Benchmark – Evidence-Based Practice Project Proposal Final Paper

Benchmark – Evidence-Based Practice Project Proposal Final Paper

Benchmark – Evidence-Based Practice Project Proposal Final Paper

Falling is one of the most challenging public health problems associated with consequences ranging from minor abrasions and bruises to serious health implications like fractures, lacerations, head injuries, and sometimes death. Over one million patients admitted to hospitals in the U.S fall every year, accounting for about 85% of all hospital-acquired health complications (Jong et al., 2019). However, studies show that the incidences of inpatient falls and injuries vary based on the characteristics of the unit, with Med-Surg units recording the highest risk for falls as compared to the intensive care units among others. In the United States, falls in the medical-surgical unit range between 3.67 and 6.27 per 1000 patient days (PDs). As such, there is a need to implement evidence-based interventions to help reduce the risks of falls in this unit. The purpose of this project is to evaluate the effectiveness of the evidence-based Fall Tailored Interventions for Patient Safety (TIPS) Toolkit in reducing the rates of falls and injuries in the medical-surgical unit.

Problem Statement

Clinical Question/PICOT Statement

Among hospitalized adult patients in the medical-surgical ward (P), does the utilization of the Fall Tailored Interventions for Patient Safety (TIPS) Toolkit (I), as compared to routine fall prevention protocols (C) help reduce the incidences of falls and injuries (O) within 24 weeks (T)?

Benchmark – Evidence-Based Practice Project Proposal Final Paper

Impact of Falls in the Medical-Surgical Unit

Falls and associated injuries among hospitalized patients are widespread in most medical and surgical wards, posing a serious threat to the safety of the patient. Accidental falls account for the majority of reported incidences in hospitals complicating roughly 2% of hospital stays. According to Dykes et al. (2020), the rate of falls among hospitalized patients in the United States ranges from approximately 3–5 per 1000 bed-days. The incidences of falls depend on the characteristic of the unit, with patients hospitalized in the medical-surgical unit being at high risk as compared to those in the intensive care unit (Lucero et al., 2019). Consequently, studies have also reported that approximately 25% of reported falls among hospitalized patients normally result in injury, whereas 2% cause fractures. Acute care patients normally display an increased risk of falls resulting from newly altered mobility, history of previous falls, medication side effects, or altered mental status among other factors (Cuttler et al., 2017). Despite the cause, the increasing incidences of falls are becoming very costly, with increased morbidity and mortality rates from fall-associated injuries and fractures. The lack of significant fall prevention intervention despite years of struggle has contributed to the frustrations among healthcare workers, researchers, and patients at risk. It is thus time to adapt nurse-led evidence-based interventions like the TIPS tool which have proven to be effective in the reduction of fall incidences among adults in the medical-surgical ward (Tzeng et al., 2021).

Organizational Culture and Readiness

The organization’s culture is characterized by the adoption of effective leadership styles, teamwork, rewards for success, and continuous quality improvement. The organization utilizes transformational leadership. The leaders recognize the vital roles that employees play in the organization’s success. As a result, they encourage open communication, responsibility, and trust among the staff (Handtke et al., 2019). Teamwork is also utilized in the organization. Employees utilize interprofessional collaboration to achieve optimum outcomes in the care process. Employees are also rewarded for their contribution to the organization’s success. The goal is to ensure that people are motivated to attain better results and that the care treatments employed are innovative. There is also the adoption of interventions that promote continuous quality improvement (Vaishnavi et al., 2019). For example, the organization builds its success on best-proven strategies to enhance its performance. These aspects support the proposed change since the existing organization’s culture encourages continuous quality improvement, innovation, and transformation of the existing systems and processes.

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Readiness Level

The organizational readiness to adopt change was done using the Organizational Readiness to Change Assessment (ORCA) tool. ORCA tool is largely used in practice to determine the readiness of an organization to implement evidence-based practices for use in the patient care process. It evaluates three aspects of organizational change readiness: the strength of the evidence supporting the proposed change, the quality of the organizational context for change, and the organization’s ability to change. The assessment using the tool showed that strong evidence supports the proposed change exists. Evidence assessment showed the readiness of the healthcare team to implement the change (Handtke et al., 2019). The change aligns with patient and provider experiences. It also enhances the realization of optimum clinical outcomes.

