Submitted by Preventing Falls in the Elderly Long Term Care Facilities Rebecca McCarthy, MSN, RN-BC, CDONA Catherine W. Adedokun, MSN, RN Roseanne Moody Fairchild, PhD, RN
The elderly long-term care population is at increase risk for falls and fall related injuries. The implementation of a fall prevention program is important for ensuring resident safety. Systematically assessing residents’ risk for falls and implementing appropriate fall prevention interventions can reduce the number of falls in the elderly long-term care residents. The article reviews a clinical practice guideline recommendation for implementation of a fall prevention program. Risk factors affecting falls in the elderly residing in long-term care are examined. Strategies for implementing a fall prevention program are discussed, including barriers to implementation.
Preventing Falls in the Elderly Long Term Care Facilities
Falls pose a serious risk for the elderly living in long-term care facilities. An average nursing home with 100 beds reports 100 to 200 falls annually (George, 2000). Falls can cause serious injuries and accidental death, and in older people. Prevention of falls in the elderly living in long-term care facilities is very important, and requires several different approaches to deal with the unique factors which may predispose the elderly to this type of injury. This paper reviews the major risk factors of falls and current clinical guidelines in fall prevention for elderly populations living in long-term care facilities. The authors also propose key features and critical aspects of successful fall prevention programs based upon a synthesis of the literature from 1996-2009.
Significance of the Problem
A fall is defined as a sudden, unintentional change in position, which results in an individual either hitting the ground or another object below his or starting point (George, 2000). The American Medical Directors Association (AMDA) (2005) reports that falls are a significant cause of injury and death in the elderly living in long-term care facilities, and according to the Agency for Healthcare Research and Quality (AHRQ) (2009), falls are the leading cause of fatal and nonfatal injuries among Americans aged 65 and older, resulting in more than two million emergency room visits. The AHRQ (2009) also found that one in ten of these emergency room visits were related to injuries from falls, with a rise in visits as patients become older. Moreover, approximately 1,800 older adults living in long term care facilities die each year from fall-related injuries and many of these falls go unreported (Center for Disease Control [CDC] 2009).
What Influences this Issue?
The elderly in long-term care facilities are predisposed to falling and may fall for a variety of reasons. Predisposing factors include, unsteady gait and balance, weak muscles, poor vision, medications, and dementia. In addition, other factors such as poor lighting, loose rugs, poorly fitting shoes, floor clutter, and beds or toilets without handrails, also may cause falls (Jenson, Lundin-Olsson, Nyberg & Gustafson, 2002). Furthermore, medical conditions such as low blood pressure, stroke, Parkinson’s disease, arthritis, Meniere's disease (affects the middle ear - causes vertigo), poorly controlled diabetes, poorly controlled epilepsy, brain disorders and thyroid problem increase the elderly client’s risk for falls (Osteoporosis-Info.com, 2009).
Review of the Literature
A study conducted by Neyens, et al (2009) evaluated the effectiveness of a multi-factorial intervention on the incidence of falls in psycho-geriatric nursing home patients. The study was conducted on one psycho-geriatric ward in 12 nursing homes in The Netherlands. Six nursing homes were allocated to the intervention group and six to the control group. The study reported that multi-factorial interventions to prevent falls that includes a general medical assessment focusing on falls; a specific fall risk evaluation tool; assessing fall history, medication intake, and mobility; and the use of assistive and protective aids have significantly reduced the incidence of falls. The researchers concluded that fall prevention targeted at psycho-geriatric patients in a nursing home setting is both possible and effective in reducing falls among those at the highest risk.
Kato, et al. (2008) conducted a study to develop a fall prevention program for elderly patients in long-term care facilities who are at risk for falls by increasing the care giving skills and the motivation of the staff members. Exercise program consisting of a warm-up, static stretching, muscle strengthening in the lower extremities, toe exercises, proprioceptive neuromuscular facilitation, and cool-down were used to increase motivation and increase the care-giving skills. The results of the study concluded that the fall prevention program helped to reduce injuries from 41.9% to 9.7% among the elderly participants while increasing the emotional support and self-efficacy among the staff members. Empowerment was considered a driving force for change. The fall prevention program demonstrated to be acceptable for use among elderly individuals in a long-term care facility.
