New procedures and constant education reduce patients’ falls, yield better outcomes
By Katherine Adams
There is one totally unique unit that operates within UTMB’s complex hospital system that exists nowhere else in the entire nation—a fully-fledged hospital and maximum-security prison, whose mission is to provide the same standard of care for incarcerated patients as that which exists in the “free world.” Hospital Galveston serves this distinct population of patients with dignity and respect, even as the nursing staff faces multiple challenges that do not occur in any other hospital.
Their success in addressing the specific issue of patients’ falls in the hospital recently earned them a Journey to Zero award, highlighting the department leadership’s strong emphasis on educating nurses and staff on newly implemented processes as the reason behind the decrease in the rate of falls.
Hospital Galveston Nurse Manager Eula Lee, DNP, RN, said the Journey to Zero is a quality initiative committed to delivering high quality, safe health care to all patients, including those in Hospital Galveston.
“We have a unique population because our patients are incarcerated, but we do not call them ‘inmates’ or refer to them as ‘incarcerated,’” she said. “They are patients. But we see a lot of challenges within our population, and because we are the only hospital of our kind in the nation, we have nothing to compare ourselves to. We have developed our own processes to care for our patients to meet the standards of practice as required in UTMB’s Best Care initiative, as well as for Journey to Zero.”
Lee said that their patients’ circumstances were entirely different from those in free-world hospitals.
“Our patients have no control over anything in their lives,” she said. “They don’t choose when they eat, when they go to bed, nor if they can get extra food. The falling issue often arises when they are ready to discharge, and their property is brought to their rooms. At this time, they do not want to return to their unit, and they will fall. That’s why we had to find a workaround to keep that from happening.”
Pain, pumps, potty, peripheral, and position
For the months of April, May, and June, Hospital Galveston had zero to five falls in all 11 units. She said some of the falls that occur are intentional, but many are not.
With those that are not, Lee said there are standards of practice in place to constantly remind the staff as well as the patients about the risk of falling, and regularly review the procedures in place to prevent that occurrence.
“We have a safety system in place, in which nursing staff check on patients on an hourly basis, and that means they open the door, go in, talk to the person, and remind them about the Five Ps—that’s an assessment of pain, pumps, potty, peripheral, and position,” she said. “We consider everyone a fall risk, and we have retrained our nurses to assess patients in this way.”
If nurses get any indication that a patient may fall, Lee continued, they put a sitter in the room with the patient and let the doctor know. “We do have unintentional falls with patients who just want their independence and think they can do something like get up and go to the bathroom, when they are still too weak,” she said. “They’re just people, like anyone else, who want to do things on their own.”
An eye toward Best Care
Hospital Galveston’s Clinical Educator Carmila Steen, MSN, said the improvements that resulted in the decrease in falls were created with an eye toward UTMB’s Best Care initiative, and addressed other protocols that also improved patient care outcomes.
“When we have a new hire, we always go over the Commitment to Best Care initiatives first, as part of the onboarding, and remind nurses that our patients have the same rights as anyone else,” Steen said.
“When nurses draw blood, they say the patient’s name and ensure it matches, and continually assess patients for pain. We have a procedure called Central Line Associated Blood Screen Infection, or CLABSI, in which we make sure patients’ dressings are regularly changed to prevent infections,” she explained. “And the Catheter Associated Urinary Tract Infection (CAUTI) procedure ensures that the Foley device, which helps patients void, is removed correctly so that the patient does not get a urinary infection.”
Steen added that with over 250 blood cultures per month, the staff is regularly educated on how to prevent culture contamination.
“All of those are designated processes and we are educating and training nurses all the time,” Steen said. “Addressing falls has been the highest priority. We need to know when falls are intentional or unintentional, and make sure the doctors are aware.”
Lee said that they designated a quality initiative champion, or primary advocate, for each of the units within Hospital Galveston.
“Those champions watch our quality improvement measures, and report to us quarterly,” she said. “When we see a unit with increasing falls, we meet with managers and staff to notify them. If there are two or three falls, especially with the same person, a task force has been created that includes Carmila and me, as well as other unit leaders, to get to the root cause of those falls, in real time.”
All their efforts and commitment are focused on one thing—providing the best possible health care to patients, with no consideration for the patient’s prior actions.
“They are paying their debt to society, and we are not here to judge,” Lee said. “Everyone is human, and we have all done things we regret. These patients have no options, and their family is not able to come. We are their only advocates when they are sick. Everyone deserves to be treated with dignity and respect.”
Top Best Care Takeaways
- Bright yellow signage that reiterates the messages, “You are a Fall Risk,” and “Call, Don’t Fall!” everywhere, including on the ceiling over beds.
- A call light system, with a light turning green (everything is all right,) yellow (it’s almost time to reassess this patient,) and red (a nurse needs to already be in this room assessing this patient) has helped reduce fall occurrence.
- Do not assume nurses or other staff members are educated in policies and procedures simply because they may have been in the role for a long time. With changes, or with new people onboarding, education is critical and sometimes there is a knowledge gap that must be addressed.
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Hospital Galveston’s Clinical Educator Carmila Steen, in flowered top, and Nurse Manager Eula Lee show signs that warn patients of fall risks in the Texas Department Criminal Justice facility.