James A. Haley Veterans Hospital: Reducing Severe Injury from Falls in
Two Medical Surgical Units; Institute for Healthcare Improvement
Collaborative

July 1, 2006 to July 31, 2007

Final Report

# 

# Abstract

The primary measurable goal set for our organization in this project was
to dramatically reduce

injury from falls on medical-surgical units so that injury from falls
(i.e. moderate, major, and

death) is reduced to 1, or less, per 10,000 patient days (10 ^-4^
Reliability Level). Several indicators

were chosen by IHI faculty to facilitate consistent reporting among the
facilities participating

in this collaborative of 11 hospitals covering a variety of specialties.
Our VA Medical Center\'s

enduring commitment to patient safety is demonstrated throughout our
organization as an

environment of innovation and excellence. We have contributed to
practice, education and

research surrounding technology integration and evidence-based practices
in fall prevention, as

one example. VA holds distinction in fall and injury prevention, in
particular hip fracture

prevention. Thus, our tests of change focused on new opportunities to
engage unit based

leadership and staff on combining innovations for vulnerable
populations.

Based on this innovative work, we selected injury prevention associated
with anticoagulation and

over age of 85 patients due to the risk for loss of function and life.
Our approach was to target

known populations which enabled new opportunities for teams to test
reliability and sustainability

of clinical interventions for patient safety. This report summarizes our
tests of change, lessons

learned and outcomes. Our test unit teams consisted of nurse managers
and staff who tested

bundled interventions specific to an injury associated with falls (such
as fracture and

hemorrhage), that had not been previously tested in a medical surgical
inpatient setting through

this multi-factorial intervention approach.

# Table of Contents

[Abstract 1](#abstract)

[Table of Contents 2](#table-of-contents)

[Project Team 3](#project-team)

[Measurable Goals 4](#measurable-goals)

[Goals Achieved and Levels of Performance
5](#goals-achieved-and-levels-of-performance)

[Table 1. Retrospective Review of 22 Previous Injurious Falls in Acute
Care
6](#table-1.-retrospective-review-of-22-previous-injurious-falls-in-acute-care)

[After Action Reviews (AAR) and Safety Huddles.
6](#after-action-reviews-aar-and-safety-huddles.)

[Teach-back education interventions with patients.
7](#teach-back-education-interventions-with-patients.)

[Toileting prior to administration of high risk pain medications.
7](#toileting-prior-to-administration-of-high-risk-pain-medications.)

[High risk falls precautions 7](#high-risk-falls-precautions)

[Comfort care & safety rounds 8](#comfort-care-safety-rounds)

[Other Initiatives: 8](#other-initiatives)

[Additional Accomplishments 9](#additional-accomplishments)

[Challenges 9](#challenges)

[Other Sources of Support 10](#other-sources-of-support)

[Lessons Learned 11](#lessons-learned)

[Project Impact 11](#project-impact)

[Post Grant Plans and Project Dissemination
13](#post-grant-plans-and-project-dissemination)

# Project Team

# 

Pat Quigley, PhD, ARNP, CRRN, FAAN

Project Director

Deputy Director, VISN 8 Patient Safety Center

Bridget Hahm, MA, MPH

Project Data Manager

Program Specialist, VISN 8 Patient Safety Center

Innette Sarduy, MPH, RN, CNAA\
Associate Chief of Nursing, Acute and Critical Care

Wanda Gibson, MS, ARNP

Nurse Manager, 5-South, Medical Surgical Unit

Sonia Collazo, BS, RN

Nurse Manager, 7 North, Medical Surgical Unit

Fanny Rice, MEd, RN

Patient Safety Manager

Kyna Tyndall, MS, RN, LHRM

Risk Manager

Susan White, PhD, RN, CPHQ, FNAHQ, CNAA

Associate Chief of Nursing, Quality Improvement and Magnet Program
Management

Gail Powell-Cope, PhD, ARNP, FAAN

Associate Chief of Nursing for Research

Sandra Janzen, MS, RN, CNAA, BC

Associate Director, Patient Care Services and Nursing

FINAL NARRATIVE REPORT

# Measurable Goals

**1. What measurable goals did you set for this project and what
indicators did you use to measure your performance? To what extent has
your project achieved these goals and levels of performance? Briefly
describe what the project actually did to meet its goals. If the goals
of the project have not been met, explain what happened and why. If
there were additional accomplishments, describe them, and explain how
and why the activities that led to these accomplishments were
undertaken. Be as specific as possible. Cover the areas described below
that are applicable to your project:**