A study conducted by Sherrington, Whitney, Lord, Herbert, Cumming, & Close (2008) examined the effects of exercise on fall prevention in the elderly worldwide. This systematic review of 44 trials with 9,603 participants revealed that the pooled estimate of the effect of exercise was that it reduced the rate of falling by 17%. The researchers concluded that this review provides strong evidence that exercise programs can reduce fall rates in older people. The sample size and astute methodology of this study provides confidence that these findings and may be generalizable to the larger population of elderly in long-term care facilities.
A study conducted by Wiens (2001) examined the role of the pharmacist in falls prevention in the elderly. The report concluded that the incidence and risks for falls could be decreased through interventions that include medication review with appropriate modifications to the elderly client’s medication regimen. Wiens explained that while there is not strong evidence for a pharmacist independently intervening to reduce falls, there is support for a pharmacist participating on a multidisciplinary team to review medications, provide appropriate suggestions to reduce high-risk medications, and provide education to the patient and the health care.
Hartikainem, Lonnroos & Louhivuori (2007) conducted a study to determine whether medication was a risk factor for falls. The study concluded that central nervous system drugs, especially psychotropics, seemed to be associated with an increased risk for falls. The researchers found that older adults taking more than three or four medications were at increased risk of recurrent falls. However, the studies included in the meta-analyses had minimal adjustment for confounding factors such as an underlying indication for drug use, dosage, or duration of pharmacotherapy.
Koski, Luukinen, Laippala & Kivela (1996) conducted a study to determine the physiological factors and medications predicting injurious falls among the elderly population in a rural home-dwelling population. The study showed some physiological factors and the use of some medications to be important risk factors. According to the study, lower-extremity muscle weakness, peripheral neuropathy, lower pulmonary capacity, difficulties in gait and use of long acting benzodiazepines and cardiovascular medications were the most important risk factors for injurious falls. The researchers found that the majority of injurious falls occurred when walking or taking a seat. Thus, training of lower extremities and supervised walking could be an effective nursing intervention for elderly clients.
Implementing a Fall Prevention Program
Implementing a best practice fall prevention program has proven to be successful in reducing falls in elderly long-term care patients. It is common knowledge that fall prevention is crucial for this population. Best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation (National Guideline Clearinghouse, 2009).
A fall prevention program should initially be piloted on one unit where it is likely to succeed before introducing it to the entire facility. A pilot study can reveal deficiencies in the project that can be addressed before time and resources are expended on a larger scale. Piloting on a unit will also allow closer monitoring of the results for evaluation before finalizing plans for program implementation.
Clinical Practice Guidelines
Clinical practice guideline recommendations important to the successful implementation of a fall prevention program are included in the best practices guideline published in the National Guideline Clearinghouse (2009). The guidelines are as follows:
Assessment: The clinical guidelines recommend assessing fall risks on admission and after a fall. Knowing who is at risks for falls is important in deciding who needs to be in the fall prevention program. Assessing after a fall is important when looking at root cause and interventions to preventing future falls. This is also important in determining if the current fall prevention intervention is effective.
Exercise: While this is not recommended as a stand alone intervention, the clinical guidelines recommend that nurses use strength training exercise as a component of a fall intervention program.
Multi-factorial: It is important when developing a fall prevention program to look at the predisposing and precipitating factors that affect a patient’s or resident’s fall risk. Implementing a variety of fall prevention interventions based upon known risk factors for falls the elderly can help in reducing future falls.
Medications: The clinical guideline recommends that nurses consult with the health care team and conduct periodic medication reviews to prevent falls among elderly in long term care settings. Clients taking benzodiazepine, tricyclic antidepressant, selective serotonin-uptake inhibitors, trazadone, or more than five medications should be identified as high risk for falls. Medication review should be conducted periodically throughout the institutional stay. Most elderly long-term care residents are on multiple medications, sometimes referred to as “polypharmacy”, which places them at increased risk for falls.
