Abstract
This study is targeted at helping find a solution to the problem of patients falling in the emergency department due to their medical conditions. It has been triggered by the recent high number of falls in the department with more than 10 patients falling within a specific time a nurse is on shift. This is a considerable high number of falls that could attract penalties for the hospital in terms of lawsuits not to mention that patients could be injured severely and develop other serious complication from the fall. There needs to be a new system in place to help curb this problem and help improve better care of the patients who are the hospital’s first priority. It will be an added advantage helping the hospital prevents any lawsuits. The process of reducing falls in the emergency department in this research follows the focus PDSA approach. This starts with identifying or finding the process to improve in this case being the reduction of falls in the emergency department. It is followed by organizing the team, making clarifications on the current system’s knowledge, which is followed by understanding the variations that exist and selecting the process, then finally making changes and improvements. The next steps that follow involve planning the changes, doing them, studying the effects of the changes and acting on what the analysis reveals. With the focus-PDSA cycle, it will be possible to tell if the proposed changes are working or if there is need to try a different approach in another cycle.
Thesis statement
There seems to be a problem in the emergency department with patients’ falls being on an all-time high. The goal is to find out how these falls can be reduced by identifying the symptoms of patients with potential of falling before it happens. This will help improve patient care and keep the hospital out of trouble caused by lawsuits
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Background
The organization faces a challenge in the emergency department with a nurse noticing that over ten patients fall during her shift. This is an indicator that there is a major problem with patient attendance and in-take procedures. To curb this problem therefore there is need to improve the existing system. It is clear that a major challenge exists in the emergency department since patients falling happen to be a common occurrence. 10 patients is a high number of patients falling in just one nurse’s shift (Morse, 2008) . It is impor tant to understand where the problem is coming from and address it head on. Patients’ education is also necessary. There also needs to be trainings for nurses and other caregivers within the hospital to help in the identification of patients with high potentials of falling when they arrive in the hospital. It is possible that with early identification of the symptoms it is possible to prevent the falls before they happen. This way patients will receive better care from the time they arrive at the hospital to the moment they leave which is the organization’s primary goal. There is also the advantage that comes with taking precautions, as the hospital will be free from suits of negligence due to frequent patient’s falls.
Data backing up Quality Improvement Initiative
This research has been advised based on the high number of patients falling in the emergency treatment as they await assistance. Last month alone in a single nurse’s shift more than ten patients fell in the emergency department, a number that is considered too high. The team trying to come up with a better system to manage falls in the emergency department includes four nurses with a few doctors still to come onboard to share their knowledge on the reasons for patients’ falls. The team intends to focus on how to identify patients with high chances of falling since this is where the main problem lies. The team will try to focus on improving the identification process of the patients that come in.
There are several root causes of this problem that have already been identified by the team including the fact that some staff members are taking shortcuts and not following the due process of checking in patients and checking them out of the emergency department. The staff also seems to lack the proper knowledge on this matter and some fail to follow protocol. The team has a number of suggestions when it comes to finding solutions among them being a re-education plan for staff members on the in-taking procedures of patients, properly formulated plan complete with questions to be asked to patients in the emergency department. All staff members must follow and finally a move to make the management understand that the goal is not just to increase the number of patients getting in and out of the emergency department by using shortcuts, but to provide quality care.
Random checks by team fall members will help determine if staff members are using the checklist properly and if improvements are happening in the department. The reduction of falls in the emergency department will be the indicator of improvement and success of the quality improvement project. How comfortable the nurses will be in identifying patients with the potential of falling will be another gauge of success for the project (Jeske & Hook, 2006) .
Literature review
Research shows that about 700000 to one million people fall in hospitals every year. These falls could result to serious injuries such as fractures, internal bleeding and lacerations. They may also trigger increased use of hospital facilities. The same researches also indicate that most of these falls are preventable by managing the underlying factors that may trigger falls in the first place. It is also possible to reduce falls by improving the physical design of the hospital setup. This is why most hospitals come up with fall prevention programs.
