Purpose and background: Patients with end-stage liver disease are frequently admitted to the hospital due to the complex nature of the disease process. This places them at risk for hospital-acquired complications and injuries which include pressure injuries, deep vein thrombosis, and falls. Inadequate communication about fall risk factors between the nurses and the patient care associates (PCAs) can put the patients in harm's way and potentially lead to falls. Creating a communication tool that addresses specific fall risk factors can increase awareness and bridge the communication gap among the nursing team.
Project design/methods: The project team was led by the unit educator and consisted of shared governance council members. The plan, do, study, act (PDSA) methodology was utilized for this quality improvement initiative. The goal of this project was to reduce the number of falls from 1.58 to one or less per month. Lewis’ Change Theory and Roy’s Adaptation Model were used to identify interventions and drive change.
Thorough chart reviews and root cause analyses identified hemodynamic changes such as low blood pressure, hyponatremia, and ascites as predisposing risk factors for falls. These findings were incorporated into a new pre-liver transplant fall risk bundle which included an updated communication tool that incorporated predisposing fall risk factors. Education was provided to staff, and fall rates pre- and post-intervention were monitored. Due to the novel coronavirus (COVID-19) pandemic, several PDSA cycles were implemented to meet the challenges and restrictions posed by the pandemic, such as staffing, patient acuity, and patient volume.
Results and outcomes: The quality improvement initiative was piloted in December 2020. Education on the fall risk bundle and the communication tool was completed by 85% of the nursing staff. The total number of falls decreased from 19 in 2020 to 9 in 2021, showing a 53% reduction in falls. As of July 2022, there have been five falls.
Implications on practice: This communication tool, specifically addressing hemodynamic changes and fall risks, bridges the communication gap between the nurses and the PCAs. The tool can be redesigned to meet the needs of specific patient populations that experience hemodynamic changes and other factors to help prevent falls.
References
1) Yildirim, M. (2017). Falls in patients with liver cirrhosis. Gastroenterology Nursing, 40(4), 306-310.
Román, E., Córdoba, J., Torrens, M., Guarner, C., & Soriano, G. (2013). Falls and cognitive dysfunction impair health-related quality of life in patients with cirrhosis. 2) European Journal of Gastroenterology & Hepatology, 25(1), 77–84.
3) Soriano, G., Román, E., Córdoba, J., Torrens, M., Poca, M., Torras, X., Villanueva, C., Gich, I. J., Vargas, V., & Guarner, C. (2012). Cognitive dysfunction in cirrhosis is associated with falls: A prospective study. Hepatology, 55(6), 1922–1930.
4) Tapper, E. B., Nikirk, S., Parikh, N. D., & Zhao, L. (2021). Falls are common, morbid, and predictable in patients with cirrhosis. Journal of Hepatology, 75(3), 582–588.
