Quality Improvement

Project
Christmas Group: Alanna Leung, Wyatt Ute,
Anna Gladbach, Mark Sauceda, Joseph Cammarata
E2Med - Med Surg/Ortho Unit at
The VA in Tucson, AZ
Patient Population:
● 25 beds
● 25-35 pts/day
● Most common: TKAs, THAs,
TURPs, and Spinal Surgeries
● Discharge Times: 24-72 hours
● Annually: 9125 - 12775 pts
Daily Staffing:
● 5-6 Nurses/shift
● 1 Charge Nurse/shift
● 1 occasional Resource Nurse
● 3-4 PCTs/shift
● Nurse Manager & Assistant Manager
located on unit
● 1 Unit Clerk on day shift
● Unit Providers round during Day Shift
for short period of time or PRN in
emergencies
AG
Quality Improvement Issue:

Fall Prevention
● 72 - 80% of this patient population is deemed a High Fall Risk
according to the Morse Fall Scale
● In 2023, there have been 125 falls in the hospital and 25 on E2Med, 18
of which resulted in injury
● Falls are the most common hospital-related adverse event

Current Fall Prevention Measures:

Checking a box in the patient’s chart stating that safety checks
have been performed in the patient’s room

(LeLaurin & Shorr, 2020)

AG
 Model for Improvement: Forming the Team

01 Nurses

Patient Care Technicians

02

Unit Managers
03

04 Unit Educators

AL
Model for Improvement: Setting Aims
Aim Statement:

Within 90 days from the commencement of project implementation, the

Medical Surgical/Orthopedic unit of the VA Hospital of Tucson, will see a
75% decrease in total falls per 1000 patient days among the adult patients
the unit cares for.

AL
Model for Improvement: Setting Aims
Aims Positively Impacted by Implementation

Safe Patient Centered

- The main goal of our project is to - Our project sets to better the safety and
improve patient safety well-being of our patients

Effective Equitable
- Studies have shown great success - Our project provides each patient with
implementing our chosen quality equal and beneficial interventions
improvement initiative

AL
Model for Improvement: Establishing Measures

Current Unit Data -

Outcome Measure - Last 10 months (January-October) - 2.73 falls per
Number of patient falls on E2 Med per 1000 1000 patient days
patient days

National Average -
3.92 falls per 1000 patient days on med surg units

(Agency for Healthcare and Quality Research, n.d)

(Agency for Healthcare Research and Healthcare, n.d.) MS

Model for Improvement: Selecting Changes
Wearable Prevention System Prevention Kits Checklists

● ● Nurse-led-prevention kits utilizing EBP ● Used a 14 item checklist

Utilized a wearable sensor SmartSock
interventions for continuous patient care ● Conducted at a university National Cancer
system
● Data collected from acute care wards in a and family engagement Institute
● Data collected from 3 academic medical
large VA, N = 1668
● Measured both groups over time for 2077 centers in Boston and NYC, N = 37,231
● Fall TIPS tool kit includes 3 prevention
Ward Days of Care (WDOC)
● Total Falls modalities
○ ○ Fall TIPS laminated poster
PUP Sock: 19
○ No Sock: 43 displayed at bedside
■ ○ EHR generated poster for
P=0.003
● Total falls per 1000 WDOC health care team
○ ○ E-bedside screen display
PUP Sock: 9.2
○ ● Overall, there was a 15% decrease in
No Sock: 20.7 DOI: 10.1097/01.NAJ.0000554037.76120.6a

falls after implementation (2.92 vs 2.49

falls per 1000 patient-days) ● Compared results from the previous 3
○ P=0.01 months
● Adjusted 34% reduction in injurious ● 37 staff member participated and
falls (0.73 vs 0.48 injurious falls per completed 90 fall prevention checklists
1000 patient-days) ○ 19% of the time bed alarm was
○ P=0.003 incorrectly set
https://www.hackster.io/news/pressure-sensing-smart-sock-wearables-eliminate-falls-in-at-risk-patients-during-a-13-month-study-4e88986b243a ● No falls were recorded
(Baker et al., 2021) (Dykes et al., 2020) (Johnston et al., 2019)

