The Use of Tailored Interventions to Prevent Falls: A Quality Improvement Project in the Telemetry Unit

Every year in the United States, hundreds of thousands of patients fall in hospitals with 30 to 50 percent resulting in injury. In Texas, the fall rate in adult patients is 33.9 percent, and in one teaching hospital in South Texas, patient fall rates have been above the national benchmark for two years (2017-2019), despite increased use of sitters for patient safety and multiple fall prevention strategies. The annual direct care cost of all fall events in the United States for individuals more than 65 years old is about $34 billion. Objectives of the fall initiative program were increasing adherence to documentation of data from the Morse Fall Assessment and tailored interventions in the electronic health record. The goal of the project was to promote patient safety by decreasing the fall rate per 1000 patient days to below the national benchmark of 3.44/1000 patient days. The project was piloted in two telemetry units over 12 weeks using the Iowa Model of Evidence-based Practice. Telemetry staff received one-on-one education from the educator in the unit using a tailored intervention poster. The Nurse Champion observed 58 rooms and conducted chart documentation to ensure universal fall precautions were carried out during every shift. Incidence of falls was tracked daily, and post fall huddles were conducted after any incidents. The average monthly fall rate after implementation was 2.47/1000 patient days, which was below the national benchmark. The fall assessment documentation in two telemetry units at DHR Health can be adapted or implemented hospital-wide. The results showed a statistically significant correlation between the Morse fall score assessment on EHR and monthly fall events (p=0. 0078). Champions were able to identify interventions and areas that needed to be improved such as education, patient engagement and stakeholder buy-in.


The Use of Tailored Intervention to Prevent Falls: A Quality Improvement Project
In the hospital and community settings, predicting which patient is most likely to fall is a continuous challenge because of the aging process, physiological conditions, medication and procedures that can leave them weak and confused (Joint Commission, 2015;Laycock, Bailie, Matthews, & Bailie, 2019). In the United States, an estimated 1,000,000 patients fall in hospitals every year, and 30 to 50 percent result in injury (Health Research and Educational Trust, 2016;Wong et al., 2011). The Joint Commission (2015) considered falls as a top 10 Sentinel Event Alert, which is defined as "unexpected occurrence that involve death and serious physical and psychological injury" (2015, p.1). According to Galbraith, Butler, Memon, and Harty (2011) There is considerable evidence for effective fall prevention, and healthcare stakeholders are implementing quality improvement projects and evidence-based practices to protect patients from harm Dykes et al., 2017;Laulirn & Shorr, 2019). There is a wealth of literature on fall prevention, and systematic reviews have identified effective interventions.
However, there is limited research regarding healthcare providers' perspectives and roles in fall prevention (Cuesta Benjumea et al., 2017). Recommended successful strategies include the use of a standardized fall assessment, fall checklist, rounding tool, and tailored interventions (Dykes et al., 2017;The Joint Commission, 2015;Spano et al., 2018;Titler et al., 2015). The focus of this project was to implement an effective and proven fall prevention intervention that could become a best practice.
Moreover, the aims of the fall initiative project were to evaluate and measure the incidence of fall, fall rates, fall rates with injury, nurses' adherence to the quality improvement project and patient family engagement of the protocol. The desired outcome was to decrease falls below the national benchmark of 3.44/ 1000 patient days (AHRQ, 2013). In addition, a goal was established for a 75% adherence rate for documentation of the Morse Fall Assessment and tailored intervention in the electronic health record and poster. This paper includes an evaluation of the outcomes of fall assessment with tailored intervention in the telemetry unit.

Significance of the Practice Problem
The hospital project setting fall rates have been above the national benchmark for almost two years in the National Database of Nursing Quality Indicators (NDNQI, 2019). Despite the increasing use of sitters for patient safety and multiple fall prevention strategies, the fall rates in hospitals continually increase. Sitters, who are certified nursing assistants, stay in the patient's room to observe and prevent falls. Fall rates above the national benchmark are public information and can cause a negative impact on the hospital's ratings and revenue (Boswell, Ramsey, Smith, & Wagers, 2001). According to Spiva et al. (2012), hospitals spend over one million dollars on patient care sitters, and evidence shows that this trend will increase in the future. In addition, falls are the leading cause of fatal and non-fatal injuries among men and women aged 65 and older (Burns, Steven & Lee, 2016). The medical cost of fatal falls is $637.2 million and $31.3 billion for non-fatal falls (Burns et al., 2016). According to the Centers for Disease Control and Prevention (CDC), the annual direct care cost of all fall events in the United States (US) for those who are more than 65 years old is about $34 billion ("Cost of falls," 2015).
In addition, the effect of falls on patients and families is burdensome because of the delay in rehabilitation (Browne & Sterne, 2019). According to the CDC (2018), approximately 33,000 fall-related deaths happened in 2015. Moreover, the average legal claim for a fall-related injury is about $55,000 (Boswell et al., 2001). Focusing on effective and reasonable interventions can improve patient fall rates.