> The primary measurable goal set for our organization in this project
> was to dramatically reduce injury from falls on medical-surgical units
> so that injury from falls (i.e. moderate, major, and death) is reduced
> to 1, or less, per 10,000 patient days (10 ^-4^ Reliability Level).
> Several indicators were chosen by IHI faculty to facilitate consistent
> reporting among the facilities participating in this collaborative of
> 11 hospitals covering a variety of specialties. The indicators
> reported to the collaborative included:

-   Falls incidence per 1,000 patient days

-   Falls resulting in minimal injury per 10,000 patient days

-   Falls resulting in moderate injury per 10,000 patient days

-   Falls resulting in major injury per 10,000 patient days

-   Falls resulting in death per 10,000 patient days

-   Days between injurious falls

-   Descriptive analysis of characteristics of the last 22 injurious
    falls in the Acute Care setting at the James A. Haley Veterans'
    Hospital

> During the project period, fall injury rates (i.e., minimal, moderate,
> major and death) were reported per 1,000 patient days. Upon the
> conclusion of the collaborative, the rates were converted to 10,000
> patient days. This change enabled teams to more readily evaluate their
> progress towards the project goal of reducing injury from falls (i.e.
> moderate, major, and death) on medical-surgical units to 1, or less,
> per 10,000 patient days (10 ^-4^ Reliability Level). For the James A.
> Haley Veterans' Hospital, these data were reported for both the
> individual medical-surgical units participating in the collaborative
> (5-South and 7-North) and the acute care nursing units.
>
> This project focused on reducing moderate to severe physical injury.
> Categories of harm (injury), established based on expert consensus,
> (National Quality Forum,
> [www.qualityforum.org](http://www.qualityforum.org/)) were used:

-   No harm

-   Minimal harm: results in application of a dressing, ice, cleaning of
    a wound, limb elevation, or topical medication

-   Moderate harm: results in suturing, steri-strips, fracture, or
    splinting

-   Major harm: results in surgery, casting, or traction

-   Death: (as a result of the fall)

# Goals Achieved and Levels of Performance

**1A. To What Extent Has Your Project Achieved These Goals & Levels of
Performance**

> The following section presents the indicators used to measure
> performance against the project goals. The work of the collaborative
> ran from June 2006 to May 2007, and data were available through March
> 2007 for this project. Aggregated baseline data were available for
> part of 2003, 2004 and 2005. Monthly numerator (i.e., injurious falls
> by type) and denominator (i.e., patient days) data were available for
> 2006.
>
> During the time period since the Reducing Injury from Falls
> collaborative began work, the following results have been seen:

-   Our fall and injury rates demonstrate that our organization is a
    leader in multi-factorial interventions to improve the quality and
    safety of care associated with falls in high risk populations. The
    overall hospital fall rate has incrementally decreased to below 2
    per 1,000 patient days. In the acute care setting, this rate has
    fallen steadily over past four years and is below 3 per 1,000
    patient days now.

-   Our organization is a national leader through the development of
    innovative tools with the National Center for Patient Safety.

-   Our injury rate demonstrated high reliability at the 10^-4^ level
    with movement towards better performance with an injury rate less
    than .05 per 10,000 patient days.

-   Unit specific trends in reducing injury from falls were identified.

-   The number of days between falls with moderate or worse injury
    ranged from 1 day to 176 days, with an average of 89.5 days between
    falls.

-   Patient perception of the overall quality of care has consistently
    ranged from 90-100 for the past nine months (using positive score on
    NRC+Picker).

