|Tags:||Health care, Safety, Workplace|
|Date published:||12 Sep 2018|
The objective of the project is to suggest and test an improvement that can be made to enhance the quality of care and safety of the elderly inpatients aged 65 years and above. Since quality and patient safety are prerequisite practices in nursing, the project aims to achieve positive outcomes by directing the practitioners on how to carry out their practice while dealing with the elderly patients in medical wards. A time frame of one year will apply to achieve the outcomes. Therefore, the project will be educative in nature by ensuring that the practitioners implement the desired evidence-based practice in the prevention of patient fall among the elderly inpatients.
The location of the proposed project will be in a hospital setting, within the medical ward. The setting hosts different patients presenting various ailments, and specifically the elderly inpatients. The project will impact positively on the management of the elderly inpatients within the hospital setting in regards to falls prevention. Therefore, the quality and safety performance will also be enhanced in the hospital setting, learning will occur, and patient safety will be promoted to greater extents. If successful, the intervention will be confirmed to be a functional approach that the nursing practitioners would apply at the workplace to ensure that the safety of their patients is guaranteed.
Background & Literature Review
A fall is defined as an unexpected descent from a supine position, standing, or sitting position (Graham 2012). Falls are tragic in health care settings as evidenced by the large numbers of harm they impact on the affected patients. According to Graham (2012), falls are ranked second in the list of events that account for patient harm. They affect 2% to 17% of all patients in the course of their stay in the hospital (Hicks 2015). Trepanier and Hilsenbeck (2014) also supports the above argument by stating that most of the harm within a hospital setting result from patient falls. These arguments indicate that patient falls a critical issue compromising patient safety and quality of care. It is also stated that falls are the leading causes of injury-related deaths among older adults. The Centers for Disease Control and Prevention (CDC) (2012)reports that at least 20% of the people who fall face a broad range of injuries classified as moderate or severe. Such injuries can impact the independence of living as stated by (Graham 2012). In most occasions, the people that fall develop a phobia towards falling even if there were no injuries sustained in the past falls. The disadvantage of the fear is that it can lead to inactivity of these patients that potentially causes their immobility and a reduction of physical activities, which in turn place the patient in danger of falling.
In studying patient falls, presenting the statistics is also essential because it helps to contextualize the issue, determine its prevalence, and quantify the overall impacts of the issue on the health systems. Statistics by Centers for Disease Control and Prevention (CDC) (2012) show that fall injuries in the people aged 65 years and above exceeded $19 billion in 2000, and its cost is expected to increase to $54 in 2020. There are reasons for the higher costs after a fall. For instance, after falling, there is greater use of health care resources and also as a result of increased hospital stay (Graham 2012). For example, in Goldsack, Cunningham, and Mascioli (2014), it was estimated that the cost hospitalization increased by $4, 200 in patients that sustained a fall as compared to those who did not maintain a fall. Hence, it implies that falls should be prevented to avoid such instances where the cost of treatment is increased, which also translates to overburdening the patient.
Standards of Care
Patient falls an issue of care and patient safety. Nurses are liable for patient safety within the hospital setting. They are also tasked with the identification of the patients at risk of sustaining injuries though falls (Hicks 2015, p. 51). Patient falls are classified as a quality indicator, and nurses should be committed to improving the care through nurse-led strategies. Falls are classified as nursing-related indicators of quality because they are related to the quality of care that a nurse offers in acute care (Quigley & White 2013). Therefore, nurses should lead from the front as the people responsible for taking care of the patients. Since falls are hospital-acquired conditions, proper plans should be set up and implemented to identify the patients that are at risk of falling, and then evidence-based practices of fall prevention applied. Ultimately, there is intuition in postulating that falls prevention is an area of interest in nursing since it is related to the quality of care and patient outcomes in the hospital setting (Hicks 2015). However, the nursing practitioners require guidelines that can help them apply the desired evidence-based interventions in fall prevention.
