blank incident report forms. As a manager, I felt that the entire stroke team had failed in the eyes of the patient and his loved ones. I dreaded making yet another telephone call to a patient’s family to tell them that their loved one had fallen while performing a transfer with staff. Moreover, the clinical team was becoming frustrated as well. They were highly trained, caring staff dedicated to teaching patients to safely increase their independence, yet patients continued to fall during transfers. How can we accomplish safe, therapeutic transfers? Furthermore, how should we communicate these techniques to all staff in all disciplines? We need to identify an effective process to minimize transfer-related falls.
Consultation: Grace B. Campbell, BSN RN CRRN CBIS, rehabilitation clinician at the University of Pittsburgh Medical Center (UPMC) Institute for Rehabilitation and Research at UPMC South Side, Terry P. Breisinger, MPT CBIS, rehabiliation team leader at UPMC Institute for Rehabilitation and Research at UPMC South Side, and Linda Meyers, COTA, certified occupational therapy assistant at UPMC Institute for Rehabilitation and Research at UPMC South Side reply.
Fall prevention is a frequently discussed topic in rehabilitation nursing. Within the past 15 years, numerous publications have outlined the incidence of falls in acute care, long-term care, and rehabilitation. Various studies note serious consequences arising from patient falls, including increased mortality and morbidity and increased medical costs (Eakman et al., 2002; Foster & Kohlenberg, 1996; Hendrich, Nyhuis, Kippenbrock, & Soja, 1995; McLean, 2004; Morse, 1997). Fall prevention will likely continue to be widely discussed, as the Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) most recent statement of National Patient Safety Goals requires that hospitals reduce the risk of harm from patient falls (JCAHO, 2005).
Fall prevention literature has focused on broad themes such as assessment of risk and development of fall prevention protocols. At least 12 valid, reliable fall risk assessment scales have been described in the literature (Morse, 1997). For patients assessed as high risk for falling, the literature does not describe focused preventive measures. For example, environmental modifications, such as nonglare floor finishes and appropriate handrails, may increase general unit safety, but do not address patient-specific risk factors. Specialized equipment, such as hip protector pads or floor cushions, may decrease the likelihood of injury when falls occur, but do not prevent falls for at-risk patients. Fall prevention protocols highlight general interventions, such as placing the call bell within reach and reminding the patient to call for assistance before getting up, but few target problems specific to particular units or patient populations.
Stroke patients are at high risk for falls (Foster et al., 1996; Grant & Hamilton, 1987; Rapport et al., 1993). Rehabilitation fall rates noted in literature are between 7.6 and 12.6 per 1,000 patient days (Florida Hospital Association, 2001). Our health system’s rehabilitation fall benchmark is 8.5 falls per 1,000 patient days. The stroke unit at our facility consistently experiences fall rates above 8.5 and often above 12.6.
The stroke unit’s fall data, including fall rates and types of falls, were analyzed. Based on review of the literature, we anticipated that unassisted falls from bed, wheelchair, and toilet would be the most frequently occurring types of falls (Grant & Hamilton, 1987; Mahoney, 1998; Rapport et al., 1993). Unexpectedly, the data showed that the most frequent type of fall occurred during assisted patient transfer, accounting for 25% of the stroke unit’s falls. The interdisciplinary Falls Task Force recommended reeducation of the nursing staff about safe patient transfers for the stroke population. Patient transfer techniques were discussed at unit meetings, and the occupational therapy and physical therapy departments provided transfer training inservices to all unit nursing staff.
Data were analyzed 8 months after the reeducation effort. Stroke unit fall rates consistently remained above benchmarks; in addition, falls during patient transfers had not decreased, still accounting for 23.5% of unit falls. Clearly, reeducation had not improved transfer-related fall rates. As a result, stroke unit clinical leaders requested that the clinical team investigate further. As a result, safe patient transfers leading to decreased falls became a formal performance improvement initiative.
Team members from nursing, occuational therapy, and physical therapy studied the current process for assessing fall risk and for performing patient transfers. Each discipline completed a functional assessment of the patient on admission, including a nursing fall risk assessment. These data, however, were often not used in a meaningful way; fall risk and functional transfer issues were often not placed on the interdisciplinary plan of care. The team members also noted that nursing communication about transfer issues was inconsistent. Techniques that staff may have found beneficial often were not passed on in shift report. In addition, although occuational therapists (OTs) and physical therapists (PTs) were considered to be transferring experts, nursing staff performed almost all on-unit functional transfers.