> We did meet the project goal of one or less fall with moderate or
> worse injury per 10,000 patient days for one test unit (5-South, 0.0)
> and Acute Care (0.30) during the study time period from June 2006 to
> March 2007. We also experienced the following successes:

-   No episodes of moderate or worse injury from a fall in over 6 months
    (through June 2007).

-   While the other test unit (7-North) did not reduce the moderate or
    worse injury from falls rate to 1 moderate or worse injury per
    10,000 patient days for the study period from June 06 to March 07,
    they did experience only 1 episode of moderate or worse injury from
    a fall which resulted in a rate of 1.69 per 10,000 patient days.

-   This was the only moderate or worse injurious fall to occur in the
    acute care setting from the beginning of the project in June 2006
    through June 2007.

**1B. Briefly describe what the project actually did to meet its
goals.**

> A descriptive, retrospective review of the past 22 injurious falls
> that occurred in the acute care setting was conducted to provide a
> starting point for the two pilot units. The results of this review
> guided the implementation of several tests of change to try and reduce
> injury from falls on the units (Table 1). Ninety-one percent (20 of
> 22) patients who experienced an injury already had a falls risk
> intervention implemented at the time of their fall. As Table 1 shows,
> traditional falls risk indicators (e.g., toileting and mobility
> issues, previous history of falls) were present for the majority of
> the patients who were injured after a fall in the acute care setting.
> Additionally, only two of the cases reviewed had less than two of the
> falls and injury risk characteristics, so the patients had multiple
> factors affecting their risk for a fall and the subsequent injury they
> experienced from that fall.

## Table 1. Retrospective Review of 22 Previous Injurious Falls in Acute Care

+--------------------------------------------------------------+---+---+
| **Falls and Injury Risk Characteristics Identified with      | * | * |
| Injurious Falls**                                            | * | * |
|                                                              | N | % |
| **(% will be over 100% due to cases with multiple            | * | * |
| identifiers)**                                               | * | * |
+--------------------------------------------------------------+---+---+
| Previous fall                                                | 1 | 8 |
|                                                              | 8 | 1 |
|                                                              |   | . |
|                                                              |   | 8 |
+--------------------------------------------------------------+---+---+
| Mobility (includes any mention of needing an assist to walk, | 1 | 6 |
| use of an assistive device)                                  | 5 | 8 |
|                                                              |   | . |
|                                                              |   | 2 |
+--------------------------------------------------------------+---+---+
| Toileting issues (includes any mention of altered            | 1 | 6 |
| elimination status, or falling while toileting, attempting   | 5 | 8 |
| to toilet)                                                   |   | . |
|                                                              |   | 2 |
+--------------------------------------------------------------+---+---+
| Altered mental status/confusion                              | 8 | 3 |
|                                                              |   | 6 |
|                                                              |   | . |
|                                                              |   | 4 |
+--------------------------------------------------------------+---+---+
| Drugs (benzodiazepines, anti-convulsants,                    | 8 | 3 |
| anti-hypertensives)                                          |   | 6 |
|                                                              |   | . |
|                                                              |   | 4 |
+--------------------------------------------------------------+---+---+
| Age (Over 85)                                                | 3 | 1 |
|                                                              |   | 3 |
|                                                              |   | . |
|                                                              |   | 6 |
+--------------------------------------------------------------+---+---+
| Blood (anti-coagulants, blood disorder)                      | 3 | 1 |
|                                                              |   | 3 |
|                                                              |   | . |
|                                                              |   | 6 |
+--------------------------------------------------------------+---+---+
| Weakness                                                     | 2 | 9 |
|                                                              |   | . |
|                                                              |   | 1 |
+--------------------------------------------------------------+---+---+
| Bones (Osteoporosis)                                         | 1 | 4 |
|                                                              |   | . |
|                                                              |   | 5 |
+--------------------------------------------------------------+---+---+

> The various tests of change are described in the sections below.

