Advanced Practice
Thou Shalt Not Fall! Decreasing Falls
In the Postoperative Orthopedic
Patient with a Femoral Nerve Block
Kimberly Foisy
orth Shore Medical Center
(NSMC), Salem Hospital, an
affiliate of Partners Healthcare System Inc., is a 250-bed acute
care teaching hospital located in
Salem, MA, near Boston. The hospital
serves a diverse patient population
with 12,000 inpatient admissions per
year. The hospital’s 32-bed orthopedic-neurologic inpatient unit, which
is split between the 6th and 7th
floors of the Phippen Building, has
an average daily census of 30
patients. Unit leadership includes a
nurse manager, clinical educator,
unit coordinator, and one day-shift
charge nurse assigned to both floors.
Average daily staffing consists of
three nurses, two nursing assistants,
and a service associate for each 16bed unit; staff can be assigned to
either floor.
N
Improvement Needs
Decreasing patient falls is a
patient safety priority for direct-care
nurses. Many regulatory and governmental agencies, such as the Centers
for Medicare & Medicaid Services
(CMS), have set standards and payment incentives to reduce or eliminate falls in the health care setting.
For example, CMS (2011) no longer
reimburses for hospitalization if a
patient has an injury as a result of an
inpatient fall. Some health care
providers suggest falls cannot be
avoided (Muraskin, Conrad, Zheng,
Morey, & Enneking, 2007). However,
staff members for the involved units
at NSMC were determined to counter this view by taking action to
address a recent increase in patient
falls on the unit.
Phippen 6 and 7 house postoperative orthopedic and neurological
246
A Transforming Care at the Bedside model was used to decrease
falls in the femoral nerve block (FNB) patient population on a 32bed orthopedic/neurologic unit in a community hospital setting.
A multifaceted, strategic practice and educational bundle was
implemented, resulting in a 75% decrease in falls among patients
with FNB.
surgical patients. Each floor has 16
private beds. A group of multidisciplinary professionals and unlicensed
staff from the two units convened to
form a team under the Transitioning
Care at the Bedside (TCAB) model
(Rutherford, Moen, & Taylor, 2009).
The team set a goal to eliminate falls
on the unit and started analyzing
falls data to determine the rate and
cause of falls that were occurring.
Data revealed as many as three falls
per month associated with femoral
nerve blocks (FNBs), with two
patients sustaining injury from
January to July 2009. The unit had a
fall rate of 5.2 per 1,000 patient days,
compared with a fall rate of 3.43 per
1,000 patient days for the facility.
Further data analysis showed 5 of 30
falls reported during that time
occurred in patients with a femoral
nerve block in place following knee
arthroplasty.
A process flow analysis revealed
the nursing practice protocol recently had been replaced by a standard
computerized nursing order set that
did not include assessment parame-
ters for the patient or a plan of care.
Furthermore, the signs at the head of
the patients’ beds stating “Fall Risk
Femoral-Nerve Block” were being
removed as soon as the FNB was discontinued. A learning needs assessment demonstrated nursing assistants did not have adequate knowledge of the definition, purpose, and
precautions needed in caring for a
patient with a current or recently
discontinued femoral nerve block. In
addition, patients and families were
not aware of the safety risks needed
during and after the use of a continuous femoral nerve block.
Literature Review
Two searches of the CINAHL database were performed to identify best
practices (June 2009; May 2011) for
literature of the preceding 6 years.
The terms searched included femoral
nerve block, falls, and orthopedic surgery. The search revealed no published nursing literature that demonstrated a decrease in falls in persons
with femoral nerve blocks after an
Kimberly Foisy, MSN, RN, CMSRN, is Clinical Educator/Administrative Nursing Supervisor,
Orthopedic-Neurological Medical/Surgical Unit, North Shore Medical Center (NSMC), Salem
Hospital, an affiliate of Partners Healthcare System Inc.; and Assistant Professor, Massachusetts
College of Pharmacy and Health Sciences, School of Nursing, Boston, MA.
