Date of Degree
Fall 2024
Document Type
DNP Scholarly Project
Academic Department
School of Nursing
Degree Type
Doctoral
Degree Name
Doctor of Nursing Practice
First Advisor
Dr. Brandee Temmis
Second Advisor
Dr. Melanie Brewer
Third Advisor
Dr. Corrine Cochran
Abstract
Problem: Fall-related events are a significant source of harm, with more than 700,000 patients falling every year in U.S. hospitals. The project was implemented in a 41-bed acute inpatient adult behavioral health unit (BHU). Over the last eight quarters, the BHU experienced an average of 3.16 falls per 1,000 days, exceeding the benchmark's median of 2.53 total falls.
Aim of the Project: The primary aim of this project was to decrease overall falls in an acute inpatient behavioral health unit.
Review of the Evidence: A comprehensive literature review identified intervention prevention bundles, compliance auditing, and staff education as effective ways to combat patient falls.
Project Design: This quality improvement project employed the Plan, Do, Study, and Act methodology to conduct rapid change cycles during implementation. The OhioHealth Change Management Model framework addressed barriers and provided planning and communication support.
Intervention: The intervention was a compliance audit tool containing all the existing fall prevention intervention criteria. Patient chart audits were completed using this tool, allowing for isolating underutilized bundle elements and guiding change opportunities.
Significant Findings/Outcomes: The number of falls during the eight-week project period was compared to those in the prior eight weeks. Using the number of falls divided by the number of occupied bed days in each eight weeks allowed a fall rate to be calculated. The number of falls during the project period dropped from six to two. The fall rate increased from 2.88 falls per 1,000 occupied bed days to 2.92 falls during the project. This rate increase is attributed to fewer occupied bed days. The overall reduction in the number of falls was considered clinically relevant.
Implications for Nursing: The impact of compliance with an existing fall prevention bundle to reduce patient falls has not been widely reported in behavioral health. There is an opportunity to continue to research and apply additional interventions that meet the needs of this vulnerable population. Fall prevention is not a universal solution without considering the needs of specialty units. This project demonstrated the success of monitoring compliance as a valid fall prevention measure. The project also highlighted the need to update the policy to reflect the complexities of this work in a behavioral health setting.
Recommended Citation
Gardner, Kristin, "Reducing Patient Falls in a Behavioral Health Unit: Improvement through Audit Implementation" (2024). Doctor of Nursing Practice (DNP) Scholarly Project. 12.
https://fuse.franklin.edu/dnp-project/12
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