Issue/Problem of Interest
Falls are the second most common adverse event within health care institutions following medication errors, and an estimated 30% of hospital-based falls result in serious injury. The severity of this problem led the Joint Commission to make reducing the risk of patient injuries from falls a national patient safety goal for hospitals in 2009 (AHRQ, 2006). Falls are a leading cause of hospital-acquired injury and frequently prolong and complicate hospital stays and result in poor quality of life, increased costs, and unanticipated admissions to long-term care facilities. Changes in health care financing in the 1990s were accompanied by a variety of cost-cutting measures in hospitals across the United States. Common cost-cutting strategies included reducing the total number of nursing hours per patient day and reducing the percentage of hours supplied by registered nurses (RNs), the most highly paid group.
The reduction in staffing led to widespread concern that patient care in acute care settings would suffer. In response to concerns about staffing and quality of care, the American Nurses Association (ANA) launched the Patient Safety and Nursing Quality Initiatives in 1994 to address the impact of health care restructuring on patient care and nursing. To facilitate the initiative, ANA established the National Database of Nursing Quality Indicators (NDNQI) in 1997, with two goals: (1) to develop a database that would support empirical monitoring of the impact of nurse staffing on patient safety and quality of care across the nation, and (2) to provide individual hospitals with a quality improvement tool that includes national comparisons of nurse staffing and patient outcomes with similar hospitals (Hart and Davis, 2010).
Patient falls impact hospitals both financially and in regulatory body status. In 2005, in response to disturbing and widely cited findings by the Institute of Medicine about the prevalence of life-threatening conditions acquired by patients in U.S. hospitals, Congress authorized the Centers for Medicare and Medicaid Services (CMS) to implement payment changes designed to encourage the prevention of such conditions. Under an amendment to the Social Security Act that was enacted on January 1, 2007, the secretary of Health and Human Services was required to identify at least two hospital-acquired conditions by October 1, 2007, that were high-cost, high-volume, or both; that resulted in the assignment of a case to a higher-paying diagnosis-related group (DRG) when they were present as a secondary diagnosis; and that could reasonably be prevented through the application of evidence-based guidelines (New England Journal of Medicine, 2009).
The CMS worked collaboratively with the Centers for Disease Control and Prevention (CDC) and on October 1, 2008, enacted new payment provisions: Medicare will no longer reimburse hospitals for a higher-paying DRG when one of eight selected hospital-acquired conditions develops during the hospital stay. The CMS heralded this move as an effort to align financial incentives with the quality of care, thereby promoting both quality and efficiency. Hospital falls and trauma were included as one of the eight conditions that, the CMS argues, “should not occur after admission to the hospital.” Three to 20% of inpatients fall at least once during their hospital stay; these falls result in injuries, increased lengths of stay, malpractice lawsuits, and more than $4,000 in excess charges per hospitalization. Thus, hospital falls represent a major patient-safety problem and may complicate a patient’s care and treatment (New England Journal of Medicine, 2009). Target Population
The target population chosen consists of patients admitted to the medical and surgical floors at two large teaching hospitals. The first hospital is a 1,000 bed not-for-profit teaching hospital located in Dallas, Texas with an average daily census of 917. This organization consists of 12 medical and surgical floors with a total bed capacity of 428. Each floor consists of the nurse manager, registered nurses, certified nursing assistants, and unit secretaries. Patients most frequently cared for on the medical floors at this facility consist of those suffering from exacerbation of chronic obstructive pulmonary disease (COPD), pneumonia, diabetes mellitus (DM), cerebral vascular accident (CVA), and sepsis. Patients most frequently cared for on the surgical floors consist of those healing from orthopedic injury and/or surgery, gastric bypass surgery, abdominal explorative surgery, neurovascular surgery, post kidney and liver transplant patients, and those patients recovering from gynecological operations.
The population of patients being cared for at this hospital comprise mostly of patients 55 years and older. Of the 428 patients being cared for on a daily basis at this organization, 15% of these patients require total assistance, 25% require extensive assistance, and 50% require limited assistance. The second hospital system, NorthShore University HealthSystem (NSUHS), is a comprehensive, fully integrated, not-for-profit health care system that serves the greater North Shore and Northern Illinois communities. NSUHS includes four hospitals with 795 configured beds with a total of medical/surgical configured beds at 495. The average medical and surgical daily census is 103.9. The medical/surgical occupancy is 62% of staffed beds on 19 units. Each unit consists of a clinical nurse manager, registered nurses, patient care technicians, and unit concierges.
The top medical DRG’s include congestive heart failure (CHF), pneumonia, respiratory, acute myocardial infarction (AMI), and CVA. The top surgical admissions include orthopedic joint replacement, general surgery, and spinal surgery. The average age of patients being cared for in this system is 68.5 years. Of the 495 patients being cared for on the medical and surgical units, at least 50% require total assistance and 50% require limited assistance. Significance
Patient falls in the hospital setting are common and may lead to negative outcomes such as injuries, prolonged hospitalization, and legal responsibility. Falls can also have serious effects on a person’s ability to function as a productive member of their family, community, or society. These occurrences have long been documented as a significant, and potentially avoidable, type of undesirable patient event (Steven, 2004). Patient falls are the second most common cause of harm in hospitals and are the leading category of reported incidents in hospitals affecting approximately three to 20% of patients during their hospitalization (Sutton &ump; Wallace, 2005). The frequency of patient falls, as recorded in the literature, ranges from 25% to 89% of all hospital adverse incidents, depending on the patient population studied (Hitcho, 2004).
The rates vary from 1.9 up to 18.4 falls per 1,000 patient days depending on organization type, and according to a study by the National Council on Aging, 30% of these incidences result in serious injury (Stevens, 2004). Another significant consequence of falls is that they are expensive and contribute to the increasing health care expenditure. An estimate of the average DRG payment for injuries sustained by a patient falling is $25, 643 (Hart, Chen, Rashidee, and Sanjaya, 2009). This is significant in that with the developing atmosphere of pay-for-performance, initiated by CMS, hospitals now have a major monetary stake in reducing the number of fall-related injuries. The CDC estimates that the cost of fall injuries will exceed $23 billion within the next few years (Tzeng, 2008).