A Informatics Integration Project

Mount Sinai Rehab Hospital

Tonya D. Bailey

August 11, 2023

NUR 718

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            This informatics integration project is being conducted in a rehab hospital and will delve into the current methods and potential improvements that can be made to decrease further and prevent falls within the facility’s inpatient population. Falls are a very costly aspect of the health care delivery system. In 2015 alone the estimated cost of falls was more than 50 billion dollars. Costly to the patients who have potentially set back their own recovery and are costly in terms of the financial ramifications of the facility who must make amends for the injuries attained when a fall occurs within its facility walls. This issue is especially problematic when one considers the fact that falls are the most common occurring incident reported. (Jung, H. et al. 2022).  The problem of falls is one that crosses all boundaries and is a seemingly complex one that has a multitude of factors which all contribute to the incident of a fall. Some of the issues which contribute to the potential for falls are Musculo-skeletal weakness, problems with balance and mobility, vision or hearing problems. Also noteworthy are pharmacological responses to medications like barbiturates or narcotics. The more risk factors that exist the more cumulative is the likelihood for a fall that results in injury.

            There are many patient factors that play a role in the safety of any inpatient stay. Some of the more critical issues are the patients’ mental status and ability to understand current limitations. This is especially poignant in amputees who have yet to grasp they have new and considerable changes to their abilities that needs be addressed before they can hope to return to a self-sufficient lifestyle. Ambulation and mobility are clearly strong indicators of a patient’s risk for falls, and they are the most prolific issues seen in any rehab. facility like the one in question here today. There is an increase in the risk for falls in patients who have declining mental status such as is found in TBI’s or CVAs. Another large portion of the patient base in Mount Sinai Rehabilitation Hospital are suffering from some type of brain injury and thus are prevalent and at an increased risk for falls. Also there is the associated nature of falls that are the number 1 cause of TBI’s to consider when looking into the correlation between mental status and falls.

            Falls are clearly an issue for all hospitals and rehab facilities since they are tracked by many different regulatory bodies like the Joint Commission and CARF. Since 2008 the Centers for Medicare and Medicaid services no longer reimburses facilities for care provided to injuries sustained during falls in their facility. Some reasons that facilities may have a part in falls is due to poor implementation of fall prevention guidelines. A lower than is feasible staff to patient ratio is another significant cause of falls. Staff who don’t follow the protocol of using alarms and safety devices such as bed and chair alarms, due to the disruption to care that they require when there is a need to respond to alarms. Ignoring alarms that don’t belong to your assigned patients can also lead to significant injury to patients who fall despite the use of alarms. Improper or inadequate use of fall prevention guidelines and neglecting to observe patients and the environment around them can also play significant roles in falls.

            Mount Sinai Rehabilitation Hospital commonly called “MSRH” is a 47-bed facility located on the 4th floor of the facility in the heart of downtown Hartford, CT. It is a very popular facility among patients and referring doctors caring for patients who need the intensity of the inpatient rehab that is offered. The facility is a CARF accredited facility for adolescent and adult rehab, as well as traumatic brain injuries and strokes. CARF stands for Commission on Accreditation of Rehabilitation Facilities, and it is an honor to be able to state proudly that our facility has gained accreditation status in four distinctive areas which greatly reflect our patient base. (CARF International, 2023). The facility offers intense physical, occupational and speech therapy of a maximum of 3 hrs. a day, 6 days a week for every admitted patient. This intensity of care ensures that our patients make incredible gains in their health and well being and most are discharged home despite some initial devastating illnesses or injuries.

            MSRH is owned by a larger conglomerate called Trinity health of New England. THoNE owns a number of hospitals, clinics and facilities in the northeast including my own. I worked first at the ‘main campus’ as we call St. Francis Hospital, before I ultimately transferred to MSRH and found a place where I love to work. St. Francis is another hospital that is owned by Trinity health. While they are at first glance run by the same organization they are both significantly separate entities and not all of the informatic systems in place at one hospital are necessarily in place in the other.