Theoretical Framework
The use of evidence-based practice (EBP) in healthcare organizations has improved patient outcomes by promoting safety and has helped many organizations in their reimbursements, which has controlled healthcare costs (Melnyk, Fineout -Overholt, Gallagher-Ford, & Kaplan, 2012). However, many hospitals are still using fall prevention programs despite the limited evidence from the literature to support their efficacy (Laws & Crawford, 2013). This project utilized the Iowa Model of Evidence Based-Practice to promote patient safety and prevent harm. According to Brown (2014), the Iowa Model applied "triggers to help healthcare providers transform research results into clinical experience while enhancing quality outcomes for patients" (p.158). Triggers are internal or external data that identify a clinical problem. The Iowa Model's conceptual framework underlined pliancy in acknowledging the importance of high-level research, but recognized that this kind of evidence will not be always available (Buckwalter et al., 2017). In this evidence-based practice project, stakeholders needed to adapt to the best available data from the available practice recommendations (Buckwalter et al., 2017).
The Iowa Model conceptual framework steps were followed chronologically. The first step was the identification of the problem triggered by the data from risk management and the NDNQI. The fall rate for the past years has been above the national benchmark, and it was a clinical problem for the organization. The chief nursing officer and telemetry unit director recognized the problem triggers for change to facilitate patient safety. According to the Iowa Model, the data and the problem catalyze change (Brown, 2014). Assessing and aligning the priorities of the unit and organization improved opportunities for success (Titler et al., 2001).
The second step was to form a team and assess current practice regarding falls and find evidencebased literature and clinical practice guidelines regarding falls (Titler et al., 2001). The literature review focused on increased fall rates above the national benchmark (Titler et al., 2001). The selected evidence-based literature and quality improvement project processes determined the accuracy of the practice recommendations proposed and the flexibility for modification, if necessary. In addition, selection of unit champions to help formulate, develop, implement, evaluate and sustain the quality improvement project was essential (Titler et al., 2001).
According to Titler et al. (2001), an inter-professional team and buy-in from stakeholders were essential. The third step was piloting the change in practice (Titler et al., 2001). The Iowa Model helped structure the process of change and enabled rapid assessment of the fall poster checklist.
The change was appropriate for adoption and stakeholders are looking to institute the change hospital-wide. Based on the literature review and synthesis (see Appendices B and C), the Iowa Model was an excellent model to translate evidence into practice.

PICOT Question
The PICOT question of the evidence-based practice project was: (P) Does use of fall assessment with tailored interventions for adult patients in the two-telemetry units (I) compared to selected universal fall precautions (C) decrease the fall rate (O) after three months of implementation (T)?
Fall was defined as "any descent to the floor with or without injury" (AHRQ, n.d.). The NDNQI definition for fall injury was: "None"-patient without injury; "Minor"resulted in application of dressing, ice or limb elevation; "Moderate"resulted in suturing or splinting; "Major"resulted in injury like traction, fracture, or liver laceration and "Death"patient died as result of injury caused by fall ("Preventing falls in the hospital," n.d.).
The Fall Assessment with Tailored Intervention Project was implemented for 12 weeks in the two telemetry units in one of the teaching hospitals at South Texas. The population was any adult patient admitted in the unit with a Morse Fall Score (MFS) of more than 0. According to AHRQ (2013), adapting the MFS tool in conjunction with clinical assessment to determine if a patient is at risk for fall was an effective intervention. The MFS scores are: MFS 0: No risk for falls, <25: Low risk, 25-45: Moderate risk and >45: High risk (AHRQ, 2013). All patients with MFS score of > 0 had the specific tailored intervention.
The intervention combined an assessment and fall checklist with purposeful rounding. A list of the combination of interventions is presented on the Evidence Table to Reduce Falls (see Appendix C). There is strong evidence supporting the use of patient-centered checklists for effective fall intervention processes (Spano et al., 2018;Titler et al., 2015). According to Madeline and Morris (2019), the use of checklists as a hand-off and a rounding tool reduced patient falls because it determined whether all prevention interventions were carried out.
The telemetry units have implemented different quality projects to try to prevent falls.
The unit did not have a specific protocol or policy regarding fall prevention. An updated, definitive policy was needed. The project was implemented for eight weeks. The baseline falls outcome performance (fall events with and without injury) for the two telemetry units was pulled from the hospital's internal database (see Appendix O). In addition, the following outcomes were measured monthly: fall rates, fall injury outcomes, and nurses' adherence to the protocol. The desired outcomes were a decrease in the fall rate to below the national benchmark (3.44/1000 patient days) and more than 75 % adherence to the poster checklist prevention protocol.

Literature Search Strategy
The databases used to search the literature using PICOT question were PubMed, ProQuest and CINAHL. The search terms employed were: fall toolkit, fall checklist, fall prevention protocol, and fall checklist intervention. To help narrow the search, the following filters were used: English language, published within last five years, hospital setting, and patient participants. The initial search using the search terms and filters on three databases returned a total of 2,097 articles including duplicate articles. The inclusion criteria applied were systematic review, randomized controlled trials, qualitative study, quantitative study, mixed control study, patients, hospitals, adult, and healthcare hospitals. The exclusion criteria applied were: nonresearch, non-English language, non-intervention, commentaries, community dwellings, psychiatric, pediatrics, psychogeriatric, and hospice setting. Applying the inclusion and exclusion criteria resulted in 64 articles. Reading the full text and applying the inclusion and exclusion criteria resulted in 19 articles. However, 9 articles did not meet criteria. The 9 articles were removed and 1 article was added which met the criteria, and was recommended by the unit director. This resulted in a final 10 articles to synthesize (see Appendix A).

Literature Results and Evaluation
The DNP project leader appraised 10 articles using the John Hopkins Nursing Research Evidence Appraisal Tool (Dearholt, Dang, Deborah & Sigma Theta Tau, 2012). Ryan, Mamaril and Swope (2017) recommended using the John Hopkins Tool to evaluate evidence when making recommendations to promote quality patient care. The DNP project leader graded the 10 articles using level of evidence and quality grade, which included five levels of evidence (Levels I-V) and quality grades (A-C). See Appendices B and C on the level of evidence and quality grades of each article.
All 10 studies answered the PICOT question. Most of the studies reported a decrease in fall rates with the use of a patient-centered fall assessment tool and checklist prevention program. There were only seven articles synthesized to develop evidence-based practice recommendations for building a fall prevention checklist intervention, other three articles were removed because the authors reviewed, assessed, and evaluated the efficacy of the EBP journals (see Appendices B & C).

