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Reducing the Incidence of Falls: The Never-ending Journey.

Fall reduction is “near and dear to the hearts of rehabilitation nurses!” Hardly a day goes by that fall prevention is not part of what they do, or their dialog with colleagues, leadership or at team conferences. Rehabilitation nurses and rehabilitation hospitals/units have been focusing on fall reduction in a serious way for the past 15 years, as we first learned just how dangerous hospitals were to patients through the Office of the Inspector General’s report, “To Err Is Human” (Institute of Medicine Committee on Quality of Healthcare in America, 1999). And yet, we continue to struggle with how to make a difference when the focus of acute rehabilitation is to promote independence among our patients. For many bedside nurses, this challenge is complicated by the very nature of what they do every day. Nurses and nursing assistants work as a group, caring for clusters of patients with an expected efficiency that can promote short cuts and sometimes gaps in care. In addition, keeping their patient safe from falls, and the nursing team’s focus on this goal, is only as good as the “weakest link.” It only takes a moment, a delay, and a single gap in care to create the perfect setting for a patient fall. Despite individualized plans of care, what we do gets delivered in bundles, often treating groups of patients using the same strategies, despite the presence of individualized plans of care. In part, this is a product of the expectations around efficiency that may not allow the individualization that a patient may require. So what have we done to make our hospitals or units safer in the last 15 years? We have done a lot. Hospitals have implemented creative solutions arising out of “Root Case Analyses” at the hospital/unit level, combined with some enhanced technology solutions and the engagement of the whole leadership team. Some of the more creative ideas have included a “ceiling tile” over a patient’s bed that reminds them, “Call, don’t Fall.” One hospital has a “Fall Pack” issued to high-risk patients on admission that includes, among other things, slip proof booties that are a MUST for their high-risk patients. Rounding strategies abound, and now we have cell phone technology that communicates with call systems, enhancing the ability of care providers to prioritize and respond more quickly to patients. Unfortunately, the strategies developed around identifying “high-risk patients” have highlighted the fact that most of the patients in rehabilitation are high risk. Research in the area of fall reduction in acute rehabilitation is limited, and often the studies have a small sample population. One study surveyed nurses across many hospital settings to determine their opinion regarding the more important strategies for their setting. For rehabilitation units, three unique strategies were identified: one-to-one support in the bathroom, use of nonslip and well-fitted footwear, and keeping pathways clear and open with equipment properly stored (Tzeng & Yin, 2015). Another study by Hanger, Wills, and Wilkinson (2014) indicated that falls during a rehabilitation stay actually may indicate better functioning at the time of the fall and better outcomes at discharge, specifically for patients whose fall was categorized as “I’m giving it a go.” In acute care hospitals, the focus on “zero events” has resulted in strategies that often “bubble-wrap” a patient to assure that a fall cannot occur, although the strategy itself is counterproductive to the patient being discharged to a more independent setting. In some ways, it “pushes off” the risk to fall to the next level of care. In rehabilitation hospitals/units when the fall rate is very low, it does beg the question of whether the focus on fall reduction may be undermining the patient’s opportunity to achieve higher levels of independence during their rehabilitation stay before going home. One of the more recent developments that may directly influence the acute rehabilitation level of care has begun with an initiative by the Center for Quality and Excellence, a companion organization of The Joint Commission. The agency has invited a network of acute rehabilitation hospitals to “partner” with them in tackling the issue of fall reduction in the acute rehabilitation setting. Select Medical operates a network of 17 rehabilitation hospitals across the country, with more than 1,200 acute rehabilitation beds, many with prestigious joint Joan P. Alverzo, PhD, CRRN