## After Action Reviews (AAR) and Safety Huddles. 

> After Action Review is a knowledge transfer technique adapted from the
> military to immediately assess a situation or event in order to
> understand what occurred, why it may have occurred and what corrective
> action will be implemented to improve the situation. In this case, the
> AAR or Safety Huddle was performed by the staff after becoming aware
> of a patient fall or after a close call. During these brief meetings,
> staff asked what happened, what should have happened, what accounted
> for the difference, and what could be done to prevent another
> occurrence. The Safety Huddles, which were transformed during the
> project period to meet the needs of the test units, became vehicles
> for examining specific patient safety incidents (e.g., not just
> falls), and for ensuring that falls precautions were consistently
> applied in the shift-to-shift hand-off process. Incorporation into the
> hand-off process also provided the opportunity for staff to reassess a
> patient's status.

## Teach-back education interventions with patients. 

> Teach backs were used by asking the patient to state what they
> understood regarding fall prevention instructions and how they would
> apply this information:

1.  Patients with a history of falls were educated on their increased
    risk for falling and injury from falling.

2.  Patients on anticoagulants were educated about their increased risk
    for bleeding after a fall.

3.  Patients at risk were asked to agree to call for help, even when
    they thought they did not need assistance.

## Toileting prior to administration of high risk pain medications. 

> Based on the retrospective analysis of 22 falls injuries in which pain
> medication was frequently identified as a factor, toileting prior to
> administration of high risk pain medications was implemented.

## High risk falls precautions

> Patients with a history of falls, osteoporosis, Morse scale score of
> 50 or greater, on anticoagulants, or have a low platelet count were
> automatically placed on [high-risk]{.underline} falls precautions. As
> the level of risk increases (low, moderate, then high risk), the
> precautions are cumulative- so that interventions are additive as the
> level of fall risk increases. Thus, high risk for fall precautions
> include universal fall precautions, low risk fall precautions and
> lastly high risk falls precautions. Specifically, these high risk
> precautions are:

-   Move patient to room close to nurses station

-   Provide chair and/or bed alarm

-   Place bedside mat on floor at side of bed unless contraindicated

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-   Every one hour observation with toileting and comfort rounds (should
    include positioning, offering fluids, snacks when appropriate and
    ensuring patient is warm and dry).

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-   Consider low bed

-   Evaluation by Interdisciplinary Team

-   For patient at risk for head injury, consult Rehab Medicine for
    consideration of helmet (Examples of patients at risk for head
    injury are those on anticoagulants, patients with severe seizure
    disorder, and history of falling and hitting head).

-   Hip protectors for patients are risk for hip fracture

-   High risk red nonskid socks

-   Visual identifiers of patient risk for falls

> This test of change also included methods for interdisciplinary
> communication of a patient's heightened fall risk through the use of
> door swivels and yellow wrist bands.

## Comfort care & safety rounds

> Both units introduced comfort care & safety rounds as one of their
> tests of change. This intervention was tested based on the results of
> researchers Meade, Bursell, and Ketelsen (2006)[^1], hourly rounds in
> acute care reduced falls (P=0.01), and by 60% one year later in the
> follow-up hospitals. One test unit, 5-South, tried multiple approaches
> (e.g., team, buddy and individual) in order to implement the comfort
> and safety rounds. The following tasks were included in the rounds:

-   Check on patient and ask them about any pain or discomfort they are
    experiencing

-   Make sure that they have water and are clean and check the bed &
    room for any hazards

-   Make sure the call light, urinal and phone within reach for the
    patient

-   Check the lighting & temperature of the room & make sure environment
    comfortable

-   Turn the patient, change dressings

> The other test unit, 7-North, first implemented Toileting & Turning
> (T2) rounds every two hours. These rounds were initially tested to
> reduce the risk of falls due to toileting needs when a patient
> attempts to toilet without help. However, this test of change failed
> due to attempts to document the rounds. Yet, staff committed to this
> intervention, learned from the trial and expanded the hourly rounds to
> general safety rounds that focused on multiple patient care needs,
> rather than turning and toileting. This trial was an intermediate step
> to achieve the comfort care and safety rounds that focused on multiple
> patient care needs, rather than just toileting. In the spirit of
> innovation, all trials provide opportunities to learn.

