This observational study assessed fall rate over time, consequent injuries, and characteristics of hospitalized patients in the periods before and after QI activity implementation. In addition, staff compliance with risk assessment on admission, as well as implementation of risk-stratified intervention plans, was examined. Before QI activities were implemented at our facility in 2007, the accidental fall rate had remained constant at approximately 2.00 falls per 1000 patient days. This study documents a 25% reduction of inpatient falls over five years, from 2.13 falls per 1000 patient days in 2004 to 1.53 falls per 1000 patient days in 2010, with the most dramatic reduction from 2006 to 2009. The consequent injury rate was less than 0.1% for any year. Feasibility of this integrated approach was excellent, as reflected by high staff compliance with use of assessment tools and implementation of intervention strategies across wards and departments.
Our initial fall rate at the beginning of the study period was lower than other studies in urban, acute-care hospitals, though in line with the lower end of the reported spectrum, typically between 2.2 falls per 1000 patient days to 6.3 falls per 1000 patient days
[20–22]. While the interventions put in place in 2006 were effective, aiding the further decrease was that the assessment rate of newly admitted patients was nearly 100% in 2010. Even if a robust preventive program exists, effectiveness is unlikely if compliance is low. A previous, observational study by Schwendimann et al. failed to show a substantial decrease in either frequency of falls or consequent injuries following the implementation of a similar interdisciplinary fall prevention program; the authors state that this was likely due to low staff compliance
. In contrast, a 2010 randomized controlled trial by Dykes et al. achieved a 46% reduction in their intervention group compared to a 25% reduction in the control group. Their staff compliance rate with intervention was 81%, corroborating the success in our study, which saw a final compliance rate of 95.3%
. This suggests that robust interventions themselves are necessary--but not sufficient--for fall prevention. Staff compliance with effective interventions is a critical, and perhaps often overlooked, factor in further closing the evidence-practice gap.
To this end, our QI activity included three elements to purposefully promote staff compliance with the fall prevention protocol. First, the Working Group in our hospital systematically involved healthcare staff on both planning and implementation levels in a multidisciplinary strategy to address the problem of accidental falls. The involvement of staff from multiple clinical and ancillary disciplines at the highest levels of planning may have influenced compliance at later points “downstream.” Second, all fall events were systematically documented, and subsequently followed by consistent short- and long-term auditing and feedback provided to hospital, department, ward, and individual staff at regular intervals. Finally, evidence-based reviews and practical training in protocol use were provided regularly to all staff in the form of repeated, evidence-based educational programming.
This study has some limitations. First, there was too little data on bone fractures after falls, thus we could not investigate the influence of our multidisciplinary QI activity on the rate of reduction of bone fractures. Second, this study was conducted in a single institution in a Japanese acute care hospital, with consequent uncertainty about generalizability. Future multi-center studies with larger numbers of patients may allow us to better clarify both effectiveness in reducing consequent injury, as well as assess the feasibility of our QI activity and result generalizability to other hospitals. The goal of our study was to decrease inpatients fall hospital-wide. Application of this protocol to those at highest risk, such as inpatients on geriatric or long-term nursing care wards, may be useful. Finally, it is difficult to distinguish the role that compliance plays in effective QI activity versus elements of the activity itself. Our initial compliance rate was already high and this may not be the case at other institutions. Our results, however, suggest that both are necessary components of QI protocols and should be maximized during planning phases. While we achieved a substantial increase in compliance rates after beginning QI activities, compliance was not well-assessed prior to its implementation. It is possible that a pre-existing “culture of compliance” contributed to the observed success. Effective ways to create and maintain this “culture of compliance” is an important future area of QI research and may vary by country, culture, and institution, and thus may not be as easily achieved in all practice settings.