Department of Mechanical and Industrial Engineering Faculty of Applied Science & Engineering

University of Toronto – St. George

MIE561H1 Healthcare Systems Case Report 4:

Falls Reduction at KPMG’s Client Hospital

Submission Date: April 5, 2016 Group 11

Group Member Name Student Number Email address

Zacks Pan 999431271 zacks.pan@mail.utoronto.ca

Farabi Shireen 998986414 fshireen@gmail.com

Ronald Hoffer 995386620 ronald.l.hoffer@gmail.com

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EXECUTIVE SUMMARY KPMG Consulting is currently working to reduce the number of preventable patient falls in a

hospital in Southwestern Ontario. The hospital, which sees mainly elderly patients, currently

incurs approximately 300 preventable falls per year. The majority of the falls occur between

midnight and 5:00 am by elderly patients attempting to ambulate to and from the restroom. The

hospital wants to reduce the number of preventable falls by 25% over the next year, while

working towards the longer term goal of making itself into the safest hospital in Canada.

Previous efforts by the Seniors Friendly Committee (SFC) to reduce the number of falls have not

made a considerable impact, and the annual rate of falls within the hospital has remained

consistent for the past five years.

Investigation of the problem has revealed a lack of physical patient restraints, inadequate night

time lighting, long nurse response times to patient call bells, and a lack of stakeholder

involvement as the four root causes of the problem.

The authors have considered three main solutions. The first is to increase stakeholder

involvement by allowing overnight visitors in patient rooms and recruiting willing patients and

their family members to the SFC. The second is to install a smart lighting system in patient

room. The system detects when a patient is waking up to use the restroom and automatically

illuminates a path to the restroom, with the lighting level being neither too dim to be useful nor

too bright to be comfortable to a freshly awakened patient. The third solution is a second

generation bed alarm that uses reduces the nurses’ workload. By reducing the attention a nurse

must give to patients that have a low risk of falling, it enables nurses respond more quickly to

patient call bells. The consequent reduction in nurse response time to call bells means that

patients are more likely to use the call bells and wait for the nurses.

The solutions were compared to each other on several criteria, including implementation

difficulty, implementation time, cost, reliability, patient satisfaction, nurse satisfaction and

impact on reducing risk of falling. The comparative evaluation revealed the second generation

bed alarm as the preferred solution.

In the long-term, we recommend that the hospital increase its data collection from falls to better

understand where, when, and why falls are happening.

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1.0 INTRODUCTION KPMG Consulting is currently working to reduce the number of preventable patient falls in a

hospital in Southwestern Ontario. The hospital, which sees mainly elderly patients, currently

incurs approximately 300 preventable falls per year. The majority of the falls occur between

midnight and 5:00 am by elderly patients attempting to ambulate to and from the restroom. 75%

of these falls occur within the cardiac surgery ward, the elderly care unit, the inpatient cardiology

ward, the inpatient chest ward, and the inpatient medicine ward.

The hospital wants to reduce the number of preventable falls by 25% over the next year, while

working towards the longer term goal of making itself into the safest hospital in Canada.

Previous efforts by the Seniors Friendly Committee (SFC) to reduce the number of falls have not

made a considerable impact, and the annual rate of falls within the hospital has remained

consistent for the past five years. These efforts have included the installation of bed alarms,

mobility checks for equipment, non-skid socks, the distribution of pamphlets to educate patients

and family members about preventable falls, falls risk assessments for all patients, and visual

display board management of patients at risk of falling.

Govind from KPMG has asked the student teams of the MIE561 Healthcare Systems class to

suggest process-related and cost-neutral solutions to reduce the number preventable patient falls

while maintaining a high quality of care and increasing patient and staff satisfaction.

