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October 31, 2014

‘Four Ps’ mean fewer falls among patients

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A simple idea being put into practice in a New York hospital has reduced the number of falls in high-risk or elderly patients. The initiative sees nurses assessing the ‘Four Ps’ — pain, position, potty and placement


Patients at a New York hospital who are at risk of falling are easily identified as a result of a simple initiative.
At the Northern Westchester Hospital in Mount Kisco, patients at high risk of falling wear yellow socks. The ‘Four Ps’ is an evidence-based practice model for assessing ‘pain, position, potty and placement’ during two-hour rounds. Nurses using the system have reported fewer falls over the last three months.
Staff nurse Cristina Fata said: “Within the last month and a half, at least on this unit, I don’t remember hearing of a fall taking place.
“That rates really well with a year ago. Obviously, our goal is to have no falls but realistically, sometimes something happens we can’t account for. This has definitely reduced the number of falls and call bells.”
The idea came from the hospital’s evidence-based practice council, said chief nursing officer Lauraine Szekely. “The nurses who are involved in the evidence-based practice council through our shared governance model were interested in looking at falls and pressure ulcers to see what evidence was out there to ensure our practice was the best and meeting industry standards,” she said.
Falls prevention
The council reviewed literature on falls prevention and examined internal data on when and where falls occurred in the facility. Nurse educator Fay Wright said: “Most of the falls at Northern Westchester were because people needed to go to the bathroom. We looked at the evidence and people were looking at toileting every one to two hours, as a way to prevent falls. It’s almost like taking tiny steps — called small tests of change.”
The next step in creating the programme was developing a fall risk-assessment tool that incorporated toileting with falls-prevention strategies, as well as continually measuring a patient’s fall risk.
“We identified procedural issues. For example, someone goes in and turns a patient, but they don’t toilet before turning and a few minutes later, the patient needs to go to the bathroom. So it’s almost double the work and uncomfortable for the patient, because they’re getting moved a couple of times,” Wright added.
Role-playing
Almost 150 nurses have been trained in the initiative. It involved role-playing and using key words to assess pain, potty, position and placement. The system has reduced their workload because they are more frequently checking on patients and anticipating their needs. This has reduced call bells.
When they are admitted and every day afterwards, patients are evaluated for risk. High-risk individuals receive yellow socks, yellow stars are put on their chart and they are identified as fall risks to the call-bell intercom operators.
“One day a patient may be okay, but the next day they may have a procedure and become a risk. This encourages us to assess our patients’ fall risks on a daily basis.
“This is a tool that is more specific to each patient — it’s in tune to their individual needs,” said Ann Marie Tietjan, a staff nurse in the psychology and cardiopulmonary units.
High-risk patients have generally been receptive to the new tool, Tietjan added. “The first day it went live, I went into a patient’s room — it was an elderly man — and told him about the new rounding, and he said, ‘That’s the best damn thing I heard all week. That makes so much sense.’ And I told him he was absolutely right,” she said.
The additional time with patients is a boon to nurses stretched by the fast-paced hospital environment, nurse Fata added.
“Even if it’s just a few minutes to toilet and turn the patient, it gives you that time and allows you to assess and pick up on cues if the patient is in distress,” she said.