Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55902, USA.
BMJ Qual Saf. 2011 Feb;20(2):170-3. doi: 10.1136/bmjqs.2010.042762. Epub 2011 Jan 5.
The authors' high-volume gastrointestinal endoscopy unit developed an infrastructure to track complications associated with endoscopic procedures in January of 2008. A result of this effort was the identification of a surprising number of patient falls in their recovery area. In response to this finding, the authors created and implemented a quality improvement project to eliminate patient falls in the endoscopy recovery area.
The authors analysed each patient fall to try to identify the root cause in each case, and found that most falls occurred in patients of advanced age or who ambulated with an assistive device and fell while changing clothes in the bathroom unaccompanied. The authors initiated a quality improvement project to identify patients at risk of falling and to make changes in the recovery room process to minimise their risk of falling. Any patient identified as a fall risk would then be accompanied to the bathroom to change by one of the allied health staff, and they would leave the recovery area in a wheelchair. The authors used descriptive statistics to analyse age, gender, use of an assistive ambulatory device and total number of endoscopic procedures. The authors used the Fisher exact test to compare the proportion of procedures that were complicated by patient falls before and after the quality improvement intervention.
In 2008, the authors completed 38370 sedated endoscopic procedures and had eight patient falls (0.02%). Three patients were female, and the mean age was 67 (range 40-96). Five of the eight patients who fell were over the age of 70 and/or used an assistive device for ambulation. All patients sustained injuries that required additional medical attention. The authors' fall prevention initiative started on 23 January 2009. From 23 January 2009 to 23 January 2010, the unit completed 42845 sedated endoscopic procedures and had no patient falls in the endoscopic unit (p=0.002).
These data demonstrate that a simple, low-cost intervention in a high-volume endoscopy centre can completely eliminate patient falls.
作者所在的大容量胃肠内镜科于 2008 年 1 月建立了一项基础设施，以追踪内镜检查相关并发症。该工作的结果是发现相当数量的患者在恢复区摔倒。针对这一发现，作者们创建并实施了一项质量改进项目，以消除内镜恢复区的患者摔倒事件。
作者分析了每例患者摔倒事件，试图确定每个病例的根本原因，并发现大多数摔倒事件发生在高龄或使用助行器的患者身上，他们在无人陪同的情况下在浴室换衣服时摔倒。作者启动了一项质量改进项目，以确定有摔倒风险的患者，并对恢复室流程进行更改，以最大程度地降低他们摔倒的风险。任何被确定为有摔倒风险的患者都将由一名辅助卫生人员陪同到浴室换衣服，并将乘坐轮椅离开恢复区。作者使用描述性统计分析了年龄、性别、使用助行器和内镜检查总数。作者使用 Fisher 确切检验比较了质量改进干预前后患者摔倒事件在所有内镜检查中所占的比例。
2008 年，作者完成了 38370 例镇静内镜检查，发生了 8 例患者摔倒事件（0.02%）。3 例为女性，平均年龄为 67 岁（范围 40-96 岁）。8 例摔倒的患者中，有 5 例年龄超过 70 岁或/或使用助行器辅助行走。所有患者均因受伤需要进一步医疗关注。作者的防摔措施于 2009 年 1 月 23 日开始实施。从 2009 年 1 月 23 日至 2010 年 1 月 23 日，该单位完成了 42845 例镇静内镜检查，内镜科内未发生患者摔倒事件（p=0.002）。
这些数据表明，在大容量内镜中心实施一项简单、低成本的干预措施可以完全消除患者摔倒事件。