As team members analyzed the process of safe functional transfers, a number of other factors emerged. Interdisciplinary dynamics, such as turf issues, served to inhibit communication and collaboration. Thus, transfer techniques were not always agreed upon nor discussed among the various disciplines. In addition, some therapists felt that the blame for falls, and thus the solution, belonged solely to the nursing team. Transfer training often occurred in the therapy gym (an ideal environment), but on the nursing unit, where the physical layout of the rooms and bathrooms was not optimal, the techniques often were not applicable. When therapists provided in-service training techniques to nursing on transfer, the staff had difficulty generalizing the training to actual patient situations. Finally, the team members realized that although licensed professional staff assess fall risk and functional transfers (the RN, the PT, and the OT), it is often unlicensed caregivers (e.g., nursing assistants) who perform the majority of patient transfers.
Existing fall prevention literature did not offer interventions to minimize transfer-related falls. A creative solution was needed that would enhance team communication and problem solving related to specific patient transfer issues. To meet this need, the team implemented an interdisciplinary transfer clinic.
The transfer clinic is held weekly on Tuesday mornings. If transfer issues arise during the week, the team schedules additional sessions so that patients can be seen as necessary. Staff from all disciplines suggest patients for transfer clinic by placing the patient’s name on a unit schedule board. Therapists schedule the patient for a 30-minute physical therapy and occupational therapy cotreatment session. (Speech therapy is included if appropriate, for example, if the patient is working on sequencing and task planning issues.) Therapists, nurses, and nursing assistants gather in the patient’s room and discuss the problematic transfers. Possible techniques are discussed and tried; techniques and equipment are identified and agreed upon by the team members. The team continually seeks input from the patient regarding his or her thoughts, ideas, and fears about being transferred. This patient feedback is key; the team members soon realized that successful transfers require that both the staff and the patient feel comfortable with the recommended techniques and equipment. Rather than an OT or PT prescribing transfer techniques, the entire team discusses approaches attempted and whether these have been successful. Nursing staff members offer suggestions and actively participate in the team’s problem-solving process. After the patient and team agree on the transfer techniques, the involved staff practice the agreed-upon techniques.
Another key feature of the transfer clinic is formal communication of results. Techniques, recommended equipment, and level of assistance for each type of transfer are recorded on a check-off form by the team. A copy is posted by the patient’s bedside, and the original is kept in the nursing kardex to cue the nurses to discuss transfer techniques in the shift report.
Data analysis at 6 months after implementation indicated that although the stroke unit’s fall rate was at times still higher than the hospital benchmark, falls related to patient transfers had decreased, accounting for only 8% of falls. Ongoing data analysis shows that transfer-related falls continue to remain low. Although we do not have specific data on patients’ satisfaction with transfer clinic, anecdotal comments from patients and families have been positive.
There are several limitations to the interdisciplinary transfer clinic. For example, a change in team membership can affect the efficacy of the intervention. Positive team member dynamics are crucial to the communication and collaboration necessary for an effective interdisciplinary problem solving forum; a new team member who lacks investment in the process can dilute the effectiveness of the transfer clinic. In addition, it is difficult to schedule the transfer clinic at a time convenient to all. Negotiation among team members has been necessary to identify a time most convenient for all disciplines. Team members must also perceive that the transfer clinic directly benefits them and their patients so that they are motivated to find an acceptable time and to enter into true team collaboration. Finally, staff ability to proactively identify patients at risk for transfer-related falls appears to be inconsistent. This may be a particular issue for less experienced staff members who may not be aware of factors that place a patient at higher risk for transfer-related falls. Future study is needed to examine the efficacy of decision-making tools, such as a protocol, to assist in the proactive identification of patients at high risk for transfer-related falls in order to ensure that they are scheduled for transfer clinic immediately upon admission.
When a fall reduction program is implemented, data trends specific to each institution or unit should be examined. A generalized fall prevention program, although helpful, cannot solve specific fall problems related to particular diagnoses or patient problems. We noted unexpected data—that falls related to transfer were the most frequently occurring falls. Next, we applied a formalized performance improvement process to the problem. Assessing the current process for patient transfers and understanding what caused variations in the process led us to the development of a creative intervention that reduced the number of transfer-related falls. The team plans to use a similar process to identify root causes and possible solutions for other types of falls, such as falls from bed, chair, and commode.
About the Authors
Grace B. Campbell, BSN RN CRRN CBIS, is a rehabilitation clinician at the University of Pittsburgh Medical Center (UPMC) Institute for Rehabilitation and Research at UPMC South Side.
Terry P. Breisinger, MPT CBIS, is the rehabiliation team leader at UPMC Institute for Rehabilitation and Research at UPMC South Side.
Linda Meyers, COTA, is a certified occupational therapy assistant at UPMC Institute for Rehabilitation and Research at UPMC South Side.
Eakman, A. M., Havens, M. D., Ager, S. J., Buchanan, R. L., Fee, N. J., Gollick, S. G., et al. (2002). Fall prevention in long term care: An in-house interdisciplinary team approach. Topics in Geriatric Rehabilitation, 17(3), 29–39.
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