Context assessment showed that the organizational leadership and staff culture aligns with the change. The organization’s leaders also adopt effective behaviors that support change. They offer regular feedback to the staff to ensure continuous quality improvement in performance. The facilitation assessment showed that the organization has adequate capacity to support change. It has adequate champion characteristics, implementation resources, plans, and leaders that can ensure the success of the process (Vaishnavi et al., 2019). The organization scored high in evidence and context assessment and moderately high in facilitation assessment. The identified strengths from the assessment include effective organizational leadership, staff readiness for change, organizational behaviors that support change, and resource adequacy. The identified weaknesses include staff shortage and lack of regular opportunities for change in the organization. The potential barriers that may affect the implementation of the project include competing interests and staff shortages.

Healthcare Process and Systems

The recommended healthcare system that should be adopted to improve quality, safety, and cost-effectiveness is integrated electronic medical record systems. Integrated medical health records are systems that have been incorporated into multiple healthcare systems to enhance efficiency in processes. It automates multiple functionalities such as diagnosis, electronic health records, billing, electronic prescribing, and practice management. The organization’s benefits of adopting integrated medical records systems include streamlining provider workflow, enhancing patient engagement, and care coordination interventions (Song et al., 2022).

Strategies to Facilitate Organization’s Readiness

One of the strategies that will be adopted to facilitate the organization’s readiness is training staff on the implementation of change. Training will ensure the staff has the desired knowledge and skills to implement the change during patient care (Handtke et al., 2019). The other intervention will be active stakeholder involvement. The staff and other stakeholders will be actively involved in project activities such as change assessment, planning, implementation, and evaluation. The last strategy will be open communication (Bista et al., 2018). Two-way communication will be encouraged to ensure the prioritization of the needs, views, and concerns of the change implementers.

Stakeholders and Team Members

The project team and stakeholders will comprise nurses, nurse managers, and leaders. Nurses will be involved in all the project steps such as assessment, implementation, monitoring, and evaluation. They will also collect data needed for evaluating the effectiveness of the change in the organization. Nurses will provide feedback that would be used in implementing improvement strategies in the change implementation process. Nurse Managers will oversee the implementation process to ensure it aligns with the developed plan. They will also obtain feedback from the nurses about the effectiveness of the change. Nurse leaders will lobby for institutional support for the needed resources. They will also ensure nurses adopt effective behaviors and strategies that support change.

Information and Communication Technologies

The information and communication technology that is needed for the project implementation is a system for monitoring falls among hospitalized patients. The system will be embedded in the existing medical health records to facilitate the accurate acquisition of data related to fall events and their associated risks. The system will enable nurses and other healthcare providers to track factors contributing to falls and facilitate the implementation of strategies to address them in practice.

Literature Review

Method

To gather adequate information supporting the utilization of the Fall Tailored Interventions for Patient Safety (TIPS) Toolkit (I) in reducing incidences of falls in the medical-surgical unit, it was necessary to look for published articles from medical databases such as CINHAL, Dynamed, PubMed, Cochrane Library, and Trip database. In addition, google scholar was also employed in the literature search. Various keywords were used in querying the database, including patient falls, fall prevention, medical-surgical ward, and fall tailored intervention for patient safety. The search was then limited to articles published in the last five years.

Main Component of each Article

Only eight articles were selected for this literature review. The first study is the research by Cuttler et al. (2017) which examined the efficacy of a fall prevention program containing fall prevention visual signaling icons and education videos integrated with bed exit alarms in improving fall and injury rates among patients in medical-surgical inpatients. The study design took the form of a performance improvement study with historic control involving a total of four medical-surgical units. As part of the intervention, trained volunteers showed patients four-minute video icons containing the patient’s interventions and risk factors. In addition, the researchers also used patients’ beds fixed with sensitive exit alarms and used for patients at risk of falling. Upon the analysis of the collected data, the researchers noted that the rates of patient falls were reduced by 20%. Falls causing injuries were also reduced by 40%.  In addition, there was a reduction by 85% in falls that led to serious injuries. This article supports the proposed PICOT as it shows the efficacy of a fall-tailored intervention in reducing the rates of falls.

