presented by Pat Quigley
Falls associated with toileting remains one of the top root causes contributing to falls among all adult patients across settings of care. Toilet-related falls occur due to intrinsic risk factors at the patient-level (i.e. impaired gait and balance, muscle weakness, incontinence) and extrinsic risk factors (i.e. toilet height, access to proper grab bars). Universal toileting strategies remain ineffective toileting programs. In this session, rehabilitation nurses will learn strategies to examine current toileting strategies as the opportunity to redesign a population-based approached to scheduled and assisted toileting and create a safer environment for safe toileting.
Dr. Patricia Quigley, PhD, MPH, APRN, CRRN, FAAN, FAANP, Nurse Consultant, is a retired Associate Director of the VISN 8 Patient Safety Research Center of Inquiry and is both a Clinical Nurse Specialist and a Nurse Practitioner in Rehabilitation. Her contributions to patient safety, nursing, and rehabilitation are evident at a national level, with emphasis on clinical practice innovations designed to promote elders’ independence and safety. For over 40 years, Dr. Quigley has practiced in the field of rehabilitation nursing, including 32.5 years with the Veterans Administration. She serves as patient safety expert for fall and injury reduction to the American Hospital Association, Washington State Hospital Association, Alaska State Hospital and Nursing Home Association, and their Hospital Engagement Networks – now Hospital Improvement Innovation Networks. She also served as fall and fall injury prevention subject matter expert for the 2013 AHRQ National Falls Toolkit and the 2008 and 2013 Institute for Healthcare Improvement Reducing Serious Injurious Falls on Medical Surgical Units. Dr. Quigley serves as a committee member of the NQF Patient Safety Standing Committee and past member of the NQF Patient Safety Complications Steering Committee, nominated by ANA. Her leadership resulted in redesign measurement of patient safety indicators for falls and fall injuries that link organizational, unit, and patient-level variables that are relevant and evidence-based. With a legacy as primary and co-investigator on health services and rehabilitation research, she has conducted large-scale studies to examine trends and cost savings on national interventions to reduce harm from falls. Dr. Quigley has served as principal or co-investigator in 35 research studies, totaling over $7.5 million. She has a track record of interdisciplinary research with health economists, epidemiologists, and statisticians for population-based outcomes research. Dr. Quigley has co-authored and served as associate director for eleven VISN 8 Patient Safety Center of Inquiry center grants from 1999-2016, totaling over $13 million. She has authored or co-authored more than 60 peer-reviewed manuscripts and more than 50 non-peer-reviewed manuscripts, book chapters, products, and media works. Dr. Quigley is grounded in practice, with a legacy of leadership in healthcare outcomes related to functional improvement, rehabilitation outcomes, and continuum of care. For over 20 years, she led an interdisciplinary clinical team in the development of evidence-based assessment tools and clinical guidelines related to assessing veterans’ risk for falls and fall-related injuries across multiple medical centers. Additionally, she provides ongoing consultation to the nursing staff, quality management, and patient safety coordinators for management of complex patients at risk for falls.
Falls associated with toileting refer to the activities specific to navigating the physical environment to use the toilet, the physical act of elimination, the environment design of the bathroom, and staffing assistance. These activities are complex and interactive. This chapter introduces an organizational framework that aligns each activity as a contributing fall risk factor that will then be categorized to a specific type of fall.
Universal approaches to patient toileting programs fail to address the unique toileting needs of each patient. Clinical practice standards require that rehabilitation nurses use clinical judgment to determine each patient’s specific toileting needs and schedule. Rehabilitation nurses will utilize their clinical expertise to maximize each patient’s functional ability to toilet and increase functional independence.
Safe toileting mobility requires that rehabilitation nurses have the physical assessment skills to evaluate a patient’s ability to manage toileting. These physical assessment skills involve patient handling (i.e., transfers, ambulation, toileting) and activities of daily living tasks (i.e., clothing management, personal hygiene toileting, grooming) that must be assessed for individualized care planning. The rehabilitation nurse must consider each patient’s functional level of dependence/independence (independent, assisted, dependent), weight-bearing status, need for caregiver assistance, and additional fall risk factors (orthostasis, centrally acting medications, diuretics). Rehabilitation nurses will have the opportunity to refresh physical mobility assessment skills into practice as a means to individualize patient care approach and engage the patient/caregiver as a partner in care.