2.0 PROBLEM DEFINITION Govind provided several details about the problem. As mentioned in the introduction, the

greatest number of preventable falls occurs to elderly patients ambulating to and from the

restroom between the hours of midnight and 5:00 am. Falls also occur when patients get out of

bed in general, when patients stand up from a seated position, and when patients being

transported through the hospital. Falls can be categorized according to the rating system in Table

1. Approximately 60% of the falls are of level-1 severity. All patients undergo a falls risk

assessment upon being admitted.

Table 1: Level of Severity of Falls

Level-0 Near miss/potential harm/damage

Level-1 No harm

Level-2 Temporary minor harm/damage

Level-3 Permanent harm/damage

Level-4 Death

Every time a fall is known to occur, it is reported and given a rating based on the fall’s severity.

An investigation is then carried out by the patient safety committee. This entails holding a

meeting with the managers to look at safety practices and suggest and implement improvements.

This task is carried out exclusively by two people from the 20-person committee. The committee

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officially meets monthly to discuss the welfare of the hospital’s senior patients, though due to

logistical challenges, meeting typically only take place quarterly.

Nurses at the hospital work twelve-hour shifts. The nurse-to-patient ratio is 1:5 during the

daytime and 1:6 at night. Every 2 hours, the nurses conduct “purposeful rounding.” This entails

checking that each bed alarm is working properly, ensuring that each patient’s call bell is within

the patient’s reach, and checking to see if the patient needs anything.

A significant percentage of the patients take sedation medications. These medications can cause

disorientation and make the patients more prone to falling within eight hours of receiving them.

For the large number of falls that occur as patients ambulate to the restroom at night,

disorientation and low levels of alertness caused by sleepiness and lack of lighting may be

contributing factors.

All rooms are equipped with call bells which the patients are encouraged to use. Once pressed,

the corresponding nurse on duty is alerted that the patient needs assistance, and the nurse

responds as soon as possible. However, nurse response times are often as great as 25 minutes

due to each nurse’s heavy workload. Consequently, patients are sometimes unwilling to use the

call bells, especially when they urgently need to use the restroom.

Although friends and family members of the patients are unable to stay overnight at the hospital,

they are able to visit throughout the day. As a result of this, extra furniture may be brought into

patient rooms during the day. When the visitors leave, they often leave the extra furniture in the

rooms, where they cause clutter. This poses a hazard to ambulating patients, particularly in the

darkness and disorientation of the night.

3.0 ROOT CAUSE ANALYSIS Potential factors contributing to preventable patient falls are a lack of physical restraint of the

patients, dim lighting in patient rooms at night, long nurse response time to call bells, and the

lack of accountability to the management of implementations by the SFC (see Figure 1). These

issues are described in detail below.

Figure 1: Root cause flow chart for KPMG’s hospital patient falls

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3.1 Lack of physical restraint of patients Hospital beds are height adjustable, and prior research has suggested that high hospital bed

heights are a contributing factor to falls for patients getting out of bed [1]. As the client is not

aware of any policy of lowering the beds at night, it can be assumed that high bed height is a

contributing factor to some of the preventable falls. Patient beds are also equipped with bed

rails. However, all four rails are often not left up at night. This poses a risk to patients who have

been deemed as “at risk” by the falls assessment. According to the client data, more than three

times as many patients fall from beds with two rails up as opposed to those with three rails up,

and ten times as many from beds with two rails up than that with four rails up (Appendix A). It

can therefore be inferred that lack of deployment of bed rails is a contributing factor to falls.

3.2 Dim Lighting in Patient Rooms According to the data provided by the client (shown in Appendix B), “confusion/disorientation”

is currently the largest contributing factor and “slipped/tripped” is the third largest contributing

factor to patient falls. It should is known that the most falls occur at night, and it is assumed that

inadequate lighting can contribute to both confusion/disorientation and tripping/slipping, and

assuming that patient room lights are turned off at night, especially in a cluttered room with lots

of tripping hazards. Therefore, it can be inferred that inadequate room lighting at night is a root

cause of the falls.