Another research was performed by Duckworth et al. (2019). The objective of the study was to evaluate the impact of a fall TIPS in engaging patients towards fall prevention and the efficacy of the fall prevention program. The research was based on a three-step fall prevention process where random audits were performed with the focus on measuring adherence which was represented by the presence of a poster detailing a fall TIPS. Analysis of the data indicated that a total of 1209 audits were performed for patient engagement, while 1401 were for the poster. Every unit attained an eighty percent adherence in both measures. Therefore, the program effectively facilitated a three-step fall prevention process making it suitable for evidence-based fall prevention. This also supports my PICOT as it showed the efficacy of the TIPS modality.

Dykes et al. (2020) performed a study on the efficacy of a fall-prevention tool kit that engages families and patients in reducing the rates of patient falls. This was a large non-randomized controlled trial with a total of 37231 research subjects drawn from several medical units. The intervention used in this study was a fall-prevention program that links evidence-based interventions for preventing falls to patient-specific fall risk factors. The tool was integrated with a continuous engagement of the family and the patients. The primary outcome was the number of patients who fell, but the secondary outcome was the number of patients who fell and were injured. The pre and post-intervention analysis showed a reduction in patient falls by 15% after implementing the intervention. In addition, upon the use of the fall prevention kit, there was a reduction in injurious falls by 34%. Therefore, the use of a fall-prevention kit led to a substantial reduction in the rates of falls and fall-related injuries. Therefore, it also supports the proposed PICOT statement.

Johnston and Magnan (2019) also performed a study on patient fall to determine the impact of the application of a fall prevention checklist on the implementation of a fall prevention protocol and the rates of patient falls. A total of 37 nursing staff were involved in the study and, in total, completed ninety fall prevention checklists. The researchers used a fourteen-item checklist based on the hospital’s already approved fall prevention protocol to evaluate the nursing staff’s adherence to every intervention and the resultant fall rates. The researchers then tracked the patient’s falls daily. Setting bed alarms were found to be the most often missed intervention, with personnel setting them wrong approximately 20% of the time. The researchers also noted that there was no patient fall during the study indicating the efficacy of the protocol. As a result, this paper backs the PICOT, as the fall prevention procedure proved crucial in lowering the rate of falls.

Dyke et al. (2017) conducted a study on a fall TIPS toolkit. The study’s objective was to use the fall TIPS tool kit in educating and engaging patients in three-step fall prevention. The implication is that the tool was also offering clinical decision support at the patient’s bedside. The program then links every patient’s fall risk assessment with possible 5 interventions. The analysis of the data indicated that there was an average of eighty-two percent unit compliance with the Fall TIPS. In addition, the mean falls rate was also reduced from 3.28 to 2.80 per 1000 patient days. Again, the researchers observed a decrease in the number of falls leading to injury. Therefore, this source also supports the proposed project and the PICOT questions as it shows that an application of a fall TIPS positively impacts the incidences of falls among inpatients.

Mayhoba and Amin (2022) conducted research intending to compare routine fall prevention and a tailored fall prevention approach for preventing falls among the elderly. Using a quasi-experimental study design, the researchers recruited one hundred and eight patients to take part in the study, with fifty-four each recruited into the control and study group. The intervention group received a tailored intervention for patient safety which entailed putting forth an individualized fall prevention strategy for every patient and a poster that was placed in a visible place to act as a reminder of the fall prevention interventions and the risks. The control group received normal care. The data analysis indicated that the patients who received usual care were close to two times more likely to fall than those in the tailored approach. The paper, therefore, supports the PICOT as it shows that the use of TIPS is efficacious in preventing falls.

Tzeng et al. (2021) conducted a study that focused on evaluating the efficacy of a fall tailoring intervention for patient safety programs in the prevention of falls and related injuries among older individuals residing in nursing homes. The intervention used in this study offers bedside clinical decision support to prevent patient falls. Upon the analysis of the collected data, the researchers noted that there was a significant decrease in the rates of patient falls, indicating that the fall TIPS intervention was important in controlling and preventing falls. Therefore, the sources also support the PICOT as it shows the importance of using a fall prevention protocol to control and prevent patient falls. 6

Avenecean et al. (2017) conducted a systematic review to evaluate the effectiveness of patient-centered interventions on falls applied in acute care settings. The data considered were on patients admitted to the surgical or medical units. The researchers reviewed only randomized controlled trials, and through a database search and refining, they obtained five relevant randomized controlled trials. Three trials found a statistically significant decrease in patient falls (p-value less than 0.04), whereas the other two found no statistical change. One notable conclusion is that the studies that had a significant reduction of falls employed patient-centered education and personalized care plans formulated based on the patient’s fall risks. Therefore, the interventions should be patient-centered for them to be more useful.