JC
 Potential Barriers to Implementation: Bacterial
Cross Contamination
Data
● In a study testing the effectiveness of
non slip socks, samples were taken
from used socks and hospital floors
● Discoveries: Studies show a risk of
bacterial transfer
○ Nearly 10% of non-slip socks
were contaminated with MRSA
○ Another study saw cross
contamination from socks to
linens(↑risk of infection)
JC
Intervention
● To prevent cross contamination
hospitals must enforce strict
infection precautions
○ Regular change of socks
○ Regular bedding changes
○ Ensure clean floors
○ Handwashing
(Jazayeri et. al, 2021)
 Potential Barriers to Implementation: Start-Up
Problems and Alarm Fatigue
Data Intervention
● During implementation, fall rates ● Require a training module to be
were at their highest during the start completed by staff before
● In the study, of the 5,078 alarms 54 implementation
were false alarms ● Ensure that each pair of socks are
○ While that is a 99.8% success working properly before use
rate, if we want to avoid alarm
fatigue we should strive for
100%

Baker et al, 2021)

 Model for Change: Testing Changes
● Educate unit about the new
change
● Review basic fall risk preventions
● Review what data to record and
parameters
Plan
● Analyze and compare data from
previous years prior to
intervention Act
● Compare # of fall between
similar units
● Educate healthcare workers to
improve shortcomings
● Improve or alter interventions
based on worker’s feedback
● Have the unit record the
amount of patients they
admit and the amount of falls
● Have nurses educate the
patient about the intervention
Do ● Record any cases of infection
● Collect number of patient and the
amount of falls on the unit every
Study 90 days
● Review what nurses/healthcare
workers need to improve
● Ask for feedback from healthcare
workers and patients
● Collect all cases of infection
 Conclusion
❖ From our research at the VA hospital, we noticed that falls was a rising
concern.
❖ Nearly one fifth of the falls in the entire hospital in 2023, occurred in the
E2MED unit.
❖ Quality improvement focused on lowering the amount of falls by
implementing wearable alarm systems.
❖ Some markers for improvement would be a 75% decrease in total fall per
1000 patient days over the next 90 days, staff reports a successful
implementation, and no increase in infections stemming from cross
contamination.
References
Agency for Healthcare Research and Quality. (n.d.). Preventing falls in hospitals. AHRQ,
https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/measure-fall-rates.html
Baker, P. A., Roderick, M. W., & Baker, C. J. (2021). PUP® (Patient Is Up) smart sock technology prevents falls among hospital
patients with high fall risk in a clinical trial and observational study. Journal of gerontological nursing, 47(10), 37–43.
https://doi.org/10.3928/00989134-20210908-06
Dykes, P. C., Burns, Z., Adelman, J., Benneyan, J., Bogaisky, M., Carter, E., Ergai, A., Lindros, M. E., Lipsitz, S. R., Scanlan, M., Shaykevich,
S., & Bates, D. W. (2020). Evaluation of a patient-centered fall-prevention tool kit to reduce falls and injuries. JAMA Network Open,
3(11). https://doi.org/10.1001/jamanetworkopen.2020.25889
Jazayeri, D., Heng, H., Slade, S. C., Seymour, B., Lui, R., Volpe, D., Jones, C., & Morris, M. E. (2021). Benefits and risks of
non-slip socks in hospitals: a rapid review. International Journal for Quality in Healthcare. 33(2),.
https://doi.org/10.1093/intqhc/mzab057
​Johnston, M. & Magnan, M. (2019) Using a fall prevention checklist to reduce hospital falls:
results of a quality improvement project. American Journal of Nursing. 119(3):p 43-49, March 2019. | DOI:
10.1097/01.NAJ.0000554037.76120.6a
LeLaurin, J. H., & Shorr, R. I. (2019). Preventing falls in hospitalized patients. Clinics in Geriatric Medicine, 35(2), 273–283.
https://doi.org/10.1016/j.cger.2019.01.007
Osborne, T. F., Veigulis, Z. P., Arreola, D. M., Vrublevskiy, I., Suarez, P., Curtin, C., Schalch, E., Cabot, R. C., & Gant-Curtis, A. (2023).
Assessment of a wearable fall prevention system at a Veterans Health Administration Hospital. Digit Health, 9.
https://doi.org/10.1177/20552076231187727