            There are 3 units on the inpatient rehab floor. 4 East is the largest unit and there is a fully functional ‘transitional living’ apartment with an en suite bathroom and kitchenette to help teach patients proper use of ADLs in anticipation of a pending discharge home. The remaining rooms with the exception of one which is our isolation, negative pressure room are double bedrooms. This gives the total number of patients 4E as 32. On 4E there are only 2 rooms that have camera observation possible. One is the isolation room, and the other is a normal 2 occupancy room. The number of staff on 4E at any one time is quite high. There are 3-5 RNs (depending greatly on the current patient census). There are 3-4 CNAs. There is a unit secretary, a senior nursing advisor, as well as a dozen or more therapists at any given time. This makes the number of staff available for responding to alarms and patient needs very high nearly all the time in 4 East. 4 North is the locked TBI unit. There are a total of 7 rooms and only 6 are occupied at one time. That is because only 6 of the 7 have camera observation possible. There is also limited staff on this unit, 1 RN, 1 CNA and 1 unit secretary. This makes collaborative care and cooperation between staff a very critical necessity. 4 South is the third and final unit that makes up the rehab floor where I work, and that which is the focus of my informatic project. 4S is another locked unit which mirrors 4N. There are 7 single rooms but only 6 are occupied at one time. Once again this is due to the fact that there are only 6 rooms which are equipped with camera observation. The staff on 4s is even more limited than that of 4N. There is only an RN and a single CNA for patient care. These factors are fairly relevant in my proposal for a decrease in falls.

            Due to the fact that I work full-time at the MSRH facility, and I am assigned to all of the units I was able to bring into this project a great deal of inside knowledge. What I didn’t know I was able to ascertain through interviews with staff that had the answers I needed and who provided me with printouts of data mining for the entire fiscal year which had just resolved in June 2023. This makes all of my data current and very relevant to my project and my proposal.

            Due to the nature of most of our patients, safety is a very important consideration, and the facility already has a fairly impressive fall prevention program in place. (See the current fall prevention itemized list for a complete listing of currently used tactics). As it stands the facility is already safer than most inpatient hospitals. However, I have found an area that seems to me to have great potential to become even safer with the use of informatics and new policies enacted for the safety of our patient base moving forward. Everyone I approached at MSRH was incredibly helpful and supportive of my designated goal to help decrease falls at our facility. I had a great database of knowledge and assistance from staff inside the facility with regard to the current systems that are in place to keep falls down and patients safe. I was able to interview the Units nursing educator, Liliana Rosa-Marasiotis, who helped get me into the monthly fall prevention meeting between the fall committee. I spoke with Latoya March, RN-BSN who is the senior nursing advisor for the fourth floor. She was able to get me a printout for the last fiscal year regarding the falls that had occurred within the facilities three units for the past year. As a floor nurse, I am also privy to the daily fall safety huddles that take place at the start of every shift. I also spoke to Jennifer Shockley, PT lead and the overseer of the monthly fall committee. All of them had a great amount of encouragement and understanding of the need to further reduce falls within the MSRH rehab unit.

            Falls are an integral part of nursing and hospital stays at a rate of 3-5 falls per 1000 bed days. There are only a percentage of the whole population who is considered a fall risk when you are in any typical hospital unit. At Mount Sinai Rehabilitation Hospital, every single patient is at considerable risk for falls. That is 100% of the population that elects to come to our facility to rehab is there because they are having significant Musculo-skeletal issues. This arguably makes fall prevention and patient safety the singular most important issue in the facility. According to the Agency for Healthcare research and Quality there are a number of reasons that patients in the healthcare system fall. One of the reasons is a baseline issue with mobility or balance, which in essence affects every single patient within our facilities walls. (AHRQ. 2019).

            Considering the high number of patients with special needs and at a high risk for falls the facility does a good job of fall prevention. Yet despite the diligence of staff and the facilities policies for our fall risk populace there are still more falls than there should be. That is the reason that I chose this as an issue to be addressed and researched in the hope that there may be some way left to decrease falls within the rehab unit. Falls are also a mitigating factor in the past medical history of many of the patients who come to rehab at MSRH. Either the fall is a consequence of another issue such as a stroke, or the fall itself is the major injury that brings the patient into our care. Falls can lead to broken bones and injuries especially in the elderly. They can also be caused by drugs and alcohol and result in Traumatic Brain Injuries which ensure the afflicted will have a lengthy stay in our TBI unit for rehab. My research has shown that in fact, falls are the most common cause of TBI’s, and over 800,000 patients are hospitalized each year as a result of injury from falls. (CDC.gov 2023).