Comparison and Contrast of Articles

The articles that have been reviewed above share the similarity of supporting the use of Fall TIPS toolkits in reducing the incidences of falls in the Medical-Surgical Unit. A total of eight research articles have been reviewed, with seven of them being primary research articles and one is a systematic review. The major theme explored in the articles is patient fall prevention, even though in diverse patient settings. One major difference was observed in the study designs employed; while some of the articles employed controlled trials, others employed quasi-experimental designs to help achieve the goals. While there is no controversy reported, all the articles reported some limitations that need to be addressed, such as inadequate sample size and the possible lack of generalizability.

Areas of Further Research

From the literature analysis performed, various gaps could be identified. For example, few studies on the topic have used a randomized controlled trial design. Being that the design is a golden standard. More research on this area should use the design to obtain better evidence that can be translated. In addition, studies should be done using larger sample sizes as well as a multicenter approach to improving the results and generalizability.

Change Model, or Framework

For appropriate development and implementation of evidence-based practice, several change models/frameworks have been proposed based on the kind of intervention being implemented. For this project, the most appropriate change framework is the Iowa model to guide the incorporation of the Fall TIPS toolkit in reducing fall incidences in the medical-surgical unit. The Iowa model was developed in 1902 at the University of Iowa Hospitals and Clinics to help guide nurses to utilize research findings in promoting the quality of patient care (Cullen et al., 2022). The model serves as a pathway to EBP, in identifying the problem, researching the potential solutions, and implementing the change. This model mainly allows clinicians to draw their focus toward knowledge and problem-focused triggers, and to question whether the use of research can help solve and identify problems in the current practice. For my project proposal, the Iowa model will play a significant role in helping clinicians identify the impact of falls in medical-surgical wards and come up with the most effective EBP intervention to help reduce fall incidences and promote patient outcomes (Tucker et al., 2019). The model will also provide a stepwise guide to promote the effective implementation of my proposed EBP intervention in clinical practice.

The first step in promoting EBP after adopting the Iowa model is to identify a trigger that necessitates a shift in EBP. The trigger can be either a problem or a piece of knowledge. The following step involves evaluation of the priority of the identified change trigger or problem for the practice or organization (Tucker et al., 2021). Once the significance of the identified problem has been considered a priority, the following step involves selecting a team of professionals who will be involved in the development, implementation, and evaluation of the EBP change. In the next step, the change leader will come up with an outline that will help guide the research aimed at identifying the most effective solution. The research findings or study outcome are synthesized and analyzed in the fifth step, to decide on which EBP is going to be implemented to solve the problem. The selected team members analyze and confirm that the selected EBP is the most applicable and effective in solving the problem. Once the team members have agreed on a given EBP, the implementation process can then begin. Once the EBP has been implemented, the last step involves evaluation of the entire implementation process and outcome in clinical practice to identify strengths and areas of weakness which must be addressed to optimize the outcome.

For my project proposal, the application of the Iowa model helped in identifying a problem-focused trigger for change in the first step, which is increasing incidences of falls in the medical-surgical ward and how it negatively impacts patient outcomes (Khandagale, 2021). In the second step, it was confirmed that this is a priority problem that requires immediate attention by identifying the most effective EBP to solve the problem entirely. The third step involved coming up with a team of professionals to guide the EBP comprising of the nurse leader, registered nurses, and physicians among other clinicians. The team carried out extensive research on the most effective way to reduce the incidences of falls in hospitals. It was discovered that Fall Tailoring Interventions for Patient Safety (TIPS) have proven to be effective in reducing incidences of falls in the medical-surgical wards (Tzeng et al., 2021). Further analysis of this intervention was conducted in the following step to ensure that there is substantial evidence supporting its use in clinical practice. Once the intervention was agreed upon, an implementation plan was developed to promote the incorporation of Fall Tailoring Interventions for Patient Safety (TIPS) into practice. Once the EBP has been implemented, the evaluation process will follow to identify areas of weakness that need to be addressed.