Themes from the Literature
The purpose of the systematic review was to examine evidence on the effectiveness of a checklist or toolkit in the management of falls. The review of the current evidence produced three themes that answered the PICOT question: Proper Assessment with Fall Risk Tools, Patient-centered Fall Checklist Intervention, and Consistent Preventive Fall Intervention for Sustainability. Adoption of these themes was the key to further reduce falls and the falls with injury in hospitals (Dykes et al., 2017). Moreover, providing staff with the evidence base behind fall preventions was an important part of the processes .

Proper Assessment with Fall Risk Tools
The 2015 Sentinel Event Alert stated that inadequate assessment was the most common contributing risk factor for falls with injury (The Joint Commission, 2015). Duckworth et al.
(2019) conducted a case control study to assess why patients who received the Fall TIPS Checklist Intervention fell. The results led to a conclusion that preventing falls in the hospital was a 3-step process. The fall risk assessment tool was a step in the intervention (Dykes et al., 2015). The American Geriatric Society's (2017) clinical practice guidelines summarized evidence-based recommendations to decrease fall and severity of injury by assessing the gait, balance and environment for safety. The Morse Fall Scale (MFS) is a tool used to identify risk factors for falls in hospitalized patients (Dykes et al., 2017). The total score may be used to predict future falls, but it is more important to identify risk factors using the scale and then plan care to address those risk factors.
The common components of fall risk assessment tools are history of fall, medication side effects, use of assistive devices (like a walker or cane), the use of IV poles or any equipment attached to the body, and unsteady gait. Dykes et al. (2017), Ambutas (2017), and Johnston and Magnan (2019) concluded the use of a fall risk assessment tool could help in tailoring patientcentered interventions. Moreover, using a fall risk assessment as the first step of intervention and arriving at a fall risk score by knowing the risk factors can mitigate the risk and help accurately implement fall interventions. Tzeng and YinYin (2015) conducted a non-experimental systematic review regarding patient-centeredness for fall prevention care and selected patientcentric and clinician-centric fall assessment tools that helped in fall prevention (see Appendices B and C). The authors concluded that these fall risk assessment tools could be key elements in fall prevention programs to close the gap in the intervention.
Melin (2018) piloted a 3-month pre-and post-intervention using the Morse Fall Risk Assessment with automatic intervention on EHR. A comparison of the pre-and post-intervention showed a decrease in the average monthly fall rate of 3.6 falls/1000 patient days. In addition, Dykes et al. (2017) and Titler et al. (2016) used the Morse Fall Assessment with checklist, and the results were significant reductions in fall rates (see Appendices B and C). Moreover, Titler et al. (2017) recommended assessing risk factors in order to make significant gains in decreasing falls.

Patient-Centered Fall Checklist
A fall toolkit or checklist is a summary of essential components of treatment or interventions to promote adherence of the interventions. There were five articles that presented the use of checklist or toolkit in the fall prevention program (see Appendices B and C). A reasonable level of evidence exists that implementing toolkits (AHRQ, 2013) or checklists (Dykes et al., 2017) reduced fall rates (Ambutas, 2017;Ayton et al., 2017;Dykes et al., 2017;Johnston & Magnon, 2019;Melin, 2019;Titler et al., 2016). See results in Appendix B.
Five of the studies were randomized control trials that tested the efficacy of fall toolkits.
In the reports of the 2 studies, the authors recommended the checklists as practical ways to prevent falls.

Engagement
The main influencing factors for adherence to the protocol were individual factors, including individual (clinical) experience, awareness, and the preference of following the plan of care. According to Ebben, Vlolet, Schalk, Mintjes-de Groot, and Van Achterberg (2014), the use of organizational factors to engage patients and nurses mitigated barriers for non-compliance.
These factors were involvement in protocol, training, education, and being in accordance with daily practice (Ebben et al., 2014). According to Ambutas (2017), project goals were achieved through stakeholder support, promotion of staff accountability, and a continual evaluation

Practice Recommendation
The rigorous synthesis of the seven studies answered the PICOT question. The level of evidence based on the John Hopkins Appraisal Tool was Level III quality B because the metaanalysis and meta-synthesis had acceptable results regarding the use of fall risk assessment with checklist intervention in the reduction of falls. As seen in Appendix C, there was reasonable evidence that was consistent with the recommendation to use fall risk assessment, patientcentered intervention and consistent patient and nurse engagement to reduce falls Dykes et al., 2017;Johnston & Magnon, 2019;Titler et al., 2017).
The practice recommendation that was used in the fall initiative program applied the three themes presented in the synthesis of the literature. The poster checklist consisted of the fall assessment with tailored intervention and patient and nurse engagement in consistent fall intervention. The poster checklist was a three-step process. The first step was to conduct a fall risk assessment using the Morse Fall Assessment. The second step was to develop a plan of care that was tailored to patient-specific areas of risk. The third step was to implement the plan consistently with nurse champions who engaged fellow nurses, patients and families in the intervention. According to Titler et al. (2015), clinician involvement in the fall risk assessment and use of fall prevention intervention targeted to patient specific fall risk decreased fall rates in 13 adult medical surgical units (see Appendix B). There was strong evidence to use the bundle or checklist for effective fall intervention processes if the intervention was specific to the patients' needs (Ambutas, 2017;Barker et al., 2017;Duckworth et al., 2019, Dykes et al., 2017. According to Dykes et al. (2019), staff needed to be involved in the process of tailoring and implementing the toolkit and of redesigning the workflow to engage patients and family in the 3step fall prevention process. The interventions were modified based on organizational policy and patient needs.
Moreover, Melin (2019) and Dykes et al. (2017) stated that fall prevention must be kept at the forefront of patient care, and that implementation of staff huddles and learning from feedback would sustain low rates of falls.

