A day spent at a local nursing workshop or continuing education day for nurses is arguably the best way for librarians and writers to get up to speed on issues that directly affect the medical outcomes of our readers and family members.
The modern nursing combination of practicality with evidence-based science, gets us to a story we can understand and apply in about an hour, the time most of the talks take up (and that hour includes the questions & answers session after the formal presentation.)
This genre and setting represents a remarkable exercise of efficiency in information delivery, not only for the intended audience of nurses, but with a reasonable probability that college educated lay listeners can learn something that they can make sense of for themselves, and tell others about with some coherence.
This proved to be particularly true with the 18th Annual Nursing Excellence in Leadership & Evidence-Based Practice Conference of the local branch (the Pi Theta Chapter) of Sigma Theta Tau International, the multinational honors society for nursing, held at the University of Arkansas at Fayetteville, on April 6, 2009.
A presentation from Evelyn Galibao, RN, BSN, and Sally Deakins, RN, BSN, of the local VA Center, entitled “Becoming Engaged in Reducing Patient Falls” was a particularly good case in point.
They discussed the formation and effects of a patient fall reduction program in the population of veterans served at their hospital.
As with most healthcare facilities, falls are common, and often extend hospital stays for patients with initial presenting complaints other than falling, far beyond what they should be.
And in many older patients, falls that happen in a hospital, if severe enough, are very much like severe falls at home, or falls when walking out of doors. They have a tendency to trigger a cascade of collateral health issues that quite literally can hastens death.
Galibao & Deakins were particularly interesting for the new insights provided on a number of different issues that are less well understood, even in medicine and nursing, because their regional patient population offered more opportunities for learning about less studied subpopulations:
· While the study did not exclude women (by far the gender most studied in the medical literature in relation to falls), or outpatients, it dealt primarily with male inpatients.
· While the majority of patients were older (by far the majority of studies in the medical literature focus on the elderly) this population also included patients in their 20s,30s , 40s, and 50s.
· While not excluding patients with dementia, diabetes-related deterioration in toes and feet, Parkinsonism, stroke, syncope related to irregular heart rhythms, recent knee or hip replacement surgery, poor vision, or clinical depression (all well-explored topics in the medical literature) it also contained patients with a wider variety of ailments including long ago war-related orthopedic trauma, closed head injuries, and chronic or acute substance abuse.
Their presentation developed some working categories of falls for the audience, drawn from prior literature and from their own observations. They classified falls quite sensibly as:
· “Anticipated:” These falls are caused by prior illnesses or injuries that should have been recorded in the patient’s history prior to, or at the time of admission. This category also includes falls resulting from instabilities known to be common side effects of drugs being taken by or administered the patient.
· “Unanticipated:” These falls are caused by underlying medical conditions that had gone undetected or that were not expected to crop up given the normal standard of care in terms of medical or surgical procedure, or pharmacology involved. In a sense, these falls are of themselves essentially diagnostic of something other than the initial diagnosis going on, or the result of idiosyncratic responses to treatment.
· “Accidental.” These falls relate to hazardous conditions like wet floors, loose rugs, hand-railings that give way, collisions with two-way swinging doors, construction or renovation mishaps, etc.
The plan of action outlined for this VA center included the formation of a multidisciplinary fall prevention team. Its members included physical therapists, pharmacists, nurses and the facility’s overall patient safety manger.
This group literally met every day there was a fall, and categorized and analyzed each one, using what was termed a RCA: Root Cause Analysis, leading to a SAC: Safety Assessment Code score, the latter based on how serious was the injury in terms of increased patient hospitalization stays and heightened need for services and procedures, as well as any cost for preventative or reparative work done on the hospital floors or grounds to prevent the accident from happening again.
A “Falls Notebook” guided those on-the-floor nurses who reported the incident in such a way as the reports were not only comparable to one another in what information they contained and how they were formatted, but that the reports also served as an ongoing guideline for the nurses themselves as to what they should be watching out for in terms of potential falls for their other patients on a regular basis.
This team and its evaluative and remedial practices led to a number of changes:
· Use of a fall potential scoring system for patients on admission
· Greater use of “Close Observation “ rooms for those who scored at higher risk for falls.
· A spreading out of the days on which planned admissions occur, since their analyses disclosed that the greatest number of falls occurred among newly arriving patients on days of admission. This was perhaps because the patients were more acutely ill or they were not yet oriented to their surroundings. But ultimately it was determined that admissions-crowded days saw a spike in the numbers of patients in relation to the number of nurses who were available to monitor them. Nursing schedules were also changed to accommodate this admissions bolus factor.
· More frequent and quicker provision of “loaner” canes, crutches, and walkers, to patients who had arrived at the hospital without their usual assistive devices.
· Greater portability of charts and/other patient progress recording technology, so that the nurses could compose their notes while at the bedside instead of having to retreat to the nurses’ station. This increased the amount of time a patient was being observed by someone who could judge their sitting, standing, getting-in-and-out of bed, their gait and general ambulatory competence and confidence.
· A greater focus on what emerged as the specific activity that seemed to pose the greatest risk of falling for men: toileting.
· A stark realization that acute or chronic alcoholism posed one of the greatest risk factors in falls, regardless of activity being undertaken at the time.
· Use of double-sided non-skid socks, a low-cost but very highly effective change, was initiated after the commonsensical observation than many of the men had worn the socks with the non-skid stripes facing up and outward, like an arm badge indicating a sergeant’s rank , rather than down, like a tire tread. Having the non-skid stripes placed on both the intended top and intended bottom meant that no matter what way the men put on their socks, fall-resistant treads would be in contact with the floor.
· Staggering the time of day when discharges occurred, because analyses showed that the incidence of falls was also quite high when too many patients were being sent out into the world at the same time.
· A financially and legally prudent awareness that some in-patients will report rather suspect “falls” (often unobserved) to either lengthen their stay (particularly if they are homeless) or obtain increased dosage of narcotic pain killers (particularly if they are already addicted).
· Heightened awareness of the need to classify some discharged patients as High Risk Veterans, so that more checking in with them by their outpatient caregivers could be initiated, thereby reducing hospital readmissions.
· Print and electronic posting of specific best practices for nurses to prevent falling on a daily basis, and quarterly reviews of progress in formal group sessions.
What was the end result of all this? The hospital reduced its yearly fall-per-bed-day ( a standard unit of measure) by about a quarter, and the severity of falls in terms of increased injuries and illness by about a third.
Not surprisingly, the hospital was cited for “Best Practices’ by the VA’s Inspector General.
Yes, it seems surprising what you can learn from nurses teaching other nurses, even if you’re not a nurse, and even if it’s only an hour.
But it shouldn’t be.
Today, nursing and its nurses get smarter every day, not by doing what what’s always been done, but by continuously learning and applying what systematic scientific studies demonstrate actually works...
And never, ever, being so self-satisfied that they stop helping each other get even better.
Tony Stankus tstankus@uark.edu Life Sciences Librarian & Professor
University of Arkabnsas Libraries MULN 223 East
365 North McIlroy Avenue
Fayetteville AR 72701-4002
Voice: 479-575-4301
Fax: 479-575-4592
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Nice to see someone writing something worth reading. Thanks.
Posted by: Glenn | April 13, 2009 at 10:09 AM