## Other Initiatives:

-   Reasons for call light use: 7-North recorded the reasons for call
    light usage in an effort to better anticipate the needs of patients
    in order to reduce the number of attempts by the patients to get out
    of bed unassisted. This initiative prompted nurses on the unit to
    begin early morning hygiene routines earlier to assist patients when
    they first woke up.

-   Better accessibility for hip protectors: Hip protectors were
    regularly issued to new patients on the test units. However,
    replacements were not readily accessible to staff which resulted in
    the intervention being inconsistently applied. By the end of the
    project period, both test units had replacement hip protectors
    stored on the units for easy accessibility.

# Additional Accomplishments 

Since 2004, the Tampa VA Nursing Service has benefited from a Fall
Prevention Program in acute and critical care. The Program Team members
are interdisciplinary and operate from a strategic plan that has
improved our fall risk assessment reliability, standardized
interventions, expanded signage, and integrated technology to prevention
hip fractures. The IHI Project helped complement the work of the
existing Fall Prevention Program for short stay patients. The pilot
teams targeted strategies to identify and screen acute care patients for
risk of injury and implement injury prevention strategies. Nursing staff
rapidly implemented hip protectors, bedside floor mats, assistive
devices and "safety & comfort" rounds at least every two hours and often
every hour. The falls collaborative members shared knowledge constructed
from data collection and reporting, data analysis, small tests of
change, and conclusions.

On May 17, 2007 a prototype change package was presented by the IHI
staff along with a story board by each collaborative participant. This
innovative change package is ground breaking work because it facilitates
moving beyond the status quo of preventing falls to preventing
fall-related injuries. Four major criteria have emerged from the
collaborative as a testable group of interventions that can be \"bundled
together\" as multi-factorial interventions that can next be tested
using research methods.

-   Age greater than 85

-   Presence of osteoporosis, or conditions that are risk factors for
    osteoporosis, such as but not limited to history of fall-related
    fracture, corticosteroid use, smoking, heavy alcohol use, current
    low bone mass, Vitamin D deficiency, presence of certain chronic
    medical conditions (such as Cancer, Renal Failure), an inactive
    lifestyle, low lifetime intake of calcium, a family history of
    osteoporosis,

-   Presence of blood diseases, bleeding disorders or use of
    anticoagulants that increase of bleeding

-   Recent surgery with a fresh suture line that could dehisce with a
    fall, especially lower limb amputation, and abdominal and thoracic
    surgeries

# Challenges

**2. Did the project encounter internal or external challenges? How were
they addressed? Was there something RWJF could have done to assist you?
Describe each challenge and the actions you undertook to address it.**

> No challenges were encountered except to revise our rating scale for
> injury for the duration of this project so that we could compare our
> data with other participating sites. The Veterans Healthcare
> Administration uses a different injury rating scale than the National
> Quality Forum.
>
> Our approach to data management and statistical analyses was unique
> compared to the other participating sites. We utilized our RWJF
> funding to support a data manager who created the database, managed
> the data, completed statistical analysis, drafted reports, and posted
> final reports to the IHI extranet website.
>
> The lack of an injury screening or risk assessment tool continues to
> be a problem for clinical practice in acute care. Many project
> participants expressed this limitation. The literature, however,
> provided direction for identifying vulnerable populations for action.
> Future efforts should be on validating fall injury risk screening and
> assessment tools, and incorporation of these tools into electronic
> medical record systems.

# Other Sources of Support

**3. Have there been other sources of support? Please summarize them,
including how much funding each entity provided, and when these funds
were received. Also include in-kind support and what was given (e.g.,
office space, computer equipment). Indicate if the total support for the
project was more than expected or less than requested.**