Research has been done in the area of reducing falls in emergency departments in hospitals as a way of improving care and safety of patients. This is especially crucial with the increased numbers of patients visiting the emergency departments in hospitals today for different reasons leading to overcrowding. According to researches done before, implementation of the fall prevention plan is what matters most in any hospital set up. It may not matter how great a program you intend to implement in concept, without the actual use of the program by the staff, the program will be of no benefit and will not improve the quality that you intended in the first place.
When you come to a point where you want to implement a fall prevention strategy it is possible that you have undergone the previous stages of assessing the need for the changes, setting goals and actually preparing for the changes after examining the best practices possible. What is left is to have the implementation team work the unit teams to implement the fall prevention practices that have been proposed in the quality improvement program. It is possible that the organization has already begun the process of implementing some of the proposed changes but some of the changes will require a complete turnaround on how tasks are completed. For this new set of changes the organization has to customize them and integrate them into the system for them to be fully implemented and sustainable.
There are certain questions that will guide the implementation process. They will also help make the change program a success. Previous researches have revealed that it is necessary to ask about the roles and responsibilities of the staff in prevention of the falls. This first part question seeks to establish the roles and responsibilities assigned to the staff, the unit team’s role, and the Unit champion’s roles as well as how the organization of the unit level work is to be. The second question seeks to identify prevention practices that go beyond the unit. The third question will establish how the new practices will be put into action. This touches on the management of the change process, pilot tests, exciting and engaging the staff as well as how to help the staff learn the new practices. To implement the suggestions and new practices it is necessary to pay attention to details. There are certain issues that must be cleared.
First, there is the matter of educating the clinical and non-clinical staff where nurses are reached out to with fall prevention education especially those that work on the night shift and weekends. There is also the need to provide trainings on fall prevention for the entire professional team thus going beyond the nurses and including other support staff in the training. It is also important to include communication of fall risks. This involves the development of mechanisms for emergency departments to communicate patients’ risk factors for falls to the emergency or admitting departments. It is also important to work on the improvement of handing off tools between shifts and departments.
Researches that have been done before also touched on the roles and responsibilities of staff members on preventing falls. Here is where the current practices are examined with the aim of improving them as well as defining roles and assigning every staff one to do. There will be a need for specific roles and communication paths to make it easy for accountability and follow-ups. It is important to note that in a hospital different units have varied ways in which they conduct their business. It is important to consider the roles of the staff based on the organization as a whole as well as the functioning of a specific unit they belong to. For these decisions to be made there is need to involve unit leaders especially managers. The roles to be played by staff members must be clearly defined to make it easy for them to understand the changes they must be part of. It is important to take the staffs’ strength and skills levels when allocating roles to them. In addition to factoring in the individual responsibilities, it is necessary to check how each role will interact. The temporary staff should also have a plan in place to help them become orientated into the fall prevention plan. They are probably going to help with the monitoring process.
Apart from the specific roles played by the staff, the champions of the unit also have major responsibilities especially with regard to successfully implementing the fall prevention plan. The champion is the specific staff member that serves as the liaison between the unit staff and the implementation team and is a crucial player especially at the implementation stage.
The staff members go to this individual to have their concerns addressed concerning the changes. He or she is responsible for reposting results, reporting on the progress of the program as well as providing updates in meetings. In case there is need for audits he or she will be at the fore front. This position can go to any staff member that works in the unit. It is necessary to have one champion per shift although the numbers can vary depending on the hospital’s needs. Previous researches point out that hospitals have been able to implement fall prevention programs because of the involvement of their staff members at different units as this is crucial for any successful implementation of a program.
Evidence based intervention that is being implemented
There are certain interventions that are already being implemented in the organization to help curb the problem of patients falling in the emergency department due to their medical conditions. An existing identification program looks to point out patients with the potential to fall. The problem is that this process is not effective as it is hence the need for further improvement. It is clear that there is a due process that ought to be followed when signing in patients and signing them out of the emergency department. However, some of the staff members seem to be taking shortcuts and avoiding the long procedures hence interfering with effectively serving patients and preventing falls. Their main aim seems to be signing in and out more patients.
The department also has put in place measures to address the inefficiencies that exist. There is the introduction of re-educating the staff members on the appropriate procedures for in-taking patients in the emergency department. There is also a plan that has been created with questions that all staff members working in the emergency department will have to use when dealing with patients that come in. This is a mandatory chart and all staff members in the department have to go through it during orientation. Also put in place is a framework that informs the department’s top level of management on the importance of avoiding creation of shortcuts to increase the number of patients coming through the emergency department since there are important factors to look at, an example being the safety of the patients.
