2063. Reducing Falls and Injuries Due to Falls in the VA System
PD Mills, Dartmouth Medical School and Field Office, VA National Center for Patient Safety, J Waldron, Field Office, National Center for Patient Safety, PA Quigley, Patient Safety Center Inquiry, VISN 8, University South Florida Nursing and University of Phoenix, Nursing Health Sciences, E Stalhandske, VA National Center for Patient Safety WB Weeks, Dartmouth Medical School, VA Quality Scholars and VA National Center Patient Safety

Objectives: Translation of research into practice is needed to improve organizational performance.  We wanted to evaluate a translation program designed to reduce inpatient falls and injuries.

Methods: Thirty-seven teams completed an eight-month facilitated quality improvement effort, during which time teams reported baseline and monthly patient fall rates (falls per bed day of care) and major injury rates (major injuries per 100 falls).  We used paired t-test analysis to determine whether fall and injury rates improved, surveys to assess team characteristics, ANOVA to identify team characteristics that were associated with success and paired t-test analysis to examine changes in team characteristics over time.

Results: While the overall fall rate decreased only slightly during the effort (6.84 to 6.42), the overall major injury rate dropped 62 percent, from 2.14 major injuries per 100 falls at baseline to 0.82 major injuries per 100 falls at project completion (paired t-test p = 0.097).  This represents an average reduction of 40.9 major injuries per month. Top performers turned in early progress reports (ANOVA, p=0.01), reported more staff support (p=0.001), stronger leadership (p=0.04) and better conflict management skills (p=0.03). By the second learning session more teams reported a better understanding of team members (paired t-test, p =. 06), a more systemic perspective (p = .04), and more data collection from patients (p = .04). Virtually all teams reported learning new ideas and methods, and a belief that the project added value to their facilities. Most teams also reported that they used information from other teams and shared information with others. Toileting interventions, use of signage to identify high-risk patients, environmental interventions, post-falls assessments, use of hip-pads, and staff education produced the greatest reductions in major injury rates.

Conclusions: The project was successful at reducing major injuries and was perceived as helpful by teams.  Limitations include observational design, potential selection bias, and lack of follow-up data.

Impact: Translation of research into practice can be facilitated by organized, team-based quality improvement initiatives.  In addition to enhancing patient safety, these initiatives may be cost-effective: the decrease in major injury rate represents a monthly savings of between $667, 569 and $765, 934.