> *In-kind Support.* JAHVH provided in-kind support for this project
> with the time for everyone except Ms. Hahm to participate. Ms. Hahm\'s
> salary was supported by RWJF funding. However, JAHVH funded air travel
> and per diem for Ms. Hahm to attend the final harvest meeting, May 17,
> 2007. IHI funded her hotel lodging.
>
> *Nurses are clearly designated as leaders and experts of the
> initiative.* The Falls Committee Chair is the ACNS/Acute Care, Ms.
> Innette Sarduy. She is the leader of the clinical program. Dr. Pat
> Quigley is a clinical expert on falls, part of the Falls Collaborative
> Faculty and manager of grant funds received for our participation in
> the Collaborative. She additionally leads an annual national Falls
> Conference, has presented widely on this topic, published numerous
> works and has ongoing research on falls. Two Nurse Managers, Wanda
> Gibson and Sonia Collazo led unit based changes on medical units. Dr.
> Susan White, ACNS/QI, facilitated team processes and web conference
> calls and presented at two state conferences to disseminate learnings.
>
> *Interdisciplinary collaboration* was evident with Ms. Bridget Hahm,
> an epidemiologist who coordinated data reporting and analysis for the
> falls collaborative to the IHI extranet project website. Risk Manager,
> Kyna Tyndall was integral to data collection, analysis, and assignment
> of injury for falls on all units in the system. Patient Safety
> Manager, Fanny Rice, assisted with data analysis, application of the
> toolkit and other preventive measures. Finally, Informatics staff
> provided or developed technology for documentation and data collection
> such as our CPRS post fall template.
>
> *Our initiative began on two medical nursing units- 5S and 7N.* These
> units participated in the bimonthly calls, reported on the extranet,
> performed tests of change, and communicated using a list serve.
> Testing of a prototype tool to assess risk of injury from falls
> developed through the IHI Collaborative was limited to these pilot
> units in order to focus discussions. This project builds on our
> culture of innovation that integrates technology at the point of care.
> For over 3 years, our acute care units have combined technology to
> create a safe environment, focusing on minimizing extrinsic fall risk
> factors. Thus, we have height-adjustable beds, bed and wheelchair
> alarms, floor mats and hip protectors as appropriate. As a result, the
> 5S and 7N nursing teams have served as experts to other non-VA
> organizations in this project.

# Lessons Learned

**4. What lessons did you learn from undertaking this project?**

a)  What lessons does the success or shortfall of the project have for
    other grantees attempting similar efforts?

-   Involve more staff nurses in discussions, not just the Nurse
    Managers.

-   Because challenges exist to regularly convene the project teams for
    ongoing implementation of this project, collect data, and respond to
    progress creativity is required to sustain communication among team
    members.

b)  What would you recommend to grantees to emulate and/or to avoid?

-   Identify accountability and responsibility for data collection and
    reporting at the onset of the program and provide resources for this
    person.

-   Standardize data collection rates that minimize changes or
    additional burden to current data collection methods (ie 10,000
    patient days or 1000 patient days).

-   Ensure that any pre-developed spread sheets are developed by an
    expert so that the automatic data displays are easy to read.

-   Provide notes from conference calls in a summary fashion of next
    actions and timelines.

-   Take the lessons learned to the next level for tool development and
    validation of risk for fall injury.

# Project Impact 

**5. What impact do you think the project has had to date? Who can be
contacted a few years from now to follow up on the project? Describe
what you believe to be the impact of the project, providing evidence for
all statements (e.g., publication in major journals, citations of the
project in literature, major press coverage, adoption of the model by
other organizations).**

