patient safety

“The idea came from our manager, when one of our young, alert patients fell and got an injury. We were all upset,” says Jenalyn Andres, RN, one of the union co-leads for her department’s UBT.

That incident spurred nurses on the 4 East-Malama West unit-based team at Moanalua Medical Center in Hawaii to set a goal to cut the number of falls in half within 12 months—from 18 in 2013 to nine or fewer by the end of 2014. The team exceeded its goal and had only six patient falls in 2014.

Steps to success

Team members adopted the No One Walks Alone falls prevention program, pioneered at the San Diego Medical Center, to help them reach their goal. The team set up a standard process to ensure success. Some of the elements of the plan included:

• checking that all bed alarms are on at the start of shift and during the shift
• having alarm pads for chairs readily available in rooms, ready for patients who get out of bed and into a chair
• placing nonskid socks on patients’ feet
• positioning call lights within reach
• using walkers to help patients become mobile

Andres, a member of Hawaii Nurses Association, OPEIU Local 50, says the team educated patients and families by sharing literature with them that included tips on preventing falls and information about the No One Walks Alone protocol. The protocol starts with the assumption that all patients are fall risks, instead of nurses trying to identify which patients are at risk. Patients are accompanied every time they get up, especially to and from the bathroom, which is when most falls occur.

Troubleshooting “hot spots”

As part of the team’s process improvement, it identified “hot spots”—things that could happen that could prevent success. For example, the team quickly discovered that it had different types of patient beds on the unit, with different bed alarms. Some of those alarms weren’t wired into the nurse call system, so staff members had to follow the sound of the alarm to figure out which patient needed assistance—which meant it took longer to get to the patient.

The UBT worked to get the issue fixed, and as a result, “a project was opened with facility maintenance and beds have been switched to a universal cord, which resolves the problem,” says Manlee Velasco, the unit’s manager and management co-lead. “In the few cases where the cord wasn’t compatible, new beds have been ordered.”

The team has had five falls so far this year, which came before the cord issue was resolved. 

Spreading a successful practice

The overall success of the prototcol has been noticed by other teams and “all of the inpatient units at the Moanalua Medical Center are now using the program," says Kim Lu, RN, the 4-East unit’s other UBT union co-lead and also a Hawaii Nurses Association member. 

The practice is a great example of spread for another reason: The “No One Walks Alone” slogan and program was created by a San Diego Medical Center UBT in Southern California that was involved in a Joint Commission pilot in 2012.

Patient safety is about more than the hands-on care delivered in a hospital or clinic. It’s also about what caregivers do to close care gaps and be sure patients get the care they need.

To ensure this happens with every abnormal prostate, breast, pelvic, osteoporosis and fecal exam, the Georgia region established a centralized Outpatient Safety Net Program. Almost four years ago, borrowing techniques from Southern California’s successful safety net program, the Georgia region dedicated the equivalent of four full-time and one part-time nurse. Their jobs: to continue reaching out to patients who don’t respond to an initial contact regarding an abnormal test result.

The program is saving lives—and has earned KP’s 2014 David M. Lawrence Patient Safety Award in the transfer category, an award for a region that successfully implements a project from an earlier award winner. The Southern California safety net system had won a 2012 Lawrence award for its work.

“If you have an abnormal stool test, you should be seen in gastroenterology,” says Rahul Nayak, MD, who served as physician program director of patient safety for Georgia when the program launched. “It will raise a red flag in our system if that doesn’t happen in a certain amount of time. That’s why it’s called a safety net—it’s the net below the tightrope walker.”            

Making contact with patients

Sonja “Patrice” Evans, RN, is the manager of Georgia’s outreach effort and leads the group of nurses. She also steps in to convince members who initially say they don’t want to come in for further testing. “We can prevent something small from turning into something big,” she says.

The nurses receive a list of patients who have abnormal results. They make two attempts to reach them by phone and send a certified letter if the calls don’t work. “Our team tries to catch a small group of patients before they fall through the cracks,” Evans says.