3.3 Nurse Response Time to Call Bells Data from the client (Appendix B) lists “needed help, did not use call bell” as the second largest

contributing factor and “toileting required” is the fourth largest contributing factor to patient

falls. As mentioned in the problem definition section, patients often must wait up to 25 minutes

for nurses to respond to their call bells. A patient may wait for the nurse the first few times, but

will soon tire of waiting each time he/she needs to use the washroom. It is likely that the patient

will eventually just skip the call bell and go to the bathroom himself.

3.4 Minimal Role of Patient Safety Committee The client indicated that there is a lack of feedback to the hospital staff from the SFC following

each fall investigation. Although the number of falls and the reason for each fall are tracked,

there are no consequences for any party. As indicated in the problem definition section, the SFC

typically meets quarterly instead of monthly as it is supposed to. As a result, there has been a

lack of follow up to measure the success of previous changes made to increase patient safety. A

lack of prioritization of falls prevention by the SFC and hospital staff may be preventing the

reduction of the preventable fall rate.

4.0 SCOPE OF SOLUTIONS The hospital has already implemented solutions such as anti-slip socks and bed. This report will

provide suggestions on improving the effect of existing measures, as well as suggestions of

solutions net yet implemented. The scope of suggested solutions will be limited to those that

reduce the risk of falling and lower the fatality rate of falls that do occur. Suggested solutions

will be limited to those that reduce the falls rate of the largest fall group, which is patients

ambulating the restroom at night. Since the hospital possesses limited resources as well as the

need to maintain a functioning environment, major alterations of the ward’s floor plan are

excluded from the scope. Changes to nurse staffing levels are also excluded from the scope.

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5.0 RECOMMENDATION SOLUTIONS

5.1 Increased stakeholder involvement This solution seeks to reduce falls by engaging stakeholders in their prevention.

5.1.1 Patients and family members joining the SFC Currently, the SFC, which is in charge of designing and implementing measures to reduce falls,

does not view the falls issue as high-priority. This is indicated by the fact that there is a lack of

interest and involvement from the committee to develop a long-term solution. We suggest that

patients and their families be included in the committee from now on. They will not only be able

to offer a new and relevant perspective on the issue, but, as the victims of the falls, they will have

an inherent interest at decreasing the rate of falls.

5.1.2 Allowing overnight visitors Another method of increasing stakeholder involvement is to allow family members and friends

of the patients to stay overnight. Visiting policies are becoming less restrictive across Canada

[2], meaning family members can now stay overnight in some hospitals. These family members

can be enrolled to accompany the patients on their night time restroom trips. Patients with

family members staying overnight would not have to wait for a nurse to respond to their call bell.

Simultaneously and consequently, patients without overnight visitors will have easier access to

the nurses, meaning that they too will not have to wait as long for assistance to travel to the

restroom.

5.2 Automatic night time lighting system This solution is based on several assumptions. The maximum number of falls occurs by patients

ambulating from their hospital beds to the bathroom between midnight and 5:00 am. It can be

assumed that the high rate of falls during this time can be largely attributed to the lower level of

alertness that patients have at this time of day. What is therefore needed is a solution that

maximizes the alertness of patients using the restroom at night. It will be taken for granted that

people at night will typically be more alert in a lighted environment than a dark one. It will also

be taken for granted that many people do not like to turn on lights in the middle of the night

because, for eyes that have just been sleeping, regular room lighting levels are far too bright to

be comfortable. It will also be taken for granted that in the hospital setting, which does not have

the same familiar light switch positions as one’s home, night time restroom users will be even

less likely to use the lights, and all the more so in multi-person rooms in which the ambulating

patient does not wish to wake up the other patients in the room.

