Case Study: Centura Penrose Sustained Fall Reduction in ED-Sustainable Reduction of Inpatient Falls in the Emergency Department

Sustainable Reduction of Inpatient Falls in the Emergency Department

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This case study focuses on the implementation of a quality improvement initiative to reduce inpatient falls in the emergency department of Penrose Hospital. Inpatient falls are preventable "never events" and are associated with increased morbidity, mortality, prolonged length of stay, and excess costs. The emergency department is a high-risk setting for falls due to the unpredictable and chaotic nature of the environment, as well as hazards such as slippery floors and prolonged use of narrow stretchers.<br /><br />The hospital conducted a root cause analysis to identify areas for improvement, including enhancing patient safety while on stretchers and increasing staff education on falls risk assessment and interventions. A literature review was conducted to identify evidence-based guidelines for fall prevention. The fall risk assessment tool was changed, and risk-stratified interventions were developed based on the assessment. This included the use of a stretcher alarm for high falls risk patients and the implementation of load cell technology for confused or disoriented patients.<br /><br />Staff education on fall risk assessment and prevention interventions was provided, and re-education was conducted periodically. Patient education on fall prevention interventions was also conducted, with compliance monitored through occasional rounds and counseling for non-adherence.<br /><br />The implementation of these interventions resulted in a 65% reduction in stretcher-related falls. The estimated cost savings per injury-related fall ranged from $12,171 to $35,000.<br /><br />The success of this initiative is attributed to a combination of caregiver and patient education, as well as the utilization of updated technology. These evidence-based interventions have enhanced the patient safety culture in the emergency department.

Keywords

quality improvement

inpatient falls

emergency department

Penrose Hospital

patient safety

root cause analysis

fall prevention

risk assessment

staff education

technology implementation