Patients who fall while in the hospital represent a serious health and economic problem. Fall rates in acute care settings are estimated at between approximately two to eighteen falls per 1,000 patient days (totaling more than one million in-patient falls annually in the U.S.), with up to 44% resulting in some degree of injury. Hospital costs for patients who fall without injury are on average $4,200 more than for non-fallers, and injury falls cost upward of $25,000 per incident. Unfortunately, however, hospitals have not had scientifically validated means for predicting which patients are at greatest risk for falling, or for preventing falls.
Two registered nurses at the University of Arkansas for Medical Sciences (UAMS), Amy L. Hester and Dees M. Davis, devised the Hester Davis Scale (HDS), a reliable and valid tool for identifying patients most likely to fall while in the hospital. At UAMS, the HDS in combination with the hospital’s comprehensive fall prevention program has resulted in a 11% reduction in overall fall rates and a 60% reduction in fall-related injuries. Cost savings from prevented falls and injuries—based on estimates by the Centers for Medicare and Medicaid Services (CMS) for fall-related injuries in hospitals, which are not reimbursed to hospitals—added up to $1.27 million for UAMS in 2011 compared to the previous year.
“We are strongly committed to data-driven outcomes,” said Amy Hester, Director of Clinical Informatics and Innovation at UAMS Medical Center. “The HDS is designed to more accurately identify patients at risk to fall, which is an important first step in a fall prevention program. As part of next steps we integrated the Vocera solution into specific fall-prevention and fall-mitigation activities.”
The Role of Vocera in Fall Prevention
Tools used in the UAMS fall-prevention program include:
• Posey Sitter Select fall alarms, which are portable units that alert staff when a patient attempts to exit a bed or chair unattended
• West Call nurse call lights, which are monitored by nursing staff at centralized call light centers on each floor of the hospital
• Orchestrator middleware
• 500 Vocera® Badges, which replaced overhead paging for internal communication among hospital staff members
When an unattended patient leaves a bed or chair, the Posey Sitter Select sends an alarm simultaneously to the West Call nurse call light system, to Vocera. The unit secretary sees the call light, and Vocera alerts the staff responsible for the patient who has gotten up—e.g., the charge nurse, the patient’s direct-care nurse, and technician—any of whom can go to the patient’s room immediately to prevent a fall.
As an alternative to the fall alarm system at UAMS, some departments have purchased specially designed beds with integrated bed alarms. The added alarm feature to these beds cost $15,000 each, and they’re not portable for use in chairs or elsewhere outside the bed.
The interface to Vocera from these built-in bed alarms takes 45 seconds—by which time a patient could have fallen before anyone’s aware they’ve left the bed. In contrast, the interface from Posey Sitter Select to Vocera is only four or five seconds.
“On the basis of the Vocera interface time alone, we could have recommended that UAMS not purchase the extra alarm feature on the beds—and UAMS could have saved hundreds of thousands of dollars,” said Hester. “In this case, Vocera doesn’t change the function of the bed alarm with the different systems, but it does alter the responsiveness. With Vocera’s sub-five second response time with the Posey alarms, the UAMS staff has much more time to intervene with at-risk patients to prevent falls.”
Improving Communications at UAMS
UAMS built new clinical facilities in 2009 and transplanted the entire hospital into the new facility. It went from a small facility where all the units were close to the nurse’s stations to a large, beautifully appointed, but much more spread-out facility. Units are 150 yards long, making it impossible for staff to see or hear what’s happening at the other end of the unit. With the move to the new facility, communication became a major issue.
“At first, we relied on overhead paging for internal communication,” said Hester. “It was very intrusive to patients, especially at night, and there was no way for the staff to give feedback when paged. For instance, nurses paged while busy with patients would have to stop what they were doing to respond to the overhead page. It interrupted care and made the patient feel like less of a priority.”
The expanded hospital layout means UAMS moved from a nurse-centric design—with consistent visibility and centrally located nurses—to a patientcentric design, with larger and more private rooms, farther from nurses station.
