In Quarter 1 of 2022-23, St Clare hospice identified that falls on the in-patient unit (IPU) were a consistent theme in reported incidents at the hospice. They began a quality improvement programme to reduce the number of falls.
This included:
analysing where and when falls occurred
analysing what patients had said about the event (for example what they were doing or trying to do when they fell)
looking at the environment to see what could be improved to help prevent falls.
Outcomes
As a result of this work, the hospice made several improvements.
The team ensured that all beds in the IPU were all fitted with bed rails, that could be used as necessary. Some beds can also be lowered to the floor to further reduce the risk of injury from a fall.
Refresher training on falls prevention was delivered to staff, along with a new falls risk assessment.
Patients that had been assessed as being at high risk of falls were issued with a sensor mat that sounds an alarm if they try to get out of bed on their own. This meant that staff could quickly go to the room to assist the patient. Additional sensor mats can be used on recliner chairs or patients’ beds.
The team developed a leaflet to be shared with patients, which explains how falls might happen and gives practical tips about how to prevent them.
The hospice also invited the Falls Lead at the local Acute Trust to visit the IPU and make recommendations for any further improvements that could be made.
Over time, the team was able to identify a clear reduction in the number of falls in the IPU.
Key facilitators
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The hospice had already committed to replacing mattresses and beds on the IPU as part of work to reduce hospice-acquired pressure ulcers. It was therefore fairly easy to make sure all the new beds had bed rails.
The IPU team was supportive of the changes made to reduce falls, and the team used daily handovers and monthly IPU staff meetings to talk about the project and celebrate progress.