Acknowledgment: The author gratefully acknowledges Kathy Clune, MSN, RN, Nurse Manager,
Phippen 6 and 7; and Taryn Bailey, MSN, RN-BC, Executive Director, Professional Practice and
Patient Education Services, for their advice and guidance in the development of this article.
July-August 2013 • Vol. 22/No. 4
Thou Shalt Not Fall! Decreasing Falls in the Postoperative Orthopedic Patient with a Femoral Nerve Block
educational intervention was implemented to nursing staff. Results of
two medical studies are described in
the following paragraphs.
Sharman, Iorio, Specht, DaviesLepie, and Healy (2010) reported
patients with a FNB have a shorter
length of stay. According to these
authors, patients ambulate earlier as
a result of the comfort maintained
with the block. A large percentage of
postoperative falls among this group
of patients have quadriceps weakness as a contributing factor.
Continuous FNB provides effective pain management as an analgesic adjunct to other modalities for
orthopedic patients. A FNB reduces
the required doses of general anesthetic agents and hence their side
effects, including nausea, vomiting,
drowsiness, and respiratory depression. The FNB also confers superior
pain management, decreases opioid
requirements, and enables earlier
ambulation and hospital discharge
(Atkinson, 2008). The use of FNB
with general anesthesia also places
the patient at a higher risk for falls.
A continuous FNB is used as an
anesthetic. A catheter is placed just
below the skin surface, next to the
femoral nerve. The catheter coats the
nerve with anesthetic, blocking
transmission of neuronal messages
and creating a feeling of localized
numbness for the patient (Kasibhatia
& Russon, 2009). This block allows
the patient to achieve more effective
pain management. The block does
not alleviate the pain on the posterior portion of the knee. An adjunct
therapy, such as patient-controlled
analgesia, often is prescribed for this
reason. Because the block causes a
weakness of the quadriceps muscle,
the patient needs assistance with
every transfer (Atkinson, 2008).
One of the cases analyzed by the
team involved a patient who was
ambulating with a nursing assistant.
The continuous femoral nerve block
had been discontinued 2 hours earlier. The patient’s knee buckled, and
he proceeded to fall to the floor. The
nursing assistant hit the door and
sustained a minor back injury. The
patient’s knee wound opened as a
result of the fall, requiring minor
suturing. Fortunately, the patient’s
FIGURE 1.
Femoral Nerve Block Patient Information Sheet
• The femoral nerve block is a regional anesthetic technique used in conjunction with general anesthesia for pain relief.
• It is an effective block that provides both safe and excellent surgical
anesthesia and postoperative pain control.
• Your leg will feel numb, but you can still move your leg
• You will have little or no pain in the front of your leg or knee. However,
you will probably have some discomfort behind your knee. That is
expected.
• Remember to discuss your pain plan with each nurse.
• REMEMBER: Ring your call bell for assistance.
• You MUST NOT get out of the bed or chair, or off the commode without
assistance.
• Your therapist and/or nurse will instruct you on the safest ways to move.
• The numbness and weakness from the block usually lasts 8-20 hours
and occasionally more than 24 hours once it is removed from your
groin.
• As the block begins to wear off, you should start your pain medicine that
was prescribed by the surgeon. REMEMBER: Ask the nurse for your
pain medication. The nurse will be offering you pain medication, but you
need to ask as well.
length of stay did not increase as a
result of this fall.
cepted into practice, and implemented August-October 2009.
Continuous Quality
Improvement Model
Patient/Family Education
Sheet
After reviewing the data, the team
developed a multifaceted plan to
educate unit staff on the safety and
care of patients with femoral nerve
block, as well as standardize the
process for patient care following
femoral nerve block. The Nerve
Block Bundle included developing
and implementing a:
1. Patient and family education
sheet to engage patients in their
care (see Figure 1).
2. Revised nursing protocol to
standardize the process for care.
