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Head Over Heels: Reducing Falls in the Delivery Suite

Royal Hospital for Women
Project Added:
9 December 2016
Last updated:
22 December 2016

Head Over Heels: Reducing Falls in the Delivery Suite

Summary

This project delivered an education program for staff and implemented a new process of cleaning the ventilation vents in delivery suite bathrooms, to reduce the risk of falls.

Aim

To reduce the rate of falls in pregnant women and new mothers in the delivery suite of Royal Hospital for Women, by 95% within six months.

Benefits

  • Reduces the risk of falls in pregnant women and new mothers.
  • Reduces length of stay and associated costs.
  • Improves patient safety and reduces the risk of physical and mental injuries.
  • Improves the cleanliness of hospital ventilation units.
  • Improves knowledge of staff regarding falls.
  • Supports the Australian Commission on Safety and Quality in Health Care Standard 10: Preventing falls and harm from falls.1

Background

Between January 2013 and March 2015, there were 11 documented falls in the delivery suite at Royal Hospital for Women. None of these patients sustained moderate to severe injuries, however there was a risk that women could seriously injure themselves. The Clinical Practice Improvement Unit identified the problem and suggested the development of a strategy to reduce the risk of falls in the delivery suite.

Implementation

  • A staff survey was conducted in September 2015, with 16 midwives who work in the delivery suite. The purpose was to understand if falls were occurring and not being recorded in the Incident Information Management System (IIMS), as well as how midwives got women up for the first time after birth. None of the midwives allowed the patient to get up without assistance, with most midwives stating that they would stay in the room while the woman showered, if she allowed it.
  • A patient survey was conducted in September 2016, with six women who had given birth in the previous 24 hours. The results showed that these patients did receive education about falls before getting out of bed. One person had a near fall and their care was mixed.
  • A flow chart was created to identify the sequence of events between birth and transfer of care to either the postnatal ward or home. There were a number of pathways identified, depending on the delivery and whether complications occurred. A cause and effect diagram was then created, to show the factors that may have contributed to falls in the delivery suite. From these charts, potential causes were identified and voted on by midwives, managers and medical staff.
  • It was identified that all but one of the 11 falls occurred in the bathroom of the delivery suite, with most of these falls caused by a vasovagal response, which is a type of fainting triggered by the build-up of heat and steam. This differed from the original hypothesis, which suggested the cause of falls was hypotension or post-partum haemorrhage.
  • To reduce the build-up of heat and steam in delivery suite bathrooms, the ventilation vents were cleaned in November 2015 and a regular cleaning schedule developed.
  • Education was provided to staff over a four-week period from January 2016, with lunchtime sessions for midwives and night sessions for night staff. It was designed to educate staff on the importance of leaving the bathroom door ajar while patients are showering, so steam can escape. It also encouraged midwives to supervise women while they take a shower in the delivery suite. A poster was developed for staff and left in the lunch room as a follow-up measure.

Project status

Implementation - the initiative is ready for implementation or is currently being implemented, piloted or tested.

Key dates

  • Project start: July 2015
  • Project implementation: December 2015
  • Project evaluation: July 2016

Implementation site

Delivery Suite, Royal Hospital for Women, SESLHD

Partnership

Clinical Excellence Commission. Clinical Leadership Program

Results

  • Falls were reduced by 50% within six months, with two falls in the July to December 2015 period and one fall in the January to July 2016 period.
  • Due to the low number of falls experienced during the project, it’s difficult to correlate these results with the solutions implemented.

Lessons learnt

  • Understanding the process of change is important. Although it seemed like a straightforward project, it took some time to get it off the ground.
  • It’s important to understand the cause of the problem before developing a solution, as the cause of falls wasn’t what was originally anticipated.
  • It’s important to involve as many midwives as possible, as they are on the floor and understand what’s going on.

References

  1. Australian Commission on Safety and Quality in Health Care. Standard 10: Preventing falls and harm from falls. 2012.

Further reading

View a presentation on this project (pdf).  

Contact

Megan Ritchie
Registered Midwife, Birthing Services
Royal Hospital For Women
South Eastern Sydney Local Health District
Phone: 02 9382 6100
megan.ritchie@health.nsw.gov.au

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