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Craig Hospital is highlighted for reducing falls and increasing quality

February 05, 2014

Falls matter. According to the Agency for Healthcare Research and Quality (AHRQ), close to 1 million falls are recorded in hospitals around the United States each year. About 10% of these hospital falls result in serious injury or even death. It comes as no surprise that preventing falls is a top priority in terms of patient safety, patient and family satisfaction, and a hospital’s quality reputation. But falls also cost money. Half of all reported hospital falls result in injury, and hospitalization from a fall can cost an average of $17,500. (And no, fall-related costs are not reimbursable by the Centers for Medicare and Medicaid Services).


Although there may not be one change that will eliminate falls completely, there are tools that can lessen the chances of a fall, including safe staffing, risk assessments, and quality measures and reporting. In fact, the National Database of Nursing Quality Indicators® (NDNQI) conducted a six-year analysis of falls in hospitals to evaluate care quality, compare falls prevention programs, and assess hospital standards for falls prevention and reporting. As part of their analysis, they performed a case study on Craig Hospital.

When compared in size with other hospitals, it may be considered small at 93 beds, but it is world-renowned for the long-term care, acute care, rehabilitation and research of traumatic brain injury (TBI) and spinal cord injury (SCI). Falls are of particular concern to our nurses as neurologically challenged patients have a high fall and near-fall risk. Although figures about falls resulting in injury were below national averages, the number of falls was still unacceptable because of our quality commitment and rehabilitation focus on treating a large number of newly injured persons with physical and cognitive impairments. It took quality data reporting through NDNQI to help our Craig nursing staff see where it could achieve breakthrough change and innovation to lower its falls rates.

Analysis of the problem identified that one of the main ways for falls to occur was when only one staff person assisted in patient transfers of the TBI patients with impulsivity, a common issue after brain injury. Discussion and study of the problem resulted in the implementation of a “Two to Transfer” policy, which was quickly embraced by staff. When transfers occur with TBI patients, two staff members are now present. This change brought the incidence rate below the national benchmark. The data helped justify the need for that second staff member.

Jen Biggs Clinical

Jen Biggs MSN, RN, CRN
Clinical Nurse Coordinator

It’s hard to argue with hard data,” says Jenn Biggs, MSN, RN, CRN, Clinical Nurse Coordinator.

Since the policy was implemented, scores for total falls for the last eight quarters ranged from 0.0 to 0.22 and strongly outpaced the national mean.

The information presented above was taken in part from the latest NDNQI Report, Reducing Falls. Increasing Quality. Learn how to help your hospital reduce falls by downloading the special Quality Brief: