Effectiveness of Team
Training on Fall Prevention
Margaret Michelle Kimrey, MSN, RN, PCCN-CMC Beverly Green, MSN, RN
LeeAnna Spiva, PhD, RN, PLNC Bethany Robertson, DNP, CNM
Marcia L. Delk, MD, MBA Sara Patrick, MSN, RN
Disclosure
• This work was supported through the 2011
Prevention Above all Discovery Grant, Medline
Industries
• The authors had full access to all of the study,
take responsibility for data integrity, accuracy of
the data analysis, and presentation
Background/Significance
• Falls are the most frequently reported safety event among U.S. hospitalized patients 1-7
• Falls are associated with increased risk of mortality and morbidity and an estimated cost of $20 billion a year 8,9
• Annual direct and indirect costs of falls estimated to reach $54.9 billion 8
• Evidence exists on fall risk factors, interventions, and
prevention guidelines, yet reducing falls in the acute care setting has been challenging 5,10-16
• Little evidence is available demonstrating interdisciplinary team efforts 17
Purpose
• To evaluate the effect of a training curriculum
based on TeamSTEPPS® with video vignettes
focusing on fall prevention for debriefing and
reinforcement on team members’ safety culture,
teamwork attitude, teamwork perception, and
communication as a mediator to reduce falls and
injuries
Methods
• Design
– A longitudinal, quasi-experimental, repeated measures, with intervention & comparison groups
• Setting/Sample
– 2 community acute care hospitals; 4 medical-surgical acute care units
– Intervention group: 16-bed orthopedic unit & 17-bed neurology unit (received training)
– Control group: 22-bed orthopedic unit & 30-bed
neurology unit (received no training & continued with usual practice)
– registered nurses, pharmacists, physical therapists, & physicians
Measures
• Demographic
• Hospital Survey on Patient Safety (HSOPS) 18
• TeamSTEPPS ® Teamwork Attitudes Questionnaire
(T-TAQ) 19
• TeamSTEPPS ® Teamwork Perceptions Questionnaire
(T-TPQ) 20
• Trained observers recorded teamwork communications and behaviors
– bedside shift report (patient handoff), safety huddle, interdisciplinary care meeting, & unit-level observer assessments
Training Intervention
• Based on TeamSTEPPS® curriculum, four domains: communication, situational monitoring, mutual support, and leadership21
– Three 30-minute training sessions; held on the units – Brief didactic lecture
– Custom designed patient video scenarios
Intervention: Training Content
Session I
Didactic: purpose of team training
Video: lacking behaviors from the 4 domains
Debriefing: role team work plays in fall prevention
Session II
Didactic: communication and situational monitoring
Video: demonstrated optimal bedside shift report, safety huddle, and SBAR
Intervention: Training Content
Continued
Session III
Didactic: mutual support and leadership utilizing
Video: vignette of team briefs, huddles and hand-offs
Debrief: information sharing fosters mutual support and task assistance; leadership for communication events; knitted all 4 domains from training together
Study Time line
Activity April 2012
May June July Aug Sept Oct Nov Dec Jan 2013 Feb Recruitment x x Champion Training x Training (Intervention) x x x Observations x x x Surveys x x x
Data Analysis Plan
• SPSS 18.0: Statistical methods- descriptive, chi-square (χ2),
repeated measures analysis of variance (ANOVA), and t tests • Chi-square (χ2) or t tests were used to compare demographic
variables of the 2 groups
• Post-hoc comparisons were performed to evaluate mean differences
• NVivo 10 used to identify patterns in observers’ hand written notes – Descriptive statistics were calculated for the patterns
– Repeated measures conducted to evaluate the effects over time • A p value of < .05 was considered statistically significant
Findings
• Demographics
– 39.36 (SD = 10.45) sample mean age
– Most were registered nurses (29.4%), female (97.1%), white (64.7%), baccalaureate prepared (41.2%), &
primarily worked day shift (79.4%)
– Differences between the 2 groups for age, gender, & education (P < .001)
– 72% of the intervention group sample attended all 3 training sessions
Questionnaire Findings-
Intervention Group Only
• HSOPS Subscales
– Feedback & communication about error (F = 4.95) & communication openness (F = 5.46) improved over time (P < .01 )