Implementation Plan

The implementation process of the evidence-based practice will involve several steps. The first step will be to examine the setting where it will be implemented and how to access potential participants. The setting for this project is the medical-surgical unit of a public hospital in the United States. Both hospitalized patients and their families will be engaged in the implementation of the TIPS Toolkit to reduce falls and associated injuries (Dykes et al., 2017). However, the entire project will be nurse-led, to promote the identification of the patient-specific fall risk factors and continuously engage the patient and their families in the fall prevention process. The patients will be selected randomly in the Med-Surg unit with the help of the charge nurse and nurses on duty.

The second step will involve coming up with an appropriate timeline to avoid time wasted due to confusion about what is to be done at what time. Due to the demanding nature of the implementation of EBP, the project leaders should have a definite timeline regarding when an activity should be completed (Jong et al., 2019). The entire project is expected to take 24 weeks. Activities involved include meeting with management and other stakeholders to explain the project’s rationale and get managerial approval, which will be done within the first 3 weeks. The budgeting and looking for resources needed to complete the project will take another 3 weeks, TIPs Toolkit training to impart necessary skills will take 6 weeks, 2 days every week, and finally, the evaluation of outcomes will take 3 weeks, with report writing and suggestions for further improvement to be made in 6 weeks, as adopting continuous training as an organizational policy document will take the final 3 weeks. The training will be based on acknowledging the involved stakeholders with the information needed to effectively implement the TIPs toolkit in the routine fall prevention process.

The third step will be to come up with a budget and list of all the resources required for the appropriate implementation of the change. To reduce the number of falls on the unit, the project leader will collaborate with nurse leaders, managers, and expert trainers on the proper implementation of Fall Tailored Interventions for Patient Safety (Avanecean et al., 2017). Also necessary are human resources, supplies, equipment, and facilities such as a training site, refreshments during the training, and writing and reading materials. A laptop, a projector, a projecting board, and an internet connection are among the computer-related expenses. Additional resources include the fall TIPS rollout guide, fall TIPS implementation protocol, and fall TIPS website. The budget and resource list have been outlined in appendix 3.

The fourth step will be to select the most appropriate data collection strategy which will be utilized to gather adequate information required to answer the research question. The most effective design for collecting data and evaluating the effectiveness of the EBP project proposal is a quantitative design. The project is primarily about determining the extent to which the TIPs toolkit can help reduce the number of falls in the medical-surgical unit which requires statistical evidence that can only be acquired quantitatively (Farghaly, 2018). The collected data will be utilized in determining the cause-and-effect relationship, hence easier to make a prediction. Quantitative research design is also more objective, scientific, fast, acceptable, and focused. Generally, my evidence-based project proposal requires the collection of feedback from numerous participants to provide a more convincing outcome to the audience, which can only be achieved through the utilization of quantitative research.

The fifth step will be to monitor the implementation process to ensure that all activities have been executed as expected. As a result, the most effective instrument is a rating scale to rate activity completion based on what was done and not done. The EBP project proposal comprises various implementation parts, as detailed in the timeline section. Each segment must be scrutinized to verify that all actions were carried out as planned (Duckworth et al., 2019). As a result, a rating scale to grade activity completion based on what was done and what was not done is the most effective tool. For example, during the training, the project leader will check to see if all the nurses arrived on time. The project leader will grade the training as completed, wanting improvement, or failing based on attendance. There will also be a space for additional comments to help guide improvement if necessary.

The following step will involve the delivery of the new intervention to the stakeholders. The process of delivering the fall prevention intervention is quite simple, involving only three main steps. The first step involves an assessment of the fall risk through screening by nurses. The second step involves coming up with patient-tailored, personalized care planning to promote reducing the identified risk of falls (Dykes et al., 2017). The final step involves ensuring consistent prevention intervention such as universal precautions and tailored intervention to promote patient-specific areas of risks demonstrated in the TIPs toolkit, which will be provided at the bedside of each patient. The nurses will need to be