HOT FEET! A fall Prevention Plan

Purpose:
Identifying a rise in falls across the Progressive Care Units (PCU), a unit based team developed a concept to reduce falls. This idea, assisted by the leadership and bedside nurses, grew into a comprehensive, visible and multidisciplinary approach to prevent the occurrence of falls.

Significance:
Falls are a common and preventable cause of injuries and trauma. In hospitals, fall related events constitute the majority of reported incidents and lead to an increased rate of patient mobidity and mortality.

Strategy and Implementation:
After analyzing contributing factors, an inspired group of bedside nurses had an idea to make at risk patients more identifiable. Research led to the developement of new highly visible tools such as red slip resistant socks, “Hot Feet” signs posted outside patients room and “Hot Feet” stickers in key areas. These tools became the basis for a comprehensive program. The managers, educators and bedside nurses collaborated to develop a new fall prevention process that would yield positive results. A fall prevention decision tree incorporating hospital policy was designed to clearly outline interventions according to patient assessment. The Schmid risk assessment tool was evaluated and variables were identified that previously had not been considered when assessing fall risk factors. A multidisciplinary plan was created defining each staff member's role in preventing falls. The new Hot Feet! program was introduced to the staff during mandatory in-services by each unit's educational team.

Evaluation:
Understanding of the “Hot Feet” program was evaluated by post-test, showing a 95% comprehension rate. Pre implementation (Quarter 1 2008 = 5.07 falls per 1000 patient days) and post implementation (Quarters 2&3 2008 = 3.70 and 3.17 falls per 1000 patient days) rates were used to measure success.

Implications for Practice:
Evaluation of the data suggests a defined, multidisciplinary approach to fall prevention utilizing researched tools reduces the incidence of falls in the Progressive Care environment.