ERproductions / Blend Images / Alamy POSTPARTUM SAFETY: A Patient-Centered Approach to FALL PREVENTION Suzy Lockwood, RN, PhD, OCN, CHPN, and Kandace Anderson, BSN, RNC Abstract Falls in the perinatal setting have received minimal attention and have not been well documented Women are at risk for falling following vaginal or cesarean birth, especially during initial attempts at ambulation Recently, a women’s hospital that averages over 500 births per month recorded a postpartum fall rate that exceeded the national mean for adult surgical patient falls A fall prevention team (FPT) of five nurses was formed with a goal to decrease the incidence of postpartum patient falls to zero within the following months A patient-centered fall prevention strategy was developed The results of this project have laid the foundation for additional research of a program that will consider not only prevention of falls in a healthy population but also the development of a risk assessment tool specific to women in the immediate postpartum period Key terms: Accidental falls; Fall prevention; Fall risk assessment; Patient safety; Postpartum period; Postpartum safety January/February 2013 MCN Copyright © 2013 Lippincott Williams & Wilkins Unauthorized reproduction of this article is prohibited 15 P atient falls account for a significant portion of injuries in hospitalized patients and are a major focus of The Joint Commission (TJC) and Institute of Medicine Falls in the perinatal setting, however, have received minimal attention and have not been well documented As suggested by Simpson (2010), falls in this specialized setting occur more often than might be expected, and could be minimized with patient education and nursing intervention Women are at risk for falling following vaginal or cesarean birth, especially during initial attempts at ambulation This fall risk can be a result of postbirth fatigue, blood loss, hypotension, weakness, or lack of sensation in lower extremities due to epidural analgesia and side effects of narcotic medications Background Hook, Devine, and Lang (2008) conducted a systematic review in an effort to identify the strength of evidence supporting recommendations for fall risk assessment In their review, they used Morse’s three categories of falls: anticipated physiological falls (e.g., unstable gait, history of falling); unanticipated physiologic falls (e.g., seizures, fainting); and accidental falls (e.g., slipping, tripping) The category into which postpartum falls belongs is “unanticipated physiological” falls, defined as falls attributed to physiological causes but the occurrence could not be predicted (Morse, 1997) This includes falls occurring in patients who are recovering from physiological events and thus are at increased risk for unstable blood pressure, syncope, and subsequent falling at certain high-risk times Relating this to postpartum patients, the physiological event is cesarean section or vaginal birth, and the highrisk times are after birthing and during the first times out of bed Hook et al (2008) considers this a screenable fallrelated special condition Based on their review, the most important factor that influences fall risk particularly in this category is the patient’s willingness, or ability, to actively participate in the fall prevention process Fall risk tools are typically designed to predict anticipated physiological falls that represent 34% to 78% of falls that occur in acute care (Currie, 2008) The Johns Hopkins Fall Assessment Tool is a nationally recognized and widely used evidence-based approach to fall risk assessment, fall prevention, and falls management (Poe, Cvach, Gartrell, Radzik, & Joy, 2005) Although the John Hopkins tool is useful in the medical–surgical population, it does not address the unique characteristics in the immediate postpartum period When using the Hopkins Fall Assessment Tool, most postpartum admissions are rated as a moderate fall risk Interventions applicable to this category include assisting with bedside sitting, personal hygiene, and toileting The postpartum patient is generally an independent healthy woman of childbearing age; their hospitalization experience is focused on the birth of a new infant Frank, Lane, and Hokanson (2009) recognized the disconnect between the traditional fall risk assessment tools and the postpartum patients Using the Morse Falls Scale 16 volume 38 | number WOMEN are at risk for falling following vaginal or cesarean birth, especially during initial attempts at ambulation and a Modified Alderete Score, Frank et al developed and implemented the Post Epidural Fall Risk Assessment Score (PEFRAS) The PEFRAS was designed specifically for postepidural, postpartum patients The validity and reliability of PEFRAS have not yet been established, but this is the first published attempt to address this specialized population In the medical–surgical and geriatric populations, evidence-based recommendations have been made for patient safety and fall prevention (Currie, 2008; Fall Prevention, 2008) In those high-risk populations, research has been conducted to explore the effectiveness of using fall risk identification bracelets, signs, stickers, or tags as an inexpensive and easy intervention (Williams, Young, Williams, & Schindel, 2011) However, study results have not indicated that these measures, as isolated interventions, decreased falls (Bell & Stirling, 2006; Coussement et al., 2008; Dykes et al., 2010; Oliver, Healey, & Haines, 2010) The National Patient Safety Goals (NPSG) encourage the patients’ active involvement in their own care as a safety strategy The Studer Group has recommended that hospitals hardwire partnerships between nurses and their patients as part of a fall prevention protocol (Studer, Robinson, & Cook, 2010) A Unit-Based Postpartum Fall Prevention Strategy