Project Setting and Overview
The hospital project setting is one of the teaching hospitals in Edinburg. The hospital setting is a large, urban medical center located in southern Texas near the border of Mexico. The hospital project setting vision and mission are "To empower every caregiver to provide quality care with compassion and excellence to every patient in every encounter" (DHRHealth, n.d., para. 2). The hospital project setting purpose and vision are "To innovate, educate, and to provide continuous improvement in healthcare" (DHRHealth, n.d., para.2). The hospital project setting is a 520+ bed teaching hospital health system. The project was started in the two telemetry units, which had a total of 64 beds. The admitted patients were usually adults with multiple comorbidities, and most patients were greater than 18 years old. These patients required cardiac tele-monitoring, blood pressure medications, diuretics, and blood thinner medications, which could predispose them to increased risk for falls. The telemetry unit was a standard medical-surgical floor with cardiac monitoring. All rooms were exclusively private and there was a four-nurse station located in the middle of the unit.
The hospital project setting was currently integrating a sitter fall safety program. There was a need to increase education and compliance in its current policy in the telemetry unit, because the unit's quarterly fall rate for the last two years was more than the NDNQI benchmark of 3.44/1000 patient days ("Clinical and performance," 2019). In comparison, the organization telemetry unit's figure was 6.5/1000 patient days (DHR Health, 2019). The Chief Nursing Officer brought this problem to the attention of the director and clinical coordinator, and most stakeholders supported the efforts to reduce falls. During the meeting with the telemetry leaders, nurse champions in the unit were easily recognized. They were the educators, physical therapists, nurses' champions, and certified nursing assistants (CNA).
The vision and mission of the hospital project setting was achieved through the implementation of evidence-based quality improvement projects. The project objectives were to: 1) implement a fall assessment with a tailored intervention checklist to incorporate fall reduction strategies into practice; 2) improve staff knowledge of fall reduction measures, particularly those to reduce injury; 3) reduce falls with injury to less than 0.3 per 1,000 patient days; and 4) reduce falls without injury in the telemetry to less than 3.44 per 1,000 patient days. One of the shortterm objectives was to empower and educate nurses to apply the current evidence-based practice on fall prevention. The long-term objectives of this evidence-based practice project were to reduce fall rates and to achieve and sustain fall rates below the national benchmark.

Project Plan
The evidence-based practice project focused on establishing a consistent fall assessment with a tailored intervention prevention policy and establishing short-term objectives to achieve and sustain the project outcomes. The use of a poster checklist prevention reduced fall events, increased patient satisfaction, and improved the well-being of each patient. Consistent huddles for every fall event and engaging champions in the unit improved the teamwork and promoted patient safety. An organizational SWOT analysis revealed strengths, weaknesses, opportunities, and threats (see Appendix I). To sustain the project and close the gap with interventions, the strengths and weaknesses of the organization were evaluated. Organizational support and stakeholder support were essential for the successful implementation of the project. This evidence-based practice project was an opportunity for the project setting to improve fall rates, promote patient safety, increase revenue and improve patient outcomes.
The framework model that was used in the quality project was the Institute for Healthcare Improvement Framework for Spread, or FFS (Nolan, Schall, Erb, & Nolan, 2005). According to Nolan et al. (2005), the organizational stakeholders should be included when planning, developing and guiding the spread of new ideas. This model was appropriate to the organization because there was a lack of stakeholder engagement (see Appendix I). The FFS was helpful in guiding the project with the support and engagement of the leaders. The FFS has four phases: 1) prepare for spread; 2) establish an aim for spread; 3) develop an initial spread plan; and 4) execute and refine the spread plan (Nolan et al., 2005). See Figure 1 for illustration of FFS.
Prepare for Spread. Prior to project planning, the DNP project leader communicated the results of the SWOT analysis to the telemetry director, chief nursing officer, telemetry clinical educator, and clinical coordinator (see Appendix I). The unit director and most of their staff noticed the engagement on the existing fall prevention initiative. The unit director and clinical coordinator were very involved in the EBP change project. They provided critical help in identifying evidence-based literature to prevent falls. The telemetry educator and clinical coordinator were also on board and acted as champions of the fall initiative program. The Fall assessment with Tailored Intervention was an EBP practice in telemetry unit that can be adapted hospital wide for spread.
Establish an aim for the project. The fall rate was above the NDNQI national benchmark of 3.44/1000 patient days (AHRQ, 2015b). The desired outcome was a decrease of falls below national benchmark or a decrease of more than 50% in falls and fall injuries as well as more than 75% adherence to the fall initiative program.
Developing an initial spread plan. The DNP project leader communicated the EBP project during staff meetings. A gap analysis was conducted on current fall protocol and practices to evaluate barriers. These barriers were communicated to the unit director and clinical coordinator; as a result, protocols and the policy were revised.
Executing and refining the spread plan. Based upon the results of the fall prevention checklist gap analysis, the clinical coordinator revised the fall prevention policy. One-to-one education tools and poster training modules were used to train all staff on the two telemetry units. The education module focused on the following themes from the synthesis of the literature: electronic Morse Fall Scale assessment, patient-centered poster fall checklist intervention, and leaders' engagement in maintaining sustainability (see Appendices L and M).
The initial training was targeted for all nurses and champions in the two units, charge nurses, resource nurses, and nursing assistants. The clinical telemetry educator used the poster educational materials, conducted one-to-one training of all nurses, and secured a sign in sheet.
Nurse Informatics presented the PowerPoint to the nurse champions and the Fall Assessment with Tailored Intervention was available on the electronic health record nursing care plan documentation (see Appendix M). The post-implementation project evaluation occurred in the first two weeks and every month. The time frame of the project was 12 weeks. There were monthly virtual meetings to assess adherence, and post huddles occurred consistently for every fall event to mitigate gaps right away. Data was collected monthly to evaluate fall rates, fall rate with injury, nurses' adherence to the protocol and patient engagement.
The initial estimated cost of the project was $13,397.70. The calculation was based on department reviews and vendor recommendations, invoices and operational budgets to identify rates of pay for nurses and nursing assistants (see Appendix K). However, the expense budgeted was not approved due to a budget constraint. Instead, the telemetry educator provided one-to-one training during staff huddles. Therefore, the final cost of the project was only $6,677.00 (see Appendix K).