How well the patients are served should be a higher priority than getting high numbers in. It is necessary for protocols to be followed to avoid making unnecessary mistakes. There is also a proposal recommending the increase of staff members in the department since the aspect of being short staffed could be triggering the use of shortcuts thus a lot of neglect could be occurring in the process and as such high levels of falls could be registered (Renteln‐Kruse & Krause, 2007) .
Plan for implementation
For proper implementation to take place there is need for a plan to roll out the proposed solutions. In this case, the plan starts with a designated staff member of the fall prevention team making random checks on patients that have already gone through the emergency department and have been processed. This is going to reveal whether or not the staff at the department is following the checklist provided when dealing with patients at any given time. The questions in this checklist are going to come in handy in the identification process of the patients that are likely to be a problem to falling because of the conditions that they have.
Apart from verifying the use of checklists, there is also the plan to randomly talk to patients at least 10% of those that have been checked in through the emergency department. This team will ask the patients questions regarding whether or not they have experienced instances of falling due to their medical conditions. From the answers gathered in this process, the fall team will have an idea of how the process is being implemented and if it is working to achieve its intended purposes or not. Apart from the activities to be done, there is also the aspect of how the nurses will be once they begin implementing the proposed changes. It will be a success if the nurses will reach a point where they are comfortable with the process of identifying all the patients with the potential of falling down. They will also have no problem with making the necessary assessments (Dykes & Middleton, 2010) .
After getting the go ahead from the management, the team continued to use the checklist in identifying the patients that are likely to fall. The result was that some nurses responded positively but the older nurses who had been in the hospital longer caused some resistance. They were used to identifying such patients differently thus do not appreciate the changes or they may not be ready for it. It is also from the implementation process that a few discoveries by the team were made. There is need for continuous randomized checks. This is because the checks that have been done are not enough to indicate any significant changes that the quality improvement program is aiming at.
Ethical considerations
There are a number of ethical considerations that have been made even when choosing the best intervention for fall prevention in the emergency department of this organization. This is based on the ethical value that the hospital holds dear and that is to provide the highest quality care for the patients that it serves. It is the responsibility of any hospital established to provide highest quality care of this patients and this is an ethical requirement that it has. Frequent falls get in the way of providing this kind of quality care as it may lead to even more severe issues, different from what the patients were suffering from when they came into the hospital.
The hospital is ethically charged to be compassionate and assist ailing patients. This is one of the factors that play a significant role when deciding to improve the quality of care by working on reducing falls in the emergency department. The medical department is governed by a code of ethics that apply in every unit of the hospital. The emergency department has a number of ethical codes that it operates on. All emergency physicians are supposed to embrace their patients’ welfare and make giving professional service their primary mandate. They are also supposed to have a prompt response without having any prejudice in them. They are supposed to respond to all emergency care needs without partiality. The emergency health workers should also strive to respect the rights of their patients and work on protecting the interest of their patients. This is especially for patients that are most vulnerable in this case being those that are likely to fall when they come to the emergency department of the hospital. The medical practitioners are also supposed to communicate truthfully to patients about their conditions, which would explain the ethical charge that they have to make necessary inquiries to patients about their conditions in order to establish whether they have a medical condition that could contribute to their falling when in the emergency department (Williams & Kidd, 2007) .
However, the need for consent can always be overlooked in the event that immediate response to patients needs is needed. The medics are also ethically required to respect the privacy of patients thus avoid disclosing any information without the patient’s consent. The only time consent is not needed is when consent may not be required from the patient to use their information is when the physician is doing it out of duty and responsibility of protecting the rights of others. Physicians working in the emergency department of the hospital are also supposed to work fairly with colleagues and take the necessary actions to protect the patients and offer them better care. It is also ethical for the emergency department workers to cooperate with people who care about the wellbeing of emergency patients.