– Teamwork within hospital units (F = 4.07, P = .03) improved mid compared to post-intervention
– Teamwork across hospital units’ (F = 4.81, P = .02) improved from pre compared to post-intervention
• Teamwork Attitude
– Improved (P = .009) mid (M = 4.16) compared to post-intervention (M = 4.55)
• Teamwork Perception
– Decreased (F = 3.92, P = .03) pre (M = 2.35), mid (M = 2.23), & post-intervention (M = 1.66)
Questionnaire Findings Continued
• No statistical differences found within the control group- scores decreased over time on all measures except teamwork within hospital units &
teamwork attitudes slightly increased
• No significant differences in the study variables between the 2 groups • Subsequent analysis, the 2 groups were combined & analyzed as 1 group
to compare the change of study variables over time
• HSOPS subscales differed for the entire sample significantly over time for 4 of the 5 subscales: feedback & communication about error (F = 4.382, P = .017); communication openness (F = 21.535, P < .01); teamwork within hospital units (F = 6.037, P < .01); & teamwork across hospital units (F = 9.248, P < .01)
• Teamwork attitudes improved over time (F = 3.240, P = .04) with a significant increase pre compared to post-intervention
• Teamwork perceptions decreased over time (F = 5.207, P < .01) with a significant decrease pre compared to post-intervention
Observation Findings
• Bedside shift report - Intervention group (n = 137) improved over time
conducting report in patients’ room, discussing patients’ mobility status, & improving communication between caregivers regarding patients’ care plan compared to the control group
• Safety huddles (n =16) & interdisciplinary meetings (n = 25) - Intervention group improved over time expressing less uncertainty about patients’ care plan & frequently communicated patients’ fall risk status compared to
control group
• Observer assessments (N = 54) - Over time intervention group improved communication related to patients’ fall risk status (F = 7.480, P < .01) • Fall related observations included consistent implementation of fall
preventative interventions such as signage & visual fall reminders (arm bracelet, yellow socks, & door sign), bed alarm usage, & ambulation assistance improved in the intervention group (F = 6.67, P < .01) • The control group had no significant observation findings
Fall Data Findings
• The number of falls decreased by 13 (62%
reduction) & fall-related injuries by 5 (71%
reduction) in the intervention group
• Pre-fall rates were 2.69 (SD = .12) & 1.03 (SD =
.43) post-fall rates (
t
= 4.27,
P
= .15)
• Pre-injury rates were .97 (SD = .55) & .24 (SD =
.34) post-injury rates (
t
= 5.05,
P
= .122)
Limitations
• Training sessions were not always interdisciplinary
• Even though training sessions were short & unit based, staff had difficulty attending & managing care duties • Local variations in patient volumes, staff turn over, etc
impacted all aspects of the study
• Low statistical power may have limited ability to detect certain differences because of a small sample size • Questionnaire length may have resulted in instrument
Conclusion
• Unique study: control group, self-report survey and observations all over time
• Team training was found to be an effective intervention to reduce falls and related injuries
• Steady improvements in perceptions of safety culture
and teamwork attitude; clinical significance was achieved in a reduction of falls
• Observed improvements with caregivers implementing fall preventative interventions and improved
communication between caregivers related to a patients’ fall risk status
References
1. Black, A., Brauer, S., Bell, R., Economidis, A., & Haines, T. (2011). Insights into the climate of safety towards the prevention of falls among hospital staff. Journal of Clinical Nursing, 20(19-20), 2924-2930.
2. Bouldin, E.L.D., Andresen, E.M., Dunton, N.E., Simon, M., Waters, T.M., Liu, M.,…Shorr, R.I. (2013). Falls among adult patients hospitalized in the United States: Prevalence and trends. Journal Patient Safety. Advanced online publication. doi: 10.1097/PTS.0b013e3182699b64.
3. Cozart, H.C., & Cesario, S.K. (2009). Falls aren’t us: state of the science. Critical Care Nursing Quarterly, 32(2), 116-127.