Recently, a women’s hospital that averages over 500 births per month recorded a postpartum fall rate that exceeded the national mean for adult surgical patient falls The national average for adult surgical patient falls per 1,000 patient days during the 12-month time period was 2.79 This mean was used for comparison since there was no national mean for postpartum falls Although actual circumstances varied, the Nursing Practice Council for the postpartum unit was concerned that the unsatisfactory fall rate could be due to a lack of patient education and staff awareness A preliminary review of post-fall reports revealed that some women were getting up to the bathroom without calling for staff assistance Following the fall, women would report to their nurse that they did not fully understand the effects and duration of epidural analgesia, and did not realize their legs were “too weak” for walking Although no injuries January/February 2013 Copyright © 2013 Lippincott Williams & Wilkins Unauthorized reproduction of this article is prohibited were sustained from the falls during the 12-month Figure Call for a Helping Hand Patient Letter period, a need to decrease the fall rate was identified in order to prevent potential injury and costs TO PREVENT A FALL, PLEASE CALL With approval from Nursing Administration, a New mothers are at risk for falling, even though they may fall prevention team (FPT) of five nurses was formed feel strong and steady with a goal to decrease the incidence of postpartum patient falls to zero within the following months What YOU need to do? Two months after the FPT was formed, a patient1) Wear the purple arm band until your nurse removes it centered approach to fall prevention was impleThis will alert all staff that you are at risk for falling mented A “Call for a Helping Hand” letter created 2) CALL for staff help using your call button or phone before by the FPT was placed in each patient’s admission getting out of bed folder (Figure 1) The letter briefly and simply ex3) Please not allow your family members or visitors to plained the risk of falling in the initial postpartum assist you out of bed period Using low-literacy concepts for developing educational material for women outlined by Wilson 4) Ask for non-slip socks These are available at your request (2011), the letter instructed the patient to call for 5) Keep foot rail on side of bed closest to the bathroom assistance before getting out of bed A Spanish raised to remind you to wait for staff assistance translation of the letter was also available The admission folder including the letter and a purple fall We are here for you! risk armband was to be placed at the bedside when Don’t be shy, ask for help!! preparing the postpartum room for the patient’s arrival The admitting nurse would thus be prompted to initiate the fall prevention strategy during initial REMEMBER, communication and assessment “When wearing a purple band, Two weeks prior to implementation all postpartum nursing staff (licensed and nonlicensed) were Call for a helping hand” educated about the new fall prevention plan Multiple methods of training were conducted including Patient _Date e-mail, staff meeting programs, and mandatory read and sign packets Packets included the letter and information on the rationale for the program and deSignificant other Date tails about the process All postpartum staff agreed to participate Nursing personnel in the newborn Staff initial nursery and labor and delivery units were informed of the fall prevention strategy for additional reinReprinted with permission from Baylor All Saints Medical Center— forcement When the woman was admitted to the postpar- Andrews Women’s Hospital, Fort Worth, Texas, 2012 tum unit, the admitting nurse and patient reviewed the letter together The patient was asked to sign meet for review of fall reports and intervention evaluation it as an agreement to call for assistance Engaging the To further increase postpartum unit staff awareness and patient in signing the letter confirmed understanding and compliance, monthly fall statistics were posted as well as created the nurse/patient partnership in fall prevention as a sign indicating the number of days since the last patient suggested by Studer et al (2010) and Hook et al (2008) fall The fall prevention program and progress on meeting The letter was left at the bedside as a visual reminder the goal of zero falls was discussed at monthly staff meetFor additional emphasis, the purple fall risk armband ings Since implementation of the postpartum fall prevenwas placed on each woman’s wrist upon arrival to the tion program, the women’s hospital has decreased their postpartum unit The purple armband was later refall rate by 50% and maintained a postpartum fall rate moved when the patient’s postpartum nurse assessed that below the 50th percentile for the national mean of adult she was able to safely and independently walk Nonslip surgical patient falls per 1,000 patient days socks, as discussed in the letter, were also placed at the Clinical Implications bedside upon admission By combining staff awareness of fall risk with a patientCompliance with implementing the fall prevention centered approach, caregivers and patients became enstrategy was monitored through leadership rounding gaged together in the fall prevention process Although Postpartum nurses and patient care technicians were rean improvement was demonstrated in the postpartum minded to answer calls for bathroom assistance promptly fall rate, continuous review, evaluation, and reinforceand to frequently remind patients to “Call for a Helping ment is essential for the safe care of obstetrical patients Hand.” The importance of hourly rounding and inclusion and to ensure compliance with the NPSG of reducing risk of the woman in discussing her fall risk during