Project Evaluation
The PICOT question of the evidence-based practice project was: (

Data Collection
The fall evidence-based practice program was implemented in the two telemetry units at DHR Health. The implementation of the Morse Falls Assessment with Tailored Intervention Education Checklist Poster (Appendix L) was a quality improvement change. All adult patients (n= 58) were evaluated for fall risk using the Morse Fall Assessment to assess any risk for falls.
Based on their score, a specific tailored intervention was implemented.
The following interventions based on the MFS need to be documented on the EHR and In addition, the audit tool included hospital universal fall precaution interventions such as yellow socks, bed alarms, yellow gowns, call lights, fall signage, beds on the lowest position, two-side rails up and alarms. The DHR Fall Audit Tool (Appendix P) was used to collect data and evaluate compliance with the Morse Fall Assessment and documentation of the tailored intervention in the EHR. The tool was adapted from the Pennsylvania Patient Safety Fall Audit Tool (PSA, n.d.). In addition, the tool was reviewed and revised with further input and collaboration from the unit director, clinical coordinator and the Stryker Bed liaison officer. A pilot audit was conducted five days prior to the scheduled audit implementation to evaluate and clarify questions. The following pieces of information were missing and added to the audit tool: visual observation of the special equipment in use along with call light, two side rails up, checking Stryker Bed alarms to ensure they are on Zone 2, and green light is on if alarms are being used.
The first audit was performed on April 28, 2020 and every week for one month.
Moreover, during the audit, the DNP project leader used an online random number generator to determine which room would be audited, and a unique code that contained number and letters was used on each audit tool to protect patient privacy. All of the sample (N=58) met the criteria, and MFS scores were all > 10. The audit data were kept in the director's office. No patient information was collected on the audit tool. The audit tool used a unique code of letters and numbers next to the patient room number. The completed audit tools were collected at the end of the audit, and data were tabulated using Excel and Graph Pad Prism for appropriate statistical analysis and data visualization (Graph Pad, n.d.).

Formative Evaluation
Patients with a normal Morse Fall Score of "0" were excluded, and scores of 10 and higher were included in the fall evidence-based practice program. The process and outcome measures were evaluated for the fall process improvement and included: Increased patient and family engagement by identifying patient risk for falls; nurses' adherence to the This data is also in Appendices Q and R. The aggregated data show that 77 % of the patients were Hispanic and 22% were non-Hispanic. The nurses' adherence for completion of the Morse Fall Assessment was 94%, which was documented on the EHR. Results from the study indicate that nurses were compliant on assessing patient Morse fall scores. In addition, 94.82 % of these patients were identified to be at risk of falling. Tabulated data revealed that 87.93% of nurses did not adhere to the procedure of marking the poster intervention, and 67 % did not document the Tailored Intervention in the EHR. Nurses' adherence to document on the poster as well as in the Cerner education documentation scored very low (see Appendices T and U). Based on these results, the DNP project leader and the Director planned to re-educate nurses and add online fall education. The DNP project leader and the DHR health educator are currently working an online mandatory class training for project sustainability. The education will include the Morse Fall Assessment with Tailored Interventions, and the EHR power form fall intervention documentation for sustainability of the project.
The data displayed in Appendices Q and R showed visual observation audit assessment cues such as fall signage on the door (100%) compliance, tailored intervention poster in the room (100 %), call light within reach (100%), all rooms have a Stryker bed (98.27%), and which rooms have the special alarm capabilities, resulting in high compliance. The result of nurses' adherence on two side rails up was 79%, the bed on lowest position was 78.83%, and wearing a yellow gown was 79.31%. One interesting audit item was 75.86% patients wearing yellow socks, and red nonskid socks upon audit were counted as yellow socks, because red socks were not specified on the audit tool. Of the ten Stryker beds that have the alarm on, nine of the beds have the green light on, and seven are on zone 2. The zone 2 and green light is a bed exit alarm for high-risk, confused patients who get out of the bed without assistance. According to Coussement et al. (2008), a bed alarm is the only intervention for patients who are confused and are at a very high risk of falling. Also, during the audit, there were 5 patients who used one-to-one sitters to prevent patient falls in addition to using the bed alarm.
Moreover, the tabulated results were presented to the telemetry director and the following measures were planned. The first measure planned was the sustainability measure, which included re-education regarding the adherence of the Fall assessment with tailored intervention to be done online and with an expected 75 % adherence rate. Increasing the nurses' champions, and recruiting more nurses on each floor to continue the evidence-based practice project was discussed. The second measure planned was the financial measure. The total cost is presented in Appendix K, and additional costs will be added regarding increasing the size of the poster for good visualization, and ordering more yellow gowns and yellow socks. According to AHRQ, the cost of falls with associated injury is $7000. There were no reported injuries on the post-fall huddle report. The third measure planned was the balancing measure; the number of sitters audited was five during the period of data collection, and each sitter cost $12.50/hr, for a total cost of $750.00. Moreover, there were no staff injuries reported on all the post huddle reports.

