Nonverbal Cognition Project: A Fall Prevention Project in a Brain Injury Unit
This session delves into the complex and often overlooked challenges of fall prevention in inpatient traumatic brain injury rehabilitation. It examines the development and execution of a comprehensive interdisciplinary fall prevention initiative, specifically designed to address the unique needs of patients with impaired cognition. The implementation of the Nonverbal Cognition Project (NCP) led to a significant 33% reduction in unwitnessed falls, a compelling testament to the effectiveness of evidence-based, collaborative care. This outcome highlights the transformative potential of proactive, patient-centered interventions, emphasizing their critical role in enhancing patient safety and clinical outcomes for some of the most vulnerable populations.
Problem: In 2023, Unit 1 North recorded 27 falls, with 41% (11/27) being unwitnessed and fall rates ranging from 1.62 to 7.49 per 1,000 inpatient days. The Nonverbal Cognition Project (NCP) aims to reduce fall incidents, particularly unwitnessed falls, and examine the correlation between fall risk and nonverbal cognitive deficits.
Measurement: Fall incidents were quantified using the fall rate formula per 1,000 inpatient days. Fishbone diagrams were utilized to identify potential contributing factors while control charts monitored fall trends over time. This comprehensive approach facilitated a thorough analysis and informed the development of targeted strategies to mitigate fall incidents.
Analysis: The analysis involved calculating fall rates per 1,000 inpatient days to standardize fall incidence. A comparative analysis was conducted using pre- and post-implementation data, with percentage reductions in total and unwitnessed falls. Statistical significance was assessed to evaluate the effectiveness of the Nonverbal Cognition Project (NCP).
Implementation: The CDT is administered upon admission and weekly to assess nonverbal cognition. Patients failing the CDT are placed on NCP rounds with four safety measures. Challenges, including staff resistance and workflow integration, were addressed through continuous education and collaboration. This research provides valuable insights for enhancing fall prevention strategies.
Results/Discussion: The implementation of the NCP in Unit 1 North led to a significant 19% reduction in total falls and an impressive 33% decrease in unwitnessed falls in 2024. Moreover, the unit maintained a fall rate of just 2.0 per 1,000 inpatient days, underscoring the intervention's effectiveness and impact.
Speakers
Supervising Staff Nurse I - Rancho Los Amigos National Rehabilitation
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Patient Safety
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Location Virtual
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Organizer NAHQ Next
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