Client Education: The clinical guidelines recommend educating patients that have been determined to be at increased risk for falls. Educating the patient on falls and fall prevention interventions increases safety awareness and reduces the fear of falling. When developing educational materials for this population, the nurse educator should consider factors affecting the aging process, and utilize methods consistent with adult learning principles.
Environment: The clinical guideline recommends that nurses should include environmental modification as a component of fall prevention strategies. Examining the environment for wet areas, clutter, poor lighting, and other environmental factors can reduce the risk of falling in nursing home patients.
Strategies that can be used to facilitate incorporating the recommendations into clinical practice based upon guidelines of the National Guidelines Clearinghouse, 2009:
1. Establish a fall committee. The members should be committed to leading the initiative. Assign someone to document and track activities and timelines.
2. Assign a dedicated clinical resource nurse who will provide support, clinical expertise, mentorship, and leadership. The individual should also have good interpersonal, facilitation, and project management skills.
3. Develop or implement new assessment tools and intervention products.
4. Plan and provide interactive educational sessions and in-service staff as necessary on an ongoing basis.
5. Promote and support successful implementation on each unit. Celebrate and acknowledge a job well done.
Resources Needed for Implementation
Implementation of the fall prevention program will require time, money and a collaborative effort from the staff. A change agent is helpful to launch a new program but the change must be carried out as a team/facility wide effort. There needs to be administrative and staff support for successful implementation and maintenance of the program (National Guideline Clearinghouse, 2009).
Cost of Implementation
The cost associated with implementing the fall prevention program would include the costs of risk management, time in the form of documentation and monitoring, any additional supplies and/or equipment, and staff training (National Guideline Clearinghouse, 2009). However, since fall-related injuries among older adults are associated with substantial economic costs which are typically much greater than the cost to implement an evidence-based fall prevention program, the benefits accrued from the implementation of such a program underscore the critical need to implement fall prevention programs in long-term care facilities (CDC, 2008).
Establishing Team Players
An interdisciplinary team structure is recommended to plan the fall prevention program, including assessment of nursing home readiness, development of clinical pathways and provision of education to both providers and patient on fall prevention. Members of this fall prevention team should include (National Guideline Clearinghouse, 2009):
· Physicians, preferably focused on a geriatric case;
· Nurses or nurse practitioners, preferably geriatric based;
· Social worker;
· Physical therapy;
· Administrators or managers.
Potential Barriers to Success
There may be some barriers to implementation a fall prevention program because human beings by nature may not like change. Staff may see this as additional work even when they understand the benefits of the program. However, the education of staff, patients, and families about fall risk and the fall prevention program should help to reduce these barriers over time.
1. Nurses should be educated in the use of a fall risk assessment tool, and should be able to describe the rationale for completing a fall assessment on admission, as well as after a fall. Staff should be familiar with different fall prevention interventions that are appropriate for each patient/resident based upon the result of the fall risk assessment.
2. Staff should be educated about predisposing and precipitating factors for falls and related prevention strategies and interventions. This will support them in understanding that fall prevention requires a multi-disciplinary approach. Staff needs to understand the different interventions available to them, in order to apply them when caring for patients.
3. Nurses should be educated about medications that increase the risk for falls in the elderly. In collaboration with the healthcare team, nurses should be able to conduct periodic reviews for elderly patients in their care.
4. Staff should understand and be able to implement environmental modifications as a component of fall prevention strategies.
Gathering Baseline Data
It is very important to establish a baseline before the implementation of a fall prevention program. Determination of a current baseline for the incidence of falls in a healthcare facility, including any historical trends, is important to evaluate whether the falls prevention attempts are making any difference. Having baseline data and information should support staff buy-in for the fall prevention program. Ongoing data collection will provide concrete feedback on the impact of the interventions in preventing falls (Registered Nurses Association of Ontario [RNAO] 2005).
Falls can be measured in different ways; therefore it is important to ensure that a consistent definition for falls is utilized by staff to support accurate data. On admission, the following baseline data should be collected from the patient/resident (RNAO, 2005):
· Living arrangements before admission;
· Admission diagnostic category;
· Medical history (stroke, Parkinson’s disease, cancer, congestive heart failure, osteoporosis or fracture related to a fall);
· Cognitive impairment (mini-mental state examination);
· Functional dependency.