3. Nursing education plan.
4. Fall prevention signage specific
to this population (see Figures 2
& 3).
5. Tip sheet for unlicensed assistive
personnel (UAP) to reinforce the
care and safety needs of the
patient with a FNB (see Figure 4).
The education plan and bundle
were presented at the NSMC Nursing
Professional Practice Council, ac-
Patient and family education are
vital in preventing falls (Agency for
Healthcare Research and Quality,
2010). The patient/family education
sheet (see Figure 1) includes information related to pain management,
duration of the femoral nerve block,
sensation of the lower extremity,
and safety guidelines to reinforce the
patient’s need to call for assistance to
get out of bed.
July-August 2013 • Vol. 22/No. 4
Nursing Protocol
Sharma and co-authors (2010) recommended hospitals develop protocols addressing decreased quadriceps
function as a result of a continuous
FNB. Prolonged nerve blockade can
last up to 30 hours after termination
of the continuous femoral nerve
block (Atkinson, 2008). This study
recommended the implementation
of a postoperative evaluation that
included proprioceptive function.
247
Advanced Practice
FIGURE 2.
Fem Block Stop Signage
FIGURE 4.
Safety in Caring for the Patient with a Femoral Nerve Block
STOP
A femoral nerve block is a peripherally inserted catheter that delivers a numbing
medicine to cover the femoral nerve. A TKR patient usually has the catheter in
place for 48 hours.
Structures Seen on Ultrasound in Left Femoral Space
(viewed from foot)
Do Not Get Out of Bed
Call for Help
FIGURE 3.
Fall Prevention Signage
Fem-Block
High Risk for Falls!
The catheter is placed just below the skin surface, next to the femoral nerve. The
catheter coats the nerve with numbing medicine; this allows for blocking of the
painful sensations from the hip down the patient’s leg.
The medicine will numb the patient’s leg. The thigh muscle, or quadriceps, will be
very weak.
The leg will be warm, and may be slightly warmer than the non-affected leg.
The patient will always need two assists when getting out of bed with this catheter
in place and for a certain period of time after removal.
Maintain the patient on The Falling Star Program.
Patient:
Room:
Date/Time Stopped:
After removal of the femoral nerve block, the same safety precautions will remain
until the patient has regained complete sensation in the leg. You need to check with
the nurse before moving the patient to determine if the patient has feeling back in
his/her leg and identify if the patient can be transferred with one assist.
Source: Reprinted with permission from Vander Beek, J. (2005).
Based upon this evidence, a nursing protocol was written to include
the following:
1. Assess the sensory, motor, and
vascular condition of the
extremity every 4 hours during
and after removal of the femoral
nerve block until the patient
obtains full sensation and motor
function returns.
2. Maintain fall precautions for the
duration of the patient stay,
regardless of assessment of
248
3.
4.
return of motor function and
sensory function.
Maintain fall risk signage for the
duration of the patient stay.
Place signage at the head and
foot of the bed to reinforce messaging for the patient, family,
and staff (see Figures 2 & 3).
Fall Risk Signage
Patients typically have the FNB
removed on postoperative day 2 in
the early morning. Patients generally
are discharged on postoperative day
4 either to home or a rehabilitation
facility. To improve patient safety,
the team decided signage would
remain for the entire length of stay.
UAP Education/Tip Sheet
Based on findings from the literature, a one-page educational sheet
was developed for all UAP (see Figure
4). The tips were developed by the
July-August 2013 • Vol. 22/No. 4
Thou Shalt Not Fall! Decreasing Falls in the Postoperative Orthopedic Patient with a Femoral Nerve Block
FIGURE 5.
Falls Associated with Femoral Nerve Blocks per Month
(January 2009 – September 2010)
Number of Falls
2.5
2
1.5
1
0.5
0
Jan
2009
Mar
2009
May
2009
July
2009
Sept
2009
Nov
2009
Jan
2010
Mar
2010
May
2010
July
2010
Sept
2010
Date
TCAB team in collaboration with
physical therapists. This education
guide was reviewed with and supplied to all UAPs, and has been
incorporated into new hire orientation for employees on these units.