There are numerous interventions that nurses can apply in fall prevention. However, concentrating on rounding can lead to positive outcomes in falls prevention among the elderly inpatients. Rounding is defined as the process through which a nurse intentionally checks on patients at regular intervals for the purpose of meeting their needs(Hutchings, Ward & Bloodworth 2013). In this approach, nurses visit patients hourly on intention purposes but not to respond to an emergency call (Forde-Johnston 2014). Hourly rounding is also important in checking the position of the patients, assessing pain, and promoting patient comfort. Evidence shows that 50% of the total falls in an institution can be effectively avoided if nurses apply hourly rounding approaches of falls prevention (Hicks 2015). The tenets of hourly rounding include anxiety reduction, covering the four Ps (position, pain, potty, possessions), environment assessment, and informing the patients about the time of return of the staff (Hicks 2015). However, the main question is whether hourly rounding is the best approach, among all interventions, that can lower patient falls in a hospital setting.
The routine rounding intervention has also been covered by Tzeng and Chang-Yi (2012) by stating that it is a corrective approach centered on reducing the risks of patient falls in the hospital while seeking toileting services. The key issue in this study is that increment in the frequency of rounds by nurses around the times of vulnerability to falling has the potency to reduce risks of falls among the patients. Continued education on routine rounding will also equip the nurses and families with adequate knowledge regarding the practice. Round checks should be performed by all staff. Aides should also be requested to maintain the checks at night whenever a patient has the desire to leave the bed in the absence of the nurse to curb the adverse event. This is part of the hospital policy that nurses should attend in-services to improve their competencies in the area. By applying this policy in their study, Tucker et al. (2012) discovered that the number of falls dropped from 9 to 2 falls in the first month of implementing the rounding intervention in the hospital. Another supporter of this evidence is the study by Olrich, Kalman, and Nigolian (2012), which found that hourly rounding decreased anxiety among the patients, and their reliance on the call system was decreased. Another suggestion by the study is that nursing assistants should be placed on each shift to help the nurses on shift to make hourly rounds. Forde-Johnston (2014) posits that nurses and their assistants are responsible for making hourly rounds and taking care of the patients’ needs. Therefore, as a result, positive clinical outcomes are achievable through the application of hourly rounding by the people assigned to carry out the task.
The approach of routine rounding or hourly rounding has been in use for decades to promote, among other factors, a reduction in the rate of patient falls. Research has shown that hourly rounding is an appropriate evidence-based practice that has indicated positive outcomes in the prevention of falls in the hospital settings (Forde-Johnston 2014; Hicks 2015). Among the rest of the interventions, it is only the hourly rounding that makes a nurse attend to a patient on an hourly basis to check issues such as pain management and comfort the patient. Other matters such as toileting are addressed in the hourly rounding. However, the implication is that hourly rounding falls prevention tasks in a manner that enhances patient safety and quality of care. Ultimately, when addressed from another perspective, hourly rounding should be part of the hospital policy whereby nurses are subjected to in-service training, taught about the practice, and encouraged to apply it in their daily routine. The practice should be replicated in every other setting that intends to lower the intensity and expenses of injuries sustained by the elderly patients due to falls.
The specific intervention selected for the improvement of patient safety and quality of care is to make at least two rounds every hour within the medical wards occupied by the elderly inpatients aged at least 65 years. The rounds should be as frequent as possible. It is recommended that the people tasked with patient care should make as many rounds as possible within the same hour. Most of the previous evidence indicate that hourly rounds have the potential to reduce instances of patient falls (Forde-Johnston 2014; Hicks 2015; Hutchings, Ward & Bloodworth 2013; Olrich, Kalman & Nigolian 2012; Tzeng & Chang-Yi 2012). The triangulation of evidence from the above studies means that rounding is a widely acclaimed evidence-based practice that can be recommended for the improvement of patient safety in hospitals. Since the project mainly covers the older adults aged 65 years and above, it implies that the rounding should be made in the wards where the older adults are admitted. Also, the same can be replicated in the residential aged-care homes. Apart from the nursing professionals, any other hospital worker can be trained on what to do to prevent patient falls.