So far, it’s working.

A systematic approach

In 2013, the most recent year for which data are available, 4,000 members were contacted about abnormal breast exam results. Of those, 93 percent were successfully scheduled for a follow-up appointment within the prescribed seven days. For abnormal pelvic exam results, 2,000 members were contacted, and 95 percent of those were scheduled within seven days.

Five hundred members—most of whom had declined or not responded to previous contacts—were reached within 100 days of abnormal prostate exam results; 87 percent scheduled a follow up. The team contacted 200 members with abnormal osteoporosis exam results, and more than 70 percent scheduled a follow up within 30 days, which exceeded the Medicare 5-Star guidelines.  

Dr. Nayak, UBT co-lead for gastroenterology at Southwood Medical Center, says one of his patients benefited from the program.

“Our safety net caught a positive (fecal occult blood test) that I had missed two months prior,” he said when accepting the Lawrence award on behalf of the team. “That patient had an advanced adenoma which was well on its way to malignancy. Without the safety net, there is no guarantee that we would have found this polyp” in time.

Now, Georgia’s program is expanding and will include other types of patient notifications.

Among the telemetry units at San Diego Medical Center, 5 West had a bad reputation: It consistently had the most patient falls at the hospital. In 2011, for example, it had twice as many as the next-worst unit. Patients were suffering, as was morale. Managers and employees tried all sorts of measures to prevent falls—such as posting pictures of falling leaves on patient doors and using color-coded arm bands on patients to indicate fall risk—but nothing was improving patient safety enough.

Only when the unit-based team launched its “No One Walks Alone” campaign in 2012 did the numbers budge. It’s part of a larger trend in health care to shift from trying to assess a patient’s risk of falling to simply treating every patient as a fall risk and ensuring each patient is accompanied—especially to and from the bathroom, which is when most falls occur.

“This is for everybody, not just some,” says Lucila Gonzalez, RN, a UNAC/UHCP member who serves on the UBT’s representative group. After all, patients newly hospitalized after a stroke suddenly cannot do many things they used to do on their own. And elderly patients who were independent at home might resist getting help. “It takes time to adjust,” says Gonzalez.

Spread what works

The pilot project on 5 West—part of a collaboration with the Joint Commission for Transforming Healthcare that also involves six non-Kaiser hospitals—included installing bed alarms to let staff know when a patient was trying to sit up, so a caregiver could dash over and assist. When patient falls decreased dramatically in the first three months of the effort, the practices were spread in November 2012 throughout the hospital. And the results have stood up. The hospital previously had been averaging 16 falls a month. In October 2013, that figure was three a month.

Some employees had doubts about the initiative when it first started, says management co-lead Estela Enriquez. “They said, ‘Just don’t make it cumbersome.’ Others said, ‘It’s just not going to happen.’” Enriquez says, “For me, as a manager, it was an issue of staffing.” At first, it was harder to ensure nurses got their breaks. UBT members worked on their department budget and hired more unit assistants. They also worked together to build in time during the day for their added responsibilities. “We’d see nurses walking around the unit with the patients,” says Enriquez. “Then there was a sense of, ‘OK, maybe we can manage this.’” 

The inpatient units are sustaining their results by talking in their huddles about the falls that do happen, rounding on patients hourly to get them out of bed and into the bathroom safely, ensuring that bed alarms are activated and celebrating their successes.

Set ambitious goals

The slogan “no one walks alone,” which came from a UBT meeting, is more than a catchphrase, Enriquez says. “It is one that resonates with patients. The wife of a patient said her husband was embarrassed that ‘a big, strong guy’ couldn’t go to the bathroom by himself. The nurse finally got through to my husband when he said, ‘No one walks alone.’”

Jenny Button, director for business strategy and performance improvement at the hospital, says a key to success is to set an ambitious goal. It’s not enough to work to “reduce” falls or get to four a month, she says. “You have to say, ‘We want no falls.’”