"Vocera lets us close the distance, in a sense, by making it easier to keep track of patients and to stay in touch with one another,” Hester said. “It saves us time, lets us multitask more efficiently, helps us respond more quickly to emergencies, and supports the logistics of patient care.”
Improving Patient Care Throughout the Hospital
Vocera is used widely throughout UAMS, not only for fall prevention. Some examples include:
• Emergency Department (ED) and housekeeping. One of the most important productivity metrics for a hospital is the time it takes for a patient to transition from the ED to a room. Communication with housekeeping is crucial, to efficiently clean the ED treatment rooms and prepare beds for admitted patients. Previously, ED nurses would page housekeeping—for instance, “Trauma one is ready to be cleaned”—then wait. With Vocera, direct two-way communi- cation between ED and housekeeping has reduced wait times significantly, which improves patient flow and boosts patient satisfaction.
• Respiratory therapy. UAMS has centralized respiratory therapy as well as a full-time respiratory presence in the ICU. If a patient outside the ICU needs respiratory therapy, nurses no longer need to page and wait, or walk around the large ICU to find a respiratory therapist. “With Vocera, you know the respiratory therapist you’re trying to reach understands what you need, and you can coordinate activities among the various patients,” said Hester. “It puts an end to interpretation, misinterpretation, and wasting precious time.”
• Pharmacy. It’s often necessary to confirm dosages for a patient’s medication and avoid sending the same prescription twice because it’s unclear whether the prescription has been delivered to the unit. With Vocera, nurses can communicate directly with the pharmacists, who know where and when medications were dispensed. Although the pharmacists do not have Vocera Badges, nurses can use their Vocera Badges to phone a pharmacist’s extension, and the pharmacist can check the information in the electronic medical record (EMR) and call back to a nurse’s Vocera Badge.
• EMR. Before Vocera, messages between UAMS’s Allscripts Sunrise EMR and the pharmacy were painfully slow and disjointed as nurses and physicians waited for pharmacists to type and print prescriptions, and call back if they had questions. “With Vocera, the clinical staff and pharmacists can talk directly and be instantly sure that everyone is clear on what will be done, and when,” Hester said. Vocera facilitates the communication workflow in multiple ways: Badge-to-Badge, Badge-to-phone, and via text messages typed using the Orchestrator middleware.
• Volunteers. “We’ve really started thinking outside the box with Vocera,” she said. “As we realize the real value of Vocera is to put it as close to the patient as possible, we’re finding innovative new ways to use the Vocera Badges.” One example is for select volunteers, such as one stroke survivor who runs a stroke support group at UAMS. The volunteer has been issued a Vocera Badge so she can communicate with the nursing staff when she’s visiting patients. “It makes her feel more integrated into the stroke team, which makes her even more effective in her volunteer role,” said Hester.
• Reminders. Using Orchestrator, UAMS staff members can set up reminder alerts to themselves via Vocera, such as, “Patient in room 234, turn him over every two hours [to prevent skin breakdown, or bed sores],” or, “Follow up on PCT documentation at two pm.”
• Telemetry. Vocera also integrates with UAMS’s Phillips telemetry system and can be set to give alarms based on changes in heart rhythms, pressure, and other factors.
• Patient Ambassadors. Staff who deliver the meal trays have just recently started using the Vocera Badges. Patients and families can call the ambassadors directly if they need a different tray or something extra to make their meal better. This service integrates patients and families into the care team and keeps professional nursing staff from spending time on tasks that can be done by nutrition staff.
“Mobile communication technology is a vital part of our hospital operations to ensure that all the departments and areas of care are working together efficiently to optimize patient care,” said Hester. “Vocera has improved so many processes at UAMS, and we keep finding new ways to integrate it into everything we do.”
“For our staff here at the hospital, Vocera has become a technology we rely on as a standard,” she said. “In addition to improving processes, Vocera has helped us leverage other resources such as our call lights, Posey alarms, and nurse call systems in a way that has improved staff utilization of these technologies. With the acuity of hospitalized patients getting higher, it is important that we continue to investigate new ways of incorporating mobile communications into our care to improve efficiencies and drive improved staff satisfaction and positive patient outcomes.”