Falling in adults 65 and older is a complex problem confronting public health, the health care system and families. Statistics alone do not begin to measure the pain, suffering and loss of independence that are experienced by older adults who fall, but a number of trends highlight the magnitude of the problem: Falling accounts for 80-95% of hip fractures in older adults. The rate of fatal falls increases dramatically with age. Falls are the leading cause of injury deaths for older adults.
Among adults 75 and older, those who fall are four to five times more likely to be admitted to a long-term care facility for a year or longer. (Mission Hospital Data, Risk Management, 2012)
For decades, hospitals and other health care organizations have integrated to understand the contributing causes of falls, to minimize their occurrence and resulting injuries or deaths. Today, organizations have begun reaching out to each other for collaboration on the best ways to prevent falls. Based on Centers for Disease and Prevention (2012) data, each year one in three older Americans (65 and older) falls and about 30% of those falls require medical treatment.
Falls are not only the leading cause of fatal and nonfatal injuries but also the most common cause of hospital admission for trauma. More than $19 billion annually is spent on treating the elderly for the adverse effects of falls: $12 billion for hospitalization, $4 billion for emergency department visits, and $3 billion for outpatient care. Most of these expenses are paid for by the Center for Medicare and Medicaid Services through Medicare.
It is projected that direct treatment costs from elder falls will escalate to $43.8 billion annually by 2020. (www.cdc.gov ).
Because unanticipated falls by nature cannot be prevented, the goal is to create an environment that would reduce injury, should a fall occur. Our current rates for falls from January 2012 through October 2012 ranged from 2-3 falls per month. By implementing an interdisciplinary Fall Team and using a fall risk assessment tool, the hospital wants to reduce inpatient fall levels by 30%. Current process is that there are not enough nurses to monitor patients on an hourly basis, only every other hour. Patients are not being properly identified as “high-risk” patients. There is not an appropriate amount of lighting, and the clutter is not being cleared by staff members from either hospital equipment to family member belongings, as well as the staff not being able to move trip hazards away from patients area before the staff leaves them by themselves.
The staff is not providing the patients with bathroom breaks on a regular basis. The staff is giving the patients undesirable amounts of fluid, which is making the patient get out of bed as well. The staff now needs to be educated on the above concerns, as well as giving them the proper training and resources and appropriate oversight of a fall prevention protocol that we will be putting in place. Involvement by staff for this project will include the following: doctors, physical therapists, occupational therapists, nurses, and other staff members who transport patients. Physicians often deal with older adult patients who have fallen or fall regularly, yet there are no specific tools readily available to primary practitioners to identify and treat those patients who are at risk for future falls. With the availability of a fall prevention program, the physician has assistance in managing these challenging patients.
Physical and occupational therapy for older adults can be utilized in multiple settings across the continuum of care, including acute care, long-term care, and outpatient clinics and in the home. Physical therapists can be very effective in developing, implementing, and overseeing an exercise program and can assist in solidifying a culture of exercise in the long-term care facility. Exercise is important in fall prevention, improving strength, flexibility, and balance. Patient, family, and caregivers require exercise techniques, with considered frequency, duration, type, and intensity, to reduce the risk of falls. Implementing fall prevention and intervention programs for the elderly presents nurses with a number of challenges as well.
There is a need for more reliable solutions that will predict falls and recurrent falls for the nurses to predict and intervene more effectively to prevent elderly falls. A fall can increase the patient’s length of stay, and the patient may require surgery from the fall or need additional means of care. Our team has collaborated by brainstorming and proposed a number of solutions to be observed. We will perform random, controlled data trials. We will use a sample of patients, hospital-based, evaluating the protocol, and then attempt to remove the obstacles to improve the outcome.
We will keep in contact with nurses who do not have any patient falls within a certain amount of time to be determined, and follow up with them to share what interventions they felt kept their patients safe. This was a list compiled of the nurse’s concerns to be monitored in the patients physical environment: Medications – those that affect the central nervous system, such as sedatives and tranquilizers, benzodiazepines, and the number of administered drugs. Bathtubs and toilets – equipment without support, such as grab bars. Design of furnishings – height of chairs and beds.
Condition of ground surfaces – floor coverings with loose or thick-pile carpeting, sliding rugs, upended linoleum or tile flooring, highly polished or wet ground surfaces. Poor illumination conditions – intensity or glare issues. Type and condition of footwear – ill-fitting shoes or incompatible soles such as rubber crepe soles, which, though slip resistant, may stick to linoleum floor surfaces. Improper use of devices – bedside rails and mechanical restraining devices that may actually increase fall risk in some instances.
The current fall-protocol involved handouts, patient identification by colored band, and frequent observation by nursing. The nursing team communicated a patient’s fall risk to staff and visitors by developing visual safety signs that were displayed in patients’ rooms. Besides these signs, the fall prevention team developed a hallway door sign, a reminder sign for any visitors and staff and they chose color yellow as recognition of fall risk; patients wore yellow wristbands when they left their room or nursing unit.
A randomized study was conducted to determine the effectiveness of the identification bracelets in preventing falls among high-risk patients. The study found that in the intervention group 41% of persons fell at least once, whereas in the control group 30% fell at least once. The results suggested that the identification system was of no benefit in preventing falls among high-risk persons. So the nurse’s focused on a plan that the Project team came up with: Hourly rounding utilizing the 4P’s as a focus (personal needs, pain, position, possessions/people) Leader rounds and concurrent audits of the nurses’ fall assessment and application of interventions Use of bed alarms
Switch from high-gloss to low-gloss wax floors (in select areas) Engaging patient care assistants as hall monitors at shift change and as ‘team leads’ for shift-based fall prevention teams Color-coded high-risk identifier emblem on all patient room doors Color-coded non-skid slippers
Fall-risk is discussed as part of shift report Certain fall risk levels are communicated to director in twice daily charge nurse shift reports High fall risk is discussed in daily patient care conferences
Once a fall occurs and the patient is stabilized, the nurse or charge nurse notifies the physician and family of the fall. The staff conducts a post fall assessment and huddles with the charge nurse and patient care team to determine immediate plan of action to further prevent a subsequent fall. Our Risk Manager follows up on the patient and/or charge nurse for further details. Strategies are then discussed and any additional interventions are considered. The emphasis of the project was on training, education and communication to increase staff and patient awareness and staff competence and compliance.
The patients at risk were identified through the use of wristbands, color-coded cards placed on the room doors and in the patient charts. As the results with the bed-monitoring system improved the nursing staff requested the use of technology for chairs and wheel chairs. Additional education with the patient and/or family was done, if the patient was coherent. A weekly “falls” meeting is held to further drill down the fall. There has been an increased awareness of fall prevention throughout our hospital. Falls data, including identified trends, is shared monthly with all hospital leaders and leaders are encouraged to share this information with their co-workers. Most departments have communication boards in their areas where this data is posted.