Problem

Preventing and reducing patient falls and injuries from falls is a major goal in healthcare.1Patients who are hospitalised and receiving treatment for cancer are often at greater risk for falls due to such factors as age, diagnosis, treatment side effects, pharmacological side effects and cognitive and/or motor deficits. Registered nurses (RNs) are expected to assess, plan, intervene and evaluate evidence-based care for patients; however, patients and families need to be included in the treatment plan including safety interventions. The purpose of this quality improvement project was to determine whether engaging patients and families in a partnership agreement as part of a comprehensive fall prevention programme on admission would reduce falls and falls with injuries on an inpatient medical oncology unit. A medical oncology unit was targeted for this initiative due to a prolonged length of stay. Because of an extended length of stay, medical oncology patients may demonstrate functional decline and in many situations suffer a fall. These patients often are not aware of these functional limitations and then sustain a fall. Hospitalised patients with cancer regardless of age are more likely to have injuries after a fall. The patient with cancer is particularly at risk for an injury sustained as a result of a fall because of their medical condition related to coagulopathies and bone-related issues. These conditions can include fractures due to bone metastases, osteoporosis or bone loss, hypercalcaemia, uncontrollable bleeding from thrombocytopenia or non-prophylactic anticoagulation therapies.2

Background

Approximately 700 000–1 000 000 patients fall in hospitals each year.3 Falls are second only to medication errors as the most common adverse event occurring in acute care hospitals each year and are the leading cause of injury-related death in adults over the age of 65. In 2013, the total cost of fall injuries was 34 billion (78% paid by Medicare) and the total cost may reach 67.7 billion by 2020.4 For the fall occurring in an inpatient setting, the hospitalisation may be prolonged, with a resulting increase in care costs and potential discharge to a rehabilitation setting instead of home.5 It has been estimated that up to 11 000 inpatient falls result in death each year.6 As a result of the prevalence of this problem, falls and falls with injury were identified by Centers for Medicare and Medicaid Services7 as a hospital-acquired condition and are not available for additional reimbursement if injuries occurred during hospitalisation. According to the Centers for Disease Control (CDC),4 one in three older adults fall each year. Although older adults are at an increased risk for falls, those with a cancer diagnosis are even more likely to experience falls and related injuries. Several studies have documented that acute care patients with cancer sustain more injuries and fall more frequently.8–10 About 20% of patients aged 65 or older with newly diagnosed cancers report a fall at home within the first six months of their cancer diagnosis.11 As a National Cancer Institute (NCI)-designated comprehensive cancer institute, it was acknowledged that oncology patients are more vulnerable to falls and injuries sustained during falls. This project took place in an NCI Comprehensive Cancer Center with Magnet Designation, located in the southeastern USA on the Florida Gulf Coast, providing inpatient and outpatient care to the adult oncology patient. There are 204 designated inpatient beds with an average daily census of 160 with 5800 patient-days per month. Twenty-seven ambulatory units provide 250 000 clinic visits yearly. There are approximately 9500 surgical procedures annually. The pilot medical oncology unit provides chemotherapeutic interventions, manages oncological treatment consequences and delivers cancer progression care. The project unit has 23 private rooms and direct care is provided in a pod arrangement with two RNs and one unlicensed oncology technician in each pod. In the quarter prior to the start of the project, 31% of house-wide inpatient falls occurred in patients that were identified as low to moderate risk for fall. Initially only patients at high risk for fall were completing a signed Fall Prevention Agreement. In order to target all patients at risk for fall, patients from low to high risk are now required to sign the Fall Prevention Agreement on admission.

Baseline measurement

All patient falls require an institutional safety report. The safety report captures each individual fall, circumstances surrounding the fall and injuries sustained as a result of the fall. All falls and injuries with falls are entered into the National Database of Nursing Quality Indicators (NDNQI)12 monthly. NDNQI reports back the fall and injury rates which are calculated per 1000 patient-days on a quarterly basis. Institutional reporting calculates the fall and injury rate on a monthly basis (see figure 1). Every two weeks falls are discussed in a formal team meeting which involves nurses at every level, from direct care to senior nursing leadership. These interprofessional team meetings include the chief nursing officer, nursing and rehab services directors, patient care managers, staff RNs, oncology technicians, physical therapists, safe patient handling, clinical nurse specialists and quality staff. Essentially, this team meeting is designed to discuss the root cause of each fall and determine how it can be prevented in the future. Anecdotal patient data are obtained regarding patient impulsiveness, as well as completion of a fall prevention agreement. These anecdotal data are the premise of attempting to improve a shared decision to participate in safety strategies, thereby decreasing patient falls and related injuries (see online supplementary material).

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Figure 1

Medical Oncology fall and injury rates.

Design

The Fall Prevention Agreement was developed by the Patient Education Team consisting of master’s degree prepared RNs. The agreement was evaluated for readability and literacy level at the fifth grade level. The current fall protocol was maintained with interventions indicated by patient risk assessment. The Fall Risk and Prevention Agreement Partnership for Patient Safety was signed by patients and/or families acknowledging their understanding and reception of fall prevention education.13 Change of risk level was communicated to patients and families on the agreement. The signed agreement demonstrated the full partnership in safety for the patient and their family. The agreement was not part of the chart and was placed on the whiteboard in each patient room. In addition, the agreement was translated into Spanish by a hospital-approved translation service to meet the diverse population of patients with cancer. Other information highlighted on the whiteboard includes provider information, daily goals and names of healthcare team members.

Strategy

Lessons and limitations

A robust fall prevention standard does not ensure care team participation in all elements to reduce fall occurrence. Historically the Fall Risk and Prevention Agreement had not been initiated on admission. Many times completion of the agreement followed an actual fall. Internal data revealed that the medical oncology patient in many cases on admission was identified as ‘moderate’ risk for fall. During the course of treatment and an extended length of stay, deconditioning and treatment side effects resulted in a fall. This patient population often overestimates their abilities and functional status. Engagement with patients and families during the admission process communicated the need for a collaborative effort for fall prevention during the patient’s hospitalisation. Although this project was limited in data, integrating patients and families into care planning may have had a slight impact in reducing falls and a significant reduction in falls with associated injury. Additional studies including a multivariate analysis are needed to determine whether supporting evidence links fall and injury reduction to the presence of a patient and family agreement.