Therefore, we propose a sophisticated lighting system that will help raise only the awake

patient’s alertness so that he/she can travel safely to and from the bathroom safely. A system of

overhead track lights such as those shown in Appendix C will illuminate only the patient’s bed,

the interior of the bathroom, and the route between the bed and the bathroom. The lighting will

be controlled automatically by a non-contact ResMed S+ sleep monitoring and analysis device

shown in Appendix D [3]. The ResMed S+ uses patented non-contact respiratory and bio motion

sensors to monitor the respiration and movement of a sleeping person. It is programmed with the

intelligence to recognize the patterns of respiration and movement that correspond to various

levels of sleep. It has an alarm clock feature that deliberately and slowly wakes up the patient

when the patient when is in a light phase of sleep. This capability will be used to slowly

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illuminate the appropriate lights when a patient becomes fully awake in the middle of the night.

The lights will gradually come up to a comfortable dim level that clearly illuminates that

patient’s path to the washroom but does not blind the patient. A source could not be found

indicating the appropriate duration of transitioning from darkness to light, but it will be assumed

to be 15 seconds from the moment of sitting up. When the ResMed S+ recognizes that the

patient has returned to the bed to go back to sleep, it will gradually dim the lights back to

darkness.

The costs associated with the system are the purchase of the $150 USD ResMed S+ device for

each patient [3], the installation of about 10 focussed light fixtures per room at a cost of

approximately $20 CDN each [4], installation labour estimated be about $500 CDN per hospital

room, and computer programmer costs estimated to be $10,000 CDN for the entire project.

Assuming a hospital with 400 beds and 200 rooms and the current exchange rate of $0.76 USD

per $1.00 CDN, the capital cost will be about $193,000 CDN.

5.3 Second generation bed alarm and notification bell The bed alarm can be improved to track patient activity and predict the patient's likelihood of

getting out of bed. This will reduce the rate of false alarms, thereby reducing nurses’ alarm

fatigue. The bed alarm system will be integrated with a web application to monitor the patient’s

movement and send potential falls message to nurses. The application will provide a time-color

labeling of each patient’s profile. If the patient’s state has any changes, the application will mark

the patient it with a color alert. Green will mean the patient is in the bed and yellow will denote

that the patient has left the bed. When the patient’s state changes from in-bed to out-of-bed, the

system will start a timer and send a “yellow alert” to the nurse on duty. If the patient is gone for

an extended period of time, the nurse will receive a “red alert” that requires the nurse to check up

on the patient. Time analysis will be performed based on washroom time data. Whereas the

current bed alarm sounds whenever the patient leaves the bed, this design calls the nurse only if

the patient stays out of bed. This reduces the number of alarms, thereby enabling nurses to

become more responsive to patient call bells and serious bed alarms.

The second aspect of this design is the notification bell. Unlike the call bell, the notification bell

does not require a nurse’s response. It merely lets the nurse know that a patient has gotten out of

bed to use the restroom. Notification bell buttons will only be given to patients who are deemed

to be at low risk of falling. The result is that patient who can reliably travel to and from the

restroom will not be required to call a nurse to do so. This will further reduce the nurse’s

workload and allow the nurse to focus on the remaining call bells and bed alarm red alerts.

6.0 EVALUATION OF SOLUTIONS The advantage of the increased stakeholder involvement solutions is that they carry no cost.

However, they rely on factors beyond the hospital’s control. There may not be a large number of

patients with overnight visitors some of the time. There may not be patients or family members

volunteering to join the SFC. The overnight visitor solution also increases clutter in the rooms,

which could actually increase the fall rate.

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The advantages of the automatic night time lighting system are its predicted effectiveness, its

fully automatic nature, and the relative lack of required training. The disadvantage is its high

capital cost.

This second generation bed alarm carries a moderate capital cost for the software development

and software and hardware installation. However, it carries a low operating cost. It has the

advantage of using the existing bed alarm equipment and patient call bell, though not all beds are

equipped with the call bell. Deploying the system on all beds would increase the capital cost.

The system is expected to be effective at diverting nurse attention to patients who are more likely

to fall without their help.

