Background Unlike inpatient units, Falls in our Emergency Department have not been reported to the National Database of Nursing Quality Indicators (NDNQI) nor benchmarked against other like Emergency Departments nationally. Unintentional falls are the leading cause of injury and the second most common cause of unintentional injury deaths in the United States, and place a great burden on Emergency Departments (1). Creating an internal dashboard to track Falls in the Emergency Department (ED) will allow our institution to analyze data implement strategies to continue our work to decrease Falls. This dashboard will also allow us to compare data with other Level 1 Trauma Emergency Departments who implement quality improvement Falls projects.

Design & Implementation A Lean Six Sigma methodology was implemented:

Mission Statement Utilize a standardized comprehensive Falls Toolkit to reduce variation while systematically reducing the incidence of Falls in the Emergency Department.

Falls Dashboard NDNQI categorizes Falls with injury:

None—patient had no injuries (no signs or symptoms) resulting from the fall; if an x-ray, CT scan or other post fall evaluation results in a finding of no injury Minor—resulted in application of a dressing, ice, cleaning of a wound, limb elevation, topical medication, pain, bruise or abrasion Moderate—resulted in suturing, application of steri-strips/skin glue, splinting, or muscle/joint strain Major—resulted in surgery, casting, traction, required consultation for neurological (basilar skull fracture, small subdural hematoma) or internal injury (rib fracture, small liver laceration) or patients with coagulopathy who receive blood products as a result of a fall Death—the patient died as a result of injuries sustained from the fall (not from physiologic events causing the fall)

Decreasing Falls in an Emergency Department using a Lean Toolkit

Jan Shepard RN, MSN, CCRN-K; Yvonne Hansen RN, MS, CCRN, CEN; Marsha K Hoeft RN, BSN, CEN;

Florentino Martinez RN, MSN, CEN, Jennifer Mattice, MS, RN, CEN;

William O’Neil RN, MSN, CCRN, CEN; Keith Taggatz RN, BSN

References 1. Mather, L. J., & Weiss, H. B. (2008). Incidence and Characteristics of

Fall‐related Emergency Department Visits. Retrieved from

https://doi.org/10.1111/j.1553-2712.1998.tb02663.x|2.

2. NDNQI Definition of a Fall. (2012). Retrieved 8/14/2019, from https://www.qualityhealthnd.org/wp-content/.../Nursing-Metrics-2012.docx

A standardized Root Cause Analysis (RCA) process was initiated using an A3 template

The first Pareto Chart identified the Behavior Health and patients who had a syncopal episode as the top two categories for Falls in the ED.

A secondary Pareto Chart using those two patient populations identified that Falls occurred more frequently with toileting and when a patient was agitated. The department implemented wheelchairs and walkers in all patient care areas and the hospital required every staff member to complete a safe patient handling class.

Results The initial downward trend with Falls in the ED shows favorable results using the newly implemented Falls Toolkit. Further work will be required to achieve a goal of 0.45 Falls per 1000 patients triaged (1) which compares to other like institutions. The slight upward trend for Quarters 1 and 2 of 2019 may be reflective of the increased number of behavioral health patients boarded in our ED.

Next Steps • Benchmark our Falls data to the NDNQI database • Review ongoing Falls data to identify key areas for reduction

efforts • Complete a literature review to identify best practices used

by other like institutions • Evaluate feasibility of Q15 minute rounding protocol for all

high-risk Falls patients • Evaluate feasibility of bed alarm utilization in the Emergency

Department • Empower the bedside nurse to utilize the available

equipment in the ED to support safe patient handling and support Falls reduction efforts

• Just-in-time coaching to reinforce Falls prevention workflows