Reducing Falls for Patients Receiving Hospice Care: A Quality Improvement Project.

Although patient falls in the acute care setting have been thoroughly studied, published studies exploring falls for patients receiving hospice care remain limited. Patients receiving hospice care present with considerable risk factors for falls, including physical and cognitive changes associated with a terminal diagnosis. An increasing pattern of patient fall rates was identified at the organization and a quality initiative was developed to address this aspect of patient care. The SMART aim of this project was to establish a sustainable process to decrease the percentage of patient falls from 5% to 3% in an organization's hospice regional branch within a 3-month period. This project adopted the Plan-Do-Study-Act process as its change model. A bundled intervention was introduced including early referrals to the therapy team for newly admitted patients, staff education, and providing supplemental patient education. The measurable outcome was to achieve a decrease in fall rates. Although the goal was not achieved within the 3-month timeframe, data did indicate a positive trend toward the intended goal. Results indicated ongoing opportunities for nurses to enhance reliability in making therapy referrals. However, nurses demonstrated consistency in providing supplemental education.