Another ethical requirement for the workers in the emergency department of the hospital is for them to continually engage in studies that will make them better at providing the right services for their patients. They are also required to act as responsible stewards of the health care resources that have been put in their charge. It is also an ethical responsibility for all health workers of the emergency department to support all efforts intended to improve the welfare of that is intended to reduce injuries and promote health care. With so much ethical regulations to guide emergency workers in hospitals, all changes that are aimed at improving quality care are supposed to be guided by these ethics (Barker & Berlowitz, 2009) .
Required resources
For the fall-prevention program in emergency departments to work there needs to be resources that are channeled towards supporting the program. Some of these resources come in form of educational support. The administration and leadership of the department needs to be in a position where they can support further education of health workers in the emergency department especially concerning re-educating the nurses and support staff in the department. The department should be prepared to offer support and materials to train all the people working in the emergency department. Getting leadership support is also very important since they will help create an environment in which to try out different proposed solutions. There is also need for communication support meaning that the department needs to cater for all communication requirements. The department needs to develop mechanism through which workers will communicate risk factors.
The other areas that the quality improvement program on reducing falls of patients in the emergency department will require support from the hospital unit as well as the emergency department is concerning the issue of increasing the number of staff members. One of the problems that have come up, as a challenge for properly identifying patients with the risk of falling in the emergency department is the fact that the unit is understaffed hence the existing staff members device shortcuts in order to help haste the process of signing in patients. In the process, they compromise quality of the service they deliver thus increased falls, as they are unable to detect and prevent falls before they happen. There may be need for information technological support and resources to help enhance the quality of service provided by the emergency department. IT services have a way of hastening the processing of patients because it is not done manually (Haines & Hill, 2004) .
This gives staff members more time to focus on what matters and that is assessing the potential risks of patients that are likely to fall in the emergency department. There may also be need for tools such as mats for the floors, assistive devices for patients and safe patient handling equipment all of which will come in handy when dealing with patients that are likely to fall due to their medical issues. Having these tools and devices within reach in the department will enhance care for such vulnerable patients, reduce the possibilities of falls, and as such help keep the hospital out of trouble. Other resources that may be needed include printers and papers, which will be used in the education process. With the right kind of support it is possible to achieve the goal of reducing falls in the emergency department and increase chances of better quality care (Hughes, 2008) .
Leadership theory to help guide implementation and sustain it
One of the most difficult things to attain after implementation of the fall prevention program is its sustenance. However, with the right support from the leaders of the department and the hospital unit as a whole it is possible to achieve success in the sustenance of the fall prevention program. While it may be easier to adopt changes in a short period, the real challenge lies in sustaining these changes over prolonged durations. For these changes to be sustainable there is need for them to be integrated into the system of the hospital in such a way that they become part of the culture and part of the business running as usual. The process of sustaining change happens gradually as improvements are witnessed. This notwithstanding there is need to think about the long lasting changes that need to happen early as the improvement process begins. You need to think about the sustenance of the program as early as in the implementation phase. This means that you should always ask yourself certain questions as you implement the program. It is important to establish the responsibilities of continuous sustenance of the fall prevention program, which needs to happen on a regular basis. It is also necessary to know about the continued monitoring of fall rates as well as prevention rates in the quality improvement process. The leadership support also plays a significant role in ensuring that you receive the necessary support to keep the newly implemented practices ongoing. There also needs to be mechanisms that will continually reinforce the desired results (Tzeng, 2011) .
In most cases, challenges to sustenance of such programs occur because fall prevention may be perceived as an initiative that is limited by time as opposed to being seen as an ongoing program. It is also possible that the exact changes that may be specific to fall prevention will not be incorporated to the routine behavior of the staff. It could also be that the initiative requires more unit-based champions. When the staff refuses to own the fall prevention program then there may be a challenge. Without the appropriate mechanisms to give staff feedback of the effectiveness of the program then chances of being disowned are high. It is important to celebrate the success of the program in every step.
The fall prevention program team should be responsible for sustaining the program on an ongoing level. It is important therefore that the emergency department and the hospital as a whole makes a decision to keep the implementation team intact even after it has made its suggestions. This team should continue as the oversight team. The key is to ensure that the fall prevention process is an ongoing one. This team can be dabbed the sustainability team regardless of whether it was the original implementation team or not. This team is responsible for regular collection of data as well as making regular reports on the progress of the implementation of the fall prevention program. It serves as the disseminating point for new information. The team allows people to participate in different levels.