The educational process consisted of
either 1:1 education or group sessions. The educator continued to
contact UAPs individually to validate understanding of the information provided.
Nursing Implications
In the calendar year 2009, Phippen
6 and 7 had a reported falls rate of 5.2
per 1,000 patient days. Following
implementation of the FNB education plan and bundle, the unit fall
rate decreased to 2.9 per 1,000 patient
days, with a facility reported rate of
3.52 per 1,000 patient days (see Figure
5). The bundle was effective in
decreasing falls among patients with
FNB, also contributing to the improved overall fall rate.
The team has been able to sustain
the gains, in large part because of the
interdisciplinary and multifaceted
approach to analyzing the issue, providing education, and implementing
necessary practice changes. The signage has continued to have a positive influence on the fall prevention
project as it serves as a helpful visual
reminder for staff, patients, and families. Education, audits, and remind-
ers to keep signs in place are ongoing. Staff members now utilize the
two-person assist method with all
affected patients during the duration
of the FNB as well as after the block
is removed, until sensation and
motor function have returned as
determined by the nurse. Patients
are more aware of the need for assistance now due to the signage and
education sheet. Patients and families have identified the value of the
information. All newly hired staff
members review the bundle during
the orientation period. Fall data also
continue to be evaluated.
Conclusion
The TCAB approach engaged unit
leaders, clinicians, and patients to
improve the quality and safety of
patient care on two orthopedicneurologic units. There was only one
recorded fall in patients with FNB
after implementation of the FNB
bundle, from September 2009 to
December 2010. It is amazing what a
little bit of knowledge and education
can accomplish!
REFERENCES
Agency for Healthcare Research and Quality.
(2010). The falls management program:
A quality improvement initiative for nursing facilities. Retrieved from http://www.
ahrq.gov/research/ltc/fallspx/fallspxman
ual.htm
July-August 2013 • Vol. 22/No. 4
Atkinson, H.D. (2008). Postoperative fall after
the use of the 3-in-1 femoral nerve block
for knee surgery: A report of four cases.
Journal of Orthopaedic Surgery, 16(3),
381-384.
Centers for Medicare and Medicaid Services
(CMS). (2011). Medicare fact sheet:
Proposals for improving quality of care
during inpatient stays in acute care hospitals in the fiscal year 2011 notice of proposed rulemaking. Retrieved from http://
www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/AcuteInpatientPPS/
downloads/FSQ09_IPLTCH11_NPRM04
1910.pdf
Kasibhatia, R.D., & Russon, K. (2009).
Femoral nerve blocks. Journal of
Perioperative Practice, 19(2), 65-69.
Muraskin, S.I., Conrad, B., Zheng, N., Morey,
T.E., & Enneking, M.D. (2007). Falls
associated with lower-extremity-nerve
blocks: A pilot investigation of mechanisms. Regional Anesthesia and Pain
Medicine, 32(1), 67-72.
Rutherford, P., Moen R., & Taylor, J. (2009).
TCAB: The “how” and the “what.”
American Journal of Nursing, 109(11), 517.
Sharma, S., Iorio, R., Specht, L.M., DaviesLepie, S., & Healy, W.L. (2010). Complications of femoral nerve block for total
knee arthroplasty. Clinical Orthopaedics
and Related Research, 468(1), 135-140.
Vander Beek, J. (2005). Finding the femoral
nerve. Retrieved from http://www.neurax
iom.com/html/finding_the_femoral.php
ADDITIONAL READINGS
Schulz-Stubner, S., Henszel, A., & Hata, J.S.
(2005). A new rule for femoral nerve
blocks. Regional Anesthesia and Pain
Medicine, 30(5), 473-477.
Turjanica, M.A. (2007). Postoperative continuous peripheral nerve blockade in the
lower extremity total joint arthroplasty
population. MEDSURG Nursing, 16(3),
151-154.