bedside of patient harm from falls shift report was also emphasized The FPT continued to January/February 2013 MCN Copyright © 2013 Lippincott Williams & Wilkins Unauthorized reproduction of this article is prohibited 17 Suggested Clinical Implications • Traditional Fall Risk Scales not address the unique characteristics of the postpartum period • Postpartum patients have short-term increased fall risks • Patient-centered education immediately following birth that includes active involvement and visual cues about risk for falling makes a difference • Further research is needed to define fall risk factors in the postpartum population Opportunities abound for research as a result of this initial project Investigation to establish common criteria associated with those patients that did experience a fall can facilitate the development of a fall risk assessment tool that would be specific to the postpartum population Although a reduction in fall rate occurred, further data could be collected to look at how various types of anesthesia, amount of blood loss, or other birthing factors relate to the incidence of falls Additionally, the influence of patient participation or engagement in education on the fall risk prevention could lead to its inclusion in evidencebased practice guidelines Until now, the focus of fall prevention strategies has been in the adult medical hospitalized or frail elderly population There are other populations however that have gone unrecognized but yet are at a risk for fall and injury TJC has called for the development of programs to reduce the number of falls and assess for fall risk in all populations The experience at this facility has laid the foundation for additional research of a program that will consider not only prevention of falls in a healthy population but also the development of a risk assessment tool that is specific to women in the immediate postpartum period ✜ Suzy Lockwood is a Professor of Nursing at Texas Christian University—Harris College of Nursing & Health Sciences, Fort Worth, TX She can be reached via e-mail at s.lockwood@tcu.edu Kandace Anderson is a Nurse Supervisor, Postpartum at Baylor All Saints Medical Center, Andrews Women’s Hospital, Fort Worth, TX The authors declare no conflict of interest DOI:10.1097/NMC.0b013e31826bae4b References Bell, E., & Stirling, C (2006) What tools help make “whole-of-patient” practices happen?: A Tasmanian falls prevention project Holistic Nursing Practice, 20, 130-136 Coussement, J., De Paepe, L., Schwendimann, R., Denhaerynck, K., Dejaeger, E., & Milisen, K (2008) Interventions for preventing falls in acute and chronic care hospitals: A systematic review and meta-analysis Journal of the American Geriatrics Society, 56, 29-36.doi:10.111/j.1532-5415.2007.01508.x Currie, L (2008) Fall and injury prevention In: R G Hughes (Ed.) Patient safety and quality: An evidence-based handbook for nurses AHRQ Publication No 08-0043 Rockville, MD: Agency for Healthcare Research and Quality Retrieved from http://www.ahrq.gov/ qual/nurseshdbk/ Dykes, P C., Carroll, D L., Hurley, A., Lipsitz, S., Benoit, A., Chang, F., …, Middleton, B (2010) Fall prevention in acute care hospitals: A randomized trial The Journal of American Medical Association, 304, 1912-1918 doi:10.1001/jama.2010.1567 Fall Prevention (2008) National Guideline Clearinghouse Retrieved from http://www.guidelines.gov/content.aspx? d=13697&search=falls Frank, B J., Lane, C., & Hokanson, H (2009) Designing a postepidural fall risk assessment score for the obstetric patient Journal of Nursing Care Quality, 24, 50-54 doi:10.1097/01 NCQ.0000342937.99036.7b Hook, M L., Devine, E C., & Lang, N M (2008) Using computerized fall assessment process to tailor interventions in acute care Retrieved from http://www.ahrq.gov/downloads/pub/advances2/vol1/AdvancesHook_25.pdf Morse, J M (1997) Preventing Patient Falls Thousand Oaks, Sage Publications Oliver, D., Healey, F., & Haines, T P (2010) Preventing falls and fall-related injuries in hospitals Clinics in Geriatric Medicine, 26, 645-692 doi:10.1016/j.cger.2010.06.005 Poe, S S., Cvach, M., Gartrelu, D G., Radzik, B R., & Joy, T L (2005) An evidence-based approach to fall risk assessment, prevention, and management Lessons learned Journal of Nursing Care Quality, 20, 107-116 Simpson, K R (2010) Patient falls in the perinatal setting MCN The American Journal of Maternal Child Nursing, 35, 364 doi:10.1097/ NMC.0b013e3181f07418 Studer, Q , Robinson, B C., & Cook, K (2010) The HCAHPS handbook: Hardwire your hospital for pay-for performance success Gulf Breeze, FL: Fire Starter Publishing Williams, B., Young, S., Williams, D., & Schindel, D (2011) Effectiveness of a fall awareness and education program in acute care Journal of Nurses in Staff Development, 27, 143-147 doi:10.1097/ NND.0b013e318217b407 Wilson, L D (2011) Developing low-literacy health education materials for women MCN The American Journal of Maternal Child Nursing, 36, 246-251 doi:10.1097/NMC.0b013e3182183bbd For 18 additional continuing nursing education articles on safety topics, go to nursingcenter.com/ce 18 volume 38 | number January/February 2013 Copyright © 2013 Lippincott Williams & Wilkins Unauthorized reproduction of this article is prohibited ... does not address the unique characteristics in the immediate postpartum period When using the Hopkins Fall Assessment Tool, most postpartum admissions are rated as a moderate fall risk Interventions... Oliver, Healey, & Haines, 2010) The National Patient Safety Goals (NPSG) encourage the patients’ active involvement in their own care as a safety strategy The Studer Group has recommended that... Robinson, & Cook, 2010) A Unit-Based Postpartum Fall Prevention Strategy Recently, a women’s hospital that averages over 500 births per month recorded a postpartum fall rate that exceeded the