Risk management data will include the following information (RNAO, 2005).
· All residents who come to rest inadvertently on the ground or floor or other lower level;
· Falls may be observed or unobserved – it is important to collect both but to distinguish between the two;
· A history of falling (repeated falls) puts a resident at higher risk and therefore, collecting all falls per resident is important;
· It is also important to collect falls with or without injury;
· It is also important to distinguish the severity of the fall. There are no standards to this; however, minor injury would include scrapes, bruises; moderate may include gashes, sprains; severe may include fracture, and even death.
The primary desired outcome for a falls prevention project is to reduce falls among the elderly. The process outcome should include an interdisciplinary approach to fall prevention and management; increased availability of experts in fall prevention and management; and systematic program deployment and evaluation. Desirable patient outcomes would include increased knowledge about falls; increased strength, balance, and mobility; increased functional independence with use of exercise and assistive/adaptive devices as needed; increased confidence in abilities; and reduced severity of fall-related injuries.
The evaluation component is necessary to determine if the program is satisfactorily achieving what it was designed to achieve (McNamara, 1998). Evaluations produce data that can verify if a program is effective. The evaluation for this program should be outcomes based, in order to identify the benefits to the clients. The clients in this case include the patients or residents, and nursing home staff and administration.
Data analysis regarding fall prevention should include the quality management department, because the department will be able to put a review process in place to analyze reported fall event information on a routine basis for learning and improvement opportunities. Use of an incident report form for falls that is specifically designed to collect data based on evidence about factors contributing to fall occurrences is important in a fall prevention program. For example, data collected might include time of day, location, activity, orthostasis, and incontinence. From the analysis of the data, one can determine the type of fall, such as accidental, anticipated physiological, unanticipated physiological fall (Morse, 1997) and severity of injury i.e., minor, moderate or major. Analysis of data also enables clinicians, administrators, and risk managers to profile the level of fall risk for their patients, along with actual factors contributing to the falls, including the identification of overall patterns and trends surrounding fall occurrences. Fall rates and the severity of injury to the patient or resident should be considered when analyzing the effectiveness of the fall prevention program.
Dissemination of the Project
Implementation of a falls prevention program should be accomplished by involving the entire organization, and would include the organization and delivery of training and in-services tailored to the learning needs of the staff in healthcare facility. Once patient health and safety outcomes of a fall prevention program are determined and summarized, the overall evaluation and result may be disseminated to the surrounding community, and to healthcare professionals both locally and nationally.
Throughout a fall prevention program, the importance of finding a way to help nursing staff deal with the issue of patient falls is of utmost importance. Ultimately, the authors would like nursing staff to recognize how vital it is to be aware of the possibility of falls among the elderly, and to underscore the nurse’s responsibility to create an environment that will be safe for patients or residents in their care.
Implications for Nursing
If nurse administrators and educators work to increase knowledge about the incidence of falls in the elderly, and assist in the changing of attitudes, perceptions, and behaviors of nursing staff in relation to fall prevention among the elderly in the long-term care setting, they can help to enhance patient safety in their facilities. Through implementation of a fall prevention program nurse administrators and educators can help health care providers gain more confidence in their abilities to work with elderly persons in regard to fall prevention.
The implementation of the program can also assist nursing staff to become more knowledgeable about important fall prevention strategies, and provide them accurate information to share with patients and families. Giving nursing staff the opportunity to achieve excellence by learning ways to reduce the risk of falls in the elderly can effectively provide a means of establishing a safe, high quality care environment.
Fall prevention is an important and timely issue that needs to be address by all healthcare providers, and especially in the care of the elderly in long-term care facilities. Applying clinical practice guideline recommendations for fall prevention is important to the development of a successful fall prevention program. Implementation of this project will have a positive implications for nurses. The program will enhance nurses’ knowledge and boost their confidence in preventing falls among their residents. An effective fall prevention program can reduce falls and fall related injuries in the elderly long-term care residents, in turn supporting increased cost-effectiveness related to prevention of falls-related injury and mortality.
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