Authors (including presenting author) :
Kwok YT(1), Lam MS(2), Lee KM(2), Kong SW(2), Chung WY(3), Yee YC(4), Chang KW(5), Chan LC(6), Tam ST(6), Kung HC(1), Tai LH(1), Chan NH(3), To CH(3)
Affiliation :
(1)Quality and Safety Division, (2)Nursing Services Division, (3)Medicine and Geriatrics Department, (4)Department of Ambulatory Care Services and Mixed Specialty Wards, (5)Occupational Therapy Department, (6)Physiotherapy Department, Pok Oi Hospital
Introduction :
There has been an increase in patient falls (from 0.72 per 1,000 in-patient bed day occupancy between Jan and Apr 2020 to 1.42 in May 2020) in Pok Oi Hospital (POH). A POH Falls Review Team was then formed in June 2020 to study and tackle the problem. The team members included medical, nursing, physiotherapy and occupational therapy falls coordinators and Quality and Safety staff.
Objectives :
(1) To form a Falls Review Team. (2) To review falls occurred in POH from Jan 2019 to May 2020. (3) To identify gap areas; and (4) To introduce interventions through a systems approach to reduce preventable falls.
Methodology :
A comprehensive review on the situation on patient falls from Jan 2019 to May 2020 and existing falls prevention measures was conducted. An environmental inspection in different units and a literature research on international falls prevention measures were also conducted as benchmarking references. Different aspects on falls prevention including assessment, communication, monitoring, patient modification and environment modification were evaluated.
Result & Outcome :
Total 217 falls from Jan 2019 to May 2020 were reviewed. The contributory factors included frequent falls due to toileting at night, ineffective falls assessment to identify patients prone to falls / with a fall history, lack of grab bars in wards and toilets and inappropriate size of safety vests provided to patients. The findings were reported to POH Hospital Liaison Committee in June 2020. Since June 2020, daily falls visits were conducted. Up till December 2020, total 87 falls were visited and 130 contributory factors were identified. The cases were discussed in the regular team meetings and 29 (33%) of them were preventable. Interventions were introduced including strengthening patient assessment and mobility by physiotherapists and occupational therapists, revising the falls educational pamphlets, reviewing the safety vests quantity and size provision, enhancing environmental safety, purchasing fall alarm mats and recommending the use of pelvic holders during sit-out activities. Since the introduction of these interventions, the falls rate from Jun to Dec 2020 was reduced to 0.64 (55% and 10% reduction when comparing with rates in May 2020 and Jan-Apr 2020 respectively).