            In the fiscal year that began in July 2022 and ended June 2023 there were a total of 47 falls within our rehab facility. 29 falls occurred on the 4E unit. 10 falls occurred on the TBI unit 4N, and 5 falls occurred on the 4S unit. There were also an additional 3 falls in the gym during therapy. To further examine these falls, the number of falls that caused injury were significantly less than the total but still substantial in a rehab facility. Of the falls on 4N 9 of them led to injury. Of the falls on 4N 3 of them led to injury. Of the falls on 4S the injuries amounted to 3 and of the falls occurring in the gym there was 1 injury. The good news is that despite the number of falls that resulted in injury there was 0 falls that resulted in significant injury or led to death. Still, I feel that we can do better.

            There is no feasible way that staff can keep an eye on every patient for every moment of the shift. Despite the number of safeguards that are in play and the dedicated usage of hourly rounding and anticipatory care, there are still falls occurring and injuries being sustained. Camera observations are good, but even on the units which have camera technology there are still a number of falls that are occurring regularly. From the nurse’s station to the patients’ rooms still requires time to get from the point of camera observation to the bedside to help intercede in the patient about to sustain a fall from chair or bed. It has been my observation that the best way to intervene in a patient who is about to do something reckless and potentially dangerous to their health is in person. That face to face, gentle encouragement and questioning to diffuse a dangerous situation in person. Once again though this is an impossible situation in any hospital setting wherein you have more than one patient in your care. Even the best nurses and staff cannot be in two places at the same time. This is a conundrum for which my informatic solution can help this factor amongst others. It will also prove to be less expensive in the long run than having to pay 1:1 staff 24 hours a day for monitoring. At this time this is the only way that MSRH can help provide constant real time monitoring of our most at risk patients on any of the units. While effective this is a costly endeavor for the facility, having to pay staff to sit with the highest risk patients every minute of the day. Even those on camera have need of 1:1 monitoring, like the 18-year-old TBI patient on 4N who has been receiving 1:1 care for over two weeks now.

            My informatic proposal to decrease the number of falls in the MSRH rehab hospital would also negate the need for 1:1 staff observation for the foreseeable future as well as decrease falls and prevent the potential compounding of patient injuries. I am talking about the AvaSure patient monitoring system. I was able to become familiar with this technology when I worked at St. Francis hospital, and it was a very cutting-edge technologic system that really helped to offer a level of patient safety and nursing piece of mind. This same technology I feel would help cut costs, reduce falls, and revolutionize the care that we can provide for our patients at MSRH. It would also reduce the need for paying staff for 1:1 observation for our high-risk patients who don’t respond to the amount of baseline preventative measures that are always in place.

            AvaSure is a consistent monitoring system that is always in use. This is a significant step up from the camera observation system that we currently have in use. When staff is unavailable due to being in other areas of care, or patient rooms, the cameras are unmonitored and there is a chance for injury to the other patients on camera. The AvaSure system, however, has a team of dedicated telesitter &/or healthcare professionals who are always keeping a watchful eye on the patients as that is their only assigned job. They are in communication with the staff nurse throughout the shift and coordinate care before each shift begins so that they can discuss each patients’ distinct needs for the day. Critical needs are exchanged like a patients LDA status and areas that are of particular note to keep an eye on. Pertinent items such as a patient may be at risk of tugging on a G tube or dislodging an indwelling catheter. This way the observer knows whether a patient should have their hands under their shirt or beneath the blankets and if it might be an issue or not. There are systems in place to protect patients’ privacy during care. The system can be paused, and a patient’s dignity can be maintained during incontinence care or the use of the bathroom. Then once the care is completed with staff, the monitoring system can return to its original function as staff goes back to its other assigned tasks. Thus, patients’ needs are met, and their safety is always assured.

