Who were the guideline developers?
The guideline developers are staff members of the progressive care unit (PCU) in Midwest Hospital. The guideline developers were selected to participate in the American Association for Critical-Care Nurses (AACN) Clinical Scene Investigator Academy (CSI). The group identified falls as the patient improvement project within the progressive Unit. Thus, they came up with the evidence-based practice guideline to guide all the nurses within the Unit.
Were the developers of the guideline representative of key stakeholders in this specialty (inter-disciplinary)?
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The guideline developers were representative of the critical stakeholders in the specialty. They included a medical-surgical clinical nurse, a nurse in the cardiac critical care, patient care coordinator, practice specialist, and physicians in the progressive care unit (PCU). The 30-bed progressive care unit has patients that require round the clock care from nurses, nursing assistants, and physicians. Thus, the stakeholders were part of the guideline developers because they interact with patients every day in the PCU.
Who funded the guideline development?
The development was funded by the AACN Clinical Scene Investigator (CSI). AACN guides nurses in implementing lasting change and transforming healthcare. AACN CSI academy provides nurses with knowledge, skills, and support to lead other peers in the unit-based change to maximum impact. CSI supported the guideline development to reduce the number of falls in the PCU, the adverse outcomes of falls to patient health, and the cost incurred by the hospital. CSI provided financial and technical support through training of the developers to help them come up with a practical EBP guideline and implementation.
Were any of the guideline developers funded researchers of the reviewed studies?
The guideline developers are not funded researchers for the reviewed studies. The guideline developers came up with the evidence-based practice guideline after attending the CSI academy as part of the CSI project.
Did the team have a valid development strategy?
The team had a valid development strategy. The team started by identifying patient falls as one of the biggest problems in the CPU. They went through the CPU’s patient information and found out that 37 patients fell in 2011 in the CPU, accounting for 46% of falls with the entire hospital. Consequently, the team had a 3.92% fall rate, which was higher than the national average of 3.37%. After developing the guideline, the developers educated all the staff within the CPU as they were the ones to implement the EBP.
Was an explicit (how decisions were made), sensible, and impartial process used to identify, select, and combine evidence?
An explicit and impartial process was used to identify, select, and combine evidence. The developers defined the criteria for evidence to be included after defining the clinical issue. The developers searched peer-reviewed journals from the past ten years on fall prevention in CPU from EBSCOhost, PubMed, and Google Scholar. The evidence was evaluated based on whether the study was thorough or not. Once the evidence was graded, the developers synthesized evidence to create the EBP guideline.
Did its developers carry out comprehensive, reproducible literature review within the past 12 months of its publication/revision?
The developers carried out a comprehensive literature review within the past 12 months of the publication. The literature was classified into two levels. The first level is made up of well-designed meta-analysis, randomized control trials, and clinical practice guidelines. Evidence-based clinical practice guidelines on the same issue serve as the strongest level of evidence. The second level of evidence involves control studies without randomization, clinical cohort studies, case-controlled studies, uncontrolled studies, and quantitative and qualitative studies.
Were all important options and outcomes considered?
All the essential options and outcomes were considered for the evidence-based practice guideline. All the crucial steps starting from the creation of the multidisciplinary panel of health care practitioners, coming up with the criteria for selecting evidence, systematic search, evaluation, and grading of evidence. The evidence-based practice guideline is a synthesis of the literature on how to prevent falls in the CPU with the implementation strategies. The EBP guideline considered all the options and outcomes.
Is each recommendation in the guideline tagged by the level/strength of evidence upon which it is based and linked to the scientific evidence?
The guideline recommended in-service training sessions for staff on fall policy, documentation requirements, and the Morse Fall Scale (MFS). Other recommendations were establishing a patient/family fall teaching contract and designing new fall signage and placing them on the ceiling above the patients’ bed. The recommendations are linked to the evidence used in the creation of the EBP guideline. For example, the first recommendation of staff education is derived from a level one literature, a systematic meta-analysis by Oliver et al. (2007). The recommendations are linked to scientific evidence as they are conclusions of rigorous studies.
Do the guidelines make explicit recommendations (reflecting value judgments about the outcomes)?
The guideline makes explicit recommendations. The guidelines make recommendations on how to conduct training on fall prevention. The developers made a 40-minute video which they used to train the staff members in the CPU. The video showed the common falls within the Unit and how to prevent them. Thus, the guideline makes explicit recommendations. Another recommendation is the adoption of new fall signage.
Has the guideline been subjected to peer review and testing?
The guideline has been subjected to peer review and testing. The guideline was published in the Critical Care Journal after it was peer-reviewed and tested. The guideline was reviewed by expert nurses before publishing to maintain the standard and quality of the journal.
Is the intent of use provided (i.e., national, regional, local)?
The intent of use of the guideline is locally within the hospital. The “No Fall Zone” guideline was implemented in the CPU. The guideline led to the reduction in fall data within the Unit by more than 50%. The fall rate fell below the NDNQI benchmark, and the fiscal impact of the guideline was $505,440. The plan is to implement the guideline in other units within the hospital by identifying that patient-specific needs across other units to guide the implementation of the EBP guideline.
Are the recommendations clinically relevant?
The recommendations are clinically relevant. The guideline led to a reduction in the fall rate within the CPU by more than 50% and a significant reduction in cost ( Cangany et al., 2015) . A reduction in the fall rate also meant that the injuries and complications associated with falling were eliminated.
Will the recommendations help me in caring for my patients?
The recommendations will help me in caring for my patients. Patients who fall frequently are those with altered mental status, abnormal gait, frequent toilet needs, and high-risk medication (Day et al., 2014). The guideline recommends analyzing patients to identify the fall risks. I will use fall signage on the ceilings to guide high-risk patients and encourage them to use fall lights and other forms of alarms rather than attempting to stand or do things on their own. I will also pay close attention to high-risk patients.
Are the recommendations practical/feasible? Are resources (people and equipment) available?
The recommendations are practical and feasible. The guideline does not require a lot of resources to implement, making it feasible. The recommendations include in-service training sessions relating to fall policy and Morse Fall Scale (MFS), a patient/family fall teaching contract, and new fall signage to warn patients. The resources for the implementation are readily available without additional cost.
Are the recommendations a major variation from current practice? Can the outcomes be measured through standard care?
The recommendations are not a major variation from the current practice. Nurses and patients are aware of some of the strategies necessary to prevent falls such as proper lighting, keeping the floors dry, and the use of non-slip footwear. The recommendations add to the current practice by emphasizing on the need for proper fall prevention strategies. Nurse education on fall prevention enlightens the nurses on the dire effects on falls on patient health and an increase in the cost of care to motivate them to play a proactive role in fall prevention
References
Cangany, M., Back, D., Hamilton-Kelly, T., Altman, M., & Lacey, S. (2015). Bedside nurses leading the way for falls prevention: an evidence-based approach. Critical care nurse , 35 (2), 82-84.
Day, L., Trotter, M. J., Hill, K. D., Haines, T. P., & Thompson, C. (2014). Implementation of evidence ‐ based falls prevention in clinical services for high ‐ risk clients. Journal of evaluation in clinical practice , 20 (3), 255-259.
Melnyk, B. M., & Fineout-Overholt, E. (Eds.). (2011). Evidence-based practice in nursing & healthcare: A guide to best practice . Lippincott Williams & Wilkins.
Oliver, D., Connelly, J. B., Victor, C. R., Shaw, F. E., Whitehead, A., Genc, Y., & Gosney, M. A. (2007). Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses. Bmj , 334 (7584), 82.