Continued monitoring of the process is also key to its sustainability success. Measurement is a major part of the PDSA approach especially if your target is on continuous improvement. Monitoring serves as a check for ensuring that the program is not veering off course. It is important to set a workflow routine that will be concerned with data collection. It is important to decide who will calculate fall rates and take care of audits. It is also important to decide to whom this information will be reported as well as what will be done to the data. This refers to details such as determining when and how frequent these data will be set up for review. This is the level where the sustainability team will determine the rates that become success indicators for the fall prevention programs. The rate might go up or low with certain changes that were not in the measurement parameters thus giving a wrong impression of the fall prevention program. These measures will ensure that you get a near accurate analysis of the programs’ performance.
The leadership of the emergency department and the hospital as a whole also has a role to play in the sustenance of the program. While the direct work of preventing patients’ falls is the unit’s staff responsibility, the leadership has a part to play in making the process a success. The staff needs a lot of support from other parts of the organization for success to be guaranteed. The leadership can provide its support in different ways including training the new employees and offering refresher courses for the employees that already exists. It can also facilitate the hiring of employees by the Human resource department whenever employees leave or when there is, need to increase the number of staff to facilitate better care and identification of patients with likelihood of falling in the emergency department. Adequate staff is necessary for better service delivery. The leadership can also contribute in ensuring program sustainability by prompting for the availability of resources and tools. If there is equipment that the department needs to be able to minimize falls then it is the responsibility of the leadership to ensure that it is available to them. The leadership may also assist in getting support from the information technology department whose staff will assist with regular and accurate reporting that is essential for sustenance of the fall prevention program (Poe & Joy, 2005) .
Overall, for sustainability to happen, it is necessary for communication to be established. The staff needs to be updated. The team will therefore have to come up with ways to communicate with the staff members in a way that is existing and informative. It is also important to incorporate it in the unit’s existing organization as a way of making it part of the hospital. This way the staff can identify with it from the early stages and thus making it easier for it to be sustained through time. If there is something that is sure going to help get people in the department on board is the financial implication of the fall prevention program. The leadership is going to appreciate the fact that costs will be reduced once the project is implemented.
Many leaders can help act as sources of communication. It is very easy to have most staff come onboard and support the fall prevention program if there is a similar support from the leadership. Leaders are known to remove barriers that could exist because of their higher level of authority. Inasmuch as the implementation team will involve every department there are things that only the leadership can handle and that is why you need to have their support from the beginning.
Change theory that will facilitate implementation
Once you know which fall change practice you want to implement and have well-defined roles and work organizations, it is necessary to develop strategies of actions. There are certain aspects you must consider when looking at implementing the changes. It is necessary to establish how you will manage changes at the frontline, how to pilot test the new practices, how to help new staff learn and how to engage the staff and help them get excited about the fall prevention program. One of the best ways of managing changes from the front line is by ensuring that the staff understand the new roles and get to know why they are important as well as have knowledge as well as tools to carry out their roles. It is also important to be able to reduce resistance to change through ensuring that the staff understand the reasons for change and agree that change is necessary.
It is also important to assist staff to set new practices as they have a potential of understanding. This comes with a promise of strategies that will increase the betterment of quality care. This is what should be a priority for the supervisors. Another way to manage the new changes is to identify barriers and minimize them using the new practices. For instance, the problem of having fewer equipment in the department can be addressed by providing them. In this study, the problem of identifying patients with risks of falling before they do can be addressed by properly analyzing their situation before they are signed in which will in turn help reduce the cases of falls and the consequences there after. It is also possible to manage these changes by engaging staff at all levels in order to buy their support for the program not to mention aid in tailoring the practices into the organization’s culture. This way the staff will identify with the changes early enough and probably reduce resistance of the useful changes being introduced to deal with the fall prevention measures in the emergency department.
For changes to be managed effectively, the implementation team needs to coordinate, guide and support implementation efforts in the pilot phase with new prevention practices being rolled out. The implementation team works with the unit leaders to support efforts of improvement. Involving front line nurses, middle level managers and clinicians at the unit level is one of the most effective ways of dealing with change. Both senior and middle level leadership is crucial for implementation of changes even in fall prevention projects. Even though in most cases the physician involvement is often ignored, it is always crucial to bring in doctors and physicians since they have a lot of knowledge on how to deal with falls and can be very resourceful in providing solutions for the department.