The solutions are evaluated against each other in As shown in the table, the second generation

bed alarm is the preferred solution. It targets the second- and fourth-largest contributing factors

to falls, costs less than the lighting solution, and is expected to improve both the staff and patient

experiences.

Table 2. As shown in the table, the second generation bed alarm is the preferred solution. It

targets the second- and fourth-largest contributing factors to falls, costs less than the lighting

solution, and is expected to improve both the staff and patient experiences.

Table 2: Evaluation comparison matrix of proposed solutions ranks solutions on a scale of 0 (poor) to 5 (excellent) in

several criteria.

Increased

stakeholder

involvement

Automatic

night time

lighting

system

Second

generation bed

alarm and

notification bell

Implementation difficulty 3 3 3

Implementation time 5 0 1

Cost 5 0 2

Reliability (double weighted) 1 (2) 5 (10) 4 (8)

Patient satisfaction 3 4 4

Nurse satisfaction 3 4 5

Impact on reducing risk of

falling (quadruple weighted)

2 (8) 4 (16) 4 (16)

Total 29 37 39

7.0 CONCLUSION Reducing the client’s hospital’s rate of preventable falls is a necessary step on the road to it

becoming Canada’s safest hospital. The falls are caused by equipment deficiencies, inadequate

lighting, long nurse response times, and a lack of stakeholder involvement in reducing falls. A

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comparison of several solutions has revealed a second generation bed alarm as the preferable

solution for reducing the rate of preventable falls.

8.0 FUTURE WORK While there is some data available that reveals the patterns and causes of the patient falls in the

hospitals, it is incomplete. Indeed, the solutions generated in this report were conceived of based

on some assumptions. Better data tracking is needed to help the nurse staff better understand

where, when, and why patients are falling. This will allow further appropriate anti-fall measures

to be implemented in the future.

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REFERENCES [1] A. Huey-Ming Tzeng, "Nursing staff’s awareness of keeping beds in the lowest position to

prevent falls and fall injuries in an adult acute surgical inpatient care setting", Medsurg

nursing : official journal of the Academy of Medical-Surgical Nurses, vol. 21, no. 5, p. 271,

2012.

[2] R. O’Reilly, D. Bournes, M. Stasiuk, and J. Petch, “Canadian hospitals being to open up

visiting hours”, Healthy Debate, 2015. [Online]. Available:

http://healthydebate.ca/2015/03/topic/visiting-hours. [Accessed: 05- Apr- 2016].

[3] "S+ sleep monitoring device | ResMed.com", Resmed.com, 2016. [Online]. Available:

http://www.resmed.com/us/en/consumer/s-plus.html. [Accessed: 05- Apr- 2016].

[4] "Search Results for recessed lighting at The Home Depot", Homedepot.com, 2016. [Online].

Available: http://www.homedepot.com/s/recessed+lighting?NCNI-5. [Accessed: 05- Apr-

2016].

[5] Tectonica-online.com, 2016. [Online]. Available: http://www.tectonica-

online.com/art/images/8bt24.jpg. [Accessed: 05- Apr- 2016].

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APPENDICES

Appendix A: Client data – types of falls

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Appendix B: Client data – top contributing factors for falls

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Appendix C: Photograph of focused overhead lights

Overhead lights with narrowly focused beams illuminate predominantly what is directly underneath them. Image from

[5].

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Appendix D: The ResMed S+ non-contact sleep monitoring device

Photograph of the ResMed S+ Sleep monitoring device. Image from [3].

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Work Attribution Table

Farabi Ronald Zacks

Report Formatting/Editing MR

Executive Summary FD, ed

Introduction FD MR

Problem Definition FD ed

Root Cause Analysis FD ed

Scope ed FD

Solution 1 FD ed

Solution 2 FD, ed

Solution 3 ED FD

Evaluation of Solutions FD, ed FD

Conclusion FD, ed

Future Work ed FD

FD = First Draft and associated research MR = Major Revisions ed = Minor Editing