The study by Tucker et al. (2012) shows specifically that rounding can potentially reduce the number of patient falls experienced in the hospital. The study justifies the proposed improvement, and there is evidence that it can be applied to improve the safety of the elderly patients. It is evident that rounding is conducted in every clinical setting, but it is timed. The main purpose of rounding is to assess pain, to give medication, toileting, or when an emergency bell is pressed. However, the rounding that is proposed in this case is different because it is not meant to fulfill the above actions. The proposed rounding is to be done anytime and as frequent as possible during the day and at night. The rounding should be done by nurses and other aid workers in the hospital to check the positions of the patients on their beds or in any elevated position. If the adjustments are conducted as soon as possible, then the cases of falls will be decreased. By doing so, it is expected that the injuries sustained by the elderly patients through falls will be reduced, the cost of treatment will be shelved, and the length of hospital stay will also be minimized.
The implementation plan will adhere to the guidelines provided by Australian Commission on Safety and Quality in Healthcare (ACSQH) (2009). The plan is an implementation guide that can be used both in hospitals and residential aged care facilities. The implementation plan will apply both informed decision-making and trial and learning. However, before the implementation of the proposed improvement, it should be noted that it will not be easier to address the fall prevention program in its entirety. Priority areas should be granted greater attention.
The following are the proposed guidelines in the methodology.
Use of reminders
Reminders that are peculiar to the patient are to be utilized in the hospital setting. The reminders will be broadcast on paper, verbally, or through computer screens (Australian Commission on Safety and Quality in Healthcare (ACSQH) 2009). These reminders will be presented publicly and in areas that are easily accessible. The main purpose of setting up the reminders is to prompt health professionals to recall information. Specifically, the reminders will address specific patients to enhance the accuracy of rounding and also to focus on an individual patient based on his or her needs.
In this approach, the elderly patients are encouraged to influence service providers (Australian Commission on Safety and Quality in Healthcare (ACSQH) 2009). The providers will take note of the specific patients, record their needs and risks of falling, and then monitor them closely to prevent instances of falls.
A hospital setting is composed of different professionals that collaborate in taking care of the patients. In this case, it is proposed that the trained professionals should meet the targeted service providers in their settings and demonstrate the intervention changes to them (Australian Commission on Safety and Quality in Healthcare (ACSQH) 2009). The targeted service providers will be enlightened on the relevance of making the routine rounds, how to make the rounds, and why they should make the rounds as frequent as possible.
Educational materials will be distributed to the targeted service providers. The materials include electronic, audio-visual, and printed information (Australian Commission on Safety and Quality in Healthcare (ACSQH) 2009). The information is directive and offers instructions on what should be done on a step by step basis. The information is meant to enhance the performance of the service providers by promoting evidence-based practice.
The progress will be audited and feedback provided. It is proposed that summaries of clinical performance over a given period should be provided. This approach will help to increase the awareness of the target group regarding their own practice, and the practice of the other service providers (Australian Commission on Safety and Quality in Healthcare (ACSQH) 2009). Learning from trials will also be determined in this step. The practitioners will receive feedback information on what has been achieved and what is required for continuous spread of the implementation of the practice. They will be capable to determine what worked, what did not work, what should be changed, and what should be maintained. This is a technique aimed at improving the areas of weaknesses and maintaining the areas of strengths.
The project will entail the participation of human subjects, which implies that the whole process should be ethical. In this case, the participants will be briefed about the objectives of the study. They will be informed of any risks likely to be encountered during the project. Additionally, the researcher will seek consent from the participants before subjecting them to the project processes. The participants will be requested to sign informed consent forms before proceeding (Cresswell & Plano Clark 2011). Regarding the survey approach, the respondents will not be coerced to provide personal information that is deemed confidential. Therefore, confidentiality and anonymity will be upheld, and the data will not be accessed by third parties. The results will only be used for the purpose of the project.
Techniques to assess project outcomes
After the implementation of the recommendations based on the above methodology, the progress of the proposed improvement will be evaluated to determine its feasibility, and whether it is achieving the intended goals. The assessment plan will start immediately after launching the implementation of the proposed intervention. Before assessment of the outcomes of the intervention, the process will be assessed first using the following indicators.
- The proportion of the staff trained in the intervention of falls prevention.
- The percentage of the patients assessed as being at risk.
- The percentage of employees and patients that are satisfied with the intervention program.