> *Initiative shows promise of usefulness to VHA.* The process of
> assessing injury or injury from falls and using a standardized method
> to quantify injury can be easily applied VHA wide using the
> definitions from NQF which are readily available. Assessing risk for
> injury provides the evidence for nurses to provide specific
> interventions to reduce injury (e.g. hip protectors). The method of
> graphically displaying results of fall rates associated with level of
> injury provides an illustration of the organization's reliability in
> the process.
>
> *Initiative impacts multiple areas.* Since the members on the Tampa VA
> collaborative are also on the Falls Committee, the information,
> changes and reporting spread quickly to other units in the hospital,
> the nursing home and home care. Monitoring injury from falls applies
> to all patients in acute care, long term care and ambulatory patients.
> Data reporting and segmentation has been expanded to these other
> settings. Our newest data displays have incorporated levels of injury
> so that we can assess falls and injury at a glance by facility, bed
> section, and individual nursing unit. Annotations to the run charts
> provide key points in our process improvement journey.
>
> *Initiative impacts facility wide.* Using a standardized scale to
> assess level of injury has been applied in our risk management
> monitoring and is now shared in our reporting of monthly data. In 2007
> the home care falls reporting system was also standardized to include
> level of injury.
>
> *Demonstrated process improvement.* Compared with results from other
> high performing organizations in the IHI Collaborative, the Tampa VA
> is a benchmark and performing at the 10 ^-4^ or 10 ^-5^ level for
> moderate and major injury levels.
>
> *Demonstrated impact on patient/staff experience.* Positive patient
> outcomes are demonstrated in reducing adverse events to patients and
> improving patient perception with the overall quality of care. Staff
> has increased insight into the patient characteristics associated with
> injuries resulting from falls and continue to test new ideas to reduce
> both falls and injury. Staff has been actively engaged in tests of
> change on the units.
>
> *Demonstrated impact on nursing-sensitive quality indicator.* The
> following Tampa VA data are reported and benchmarked with NDNQI and
> the 11 hospitals in the IHI collaborative:

-   Fall rates per 1,000 patient days have continually declined over the
    past 3 years and our performance is better than the NDNQI mean and
    often better than benchmark.

-   The fall injury rate in our medical and surgical units is better
    than NDNQI mean benchmarks. The percent of falls with moderate or
    greater injuries is better than NDNQI benchmarks in all but one unit
    (stepdown) not part of the pilot.

-   Monitoring of time interval between falls with moderate or major
    injury has been initiated to provide additional ways to measure
    reduction in injurious falls.

-   Comparison with participants in the IHI Collaborative demonstrates
    that the Tampa VA leads performance in both of fall rate and
    injurious fall rate.

> *Demonstrated long-term integration into structures and processes.*
> Data collection, reporting, analysis and improvement now routinely
> include fall rate, and injury rates segmented into categories of
> injury. Assessment for risk of injury is the next step to be addressed
> for improvement.

For future information, please contact Dr. Pat Quigley, Project
Director, at <Patricia.Quigley@med.va.gov>, phone: 813-558-3912

# Post Grant Plans and Project Dissemination

**6. What are the post-grant plans for the project if it does not
conclude with the grant?** Include a description of the following that
are applicable:

This project is concluding with the termination of the grant; however,
the program components have been strategically added to the work of the
existing Tampa VA Fall Prevention Program.

**7. With a perspective on the entire project, what have been its key
publications and national/regional communications activities? Did the
project meet its communications goals?**

*Nursing leaders have formally disseminated information on this
initiative* in a variety of venues.

-   Reducing injury from falls was presented at a state conference of
    the Florida Organization of Nurse Executives (FONE) best practice
    meeting in October 2006.

-   Descriptions of our fall and injury data and our benchmarking
    process was presented by Ericka Lewis at the first National Database
    of Nursing Quality Indicators (NDNQI) conference held in Las Vegas
    in January 2007.

-   A poster was presented at the 4^th^ Annual Florida Magnet Nursing
    Research Conference in St. Petersburg in February 2007.

-   In May 2007, a poster storyboard was presented nationally at an IHI
    conference to provide outcomes of the year-long collaborative, led
    by Dr. Pat Quigley and Bridget Hahm, MA, MPH, on behalf of the team.

-   Wanda Gibson, MSN, RN presented *Reducing Injury from Falls in Acute
    Care* James A. Haley Hospital Update at the February 2007 national
    meeting of the IHI Transforming Care at the Bedside meeting in
    Houston, TX

*Office of Nursing Service: Innovation Award.* In May, 2007, this
project team was submitted to the VHA\'s Office of Nursing Service for
the 2007 Innovation Award Program. We are awaiting response to our
submission.

[^1]: Meade, C., Bursell, M., & Ketelsen, L. (2006). Effects of nursing
    rounds on patients\' call light use, satisfaction and safety. AJN,
    106(9), p. 58-70.