Summative Evaluation
The DHR Health Institute for Research and Development scientist and the DNP project leader used the Fisher's exact test and Chi-square for statistical analysis. The Fisher exact test and chi-square were used to check if there was a decrease or change in the fall event when these two variables were compared (intervention and outcome). The results of the data analysis of the following variables were analyzed: the Morse fall assessment and tailored intervention documented on EHR (Cerner) was not statistically significant with p >0.999, as seen in Appendix U ; the Morse fall assessment and tailored intervention documented on the poster did not make a difference with a p > 0.999 (Appendix T); the Morse fall assessment and use of fall equipment were not statistically significant when data was run using a chi-square p > 0.9992, as seen in Appendix V.
An additional analysis was conducted using a total of 54 eligible patient charts. The number of falls that happened in April and May (April was 60% and May was 40%) were analyzed to check if there was a decrease or change in the risk to fall. The MFS assessment documented on EHR was 16.67% in April and 83.33% in May. A Fisher exact two-sided test was used to determine the association between month vs. MFS assessment vs. fall events. The results showed a statistically significant correlation between the Morse fall score assessment on EHR and fall events p=0.00 78, as shown in Appendix W.

Discussion
The Fall Assessment with Tailored intervention is an adaptable evidence-based practice change. The process of the evidence-based practice project included a Morse Fall Score (MFS) and poster with tailored interventions. Nursing adherence to the MFS showed a statistically significantly higher compliance on the assessment and EHR documentation (94.73%, p= 0.0078). According to Dyke et al. (2010), the evidence-based fall prevention toolkit that included the Morse fall assessment showed 81% compliance on the control floor and 94% compliance on the intervention floor. The teaching hospital is accredited by the Joint Commission, and the fall prevention evidence-based practice project was a contract between the hospital and patients to promote patient safety. The telemetry average fall rate after implementation was 2.47/1000 patient days, which was still below the national benchmark of 3.44/1000 patient days (AHRQ, 2015b). The average monthly fall rate over the 12-week implementation was 2.47/1000 patient days. Melin (2018) piloted a 3-month pre-and postintervention using the Morse Fall Risk Assessment with automatic intervention on EHR. A comparison of the pre-and post-intervention showed a decrease in the average monthly fall rate of 3.6 falls/1000 patient days (Melin, 2018). The fall assessment documentation in two telemetry units at DHR Health can be adapted or implemented hospital-wide. The results showed a statistically significant correlation between the Morse fall score assessment on EHR and monthly fall events (p=0.0078).
Assessment is one of the key best practices recommended for fall prevention (Cuesta, Benjumea et al., 2017;Dykes et al., 2017;Melin, 2018;Titler et al., 2016). The tailored intervention and universal fall precaution guidelines based on the Morse Fall Score were part of the checklist. Adherence to documentation of the fall prevention on the poster was found to be low, as 87.93% of the posters were not marked, updated or completed. In addition, there was also low adherence to the recommendation to document the tailored intervention in the EHR (36.07%). Therefore, the goal of 75% adherence on the education documentation was not met. Dykes et al., (2017), showed more than 80 % adherence of the tailored intervention was achieved when patient and family were involved in the plan of care. During the project implementation and evaluation, family members and visitors were not allowed in the unit due to COVID-19, and this may have affected the results. The Fall Assessment supports the conclusion in the reduction of fall events. The tailored interventions present an opportunity for offering more education and training, closing the identified gaps or barriers found during the entire process of project implementation, and evaluating to find alternatives to educate family and engage them in the planned intervention.

Limitations
The study was limited by the short period of education and training. The original plan to give nurses an hour of paid training was not approved due to budget constraints. The telemetry educator provided the training during their "downtime" but was not able to train all telemetry staff because of the COVID-19 pandemic. Additionally, the DNP project leader found out that nurses scored poorly on the "patient and family education on tailored intervention" audit. Due to the COVID-19 pandemic, there were no visitors allowed during the project implementation.

Education could have been provided during admission when fall assessment is usually initiated.
Furthermore, instead of no education being documented or given, family members should have been educated via a phone call. Patient engagement on the tailored intervention should be added on the audit tool to supplement patient and family engagement, to get more precise results.
Another limitation was the inconsistent use of the universal fall precaution supplies due to the availability of supplies. During the audit, the telemetry unit ran out of yellow gowns and yellow socks although nurses are aware of the universal fall supplies and used red nonskid socks on their patients instead. On the audit, these patients were marked wearing yellow socks. The next concern was the budget constraints. The DNP project leader faced challenges on the education and training on fall and tailored intervention and fall posters inside the telemetry room. The original plan of paying nurses for an hour of training was not approved due to budget constraints.
In addition, the plan to print and use 12 x 20 posters as recommended was not granted. The 8 x 12 posters were too small, and most patients verbalized that the posters were too small and too hard to see from the bed, so the patients were not able to identify their risk and intervention. To promote patient safety, the limitations, barriers, and opportunities were shared with the director and clinical coordinator so that corrective actions could be taken and to close the specific gaps in fall prevention.

Implications
Falls in hospitalized patients are a pressing safety concern in the organization because of unreimbursed costs of fall-related injury, which range from $7000-$30,000 depending on the severity of the injury (Spetz, Brown & Adin, 2015). According to Agency Healthcare Research and Quality (AHRQ), falls are preventable injuries which can cost an estimated $700,000 to $1,000,000 for hospitalized patient falls annually (AHRQ, 2015a). It is imperative for nurses to implement the fall assessment with tailored interventions by educating patients on the specific fall interventions to promote patient safety and prevent falls. Structured educational material that will include fall risk assessment with tailored intervention and universal fall precautions should be a standard of care for adult patients admitted in the telemetry unit who have a Morse Fall Score of low risk, medium risk or high risk.

