Poster Sample: A Falls-Prevention Bundle in Elderly Care

Type: Academic Poster  |  Subject: Nursing  |  Level: Undergraduate  |  Word Count: ~900 words

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The Brief

Produce a quality-improvement poster evaluating the introduction of a falls-prevention care bundle on an older adults’ ward, reporting falls rates before and after implementation, for a Level 6 Nursing Practice Improvement poster assessment.

Reducing Inpatient Falls in Older Adults: Evaluation of a Falls-Prevention Care Bundle

H. Ojo, School of Nursing, University of Ashcombe

Introduction & Aims

Falls are the most commonly reported inpatient safety incident among older adults and are associated with fracture, prolonged admission, hospital-acquired deconditioning and a lasting loss of confidence in mobility that can outlast the physical injury itself. Beyond the immediate physical injury, a fall can trigger a fear of falling that leads some older patients to reduce their own mobility further, increasing the risk of deconditioning and delayed discharge, a cycle the ward team was keen to interrupt. National guidance recommends multi-component falls-prevention bundles combining risk assessment with environmental and behavioural measures, yet many wards still rely on generic risk-assessment paperwork without a coordinated set of follow-on actions for patients identified as high risk.

This poster evaluates a falls-prevention care bundle introduced on a 28-bed older adults’ ward, comparing falls rates and falls-related harm for the 12 weeks before and the 12 weeks after implementation, to establish whether the bundle was associated with a measurable improvement in patient safety.

Methods

• Design: a before-after quality-improvement evaluation using routinely collected incident-reporting data, registered locally as a service evaluation rather than research requiring separate ethical approval.
• Bundle components: a validated falls-risk screening tool completed within four hours of admission, coloured wristbands and above-bed signage for patients identified as high risk, hourly intentional rounding covering positioning, pain, personal needs and placement of essential items, bed and chair sensor alarms for the highest-risk patients, and a patient and family education leaflet on reducing falls risk.
• Patient and family involvement: the education leaflet was co-designed with a small patient and carer feedback panel before roll-out, to check its language and layout were appropriate for the ward’s typical patient group.
• Staff training: all registered nurses and healthcare assistants on the ward completed a 30-minute bundle briefing before roll-out, and compliance was reinforced through twice-weekly spot checks by the ward sister during the post-implementation period.
• Data: falls per 1,000 occupied bed-days and falls-related harm grade, drawn from the ward’s incident-reporting system for each 12-week period, with occupied bed-days taken from routine ward occupancy records.
• Analysis: descriptive comparison of rates between the two periods; harm-graded falls categorised as causing moderate or severe harm using the standard local incident-severity scale.

Results

The falls rate fell from 14.5 to 8.0 per 1,000 occupied bed-days after the bundle was introduced, a reduction of roughly 45% despite a broadly similar bed occupancy across the two periods. Falls causing moderate or severe harm fell from nine to three over the same comparison periods, a proportionally larger reduction than for falls overall, suggesting the bundle may have been particularly effective at preventing the more serious incidents. No adverse events attributable to the sensor alarms or wristbands, such as skin irritation from prolonged wristband use, were reported during the post-implementation period.

Discussion

The reduction in both overall falls and harm-causing falls is consistent with the evidence base for multi-component falls-prevention bundles, which combine risk identification with environmental and behavioural measures rather than relying on paperwork alone. The larger relative reduction in harm-causing falls may reflect the sensor alarms and intentional rounding intervening before a fall could progress to a more serious outcome, such as reaching the floor from a standing position.

As a before-after design without a comparison ward, several alternative explanations cannot be fully excluded. Seasonal variation in patient acuity and case mix between the two 12-week periods, a Hawthorne effect from increased staff attention during the evaluation, and incident-reporting behaviour itself changing alongside the bundle roll-out could all have contributed to the observed reduction. A longer follow-up period and, ideally, a stepped-wedge design across several wards would strengthen confidence that the bundle itself, rather than these other factors, drove the change. Staff feedback gathered informally during the evaluation period was broadly positive, with ward staff reporting that intentional rounding also surfaced other unmet needs, such as unaddressed pain or toileting requirements, alongside its falls-prevention purpose.

Conclusion

• Introducing the falls-prevention bundle was associated with a meaningful reduction in both falls incidence and falls-related harm on this ward.
• Risk screening, intentional rounding and sensor alarms were feasible to embed within routine ward care without additional staffing.
• The larger relative fall in harm-causing incidents suggests the bundle may be particularly valuable for preventing the more serious outcomes.
• Positive informal staff feedback suggests the bundle was acceptable to deliver alongside existing ward workload, supporting its continuation beyond the evaluation period.
• Ongoing audit of bundle compliance, and evaluation across additional wards, is recommended to confirm the reduction is sustained and generalisable beyond this initial evaluation.

Key References: NICE (2013, CG161); Oliver et al. (2010, BMJ); Cameron et al. (2018, Cochrane Database of Systematic Reviews); Hempel et al. (2013, Journal of General Internal Medicine).

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