249
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.
From all that have been discussed so far, research and evidence-based nursing
practice is relevant to health care. As a consumer of research, how will you apply
what you learned in class in your nursing practice? Speak to the following points
below in 300 to 400 words.
1. What are some of the important issues you learned about research and evidence-based nursing
practice?
2. How has the class prepared you to succeed in the clinical area and as a professional nurse?
3. How and when will you integrate what you have learned in class as you practice your
profession as a nurse?
1.
Analyze and discuss why a QI project was needed.
According to the article, the QI project was initiated because there has been an increase in falls
among postoperative orthopedic patients with a femoral nerve block (FNB), and there was
therefore a need to these eliminate falls by identifying the causes and introduce a quality
improvement to improve the current process to eliminate or reduce the falls (Foisy, 2013).
2.
What initial steps were assessed by the QI team? Discuss their findings including the
data.
The initial steps by the QI team was to analyze the fall data and determine the rate and cause of
falls. According to Foisy ( 2013), the data revealed that “ as many as three falls per month
associated with femoral nerve blocks (FNBs), with two patients sustaining injury from January to
July 2009. The unit had a fall rate of 5.2per 1,000 patient days, compared with a fall rate of 3.43
per 1,000 patient days for the facility. Further data analysis showed 5 of 30 falls reported during
that time occurred in patients with a femoral nerve block in place following knee
arthroplasty”(p.246). Additionally, the team also completed a flow analysis, which revealed that
the nursing practice protocol recently had been replaced by a standard computerized nursing
order set that did not include assessment parameters for the patient or a plan of care.
Furthermore, the signs at the head of the patients’ beds stating “Fall Risk Femoral-Nerve Block”
were being removed as soon as the FNB was discontinued (p. 246). The authors also completed a
learning needs assessment, which showed that “assessment demonstrated nursing assistants did
not have adequate knowledge of the definition, purpose, and precautions needed in caring for a
patient with a current or recently discontinued femoral nerve block. In addition, patients and
families were not aware of the safety risks needed during and after the use of a continuous
femoral nerve block” (p.246).
3.
Why was the focus of the QI project on a specific population?
The focus of the QI project on postoperative orthopedic patients with a femoral nerve block
(FNB) because they were the ones that were experiencing falls at an alarming rate.
4.
Analyze the QI model used for this project. Name and discuss an alternative QI
model that could have been used in this project.
The QI model that was used for this project was the Transitioning Care at the Bedside (TCAB)
model (Foisy, 2013; Rutherford et al., 2009). Some components of TCBA are Safe and Reliable
Care, Vitality and Teamwork, Patient-Centered Care, and Value-Added Care Processes. The
purpose of a TCAB is to help the are team to evolve ideas that changing the way that patients are
cared for especially professionals that spend the most time with patients at their bedside. The use
of the model for the QI is appropriate given that the focus is on care transformation at the care
level. Another model that can be used for this model is the Hendrich Fall Risk Model (HFRM),
which can also be used to evaluate fall risks.
5.
Evaluate the findings of the QI project. Were the findings relevant? How did the
RNs utilize and integrate the findings into their nursing practice?
The findings to this project were relevant as it related to its overall purpose of the
study. According to authors, the RN’s integrated the findings to address some of the issues
within the unit that contributed to the falls and to improve their overall practice. Specifically,
they improved their ability to learn the protocols around proper placement of signage.
6.
What is your cosmic question?
Will QI improvement studies lead to better outcomes if qualitative methods were used or if
quantitative approaches were used.
References
Foisy, K. (2013). Thou shalt not fall! Decreasing falls in the postoperative orthopedic patient
with a femoral nerve block. Medsurg Nursing: Official Journal of the Academy of MedicalSurgical Nurses, 22(4), 246–249. PMID: 24147322.
Rutherford, P., Moen R., & Taylor, J. (2009). TCAB: The “how” and the “what.” American
Journal of Nursing, 109(11), 517.

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