Internal Dissemination
The presentation of the EBP project was scheduled on July 14, 2020, during one of the bi-weekly quality patient safety meetings of directors. The stakeholders present were the risk management director, quality director, some of the unit department directors, and their clinical coordinators. Due to the COVID-19 pandemic, the presentation of the fall assessment with tailored intervention results was conducted through a virtual meeting. The DNP project leader used a PowerPoint poster and delivered the quality improvement project results for 10 to15 minutes. The poster presented the significance of practice problem, the PICOT question, practice recommendation, project overview, evaluation, results, implications and conclusions. In addition, the project results were also presented to the telemetry unit staff and to the champions on July 20, 2020.
The DHR Health Institute and research scientist also planned to present this project's results to the trauma unit staff and stakeholders. No final approval has yet been received from the neurosurgeons and directors because of the pandemic, but it is anticipated. According to Siedlecki, Montague, and Schultz (2008), information should be disseminated at the institutional level before it is disseminated to the public to prevent ethical pitfalls.

External Dissemination
According to White, Dudley -Brown, and Terhaar (2016), dissemination is an essential part of the translation of evidence. Edward (2015) noted it is also an important step toward practice change. For the external dissemination, the three main methods (poster, presentation, and manuscript or paper) can be used. Each method requires structure and has specific requirements for publication. The DNP scholarly paper was initially published to the University of St. Augustine for Health Sciences' an institutional repository, called SOAR@USA, which is available in the USAHS Library. The full text scholarly paper was also submitted to Henderson Library on August 5, 2020.
The DNP project leader is also a member of the National League of Nursing (NLN), she plans to present the scholarly paper through a poster. First, she must submit an abstract for leadership review in order to be approved for presentation at the NLN Summit in Florida on September 26-30, 2020. If approved, the presentation will incorporate the framework model Nursing Process for Fall Assessment and Intervention. However, the NLN Summit may be cancelled or held remotely due to COVID-19.
The DNP project leader would also like to publish her project in The Joint Commission Journal of Quality and Patient Safety. The project is appropriate to be published in this journal because this journal: "is dedicated to providing new ideas and information to improve the quality and safety of healthcare" (JCJQPS, 2019, p.3). Subsequently, the DNP project leader followed the journal's guidelines for manuscript submission: the text was limited to 4000 words and organized into Introduction, Methods, Results, and Discussion (JCJQPS, 2019, p.4). As part of the publication decision process, the submitted manuscript will be subjected to peer review.

Conclusion
The Fall Assessment with Tailored Intervention for adult patients in the telemetry unit showed clinically and statistically significant results in decreasing fall events within a 12-week period. The DNP project leader found that the Morse Fall Assessment showed clinically and statistically significant results in decreasing the fall rate over 12 weeks with an average of 2.47 /1000 patient days, which is below national benchmark. In addition, there were no injuries for all the fall events. Dykes et al. (2017), Ambutas (2017), and Johnston and Magnan (2019) concluded that the use of a fall risk assessment tool can help in the process of tailoring patientcentered interventions. Moreover, using a fall risk assessment as the first step of intervention and arriving at a fall risk score by knowing the risk factors can mitigate the risk and successfully implement fall interventions. The findings support the conclusion that the Morse Fall Assessment can be used as an assessment tool to apply specific tailored interventions to promote patient safety and prevent falls.

Results
The Agency for Healthcare Research and Quality (AHRQ, 2013) has recommended that falls be measured as a rate to account for the unit's census at a given time. Therefore, the fall rate was calculated based on the NDNQI recommendation, which is the number of fall incidences occurring in a month divided by the total number of occupied beds for the same month, multiplied by 1000 (AHRQ, 2013); There was a decrease in the rate of fall for the month of February, which was 2.29/1000 days' patient days, and March, which was 1.77/ 1000 patient days. The April fall rate increased tremendously from 1.77/1000 patient days to 4.75/ 1000 patient days. The month of May fall rate was 1.74/1000 patient days. The average monthly fall rate over 12-week implementation period was 2.47/1000 patient days, which was below the national benchmark of 3.44/1000 patient days. The fall assessment documentation in two telemetry units at DHR Health can be adapted or implemented hospital-wide. The results showed a statistically significant correlation between the Morse fall score assessment on EHR and monthly fall events (p=0.0078).