4. Healey, F., Scobie, S., Oliver, D., Pryce, A., Thomson, R., & Glampson, B. (2008). Falls in English and Welsh hospitals: A national observational study based on retrospective analysis of 12 months of patient safety incident reports, Quality & Safety in Health Care,17(6), 424-430.
5. Inouye, S.K., Brown, C.J., & Tinetti, M.E. (2009). Medicare nonpayment, hospital falls, and unintended consequences. New England Journal Medicine, 360(23), 2390-2393.
6. Lohse, G. R., Leopold, S. S., Theiler, S., Sayre, C., Cizik, A., & Lee, M. J. (2012). Systems-based safety intervention: Reducing falls with injury and total falls on an orthopaedic ward. Journal of Bone and Joint Surgery, 94(13), 1217-1222. Retrieved from http://dx.doi.org/10.2106/JBJS.J.01647
7. Walsh, W., Hill, K. D., Bennell, K., Vu, M., & Haines, T. P. (2010). Local adaption and evaluation of a falls risk prevention approach in acute hospitals.
International Journal for Quality in Health Care, 23(2), 134-141.
8. Centers for Disease Control and Prevention (2010). Costs of falls among older adults. Retrieved from
http://www.cdc.gov/HomeandRecreationalSafety/Falls/fallcost.html
9. Gribbin, J., Hubbard, R., Smith, C., Gladman, J., & Lewis, S. (2009). Incidence and mortality of falls amongst older people in primary care in the United Kingdom.
Quality Journal Medicine, 102, 477-483..
10. American Geriatrics Society (2011). 2010 AGS/BGS Clinical practice guidelines: prevention of falls in older persons. Retrieved from
http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinicalgui delines_recommendations/prevention_of_falls_summary_of_recommendations/
11. American Medical Directors Association. (2011). 2011 Practice guidelines for fall and fall risk. Columbia, MD: American Medical Directors Association. 12. Cameron, I.D., Murray, G.R., Gillespie, L.D., Hill, K.D., Cumming, R.G., & Kerse, N. (2010). Interventions for preventing falls in older people in nursing care
facilities and hospitals. Cochrane Database of Systematic Review, 1,doi:10.1002/14651858.CD005465.
13. Clyburn, T.A., & Heydemann, J.A. (2011). Fall prevention in the elderly: Analysis and comprehensive review of methods in the hospital and in the home. Journal Am AcadOrthop Surg, 19(7), 402-409.
14. Coussement, J., De Paepe, L., Schwendimann, R., Denhaerynack, K., Dejaeger, E., & Milisen, K. (2008). Interventions for preventing falls in acute and chronic care hospitals: A systematic review and meta-analysis. Journal of the American Geriatrics Society, 56, 29-36.
15. Oliver, D., Healey, F., & Haines, T.P. (2010). Preventing falls and fall-related injuries in hospitals. Clinical Geriatric Medicine, 26(4), 645-692. 16. Tinetti, M.E., & Kumar, C. (2010). The patient who falls. JAMA, 303(3), 258-266.
17. DiBardino, D., Cohen, E.R., & Didwania, A. (2012). Meta-analysis: Multidisciplinary fall prevention strategies in the acute care inpatient population. Journal of Hospital Medicine,7, 497-503.
18. Sorra, J.S., & Nieva V.F. (2004). Hospital Survey on Patient Safety Culture. (Prepared by Westat, Under Contract No. 290-96-0004). AHRQ Publication No. 04-0041. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from http://www.ahrq.gov/qual/patientsafetyculture/hospsurvindex.htm
19. Baker, D.P., Krokos, K.J., & Amodeo, A.M. (2008). TeamSTEPPS® Teamwork Attitudes Questionnaire. American Institutes for Research, Washington, DC. Retrieved from http://teamstepps.ahrq.gov/TeamSTEPPS_T-TAQ.pdf
20. American Institute Research. (2010). TeamSTEPPS® Teamwork Perceptions Questionnaire (T-TPQ). American Institutes for Research, Washington, DC. Retrieved fromhttp://teamstepps.ahrq.gov/Teamwork_Perception_Questionnaire.pdf
