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Four P’s Initiative Reduces Patient Falls at Northern Westchester


Patients at risk for falls at Northern Westchester Hospital Center in Mount Kisco, N.Y., are easily identifiable. They wear yellow socks. It is part of a new way of doing things at the facility, an innovative falls prevention initiative designed and carried out largely by nurses.

Unofficially called the Four P’s, the evidence-based practice model incorporates pain, position, potty, and placement markers into two-hour rounding. Because the program is only 3 months old, official falls data isn’t available. But the nurses, who round in the units where falls traditionally occur, report fewer occurrences.

“Within the last month and half, at least on this unit, I don’t remember hearing of a fall taking place,” says Cristina Fata, RN, BSN, staff nurse on the mixed medical unit. “That rates really well with a year ago. Obviously our goal is to have no falls, but realistically sometimes something happens we can’t account for. This has definitely reduced the number of falls and call bells.”

The idea behind the Four P’s arose from Northern Westchester’s evidence-based practice council, says Chief Nursing Officer Lauraine Szekely, RN, MBA, who also is the senior vice president for patient care services at the 235-bed facility.

“The nurses who are involved in the evidence-based practice council through our shared governance model were interested in looking at falls and pressure ulcers to see what evidence was out there to ensure our practice was the best and meeting industry standards,” Szekely says.

To that end, the evidence-based practice team reviewed existing literature on falls prevention and examined internal data on when and where falls occurred in the facility, says nurse educator Fay Wright, RN, MS, SPRN-BC, coordinator of evidence-based practice and clinical instructor at Northern Westchester.

“Most of the falls at Northern Westchester were because people needed to go to the bathroom, and if you think about it, that makes sense because you wake up in the morning and you have to go,” Wright says. “So we looked at the evidence, and people were looking at toileting every one to two hours as a way to prevent falls. It’s almost like taking tiny steps — called small tests of change — in the change process.

The next step in creating the program was developing a fall risk assessment tool that not only incorporated toileting with falls-prevention strategies done during rounding, but also continually measured a patient’s fall risk.

“This is the beauty of the small tests of change,” Wright adds. “We identified procedural issues. For example, someone goes in and turns a patient, but they don’t potty before turning and a few minutes later the patient needs to go to the bathroom, so it’s almost double the work and uncomfortable for the patient because they’re getting moved a couple of times. [We’ve] developed a system that helps people work together.”

Four P’s Primer

Nursing professionals saw how the elements of the tool fit together in April during a comprehensive training. Close to 150 RNs, LPNs, technicians, chart coordinators, and respiratory therapists received education designed and administered by Wright on the new program.

“We had a bed set up with a mannequin, and everyone role played what they needed to do during rounding and used the key words to assess pain, potty, position, and placement,” Wright says. “At first people were like, ‘We can’t do this,’ but once they started doing it they got really engaged and played with it.”

While the enhanced rounding intrinsic to the Four P’s initially seemed like more work for bedside nurses, that perception quickly was dismissed.

“It’s less work in a way because when you’re frequently checking on patients you’re anticipating their needs and decreasing the call bells,” says Katerina Langer, RN, staff nurse in the orthopedic and neurology units. “But safety is the biggest concern, so whether it’s more or less work we’ll do whatever’s necessary to improve safety and prevent falls.”

The assessment component of the Four P’s provides another layer of prevention. Upon admittance and each ensuing day, patients are evaluated for risk. Not only do high-risk individuals receive yellow socks, they are charted with yellow stars and identified as fall risks to the call-bell intercom operators.

“One day a patient may be OK, but the next day have a procedure and become a risk, and this encourages us to assess our patients’ fall risks on a daily basis,” says Annmarie Tietjan, RN, BA, PCCN, staff nurse in psychology and cardiopulmonary units. “This is a tool that is more specific to each patient — it’s in tune to their individual needs.”

Patient Acceptance

High-risk patients generally have been receptive to the new tool, Tietjan says.

“The funniest thing happened. The first day it went live I went into a patient’s room — it was an elderly man — and told him about the new rounding, and he said, ‘That’s the best damn thing I heard all week. That makes so much sense,’ and I told him he was absolutely right,” Tietjan says. “It really gives us an opportunity to talk to the patients and see what they need.”

The additional time with patients is a boon to nurses stretched by the fast-paced hospital environment, Fata adds.

“Even if it’s just a few minutes to toilet and turn the patient, it gives you that time and allows you to assess and pick up on cues if the patient is in distress,” Fata says. “I don’t think it makes you a better nurse, but it brings out top-notch nursing; it’s more about personal nursing. With turning and positioning and being about the patient more, it makes it more personal and patients see the difference.”


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Robin Huiras is a freelance writer. To comment, e-mail

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