Evaluation procedures
An effective fall prevention program can only be determined by the results it gives. This means that there is need for evaluating the progress of the program especially if the implementation appears to be going well. You would want to know how effective it really is and tell if the changes proposed, are taking shape in the department. This can only be made possible through monitoring and evaluation of the program’s progress. One of the main components of this process is gathering feedback from involved staff. This evaluation can be done in question form where the implementation team gathers feedback from unit leaders. This information is then communicated to the staff in report form. Involving the entire staff members of the department is the surest way to guarantee full support from the staff members since they feel like they belong. Being let in is one of the easiest ways to implement successfully the fall prevention program in the emergency department. When every person involved gets to become part of the program from the start chances of resistance are minimized significantly and the right support achieved.
Alternative processes, plans for sustainability
The fall prevention team feels that the plan of bettering assessment of patients that are potentially likely to fall is the best approach to reduce falls. In fact, they believe that with the recommendations and progress of the program for the emergency department, the plan can then be spread to the other units in the hospital. This plan is one that can be used in the different departments across the hospital to help enhance the provision of better care for patients, which is the primary objective of the hospital to begin with. Therefore, there may not be any plan that offers an alternative to what is already in place. The goal is to involve the different stakeholders in the hospital and gunner the necessary support to allow full implementation of the process in the hospital. The proposed methods that will enhance sustainability of the process are the same that will be implemented all through even when being introduced in other new departments across the hospital. The team believes that there is need for training the staff members at least on a semiannual basis until it reaches a point where everyone understands the need for these changes not to mention that they will be equipped to manage the changes better. The training will help raise awareness of the risks involved.
Improvement of outcomes and next steps
The proposed changes will remain as they are without any need for changes until such a time when there will arise significant concerns to trigger changes. There may also be need to improve the outcomes if there are recommendations proposing that there is need for intervention on the current quality improvement process. This may in turn lead to recommendations of changes on how assessments are conducted as well as how patients with the potential for falling are handled. A major part of improving outcomes and the next steps is maintaining the excitement of the staff about the change. With the challenges that come with implementation of changes, the results are not always visible in the first incident. It is important to find small successes that can be rewarded early enough since sometimes even with excellent implementation it can be difficult to achieve desired results. For the next steps of improving the process of acceptance, it is important to focus on the staff turnover challenge. The new staff should be modified in such a way that they are able to include a focus on prevention. They also need to be integrated into the new units fall prevention program, which in turn helps maintain a culture that will in turn positively influence orientation towards the goal of fall prevention.
Conclusion
Fall prevention in emergency departments and other hospital units as a whole is achievable. Sticking to the focus PDSA process is one of the ways to easily improve quality in any medical unit. In this case, the emergency department decided to focus on the fall prevention process to improve in order to assist patients that are likely to fall and in turn save the hospital some trouble that could be accompanied with lawsuits. It is important to identify a process that requires improvement, organize a team that will be dedicated to seeing the process through, have some baseline information or data to work with from which you will verify the steps and select process changes and interventions for improvement. All through from the improvement to implementation and sustenance of the program, the goal is to ensure that the process is involving all staff members as this is crucial for success of the fall prevention program.
From this assignment, it was discovered that the main problem triggering the many falls in the emergency department, with 10 falls being registered per shift, was because of poor assessment of symptoms that risk patients exposed when they got to the emergency department. The best way to tackle this problem therefore is to improve assessment, which would be done through introducing a mandatory chart with questions that each patient entering the emergency department would be asked. The staff members would be forced to use these charts to help them assess patient better as opposed to taking shortcuts. With the support of the leaders and proper implementation of the changes, some improvement was realized. This leads to the continued use of the suggestions until that point when recommendations for change will come up. Regardless of whatever fall prevention program is adopted, this approach of assessment appears to be the best solution although it is not full proof since falls are emergencies and accidents that are sometimes impossible to control no matter how cautious one is. Therefore, reduction of the falls is considered a major advancement.
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