The primary strength of implementing the Morse Fall Assessment with Tailored
Intervention was its collaborative approach and the teamwork encountered during the implementation and evaluation, despite the unprecedented event of COVID-19. Another strength is the Morse Fall Assessment compliance on EHR and treating all patients as risk to fall. Also, EHR power form with tailored intervention is part of daily assessment that is available in the nursing care plan. In addition, nurses have high compliance on use of call lights, fall signage on the wall, and placing bed at lowest position. Also, the nurse coordinator, who used the tailored intervention poster, found it is easy to read, apply, and understand. Involving family members in the fall prevention plan targeted to patient specific fall risk has decreased fall rates during the first two months of implementation. The fall audit tool aids in the identification of variation to nursing practices that depart from clinical standards. Moreover, the clinical coordinators can therefore take corrective actions to address specific gaps in the tailored intervention to promote patient safety. post implementation study in the U.S. Applied Nursing Research, 31, 52-59. https://doi.org/10.1016/j.apnr.2015.12.004 Tzeng, H., & Yin, C. (2015. Patient engagement in hospital fall prevention. Nursing Economics, 33 (6)  Reduce falls with injury to less than 0.3 per 1,000 patient days on study units.
Reduce falls without injury on study units to less than 3.4 per 1,000 patient days.
Unit 1, 81 falls were documented in 2013. Falls from bed had the highest frequency (40%, n=73), followed by falls related to toileting or commode usage (27%, n=22) Unit 2, 54 falls were documented. Of 38 falls related to toileting (70%), seven involved injuries (six minors, one major) Changes in falls and fall with injury per 1000 patient days.
Interprofessional individualized care plan and post-fall huddle included patients and families. Can prevent fall Project goals were achieved through leader support and promotion of staff accountability. Staff were involved in problem analysis, fall toolkit implementation, ongoing review of falls, and continual evaluation of the process. The organization's safety climate improved as staff became accountable for reducing falls and preventing injury.
Opportunities for interprofessional education were addressed by the project director at various department meetings.
Continued mentoring by fall team members and unit leaders, confirming the importance of organizational systems.
The infrastructure and capacity to identify and address solutions for patients were successful because of unit champions' diligence and continual feedback Fall decreased from 7.98 to 6.6/. 23.8 % improvement on the fall rate Pre-post implementation study with 60 percent response rate Nurse survey 720 12 focus group 24 interviews Response rate= 420 (60 %) The study identified barrier and enablers to the implementation of 6 PACK program. Barrier identified: beliefs that fall cannot be prevented, limited knowledge on fall prevention, and lack of ownership. Enablers: education and training, improved leadership, use of data to drive practice change, use of reminders, audits and feedback. The need to have leaders and champions.
The recommendation on how to tackle barriers will be helpful to close the gaps on the implementation.
Stakeholders response and suggestion to address barriers will be helpful in the sustainability of the quality improvement project. Barker, Morello, Ayton, Hill, Brand and Livingston (2017) Acceptability of 6 PACK fall prevention program: A preimplementation study in hospitals participating in a cluster randomized controlled trial Fall risk tool 3.
Patient walking aids within reach 6.
Bed alarms The study confirmed acceptability of the 6 PACK program / Nurses perceived that the program is suitable, practical and beneficial ways to reduce falls.
The survey has recommendation regarding barriers to the 8 items listed. Applying those recommendation on the conceptual model will be beneficial. Cuesta-Benjumea et al., (2017) Fall prevention among older people and care providers: protocol for an integrative review Fall injury rates multiply by number of in patient fall with injuries by 1000 dividing by total number of in-patient days.
Types of Fall injuriesdefined as Minor"resulted in application of dressing, ice or limb elevation; Moderate-resulted in suturing or splinting; "Major"resulted in injury like traction, fracture, or liver laceration and "Death"patient died as result of injury caused by fall.
The decline in fall rates from pre-(X¯ = 3.69; SD = 1.43) to postimplementation (X¯ = 2.7; SD = 1.34) was not statistically significant (− 0.251 on the log scale; SE = 0.15), but demonstrated a trend toward significance (p = 0.09) with a 22% decline in fall rates. Fall compliance significant improvements (p < 0.001) from pre-to postimplementation indicating that fall prevention interventions were implemented to address patient-specific fall risk factors Number of times intervention(s) was received per 100 patient days (example: received a mobility intervention 88 times per 100 patient days).
The Translating Research into Practice intervention improved use of fall prevention interventions targeted to patient-specific fall risk factors. The study also demonstrated improvement in reduction of fall rates and types of fall injuries. To make significant gains in reducing falls in hospitals, clinicians must do more than arriving at a fall risk score with subsequent implementation of general fall reduction interventions; they need to know each patient's risk factors for falls and implement fall prevention interventions to mitigate those risks. Staff need to be involved in the process of tailoring and implementing the toolkit and redesigning the workflow to engage patients and family in the 3-step fall prevention process. The interventions can be modified based on organizational policy and patient needs. Patient engagement and nurse consistent intervention in the fall checklist poster and EHR Leadership support to sustain fall. Framework will maintain toolkit adoption, sustain evidence fall prevention and prevent falls The use of a framework to address barriers is a framework for improvement Johnston  The inclusion criteria applied were systematic review, randomized controlled trials, qualitative study, quasi experimental patients, hospitals, adult, healthcare hospitals. The exclusion criteria applied were: non-English language, non-intervention, commentaries, community dwellings, psychiatric, pediatrics, psychogeriatric, and hospice setting.
The use of fall checklist as a handoff report. Most common errors on the 14 items fall checklist interventions are: Bed alarm, signage No fall occurred during pilot program.
A sharp decline in the fall incidence Small number of observation and short period of time. monthly fall rate of 3.6 falls/1000 patient days and a 44.5% decrease in the actual number of falls per month.
The pilot unit had an average monthly fall rate during the pre-intervention period of 8.67 falls/1000 patient days, Performing Schmidt fall risk assessment tool Using fall checklist can promote adherence of the fall interventions. Checklist map out minimum steps necessary to completely and correctly do the multiple task. Checklist will prevent oversight.
There was no patient education done or patient engagement. Education training and nurse adherence was measured through a checklist evaluation Melin, (2018) Level I Grade A Does Use of specific consistent fall risk Assessment tool decrease fall? Does use of patient centered fall Checklist or toolkit reduce fall? Does use of consistent fall prevention and patientfamily and interprofessional engagement reduce fall?

ProQuest
The inclusion criteria applied were systematic review, randomized controlled trials, qualitative study, quasi experimental patients, hospitals, adult, healthcare hospitals. The exclusion criteria applied were: non-English language, non-intervention, commentaries, community dwellings, psychiatric, pediatrics, psychogeriatric, and hospice setting.
The pre-intervention period of 8.67 falls/1000 patient days. The average monthly fall rate of 5.07 falls/1000 patient days Consistent Fall risk stratification using Morse fall risk >45 score are on High fall risk and bed alarm and chair alarm are activated Automatic intervention of Universal fall precaution. There was no checklist used but intervention is patient centered.
Staff received training and education and was done prior to implementation. Patient education was not mentioned.
Legend: RCT-randomized controlled trials, Agency for Healthcare and Research Quality (AHRQ) STRATIFY DV-Dependent variable, IV-Independent Variables, CPG-clinical practice guidelines model, EBPI= evidenced based practice improvement, CQI-continuous quality improvement Education and consistent risk stratification reduced falls. Ongoing falls education for staff Titler et al., (2016) Level Appendix 0