HOLD ON If a patient appears to be a falls risk, designate a nurse to help her get dressed and make it safely to her ride home after surgery.

The OR staff at the Hospital of the University of Pennsylvania (HUP) in Philadelphia, Pa., knew they were having too many patient falls: 9 in 2014 and 12 in 2015, a disturbing rise they attributed to the rise in outpatient surgeries and the challenges of caring for ambulatory patients as opposed to bedridden inpatients.

"We needed to ask questions more applicable to the outpatient setting," says Ann Marie Morris, MSN, RN, CNOR, HUP's nurse manager of perioperative quality and safety. Ms. Morris says that although each of their patient falls happened away from the operating table, they had a few near misses with patients on the OR table, too. "As soon as you let your guard down, you end up with a fall," she says.

And the patient falls were affecting more than just the hospital's numbers. "I think the nurses felt helpless," says Michael Ham, MSN, RN, CCRN, CPAN, HUP's perioperative clinical practice leader. So the OR staff did a department-wide analysis of the falls to identify trends. Then, they consulted with academic health centers, met with the hospital-wide falls committee and spoke with physical therapists about what strategies they should implement to avoid patient falls in the outpatient setting.

After instilling those strategies, the hospital saw a 44% reduction in patient falls from 2015 to 2016, with only 7 patient falls. In 2017, that number dropped to 4. "We are constantly reinforcing and identifying how and where we can be more diligent," says Ms. Morris.

Here are the 4 key ways HUP lowered its patient falls, and how you can, too.

1 Ask 3 questions to determine the patient's fall risk.

During pre-op, first ask, "Have you fallen more than once in the past year or hurt yourself in a fall?" Next, "Do you feel you are at risk of falling?" And finally, "Do you have trouble dressing, grooming or bathing?" If the patient answers "yes" to any of those 3 questions, that helps indicate whether you might need to take extra precautions to prevent a fall. It's also important to consider the physiologic effects of anesthesthetic agents and preparation for surgery, including NPO requirements, and how those factors impact a patient's fall risk.

Make sure you repeat the 3 questions in post-op. If patients appear to be a falls risk, have one of your nurses stay at bedside to help them get dressed and make sure they aren't ever walking alone. Ms. Morris says her hospital keeps extra-wide chairs at bedside for patients to put their belongings on. That way, everything is close by for them to avoid any risk of falling while getting ready to head home.

2 When tilting the table in the OR, make sure all staff is at bedside.
Alert your staff that the table is going to be tilted. "We cannot tilt the table without telling the team, so everyone is right at the bedside and haven't stepped away," says Ms. Morris. "We had an incident here where the table was moved, and the team wasn't focused on that, and a patient did start to slide off." Although the patient didn't fall off and hit the floor, Ms. Morris says it could have been a possibility. "If someone steps away from the field and doesn't know what's happening, [a fall] could happen," she says.

When dealing with a larger patient, be especially careful and alert when tilting the table. "A patient of size can be challenging," says Danielle Mouradjian, BSN, RN, CCRN, a nursing professional development specialist at HUP. "If a patient is coming at you, you have to say, 'No more tilting.'"

3 Make sure patients can walk safely on their own in post-op.
In what they call their "Get Up and Go" test, HUP's OR staff has their patients stand up, walk 10 feet, and then turn around and walk 10 feet back and sit down after surgery to ensure that they're safely able to ambulate. "Use scores of 1 through 5 for each part of the assessment," says Mr. Ham. "If it's a score of 3 or above at any point, the patient is a fall risk." During the gait assessment, emphasize to your patients that they should pump their legs before they stand up and should always stand up slowly in case of dizziness. The OR staff says a lot of the falls they've seen have been young, healthy people who were simply affected by the medications they were on. "We explain that you feel like you're awake, but the rest of you might not be completely awake yet," says Mr. Ham.

4 Follow up regularly with staff to standardize your practices.
"Standardization is important," says Ms. Morris. Follow up continuously with your staff to make sure everyone is using the same protocols to prevent patient falls. "We had issues with Get Up and Go," says. Ms. Morris. "We had it in place and thought everyone was doing it, but everyone interpreted themselves how to do it." She says that some nurses were having patients walk 50 feet to the bathroom as an assessment, which put them at risk of falling when no one was close enough to help. Others were having patients walk 2 feet to their belongings, which wasn't a strong enough assessment. The idea is to perform a limited gait assessment — a 10-foot walk, up and back — without endangering the patient.

If the worst-case scenario does happen, use that case study to educate your staff and explore why it happened and how it could've been prevented as a team. "It's a good learning tool to see something that really occurred and apply standardization to it," says Ms. Mouradjian.

Ounce of prevention
Although patient falls might be rare, your OR team is the last line of defense in preventing them. By taking the time to assess your patient and working in extra steps to keep riskier patients from falling, you could avoid a slippery situation — and maybe slash your own patient falls by half. OSM