Date of Award


Degree Name

Nursing (D.N.P.)


College of Nursing


Introduction. Falls are the leading cause of injury and injury death in adults over the age of 65. A retrospective examination at Level 1 trauma center in the Midwest found that 19.4% (118/605) of older adults admitted with a ground level fall were readmitted with a subsequent fall and injury. The aim of this quality improvement initiative is to determine if the implementation of an evidenced based patient toolkit and a discharge algorithm for providers will reduce outpatient falls. The objective was to reduce hospital readmission due to repeat fall.

Methods: The design of this project was mixed methods, observational, with a pre- /post-comparison to evaluate improvement. The setting was on an inpatient medical surgical trauma unit in an acute care hospital in the Midwest. Participants were providers, nurses, and patients. A toolkit was to be provided to patients fitting inclusion criteria at discharge to be utilized at home. Trauma service line providers were to utilize an algorithm at discharge.

Results: Two nurse surveys were administered. Implementation of the project was impacted by other initiatives and the COVID-19 pandemic shifting the organizations priorities and limiting student access to the site. Completion survey rate 3.6% (2 of 55). RN mean years of employment 3.5 (Standard Deviation [SD] 1.2). !00% reported they were able to review toolkit. There was 0% change in discharge practice after education.. Half of the nurses that completed the survey reported they provided patients with a ground level fall education a discharge. 100% of nurses reported they rarely/never discuss patient fall risk with providers during rounds.

Conclusions: Use of an evidenced based patient toolkit and a discharge algorithm for providers could potentially decrease readmission due to repeat ground level fall and injury. Further implementation efforts will be needed to evaluate effectiveness.