The team nominee had an increase of patients falling for 2 months. The team knew they had a problem and needed to fix their care to keep their patients safe. The team with the help of the fall champion identified two main areas of focus. The first area was doing a deep dive into why the falls were happening. The team identified two main buckets of why the falls were occurring. The first bucket was identified as the “cardiac bucket”.

For example, if the patient felt dizzy or was syncopal with ambulation. Being a cardiac unit, cardiac events happen frequently. The second bucket the team identified was their patients were frequently on diuretics, which caused the patients to need to urinate frequently and often urgently. The team practices a No Pass Zone for call bells. That means everyone on the unit despite their assignment has ownership of call bells. During the deep dives, it was identified that there was no way for the entire care team to know that a patient was at risk of falling related to cardiac symptoms or if the patient was receiving diuretics. The team developed a visual aide to help the entire care team on the unit. The goal was to signal the team to be cautious about moving the patient and to consider getting extra help. The team decided to use a red or yellow sign on the patient’s door to their room. The red sign meant this patient was at risk of getting dizzy or was ortho positive. The yellow sign meant this patient was given diuretics and may have urgency when going to the bathroom. This also allowed the staff to tailor intentional rounding and to be proactive and ask the patient if, they need to use the bathroom.

This initiative was extremely beneficial in reducing falls. During the team’s work with identifying high-risk falls patients, they discovered their patients were at risk of being ortho positive. The problem was with the team striving to prevent falls there was a general lack of knowledge of which patients were ortho positive. The team came up with the idea to have an icon to show on the patient green screens in the room to alert everyone on the care team that the patient was ortho positive. The falls champion on the unit took that idea to the organizational fall champion council. They liked the idea and put it in production for the entire organization. Therefore, if the patient is ortho positive, the nurse documents it Epic and an icon shows on the green screen in the room to alert the entire care team that the patient is ortho positive prior to ambulation.

A key piece to the unit’s fall prevention was intentional hourly rounding. The team wanted to leverage this as the best way to prevent falls. Their goal was to be proactive instead of reactive. One way to help measure the effectiveness of their rounding was to use the Press Ganey patient satisfaction surveys. The question the team focused on was “nursing staff checked on you every hour”. The team knew that if they focused on developing a relationship with their patients so they knew they would be checked on every hour it would improve their care, decrease patient falls, and ultimately improve patient satisfaction scores. The team started the fiscal year at 32% of their patient’s perception of “nursing staff checked o you every hour”. For the month of February, the results were 69%! This was a monumental win for the team! All their hard work was paying off. For the fiscal year, the team is at a rate of 46%. The team has also seen a large decrease in the overall patient fall rate and is meeting its goal for the fiscal year.