- The applicability of the injury and falls prevention intervention
Several tools will be used to assess the outcomes of the proposed intervention. It is advisable to use the already existing tools rather than developing new tools. In most cases, the most fundamental assessment tools to measure the progress of the program include observation, survey, and focus groups (Australian Commission on Safety and Quality in Healthcare (ACSQH) 2009). The three techniques have been in existence for long and have been used by various researchers. The proposed project will consider the use of survey and observation techniques for assessment purposes.
The survey methodology has been used in numerous health care studies involving a large number of participants. In the study by Hasson et al. (2014), the authors used the survey methodology to evaluate the outcome of the proposed intervention on organizational changes. Risk assessment of the speech in the study was also achieved by using the inquiry approach. The survey approach is appropriate when a broad cross-section of participants is involved. For instance, in Hasson et al. (2014), a total of 1472 respondents participated in the study; therefore, the use of survey approach was appropriate for this type of sample because it is reliable in the collection and analysis of huge amounts of data. In the proposed study, the survey will be used to collect responses from the participants regarding the applicability of the monitoring intervention of falls prevention. To enhance the quality of data, the researcher will test the questionnaire items for reliability. A preliminary sample of the questionnaire will be presented to a set of individuals for testing purposes. Afterward, the items will be edited following the recommendations of the initial sample before being presented to the study sample.
The observation technique will also be appropriate for this study to assess the changes made in fall prevention. In the proposed study, the nursing staff and allied health workers will be observed after undergoing orientation training on routine rounding. Approximately 1000 observations will be made in the course of the project. A checklist will be used to record the observations. For instance, every routine rounding will be recorded on the checklist using a tick. Observations will be made 12 hours each day until the end of the 1000th view. The technique has been previously employed by Chavali, Menon, and Shukla (2014) to observe the hand hygiene compliance among healthcare workers in a tertiary care hospital setting. To improve the quality of data collected, the observers will undergo training on correct rounding techniques. A preliminary observation will also be conducted on another healthcare environment issue and the results compared. Therefore, with the application of the preliminary remark, inter-observer variation will be reduced, and the uniformity of data collection guaranteed Chavali, Menon, and Shukla (2014). Ultimately, the results will be expected to suit the needs of the project.
The application of the proposed intervention has been supported by the previous studies, which implies that it can be used as an evidence-based practice in the clinical settings. As stated in the earlier studies, patient falls an issue of care and patient safety in health care facilities (Hicks 2015). Therefore, the problem can only be solved through nurse-led strategies. Nurses should maintain their functionality in enabling the implementation of the routine rounding intervention to reduce patient falls. The proposed intervention is aimed at improving the quality of care through full participation of the nursing practitioners as stated by (Quigley & White 2013). Regarding routine rounding, Hutchings, Ward, and Bloodworth (2013) appropriately intentional checks should be conducted to confirm the safety of the elderly patients. Another study that supports the proposed intervention is Tzeng and Chang-Yi (2012), which states that routine rounding is a corrective approach to preventing falls.
The implementation of the project is likely to encounter a series of challenges. The first challenge entails data collection in the clinical setting. For example, observation might be termed invasive by some participants especially when applied in the hospital setting. Some patients may also feel unsafe in the presence of the observer. Moreover, there are high chances of missing to record some of the critical observations. Another methodological constraint is that the participants might be conditioned to adhere to the routine only because they are being observed but later change the approach. Also, the survey approach requires adequate time for the staff to complete. Time constraints might affect data collection using the inquiry approach.
The intervention itself presents several contextual implications. There might not be enough staff to constantly make rounds while at the same time attending to the other patients. This intervention requires the availability of an adequate number of the staff to achieve the desired outcomes. Additionally, change is usually resisted, and hence some of the nurses might be unwilling to participate fully. Further study is required to determine the attitudes of nursing practitioners on the change of clinical practices.
Conclusion and recommendation
The aim of the project is to determine whether routine rounding reduces the rate of falls among the elderly inpatients. The project is expected to offer a solution to the increasing trends in patient falls. The potential finding from the previous studies is that routine rounding potentially decreases the cases of patient falls. The proposed intervention is expected to promote the quality of care and patient safety in the selected hospital setting. The future study should implement other fall prevention interventions apart from routine rounding. Focus group technique is recommended as a methodology in the future studies. Ultimately, the nursing practice is expected to be enhanced as regards patient safety.