            One of the most influential abilities of the AvaSure system of patient monitoring is the ability for the observation team to speak to the patient in the rooms. This function can be helpful to reorient the patient and remind them about why attempting to get out of bed alone may be deleterious to their health. The team can encourage the patient to press the call bell and wait for staff, while simultaneously alerting the staff that the patient is starting to get out of bed without assistance. The typical camera observation system that is currently in use doesn’t have this capability and is not monitored 100% of the time due to the staffs’ other duties since there is no one person assigned to monitor the cameras exclusively.

            In conclusion, It is only further through the direct use of technology and informatics that a significant decrease in falls could be reached. While the Mount Sinai Rehabilitation Hospital has done a lot to increase patient safety and prevent falls, it is clear that there is still a fair bit of room for improvement to its currently active policies and procedures. 47 falls in the fiscal year of 2022 means that we do not have all the bases covered for all of our substantial efforts. It is for these reasons I feel strongly that the AvaSure system would be extremely beneficial to the facility as a whole. It could potentially assist in decreasing patient falls, giving the patients that require it constant and consistent monitoring while allowing staff to provide quality care to every patient without the contributory concern over the safety of certain patients who can’t or won’t comply with their own safety issues. It is my belief that the AvaSure system would eventually, despite the initial cost in equipment, lead to a decrease in cost of patient care. The constant monitoring systems with the ability to converse with patients without needing to enter the room will easily lead to a decreasing in falls while simultaneously lead to a significant increase in positive outcomes for the patient base that chooses to entrust MSRH with its rehab needs.  

            I discussed the idea of AvaSure monitoring with my floor supervisor and she agreed it was a good idea and said that she has subsequently been in touch with St. Francis Hospital to see about getting some AvaSure machines for our own facility as well. The power of informatics in patient centered care and positive outcomes cannot be denied, and successful facilities can only try and keep abreast of the growing need for constant upgrades to help promote quality outcomes and keep abreast of the most relevant care using evidence-based practice.

Current preventions and Informatics in place for fall prevention:

Bed wheel locks

Smart beds that notify when the bed is left in a high position.

Bed alarms

Chair alarms

Wrap around release alarms

Camera observation (in 14 rooms out of 31)

Fall tracking infographics.

Fall committee (monthly meetings)

Daily shift change fall huddle

16 hrs. of training with PT/OT in proper transfer and body mechanics

‘Call don’t Fall’ patient agreement.

Call Bells and belongings within reach at all times

Hourly rounding and anticipatory care provided.

Bladder and Bowel schedules

In/OOB schedules

Gait Belts

Regular medication reviews

Immediate staff response to all alarms

Daily PT/OT screening for mobility deficits

Daily fall risk assessment completed each shift.

Regular safety checks and maintenance of assistive devices

Environmental safety and maintenance

Fall risk bands.

High fall risk socks

‘rising star’ fall risk door markers.

1:1 observation

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Citations:

Bailey, T., & Coffey, E. (2023, August 5). AvaSure Proposal. personal.

Bailey, T., & Shockley, J. (2023, August 1). Fall Meeting observation. personal.

Bailey, T., & March, L. (2023, July 21). Informatics Interview. personal.

Bailey, T., & Rosa-Marasiotis, L. (2023, July 21). Informatics Interview. personal.

CARF International. (2023). Who we are. https://www.carf.org/About/WhoWeAre/

Centers for Disease Control and Prevention. (2023a, May 12). Facts about falls. Centers for Disease Control and Prevention. https://www.cdc.gov/falls/facts.html

Falls. Patient Safety Network. (3019, September 7). https://psnet.ahrq.gov/primer/falls#:~:text=Epidemiologic%20studies%20have%20found%20that%20falls%20occur%20at,are%20also%20at%20very%20high%20risk%20of%20falls.

Home Page. AvaSure. (2023, May 5). https://avasure.com/

Jung, H., Park, H.-A., & Lee, H.-Y. (2022, April 1). Comparisons of fall prevention activities using Electronic Nursing Records: A case-control study. Journal of patient safety. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9359761/

Mount Sinai Rehabilitation Hospital. Trinity Health of New England. (n.d.). https://www.trinityhealthofne.org/location/mount-sinai-rehabilitation-hospital-1

YouTube. (2023, July 6). Mount Sinai Rehabilitation Hospital. YouTube. https://www.youtube.com/watch?v=Z3NmTGMdWW8